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17568406-DS-8 | 26,880,356 | Estimada Sra. ___:
Fue un plazer de cuidar para ___ cuando estaba ___ hospital!
PORQUE ESTABA ___ HOSPITAL?
- Estaba hospitalizado porque estaba sufriendo mucho dolor en
sus articulaciones.
CUANDA ESTABA ___ HOSPITAL:
- ___ medicamentos para ___ dolor.
- ___ dosis de prednisona hacia 5 mg por dia hasta 10 mg
por dia.
- Hicimos pruebas de sangre para averiguar si tenia una
infeccion.
DESPUES DE ___ HOSPITAL:
- Tome todos sus medicamentos prescritos.
- Asiste a sus citas con ___ y nefrologos.
Saludos cordials,
___ medico a ___ | Ms. ___ is a ___ woman with MCTD/overlap
syndrome c/b lupus nephritis who presented with worsening joint
pain and leukopenia of unclear etiology. Work up was notable for
positive CMV IgG and IgM. | 79 | 33 |
14391494-DS-20 | 21,698,195 | Dear Ms. ___ de ___,
It was a pleasure taking care of you during your stay. You were
admitted for shortness of breath, due to high blood pressure and
volume overload. You were given medications to lower your
pressures, and you had fluid taken off with dialysis. Your
symptoms improved. Please follow up with your primary care
physician at discharge, and attend dialysis.
Best,
Your ___ care team | ___ ___ woman with ESRD on HD (___), Afib on
coumadin, presenting with SOB due to volume overload and
hypertensive emergency, resolved with HD and blood pressure
control.
# Hypertensive emergency/volume overload: The patient was
admitted with blood pressure in the 200s and pulmonary edema,
causing shortness of breath. Though she was at her documented
dry weight; she has likely had lost body mass in setting of
recent colectomy and had subsequently been under-dialyzed. 3.6L
were removed during urgent dialysis at ___ on admission to
relieve HTN and flash pulmonary edema. TTE was w/out new wall
motion abnormality. BP in 150s-170s prior to discharge and her
symptoms had resolved. Her home blood pressure medications were
continued at discharge. Need to dialyze to new lower dry weight
in future.
# Guaiac Positive Stool: The patient had one guaiac positive
stool on admission. Hct was stable and she had had no overt
blood in her stool. Given her recent hemicolectomy, she may have
had some mild bleeding with her healing colon. Her hct was
stable, reticulocyte count was elevated, and iron was wnl. Will
continue epo at dialysis.
CHRONIC INACTIVE ISSUES:
# Afib: continued coumadin, metoprolol
# ESRD: Anuric at baseline, ESRD likely from DM and HTN
nephropathy. Received urgent HD in ICU for volume management.
Continued sevelamer, cinacalcet, nephrocaps.
# PVD: continued aspirin, statin
# T2DM: continued NPH, add ISS
# GERD: continued omeprazole
# Adenocarcinoma s/p hemicolectomy: Continued home pain control
and anti-nausea medications | 67 | 242 |
10523012-DS-3 | 24,390,795 | Dear Ms. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had fevers to 102
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Blood cultures, urine cultures, and chest CT were performed
without revealing a cause of the fevers
- transesophageal echocardiogram could not be performed until
___, and since you were feeling well, with no fevers,
normal white blood cell count, it was felt safe for you to go
home with close follow-up and to return for the echocardiogram
as an outpatient.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please monitor your temperature and if you start to have
fevers again please call your doctor.
- Please be sure to attend your follow-up appointments. Your
echocardiogram is being arranged for you.
We wish you the best.
Sincerely,
Your ___ Team | SUMMARY
========
Ms. ___ is a ___ year old woman s/p MVR, tricuspid annuloplasty,
MAZE and left atrial appendage ablation in ___ on warfarin,
s/p DCCV for atrial fibrillation in ___, hyperlipidemia, with
of breast cancer s/p chemotherapy and surgery ___ and ___
arimidex, OSA intolerant of CPAP, and pulmonary artery
hypertension who presented with recurrent fevers, bilateral
sub-clavicular pain, and L calf pain. Despite workup, no cause
was found for her fevers; TEE remains to be done outpatient. She
was also found to have hematuria with unremarkable sediment.
#Recurrent Fevers
Patient reported fevers up to ___ for 9 days preceding
admission, and 1 week of similar fevers in ___ which was
attributed to viral illness. There was initial concern for
temporal arteritis given L temporal soreness, fevers, and
elevated CRP/ESR. Rheumatology was consulted and the decision
was made to defer steroids as GCA was unlikely (no visual loss,
jaw claudication, progression, or other features c/w
vasculitis). Malignancy was considered but thought to also be
less likely given unremarkable differential, absence of LAD, and
no concerning findings on admission CT chest. Does have a remote
history of breast cancer, but no signs of recurrence, no
lymphadenopathy. Also closely followed with breast
MR/mammography. Workup for infection included blood cultures
without growth, CT chest and CXR without acute process, UCx
without growth, skin was unremarkable, and she had no oral
lesions. The fact that she remained in sinus rhythm after recent
cardioversion is also somewhat reassuring against infection. She
did not experience any other localizing signs or symptoms of
infection. Reassuringly, no current stigmata of endocarditis,
though could be subacute presentation or localized abscess. She
does meet 2 Duke minor criteria. CTA without signs of PE and
___ negative for DVT. No signs of infection on CXR and UA
without signs of infection although some hematuria that's been
improved.
She will have a TEE outpatient, and blood cultures must be
followed up.
#Hematuria
Hematuria on UA with sediment showing elevated RBCs, none
dysmorphic, no casts. Protein/Cr ratio of 0.3 but improved to
0.2 on recheck. She has no signs of symptoms of cystitis, though
did recently have UTI at rehab s/p antibiotics. Recommend a U/A
be repeated in ___ weeks as this microscopic hematuria could be
related to her recent infection.
#MVP s/p mitral valve bioprosthesis (___)
#Tricuspid regurgitation s/p annuloplasty (___)
Currently doing well after surgery. High CRP may be explained by
recent surgery. Continued warfarin with goal INR ___, Aspirin 81
mg PO DAILY.
#Atrial fibrillation s/p MAZE, left atrial appendage ablation
(___) and s/p DCCV (___)
Currently in sinus rhythm. Continued Warfarin, goal INR ___.
Continued
atenolol 12.5mg daily.
#Chronic Iron Deficiency Anemia
Hgb stable since ___ at which time Dr. ___ her to
start taking iron supplementation. | 159 | 445 |
16681170-DS-6 | 28,581,421 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
the ___. As you know, you were
admitted for fast heart rates and low blood pressure. We did
blood tests with showed your heart enzymes were elevated, but we
feel this was not due to a heart attack but because your heart
was working too hard. Because your heart rates were difficult
to control with diltiazem and metoprolol, you were given
ibutilide and amiodarone, and your heart returned to a normal
rhythm. Your blood pressure and heart rates improved with these
medications. We were able to stop diltiazem because you no
longer need it to control your heart rate. You will continue to
take amiodarone on a gradual taper. See the attached medication
sheets for detailed instructions. Of note, diltiazem and
sotalol were stopped, metoprolol was started, and amiodarone was
started.
AMIODARONE DOSING SCHEDULE
[] ___ : amiodarone 400mg BID
[] ___: amiodarone 400mg daily (for 3 weeks)
[] ___: amiodarone 200mg daily
We also started you on a blood thinner called coumadin to reduce
your risk of stroke because of your abnormal heart rhythm called
atrial fibrillation.
If you develop any chest pain, fast heart rates, shortness of
breath, lightheadedness, or leg swelling, please return to the
hospital immediately. Please take your medications as
instructed. Please followup with your primary doctor and
cardiologist.
Sincerely,
Your ___ Care Team | ___ yo F with hx of AFlutter, DMII, apical hypertrophic CM with
chronic dCHF, and cognitive decline who presents with
asymptomatic hypotension that resolved prior to ED arrival and
found to have elevated troponins without vital sign derangements
or ECG changes in the ER, hospital course notable for atrial
flutter with rapid ventricular response, difficult to control
with medications.
# Atrial Flutter: On prior admission she was admited with HR in
140-160s. Patient with extensive history of atrial flutter s/p
several cardioversions and medication titrations. Had been on
sotalol+diltiazem until recently, when diltiazem was held by her
cardiologist Dr. ___ low BP.
- She presented with flutter and RVR to the 160s. Patient
intermittently wavering between Aflutter, Afib, and NSR. On the
floor she required multiple doses of IV and PO doses of
metoprolol, diltiazem
- She underwent TEE to confirm no left atrial clot, and was
loaded with amiodarone.
- She converted to sinus rhythm but developed post-cardioversion
pulmonary edema and required oxygen through non-rebreather,
monitoring and diuresis in the CCU.
- In the CCU, she converted back to atrial flutter, so she was
chemically cardioverted with ibutilide and loaded with IV
amiodarone
- She remained in sinus rhythm and stable on room air for > 48
hours prior to discharge.
- She was also started on warfarin with goal INR ___, should
continue at least 1 month post-cardioversion. She had a prior
GI bleed on anticoagulation. Risks and benefits discussed with
daughter, ___. Aspirin stopped.
- Diltiazem and sotalol were stopped
- Metoprolol XL 75mg daily started
- Amiodarone load as below:
[] ___ : amiodarone 400mg BID
[] ___: amiodarone 400mg daily (for 3 weeks)
[] ___: amiodarone 200mg daily
# Hypoxemic respiratory failure: Due to acute pulmonary edema,
likely post-cardioversion pulmonary edema as it occurred about
___ hours after cardioversion. She required NRB and was given
IV lasix with good response. She remained stable on room air
for > 48 hours upon discharge, on her home doses of lasix and
spironolactone.
# CCU Course: Patient transferred to CCU for persistent NRB
requirement. Diuresis was continued, and patient was given 80 IV
lasix 8 pm on ___ and 40 IV lasix ___. On am of ___ AM
she went into Afib with RVR into 140s, SBPs high 90's, 5 IV
metop x2 without response and then after 15 IV dilt HR went to
85. Too agitated to get PO or EKG. AS of am ___ patient has
satting on RA atfer diuresis with lasix. Heparin gtt was stopped
(was therapeutic) and coumadin 4 mg daily was started (down from
planned 5 mg daily dose due to rise in INR second to only 2 mg
coumadin dose). Patient was called back out to floor on ___,
and was readmitted to CCU on ___ atrial tachycardia with
ventricular rates in 170's. In CCU; patient recieved ibutilide 1
mg X2 and converted to sinus rhythm w/ HR 70's. Started on
amiodarone drip with plan to start 400 BID after 24 hours. Also
received IV lasix for low UOP and fluid overload with good
response.
# Apical Hypertrophic Cardiomyopathy: Patient has history of
cardiomyopathy, with seemingly increased EF>55% since
decompensation in ___. Diuresis as above.
#Troponinemia: Troponin T elevated to 0.11. None were measured
last admission. Patient otherwise without angina and EKG
unremarkable for ischemic changes. Likely from demand ischemia
in the setting of persistent Aflutter with RVR superimposd on
known hypertrophic cardiomyopathy. Patient has no history of
CAD. Trop 0.11-> 0.13->0.11.
# Hypotension: Per ECF had quickly resolving hypotension that
was asymptomatic and not associated with tachycardia or mental
status change. Low blood pressure may be from poor PO intake in
the setting of dementia, episodes of Aflutter with RVR, and
multiple medications (dilt, sotalol, lasix, spironolactone). No
clinical evidence for sepsis or cardiogenic shock. Currently,
SBP stable at low 110s.
CHRONIC ISSUES:
================================
# Depression/Anxiety: Continued clonazepam, seroquel, zoloft.
# Hyperlipidemia: Continued home Zetia.
# DM Type II: On glipizide and Lantus 44u at home.
# GERD: Protonix 40 (increased from home dose given h/o GI bleed
on anticoagulation)
# Hypothyroidism: Continue home levothyroxine. TSH 0.81. | 238 | 705 |
13490800-DS-20 | 27,298,032 | Dear Ms. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted because you were found to have a
urinary infection called pyelonephritis. You were treated with
intravenous antibiotics and clinically improved. You were
transitioned to oral antibiotics which you should continue to
take for 10 days, last dose ___.
Please START taking:
Ciprofloxacin 500mg twice daily for 10 days
Please take the rest of your medications as prescribed and
follow up with your doctors as ___. | ___ yo F with hx of ureteral reflux who presents with dysuria,
fever, nausea and vomiting found to have UA concerning for
infection
# pyelonephritis: Patient presented with dysuria, fevers up to
102, nausea and vomiting. She initially went to ___
___ where she was administered an IM dose of ceftriaxone and
IV fluids. It was recommended that she go to the ___, however she
returned home. Her symptoms persisted and she then came to the
___ for evaluation. She was initially started on IV ceftriaxone.
Urine culture on admission showed no growth. However, urine
culture from ___ obtained on the previous day
showed >100K pansensitive E. coli. She was transitioned to po
ciprofloxacin. Her UTI may have been precipitated by sexual
intercourse several days prior to admission. She denied any
vaginal discharge or pain. Urine chlamydia was sent and was
negative. Given her clinical improvement with being afebrile x
24h, she was discharged with 10 days of po ciprofloxacin and
plans to follow up with her PCP.
Of note, several hours after she was discharged, her family
called us to report she again had spiked a fever to about ___.
Since she was still within 48-72h of initial antibiotics, and
culture data indicated ceftriaxone was effective, we advised
them to continue monitoring her at home and bring her in to her
physician or the ___.
# contraception - patient had discontinued her OCP ___ days
prior to presentation and was reportedly having spotting. She
was instructed to start a new pack after her cycle is complete
and to use a back up method of protection for at least 1 week.
TRANSITIONAL ISSUES
- final blood cultures pending at time of discharge
- contact: ___ ___
- code: full | 82 | 287 |
12817942-DS-11 | 21,019,046 | Dear Ms. ___,
You were admitted to ___ and
underwent right lower extremity angiogram and stent placement on
your popliteal artery. You have now recovered from surgery and
are ready to be discharged. Please follow the instructions below
to continue your recovery:
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Ms. ___ is a ___ with non-healing ulcers in her left lower
extremity who was admitted to the ___
___ on ___ for assessment of her left lower extremity
vasculature. She was initially managed with IV Abx and a heparin
drip for anticoagulation. The patient was taken to the
endovascular suite and underwent LLE angioplasty and peroneal
artery stenting. For details of the procedure, please see the
surgeon's operative note. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where she remained through the rest of the hospitalization.
Post-operatively, she did well without any groin swelling. She
was able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. She was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions. | 379 | 161 |
11922236-DS-33 | 29,175,363 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY YOU WERE ADMITTED:
-You were having difficulty breathing
-We felt this was due to your heart failure, and you had too
much fluid in your body
WHAT HAPPENED IN THE HOSPITAL:
-You received medicine to remove extra fluid from your body
-Your breathing improved and remained stable on your home
medications
WHAT YOU SHOULD DO AT HOME:
-Take all of your home medications as prescribed
-Weigh yourself every day. If your weight goes up 3lbs in a day,
or 5 lbs in a week call your doctor
-___ low-sodium diet
-Your upcoming doctor's appointments are listed below
Thank you for allowing us to be involved in your care, we wish
you all the best | ___ man with h/o HFpEF (EF >65% ___, COPD, HTN, and atrial
fibrillation on warfarin, presenting with acute onset dyspnea,
accompanied by orthopnea and PND, most concerning for acute
decompensated HFpEF exacerbation. | 115 | 32 |
15628922-DS-14 | 29,497,122 | Dear ___,
___ was our pleasure caring for you at the ___. You were
admitted to the hospital for a seizure. After multiple tests,
the neurology team concluded that your seizure was most likely
due to abnormally low levels of electrolytes. You were
transferred to the cardiac ICU service after your blood
pressures were low and we found you to have acute heart failure.
You did well with diuresis and was transferred out of the ICU.
Changes to your home medications include:
-START Dilantin (phenytoin) 100mg three times per day
-START Metoprolol succinate XL 75mg daily
-START Bactrim SS 1 pill daily
-START taking 1 baby aspirin daily, calcium supplements and
vitamin D
-DECREASE dose of lisinopril to 10mg daily
-STOP taking hydrochlorothiazide and omeprazole
You will follow up with your primary care physician as well as
gastroenterology, cardiology and neurology as an outpatient. We
will call you tomorrow with the results of your test for c.diff.
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward. | This is a ___ yo F with HTN, DM2, HL, but no known CAD or CHF who
presented to the ED after tonic-clonic seizure likely in the
setting of electrolyte abnormalities. The patient was intubated
for airway protection and was hypotensive after admission to the
neuro service. A bedside TTE showed ? of new systolic
dysfunction and LV hypokinesis. The patient was transferred to
the CCU for management of ? cardiogenic shock.
# Acute Systolic Heart Failure: The patient had a bedside TTE
performed by anesthesia that showed ? of new systolic heart
failure with LV hypokinesis. The TTE was initially performed due
to transient hypotension. ___ Echo results: Severe left
ventricular systolic dysfunction (estimated EF is 10%) and
severe right ventricular systolic dysfunction. Given these
findings, cardiology was consulted and recommended r/o ischemia
and IV diuresis. The patient had initial negative CE with
elevation of trop to 0.59 --> 0.55 12 hours later. EKG did not
show signs of ischemia. Other possibilities included
decompensation of undiagnosed CHF given acute illness,
hypertensive CM, tachycardia induced CM, or idiopathic dilated
CM. LOS fluid balance +6L and CXR with mild pulmonary edema at
time of transfer to CCU. The patient was diuresed with IV lasix
bolus as needed. Repeat ECHO on ___ that showed EF of ___
and mild focal wall motion abnl secondary to acute illness vs.
wrap-around LAD lesion. The patient was started on metoprolol
and lisinopril on ___ and they were titrated to control BP and
HR.
# Seizure: The patient had new onset seizure in the setting of
nausea and vomiting and low mag, potassium, calcium. The patient
was loaded with dilantin and admitted to the neuro ICU. Head CT
normal. LP bland. No other focus of seizure identified. MRI
showed small vessel disease. Most likely seizure
metabolic-related. Acyclovir and ceftriaxone were intially
started and d/c when bland LP results and no signs of
meningitis. HSV PCR also negative. Dilantin was continued with a
goal level of 15. She was transitioned to PO dilantin 100mg TID
and per neuro will need to continue for ___ months with taper if
no more events. MRA of brain and neck done prior to discharge
and normal.
# Blood culture positive for coag negative staph: The patient
was hypotensive with elevated lactate and WBC 30K and was
temporarily on phenylephrine. Blood cultures returned positive
for GPC in chains and clusters, however all subsequent cultures
have been negative to date. Vanc discontinued on ___, and
patient had been afebrile and hemodynamically stable after
weaning from phenylephrine on CCU service.
# Diabetes: The patient has DM2 and was on insulin gtt in neuro
ICU. Pt was transitioned back to ___ upon coming to CCU service.
# Crohns: Seen by GI team on ___ on previous hospitalization
where pt had abdominal pain and N/v/d for many months associated
with weight loss and failure to thrive with repeat endoscopy
showing inflammation and suggestion of granulomas. Crohn's
disease was the most likely diagnosis given granulomas found in
GI tract biopsies. Pt was maintained on prednisone 20mg BID
during course and per GI team, would like pt on this dose for
next ___ months. CCU team started pt on Bactrim for PCP
prophylaxis as well as Vit D and calcium supplementation. Pt is
to followup with GI as outpt.
# Hypothyroidism: Continued levothyroxine. TSH within normal
limits on this admission. Remained clinically euthyroid. | 168 | 564 |
11862339-DS-4 | 27,538,481 | Dear Mr. ___,
You presented to the hospital with fevers and bacteria in your
blood. This was likely related to an infection of your dialysis
line. You were treated with antibiotics, and this line was
removed. You will need four weeks of antibiotics after leaving
the hospital.
It was a pleasure taking care of you, and we are happy that
you're feeling better! | ___ y/o M with PMHx of ESRD on HD, DM, HTN, HLD, COPD, who
presented with fevers and chills,found to have MSSA bacteremia
concerning for HD line infection.
# MSSA bacteremia
# Concern for Tunneled Line Infection
Patient presented with fever, leukocytosis, positive blood
culture positive for MSSA in the setting of tunneled catheter.
TTE and TEE were without obvious vegetation. Pt was on
vancomycin, transitioned to cefazolin based on culture data.
Tunneled line was pulled. He was seen by ID who recommended a
four week course of cefazolin dosed with HD (3g post HD on
TThSa), last day ___. Dose of cefazolin increased based on
body weight.
# ESRD on HD, presenting with acute hyperkalemia: Patient on
dialysis over the past few months and presented with
hyperkalemia in the setting of dietary noncompliance. Underwent
HD with resolution of hyperkalemia. Renal was following. His
fistula was successfully used (had not been in use ___ hematoma)
prior to pulling HD line.
# Thrombocytopenia: Admission platelets of 137, no prior
baseline. No signs or symptoms of active bleeding. Mild
thrombocytopenia may be reactive in the setting of sepsis.
Overall stable though he was also noted to have leukopenia and
mild anemia as well. Would recheck CBC as an outpatient, with
further workup if findings persist.
# Elevated troponin: Patient with an elevated troponin to 0.21,
increased to 0.30 in the setting of renal failure. Patient
denied chest pain or shortness of breath. CKMB negative.
Troponin was stable on repeat.
# HLD: continued Atorvastatin 40 mg PO QPM
# HTN:
Continued CARVedilol 18.75 mg PO BID and NIFEdipine (Extended
Release) 60 mg PO DAILY
# Primary prevention:
Continued Aspirin 81 mg PO DAILY
# DM:
Continued home NPH and placed on ISS while hospitalized
> 30 minutes spent on discharge coordination and planning | 61 | 289 |
18516354-DS-3 | 29,186,486 | Dear Mr. ___,
You presented with symptoms concerning for a stroke or other
neurological process. Based on our work-up, the likelihood of an
acute neurological problem is very low. It is difficult to
determine the precise cause of your symptoms. It is possible
that some of your symptoms are due to your body's response to
stress.
At the time of discharge, you have shown significant
improvements and we expect that you will continue to improve.
It was a pleasure taking care of you at ___. We have not made
any changes to your previous medication regimen. Please follow
up with your primary care physician as needed. | Mr. ___ is a ___ RH yo man with past medial history including
HTN, HLD, Meniere's s/p vestibular neurectomy, urinary retention
presenting with gait instability accompanied by nausea and
sensation of spinning. Neurologic exam is notable for several
functional components including propulsive gait. When standing,
his body may propulse to the right, left, forward, or backward.
It appears that he may fall if not restrained. When he is
distracted, he is able to stand without assistance and does not
propulse in any direction. Neuro exam is also notable for
crossed sensory findings in the right face and left side of the
body including vibration that splits midline. He has giveway
weakness of the left arm and leg that improved over the course
of the hospitalization. Clinical exam and MRI does not indicate
stroke. This patient has physical manifestations of severe
stressors in his life (brother died recently and he has now lost
all of his immediate family members). The patient was evaluated
by psychiatry and diagnosed with a somatoform disorder.
Treatment is supportive care, and the patient is expected to
improve with time. He was discharged home, on his home
medications. He was cleared by ___ and did not need rehab
services. | 103 | 202 |
13919890-DS-14 | 21,335,396 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because of low blood pressure.
We think this was related to a very fast heart rate and to your
dialysis. You were treated with Metoprolol, a medication to slow
your heart rate and your blood pressures improved.
You should continue taking Metoprolol at home and follow up with
your PCP and ___ within one week of discharge. Your INR
level was elevated and so we would like you to hold your
Coumadin or warfarin dose today and have your INR checked on
___. Once this value comes back the ___ clinic
will instruct you as to what to do with your dose.
We wish you all the best in your recovery!
Sincerely,
Your ___ Team | Mr. ___ is a ___ y/oM w/ hx ESRD from hypertensive
nephrosclerosis on PD, CAD (s/p CABG, MV replacement, TV
repair), CHF (EF~40%), afib (on coumadin), HTN admitted for
persistent hypotension, poor appetite and fatigue.
#Hypotension:
Patient presented with persistent blood pressures in 90's/40's
over previous week. Differential for hypotension was broad.
Patient's blood pressure had been persistently low since valve
replacement surgery, so it was considered that this represents
new baseline. Patient also presented with leukocytosis with
urinalysis suggestive of infection, so sepsis was considered
possibility. Patient receiving PD for ESRD, so hypotension may
have been secondary to aggressive UF. Finally, patient in atrial
fibrillation with rapid ventricular response on admission (home
Metoprolol held after previous hospitalization), so this was
considered a contributing factor. Patient underwent more
conservative PD on night of admission (3 cycles instead of 5).
His metoprolol, which had been discontinued after his recent
cardiac surgery, was resumed, with improvement in his rates and
subsequent increase in blood pressures. Patient's pressures
remained in 100-110's systolic and he was asymptomatic, so he
was discharged home with close PCP follow up.
#Atrial Fibrillation on Coumadin: Patient in atrial fibrillation
with rapid ventricular response on admission. He was previously
on Metoprolol 12.5mg BID at home, but this has been decreased
and then held since last hospitalization. Patient was started on
Metoprolol Tartrate 25mg BID and subsequently Metoprolol XL 50mg
daily, with good rate response. Patient's blood pressure
improved with rate control. He was continued on Coumadin (had
been getting 1.5mg daily in recent weeks, down from previous
home dose of 2.5 daily). INR supratherapeutic on day of
discharge, so Coumadin held and patient discharged with plans to
have INR checked the following day. Patient also discharged on
Metoprolol XL 50mg daily, with Cardiology follow up.
#Troponin elevation:
Patient's troponin elevated to peak of 0.66 on admission. CK-MB
was flat and patient had no ischemic changes on EKG. Likely Type
II NSTEMI in setting of persistent hypotension and kidney
disease.
#ESRD on PD: Patient followed by Dr. ___ in nephrology. He
performs PD daily at home. Renal was consulted in ED, who
recommended more gentle PD in setting of hypotension. He
underwent 3 cycles (versus typical 5) on night of admission. We
continued home calcitriol, Sevelamer and Nephrocaps and
monitored electrolytes closely. Patient continued PD while
inpatient under the supervision of Renal. Discharged to continue
home HD. Patient will follow up with Dr. ___.
#CAD s/p CABG: Patient had no chest pain on admission and
troponin elevation thought to be Type II in setting of demand.
Patient continued on ASA 81mg and Atorvastatin.
#Leukocytosis: WBC was elevated to 13.1 on admission. Patient
had urinalysis indicative of infection, but no symptoms of UTI.
Urine culture grew ___ yeast. Chest X ray showed no
consolidation. PD fluid sent for gram stain and culture, both of
which were negative. Antibiotics were deferred and WBC
downtrended without intervention.
#Cdiff: Patient had recent hospitalization for cdiff infection
with plan to treat with Metronidazole for 14 day course. Patient
was continued on Metronidazole.
#Anemia: Hemoglobin was 10.1 on admission, which appears to be
baseline. Anemia thought to be due to severe renal disease.
Hemoglobin was monitored throughout admission and remained
stable.
Transitional Issues
=======================
-Medications ADDED during this hospitalization: Metoprolol XL
50mg daily
-Medications CHANGED during this hospitalization: Warfarin home
dose decreased to 1.5mg daily during hospitalization but held on
___ as INR was 3.4. Patient should have INR check on ___
___ with ___ clinic and determination of
whether Coumadin should be restarted.
-Patient continued treatment with PO Flagyl for previously
diagnosed cdiff infection during this admission. Patient still
having loose stools. He should follow up with PCP upon
completion of his antibiotics if still symptomatic.
-Urine culture and Peritoneal dialysis fluid culture/gram stain
still pending at discharge.
-CODE: Full (confirmed)
-EMERGENCY CONTACT: wife ___ | 126 | 639 |
19441198-DS-3 | 25,409,152 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weightbearing LLE
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 <30 DAYS OF REHAB
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 after POD3. 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.
Pin Site Care Instructions for Patient and ___:
For patients discharged with external fixators in place, the
initial dressing may have Xeroform wrapped at the pin site with
surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions. | Mr. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L distal and tibial and fibula fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for open reduction and
internal fixation of tibia and fibula, which was completed
without complications. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the LEFT lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 704 | 263 |
15477885-DS-8 | 21,608,276 | INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand 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 in the 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:
Take 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
ANTIBIOTICS:
- Please take linezolid until ___
- Please obtain 1-week discharge labs (CBC w/diff, Cr, BUN,
LFTs, CRP/ESR) to be faxed to ___.
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 keep the area clean and dry. Please cover the wound
with gauze - you can use a 4 x4 gauze on the wrist area and
upper arms, and then use some extended gauze between the
fingers. You can remove the wick from the back of your hand.
Please change the dressing every 2 days.
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 Hand Surgeon, Dr. ___. 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:
Work on ROM, stretching
Three times daily for patient, three times weekly sessions
Maintain volar resting splint
Treatments Frequency:
Please to try please apply dry sterile dressing to the right
upper extremity every 2 days:
Adaptic cut to size over the dorsal and volar wrist and hand
incisions. Subsequently covered with a dry sterile gauze,
wrapped in Kerlix, placed into a prefabricated volar resting
splint and wrapped with an Ace wrap. | Patient was initially evaluated on ___ with concern for
right upper extremity cellulitis. Laboratory values were
overall reassuring, however patient had persistent pain,
particularly over the dorsal aspect of the right hand with some
underlying fluctuance. Patient was also noted to have some
increase in numbness and paresthesias over the median nerve
distribution of the right hand. While in the emergency
department, patient was started on broad-spectrum antibiotics
including vancomycin, Zosyn, clindamycin. Patient underwent an
initial noncontrast CT scan which demonstrated no evidence of
air within the extremity. Upper extremity ultrasound performed
in the ED was also negative for DVT.
On hospital day 1, in the morning, patient's small finger was
noted to have slight duskiness at the volar pad. Over the
course of the day, this spread to include the volar pad of the
fourth digit. Vascular surgery was consulted who felt this was
potentially secondary to occlusion of a branch of the palmar
arch secondary to significant edema from infection. Patient was
started on full dose aspirin. Patient then underwent a CT ___
of the right upper extremity which demonstrated no significant
etiology to explain his sudden swelling.
On hospital day 1 evening, patient was taken to the operating
room for irrigation and debridement of his second through fifth
digits, carpal tunnel, volar and dorsal forearm, and medial arm.
Murky tissue, fluid, and evidence for infection as well as
dorsal hand abscess was encountered. A wick was placed.
From an infectious diseases standpoint, patient's intraoperative
cultures, as well as outside hospital cultures obtained from
___ grew out group a streptococcus species. Patient
was initially narrowed to ceftriaxone and clindamycin. On
___, patient was further narrowed to ceftriaxone and
linezolid. Patient's white blood cell count remained mildly
elevated, between 11 and 15. This was discussed with ID and felt
to be ___ to bandemia maturation with subsequent downtrend on
discharge. ID finalized recommendations to PO levofloxacin until
___ at the time of discharge.
___ hospital course was also notable for an acute kidney
injury, likely secondary to contrast-induced nephropathy as well
as initiation of vancomycin and Zosyn. Patient had a peak
creatinine of 3.2 which subsequently down trended. Nephrology
was consulted who felt that the acute kidney injury was likely
secondary to contrast-induced nephropathy in addition to Zosyn
and vancomycin. Creatinine had downtrend to 2.0 on discharge.
Patient continued to make adequate urine output throughout his
hospital course.
Patient had some intractable hiccups as well as abdominal
distention and bloating following both of his procedures, likely
a mild ileus secondary to repeated general anesthetics. At no
point did patient have nausea or vomiting. Patient was
maintained on a bowel regimen and his symptoms improved. A KUB
obtained showed evidence for constipation and no evidence for
obstruction or other pathologic process. These symptoms had
resolved at the time of discharge. | 629 | 486 |
16934858-DS-9 | 27,368,785 | Dear Ms. ___,
Thank you for coming to ___!
Why were you admitted?
-You were admitted after a fall on ___.
What happened while you were in the hospital?
-You underwent a C5-C6 anterior cervical discectomy and fusion
on ___.
-You had a fever after the operation and were diagnosed with
pneumonia. You completed a 5 day course of 2 antibiotics
-You also had some anemia after your operation, so you got 1
unit of blood on ___
-You were noted to have some swallowing difficulty after your
operation, but you did well and were on a regular diet prior to
discharge
What should you do when you leave the hospital?
- We recommend home physical therapy
-Although we think the safest thing is for you to eat ground
solids for the next few days, you requested to resume your
regular diet even with the risk of choking or aspiration.
Therefore you may continue on your regular diet but if you start
to develop difficulty swallowing especially in the next day,
please come back to the hospital or call your doctor for further
evaluation.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- No contact sports until cleared by your neurosurgeon.
- Do NOT smoke. Smoking can affect your healing and fusion.
- Please avoid swimming for two weeks.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Medications
- Do not take any anti-inflammatory medications such as Motrin,
Advil, and Ibuprofen etc
for 2 weeks.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ (NEUROSURGERY) for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- New weakness or changes in sensation in your arms or legs.
It was a pleasure taking care of you! We wish you all the best!
- Your ___ Team | Ms. ___ is a ___ yo F with CHF, HTN, CAD with previous coronary
bypass on aspirin, and CKD who sustained a fall from standing.
She was brought to the emergency department alert, oriented, and
in stable condition by her daughter for further evaluation.
Imaging showed a C5 fracture and multiple facial fractures. She
was admitted to the trauma service ___ for further management. | 367 | 65 |
11289183-DS-20 | 25,546,380 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital because you were having chest
pain. Your chest pain went away after taking nitroglycerin. You
had tests which showed you were not having a heart attack. You
also had a stress test which was normal and you didn't have any
more symptoms. We think that we can treat this chest pain with
medications. You should continue taking nitroglycerin if you
have chest pain with activity. If your chest pain happens again
or is increasing in intensity or frequency, you should call your
cardiologist right away.
IMPORTANT INSTRUCTIONS:
- please temporarily stop taking amlodipine. Your blood
pressures were normal in the hospital. Your Primary doctor may
instruct you to resume it.
- please change your full dose aspirin to baby aspirin.
We wish you the best!
Your ___ care team | ___ with a history of CAD s/p DES in ___ to LAD, s/p cath ___
with mild LMCA disease, RCA 30% stenosis, HTN, HLD, type II
diabetes (diet controlled) who was admitted for chest pain. | 141 | 35 |
16038868-DS-9 | 21,127,350 | Dear Ms. ___,
You were admitted to the gynecology oncology service for a small
bowel obstruction. You were conservatively managed. You were
made n.p.o. Your nausea was treated with antiemetics. Labs
were done which showed no signs of systemic infection. You were
afebrile with stable vital signs and monitored closely for
resolution of symptoms. You continued to have bowel function
present while you were in the hospital. You are discharged home
on a low residual diet. A handout was given to you with
instructions on maintain a low residue diet. Your home
medications were continued. You have recovered well and the team
now feels it is safe for you to be discharged home. Please
follow these instructions:
* Take a stool softener to prevent constipation. You may
continue your current home regimen for stool softeners
consisting of senna, colace, and polyethylene glycol. If you
continue to feel constipated and have not had a bowel movement
within 48hrs of leaving the hospital you can take a gentle
laxative such as milk of magnesium.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* Please continue on your low residual diet
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms | Ms. ___ was admitted to the gyn/onc service with an SBO.
She was made NPO for bowel rest/decompression in the ED prior to
transfer.
*) SBO
Patient presented to ___ clinic appointment, where she was
found to be nauseous with abdominal distension. She had been
increasingly nauseated over the past few days, with several
episodes of vomiting, most recent the day prior. She did report
one medium-sized, normal appearing bowel movement the morning of
presentation
and passing flatus. Upon presentation, patient was afebrile with
normal vital signs. Her abdominal exam showed no peritoneal
signs. CT scan of abdomen and pelvis was consistent with
persistent mechanical small bowel obstruction, likely chronic
and partial, with a dominant transition point in the right
hemipelvis at the level of the mid to distal ileum. Multiple
additional transition points within the more distal ileum.
Interval progression of uniform small bowel mural thickening
with persistent peritoneal enhancement and thickening suspicious
for peritoneal disease as the etiology for obstruction. Interval
increase in size in small right-sided pleural effusion with
pleural enhancement, which may be related to disease involvement
vs. infection. Trace perihepatic free fluid with questionable
early scalloping along the right hepatic border, which may
represent an early subcapsular deposit. She was made NPO and
given IVF to begin conservative management. On hospital day 1,
she continued passing flatus and did not have any emesis. She
was maintained on IVF and NPO. On hospital day 2, she had a
bowel movement. Her diet was slowly advanced that day. She was
seen by a nutrition consult to educate her on a low residue
diet after discharge. She was also seen by social work during
admission.
On hospital day #3, she was tolerating a low residue diet. She
continued to pass flatus, had a bowel movement, and a normal
abdominal exam. She was discharged home in stable condition.
*)Tachycardia
Patient noted to have mild tachycardia on hospital day 1. O2
sats 94% RA. Her baseline was 80-90s during prior admissions.
She did feel her heart rate had been a bit faster. She denied
chest pain, shortness of breath, fevers, chills, and abd pain.
She had been ambulating and did not report any dizziness. She
did report voiding normal amounts. A chest CT was performed
which showed no evidence of a PE. A right sided plural effusion
was seen that was larger than the one seen on her imaging from
___. An ___ guided therapeutic thoracentesis was attempted on
hospital day 2 but ultimately aborted because the size of the
effusion was insufficient to drain. Patient was asymptomatic
during the remainder of her stay and her rate ranged from
___ with O2sats in high ___ on room air. She was deemed
stable for discharge. | 247 | 454 |
11456564-DS-12 | 29,433,278 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for shortness of breath and found to have a blood clot in your
leg, a piece of which likely traveled to your lungs, causing
your shortness of breath. We treated you for a pulmonary
embolus (blood clot in the lung) with intravenous heparin and we
started you on coumadin (a blood thinner that you should
continue to take by mouth at home for treatment of the clot).
The coumadin level in your blood will need to be monitored by
occasional blood tests. Depending on your blood tests, your
coumadin dose will be periodically adjusted. Please have your
blood drawn at ___ on ___ and follow up with Dr.
___ at the appointment listed below. | Mr. ___ is an ___ gentleman with a history of colon
cancer s/p colectomy, prostate cancer s/p radiation, and
eosinophilic asthma who presented with three days of pleuritic
right sided chest pain associated with shortness of breath. He
was found to have an elevated D-dimer and positive lower
extremity ultrasound concerning for acute pulmonary embolism.
# Likely pulmonary embolism: Given positive lower extremity
ultrasound and d-dimer, presentation highly suggestive of acute
pulmonary embolism. CTA was deferred due to renal insufficiency
and the decision was made to empirically treat for pulmonary
embolism. He was started on a heparin drip as a bridge to
coumadin therapy on ___. He is not a candidate for lovenox
given chronic kidney disease. A TTE showed no evidence of right
heart strain. It appears that the incident was unprovoked. He
denied recent travel, but states he has been less ambulatory
than usual due to lower extremity cellulitis which is now
resolved; also has a history of cancer and is due for
colonoscopy. He was therapeutic on warfarin 5mg daily as of
___ with an INR of 2.2. He should have an INR rechecked
___ with results to be faxed to Dr. ___. Held home
nifedipine to prevent nodal blockade in setting of unknown clot
burden; restarted on ___.
# Acute on chronic kidney injury: Resolved. Baseline Cr 1.4-1.8
per Atrius records. Creatinine peaked at 2.1 on ___ and
improved to 1.3 on ___ with encouraged PO intake and holding
of home lisinopril. Unclear etiology as he was not hypotensive,
only new medications were heparin and coumadin, no evidence of
obstruction.
# Hypernatremia: Resolved with encouraging PO intake and holding
home lasix.
# Normocytic anemia: Hematocrit downtrended during hospital
course, but he had hematocrit ___ on prior admissions, so he
was likely hemoconcentrated on admission given poor PO intake
for several days due to feeling unwell. He has chronic back pain
secondary to spinal stenosis, denied any new or changing back
pain; denied melena, hematochezia. He is due for colonoscopy,
which should be followed up by his PCP.
# Elevated troponin: Likely secondary to pulmonary embolism.
Downtrended. Chest pain atypical and no ECG changes to suggest
ischemia.
# Leukocytosis: Resolved. Likely due to acute PE. U/A and CXR
negative. No cough. Endorsed some dysuria on ___ no
increased frequency or suprapubic discomfort, repeat U/A
negative. No diarrhea.
# Mild transaminitis on admission: Synthetic function normal. No
baseline LFTs found in atrius record. LFTs normalized as of
___.
Chronic issues:
# Hypertension: Initially held home nifedipine to prevent nodal
blockade in setting of unknown clot burden. Restarted home
nifedipine ___. Held home lisinopril and lasix in setting of
___ and hypernatremia, respectively. Lisinopril restarted at
20mg daily (home dose is 40mg daily) on ___. Restarted home
lasix on ___. SBPs 110s-130 at time of discharge.
# Eosinophilic PNA: Continued home prednisone.
# PUD: Continued home ranitidine
# Asthma: Continued home albuterol. Held symbicort as not on
formulary but advised to resume taking upon discharge.
.
## Transitional issues:
- he will need an INR and CHEM7 checked on ___, with
results to be faxed to Dr. ___
- his home lisinopril was briefly held due to acute kidney
injury and was restarted at 20mg daily on ___ (home dose is
40mg daily). His home lasix and nifedipine were also held and
restarted on ___ with resulting SBPs 110s-130.
CODE: Full
COMMUNICATION: Patient, wife ___ ___ | 132 | 570 |
14314429-DS-19 | 27,853,284 | Dear ___,
___ was a pleasure taking care of you during your stay at the
___. You came into the hospital
because you stopped breathing, which then caused your heart to
stop beating. You were given chest compressions, and your heart
and breathing restarted. We think this was due to taking too
many medications which decrease your breathing, in addition to
alcohol use which caused low magnesium levels. Low magnesium
levels can lead to a very dangerous heart rhythm that can be
fatal.
Your heart rate and lab values remained stable, and you were
able to be discharged home. Please try to abstain from alcohol
as it can cause changes in your electrolytes which can lead to a
very dangerous heart rhythm.
Please follow up with the appointments below.
Thank you for letting us participate in your care.
We wish you all the best,
Your ___ Team | Brief Hospital Course:
====================================================
___ year old Female with history of hypertension and asthma found
to be in respiratory arrest progressing to ventricular
fibrillation arrest with return of spontaneous circulation after
5 minutes of chest compression and transferred to ___ ICU for
higher level of care.
#Cardiac Arrest: Her ventricular fibrillation is likely
secondary to hypoxia from respiratory arrest in the setting of
alcohol, tricyclic antidepressant, and opiate use. She was also
found to have hypomagnesemia, which may have contributed to her
arrhythmia. Her electrolytes were repleted and she remained
hemodynamically stable in sinus tachycardia during the
hospitalization. She was discharged on magnesium oxide and her
home nifedipine. We did not continue her Nucynta (tapentadol) or
cyclobenzaprine.
#Hypoxia: In the MICU, she was saturating 92% on 4 liters nasal
cannula, but was on room air after transfer to the medicine
service. Her chest x-ray was without obvious consolidation. She
should have an outpatient chronic obstructive pulmonary disease
workup with pulmonary function tests.
#Chest discomfort, throat pain: Her chest pain and throat pain
are reproducible on palpation and are consistent with trauma
from chest compressions. She was treated with oxycodone and
acetaminophen and a chloraseptic throat spray. Her pain
gradually improved prior to discharge.
#Sinus tachycardia: Her heart rate was consistently in the
100s-110s and was likely due to opiate withdrawal. There was no
evidence of dehydration and her thyroid function was within
normal limits. She was monitored on telemetry and her home
nifedipine was continued. She was hemodynamically stable at
discharge.
#Alcohol Abuse: The patient did not have any signs of withdrawal
during her hospitalization. She was treated with thiamine,
folate, and a multivitamin. Her Nucynta (tapentadol) was not
restarted. A social worker saw her in the hospital and scheduled
follow-up.
#Chronic Hypertension: Prior to discharge her blood pressure was
uptrending and her home hydrochlorothiazide and losartan were
restarted.
#Transaminitis: Her liver function tests and lactate were
elevated, which was attributed to shock liver in setting of
cardiac arrest, although her AST to ALT ratio in setting of
alcohol abuse also suggested alcoholic hepatitis. We trended her
liver function tests and monitored her clinically.
#Leukocytosis: She had a mildly elevated white count that was
likely secondary to aspiration pneumonitis versus stress
reaction. She was afebrile and without a cough during her
hospitalization and her white count downtrended without
treatment.
#Asthma: We continued her home medications.
#Smoker: We gave her a nicotine patch and encouraged her to stop
smoking.
# CONTACT: Sister, ___ Friend ___
___ PCP ___
___
TRANSITIONAL ISSUES
[] Patient discharged with magnesium oxide 400mg daily
[] Please check repeat chem 10 panel and evaluate for
hypo-magnesemia. Please adjust magnesium repletion PRN
[] Please consider PFTs as an out-patient for evaluation of COPD
[] Cyclobenzaprine discontinued on discharge
[] Nucynta ER (tapentadol) discontinued on discharge
[] Please re-address code status with patient as an out-patient.
After transfer to the general medicine floor, the patient stated
that she was DNR/DNI. We recommend readdressing this as an
out-patient.
[] Limit opiate prescription to select medical providers
(patient has multiple prescribers). Limit use of Nucynta
(tapentadol) and cyclobenzaprine.
[] Patient should follow-up with social worker regarding
substance abuse. | 144 | 507 |
16720944-DS-21 | 29,627,001 | You were admitted to the hospital with abdominal pain. We were
initially worried about "Cholecystitis", which is an infection
of the gallbladder, although in the end this did not appear to
be the case.
You underwent a biopsy of the cancer that is currently affecting
your liver, lungs, and lymph nodes. We are still waiting on the
final results of this biopsy. You have already scheduled an
appointment at the ___ oncology office ___,
where they can discuss further plans and options once we have
more information.
If you have worsening symptoms you can call your doctor or
return to the hospital, depending on the severity of the
symptoms and your preferences. | ___ is an ___ year old woman with recently
discovered lung and liver masses with axillary, mediastinal, and
mesenteric adenopathy concerning for new metastatic malignancy,
who presented to ___ with worsening RUQ and epigastric
pain and was found to have evidence of possible cholecystitis on
CT scan, transferred to ___, where RUQUS was not consistent
with acute cholecystitis. She underwent biopsy to diagnose her
new malignancy, which was pending at discharge.
#New malignancy
Patient noted to have lung mass on CXR last month at ___,
then underwent CT at ___ last week, which showed multiple
lung masses with extensive mediastinal and hilar lymphadenopathy
and large liver lesions with enlarged porta hepatis and
peripancreatic lymph nodes, and a large R axillary node.
Underwent biopsy ___, with prelim path possibly suggestive of
neuroendocrine, although final path pending at time of
discharge. CA-125, ___, and CA ___ all elevated, CEA
normal. She will be seen this week at ___
for oncologic care, but she is fairly certain she will decline
any cancer therapy and will pursue comfort focused care. She was
seen by social work but declined palliative care consult during
admission. Her son ___ was present for most of the admission
and was very supportive. By the time of discharge she was having
minimal dyspnea or abdominal pain, and so was kept on her home
inhalers and PRN tylenol but did not need other symptomatic
meds. Patient wished to be DNR/DNI and completed a MOLST prior
to discharge.
#Cholelithiasis (initial concern for cholecystitis)
#CBD dilation
Patient presented with new RUQ and epigastric pain, found at
___ to have normal WBC and afebrile, although CT scan showed
distended gallbladder with thickening potentially consistent
with cholecystitis. She was transferred and underwent HIDA scan,
which showed cystic duct obstruction. However she never had
significant evidence of sepsis, and RUQUS on ___ was not
consistent with cholecystitis. She does have a gallstone in the
neck of the gallbladder that may be intermittently obstructing.
Antibiotics were stopped after the ultrasound was obtained. The
ultrasound did show mild CBD dilation, but given her improved
symptoms and normal bilirubin, as well as her preference to
avoid procedures, there was no indication to consider MRCP or
ERCP. She was tolerating a diet well prior to discharge.
#Mild tachycardia
At baseline (90s-100s) per her son. Given her excellent
functional status by discharge this was no pursued further.
#Loose stool
Patient with several loose stools prior to discharge, but this
is apparently her baseline, and she suspected that this was
related to eating more in the past day or two. She was otherwise
feeling well.
============================
============================ | 111 | 429 |
19543226-DS-11 | 22,950,641 | Dear Ms. ___,
You were admitted to the hospital after you experienced a
worsening of your asthma symptoms. The cause of this
exacerbation may have been a combination of your recent
emotional stress, dust exposure, cigarette smoking, and not
using your medications like you're prescribed. You were treated
with steroids and medicines to help you breathe and improve your
cough, and you improved significantly before being discharged
home.
We gave you a new medication called Advair to help with your
breathing. We also stopped your atenolol because of a very small
risk of making asthma worse. It is important that you follow up
with your primary care doctor to make sure your blood pressure
is controlled and to optimize your asthma medications.
We wish you the best,
Your ___ Care Team | BRIEF SUMMARY
=============
Ms. ___ is a ___ year old female with PMHx of uncontrolled
asthma, GERD, and HTN who presented with worsening shortness of
breath and wheezing after smoke and dust exposures, the loss of
her father, and non-compliance with medications. She was treated
with prednisone and nebulizers and was given an Advair inhaler
___ + ICA) for additional asthma control. She experienced a
significant improvement in her symptoms and was discharged with
a prednisone taper and nebulizers as needed. Of note, her
atenolol was discontinued given theoretical risk of
bronchospasm, her pantoprazole was increased to 40 mg q 12 h,
and she was started on fluticasone nasal spray for post-nasal
drip.
ACUTE ISSUES
#Asthma exacerbation: The patient states that she has had a
chronic cough for one month prior to admission. One week prior
to admission, she developed intermittent fevers, rhinorrhea,
sore throat, and nasal congestion. A few days prior to
admission, her father died, and because of the stressors she
took up smoking again (former smoker) and did not take her
medications appropriately. She also said her family member was
dusting her house the day prior to admission, which seemed to
exacerbate her symptoms. The day of admission, she woke up with
significant wheezing and shortness of breath, so presented to
the ___ ED. During her course, she was treated with prednisone
and nebulizers, was counseled on smoking cessation, and was
prescribed an Advair inhaler for persistent asthma, fluticasone
nasal spray for post-nasal drip, and had her Protonix increased
to Q12H due to continued GERD symptoms. The patient experienced
a significant improvement in her symptoms over two days.
-The patient was discharged on a prednisone taper: 40 mg daily
for 5 days, then 40mg daily for 2 days, 30mg daily for 2 days,
20mg daily for 20 days, then 10mg daily for 2 days
-The patient's atenolol was discontinued due to the theoretical
risk of bronchospasm
-The patient was prescribed Advair 250/50 1 puff BID for
optimization of her asthma therapy
-The patient was prescribed fluticasone nasal spray given
persistent post-nasal drip in the setting of a URI
-The patient's pantoprazole 40 mg q 12 h due to persistent GERD
symptoms
CHRONIC ISSUES
# HTN:
- Discontinued atenolol given theoretical risk associated with
bronchospasm
- Continued amlodipine 5 mg daily
# GERD: Increased pantoprazole to 40mg q 12 h as above given
continued acid reflux symptoms and her frequent asthma
exacerbations
# Pain control: Continued home percocet and cyclobenzaprine.
Gave Lidocaine patch and Bengay cream for additional pain
control
TRANSITIONAL ISSUES
===================
-The patient was discharged on a prednisone taper: 40 mg daily
for 5 days, then 40mg daily for 2 days, 30mg daily for 2 days,
20mg daily for 20 days, then 10mg daily for 2 days
-The patient's atenolol was discontinued due to the theoretical
risk of bronchospasm
-The patient was prescribed Advair 250/50 1 puff BID for
optimization of her asthma therapy
-The patient was prescribed fluticasone nasal spray given
persistent post-nasal drip in the setting of a URI
-The patient's pantoprazole 40 mg q 12 h due to persistent GERD
symptoms
-The patient was noted to have a small abscess at her right
axilla. She was given a prescription for bacitracin and
instructed to follow up with her PCP if this does not improve.
She may need I&D if it worsens or fails to improve | 127 | 540 |
11748996-DS-22 | 26,509,757 | You were admitted with sweats, tender glands in your neck, and
worse pelvic pain. You had a pelvic ultrasound that was
unremarkable, and your blood work is entirely unremarkable,
without any sign of infection. You were seen by the infectious
disease doctors and there is no clear evidence of infection, and
you have completed your course of antibiotics so your PICC line
was removed. In regards to your fatigue, we evaluated your
thyroid and adrenal gland functioning, and they are normal. You
were evaluated by the gynecologists and they think that the
pelvic pain that you have may be residual from prior infection.
We have made a urogynecology appointment and they are working on
moving it up. You will see the infectious disease specialists
next week and you can discuss with them getting a second
immunology opinion. Please discuss with your gynecologist how to
obtain pelvic floor therapy.
You were admitted with sweats, tender glands in your neck, and
worse pelvic pain. You had a pelvic ultrasound that was
unremarkable, and your blood work is entirely unremarkable,
without any sign of infection. You were seen by the infectious
disease doctors and there is no clear evidence of infection, and
you have completed your course of antibiotics so your PICC line
was removed. In regards to your fatigue, we evaluated your
thyroid and adrenal gland functioning, and they are normal.
You were evaluated by the gynecologists and they think that the
pelvic pain that you have may be residual from prior infection.
We have made a urogynecology appointment and they are working on
moving it up. You will see the infectious disease specialists
next week and you can discuss with them getting a second
immunology opinion. Please discuss with your gynecologist how
to obtain pelvic floor therapy. | Ms. ___ is a ___ female with the past medical history
of reported immunodeficiency, depressions,
anxiety, migraines, IBS, and recent PID and bacteremia who
presents from the ER with acute on chronic pelvic and abdominal
pain as well as swollen lymph nodes and reported night sweats.
She also endorses debilitating fatigue and back pain.
# Abdominal pain, pain on urination, pelvic pain - Had CT last
admit, and pelvic u/s this admit. Per GYN, pelvic exam
revealed some adnexal tenderness, which they felt was consistent
with recent episode of PID.
She will f/u with urogynecology. Given her negative imaging,
lack of any present infection, possible that her symptoms are
functional in nature.
# Sweats - no recurrent sweats or fevers in hospital, ESR 6,
normal WBC count. Blood cultures negative. She was seen by ID
staff who advised discontinuation of antibiotics now that course
of antibiotics for PID had been completed.
# Fatigue: TSH WNL, AM cortisol was 5.4, so stimulation test
done, and results within normal limits.
#Left submandibular and anterior cervical tenderness and
adenopathy - no tonsillar abscess appreciated.
#Possible immunodeficiency, recurrent infections - reviewed
outpatient immunologist notes, testing. She will f/u with Dr
___ obtain a second opinion
#Headache
She has chronic migraines. Continue Toradol and Triptan
#Constipation
She has chronic constipation. Continue bowel meds
# Back pain, fatigue: Unclear if these are a part of her pelvic
pain process or separate. Can consider outpatient rheumatology
evaluation.
#GERD/NSAID risk
- Continue Ranitidine since NSAID is parenteral
#Depression
--wellbutrin, Zoloft,clonazepam continued. Patient endorsed
significant amounts of stress in her life, history of trauma in
distant past. She has discussed her mood d/o with PCP and also
has a psychiatrist. | 303 | 298 |
10009021-DS-18 | 27,368,161 | Dear Mr. ___,
You were admitted for IV treatment of your lip and chin
ulcer/mass. You were evaluated by dermatology and infectious
disease, and your ulcer/mass was thought to be a herpes lesion
with a bacterial (MRSA) infection. The mass was biopsied and
sent for pathology, which is still pending. You were treated
for MRSA with vancomycin, and HSV was treated at first with
acyclovir, then switched to foscarnet. You will continue
vancomycin through ___ and foscarnet for ___ weeks (exact
duration to be determined at outpatient visit).
You will need frequent laboratory monitoring of your kidney
function while on the foscarnet. Please go to the ___ clinic
lab on ___ between ___ AM (before your morning vancomycin
infusion) for your lab draw.
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team | ___ M with HIV (on HAART; ___ CD4+: 136, CD4%: 5, VL: <75)
and recently diagnosed hepatitis C with a R lip/chin lesion
rapidly increasing in size, positive for MRSA and resistant to
acyclovir, bactrim, keflex, minocycline.
Patient with HIV (CD4 119, VL 34 on this admission) on HAART
presented with rapidly enlarging lip/chin lesion/mass over past
three months, resistant to bactrim, acyclovir, keflex. It was
positive for MRSA without improvement on minocycline. He was
admitted for IV vanc, and evaluated by derm and ID and felt to
be HSV (possibly verrucous HSV per derm) vs malignancy with MRSA
superinfection. He was treated with IV vanc and initially
high-dose acyclovir then switched to foscarnet per ID and derm
consult recs. Viral culture of lesion was positive for HSV-2.
Biopsy of the satellite newer lesion is pending at discharge. A
PICC line was placed for IV abx with home ___. He is to continue
foscarnet for ___ weeks (exact duration to be determined on
outpatient followup) with 500cc normal saline infusion prior to
each foscarnet infusion. Electrolytes and renal function to be
checked twice weekly while on foscarnet. Vancomycin was
increased from 1g Q12H dosing to 1750mg Q12H due to low vanc
trough. He is to continue vancomycin through ___ with trough to
be checked on ___. Follow up with PCP ___, and
___ clinic were scheduled at discharge.
# HIV Infection: Checked with CD4 count ___.
Continued on atazanavir, ritonavir, abacavir-lamivudine, Bactrim
ppx.
# Hepatitis C: Recently diagnosed with LFTs elevated, which were
stable/downtrending at discharge. Previously referred to Dr.
___ with no appointments made. He will follow up with
___ clinic for current lip/chin lesion and will subsequently be
scheduled for followup for his hepatitis C. | 137 | 295 |
19979469-DS-16 | 20,045,455 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted with gastrointestinal bleeding and you
received blood transfusions which you tolerated well. You were
also seen by the gastroenterology specialists who performed an
upper endoscopy and colonoscopy. They found areas of
inflammation in the esophagus, stomach and small intestine, but
no sites of active bleeding. At this time, you do not require
further gastrointestional follow-up or imaging studies. It is
important that you stop taking medications that may lead to
bleeding, such as Motrin (ibuprofen) and aspirin. You should
also refrain from ingesting hydrogen peroxide solution as you
were recently doing. You will also need to have blood work done
on ___, to check your hematocrit level (blood level).
If in the future you notice bleeding, weakness/dizziness,
shortness of breath, or chest pain, please call your PCP or come
to the emergency room. | Mr. ___ is a ___ yo male with history of Hepatitis C c/b
cirrhosis with prior hx varices, obstructive jaundice,
unresectable stage IIB ampullary adenocarcinoma s/p operative
resection ___, ERCP and stent placement who presents with
lightheadedness for 2 days in the setting of hematochezia and
significant hematocrit drop.
# GI BLEED: He presented with 2 days of dark bloody stools, and
his Hct dropped from baseline of 30 to 21. This is likely lower
GI given presence of red/maroon colored stools, however source
not entirely clear. Differential included upper source from
local extension of tumor vs. lower source (diverticular, AV
malformation, ischemic). He received 3 units of pRBCs on
admission to the ICU, and his hematocrit remained stable
thereafter. He was treated with IV protonix, and received an
upper endoscopy and colonoscopy which showed esophagitis,
gastritis and duodenitis with duodenal erosions. There were no
active sites of bleeding. At the time of discharge, his
hematocrit was stable at 26.6 and he was started on daily PPI.
There was no need for GI follow-up or further work-up.
# Lightheadedness: He presented with lightheadedness, likely
orthostatic dizziness due to his GIB. His blood pressures
remained stable after his transfusions, however his home
amlodipine was held. At the time of discharge, he did not have
lightheadedness, and his hematocrit was stable. His Amlodipine
was held on discharge, with the instructions that this could be
restarted after being seen by his PCP for HCT check and vitals.
# Ampullary Adenocarcinoma, stage IIB: s/p operative resection
___ however, stage IIB ampullary found intraoperatively to
have unresectable disease secondary to regional lymph node
metastases. Hx obstructive jaundice s/p ERCP and stent
placement. He was previously on capecitabine, however this was
held during this admission given his GI bleed.
# Hepatitis C / Cirrhosis: MELD score 6. Child's ___ class A.
Reported hx of varices, however EGD ___ neg for varices. No
ascites was appreciated on exam, so there was no need for
diuresis or SBP prophylaxis. His mental status was clear and
there was no concern for encephalopathy.
# MOOD: stable, continued his home fluoxetine | 158 | 356 |
11579639-DS-13 | 27,723,733 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted due to oxygen desaturations
while walking and concern for fluid overload. While you were in
the hospital, you were given medications to get rid of excess
fluid and your heart was found to have normal squeezing function
(Left Ventricular Ejection Fraction) but we suspect it had
abnormal relaxation (diastolic dysfunction). To prevent extra
fluid build up, you were sent home on a medication called Lasix
(Furosemide). Please take one 20mg pill every other day .
It will be important to measure your weight every morning (after
urinating, before eating) and record these numbers. If they
change more than 3lb in 24 hours, this can be a sign of fluid
overload and you should call your doctor's office.
Please follow up with your primary care doctor and cardiologist
as scheduled below. The ___ service will draw labs on
___.
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old lady with PMH significant for HTN,
HLD, CAD s/p RCA stenting and DES to LAD, type II DM and
hypothyroidism who presents with asymptomatic desaturation with
activity.
#) Acute Decompensation of Diastolid Congestive Heart Failure
Her desaturations down to 79% in clinic with ambulation are
likely secondary to pulmonary edema. An ECHO during this
hospitalization showed a LVEF of 50-55%, without specific
comment on diastolic dysfunction-- however this is highly
suspected given clinical history and improvement of
desaturations with lasix. She was diuresed and established on a
regimen of PO 20mg lasix every other day prior to discharge.
Her ambulatory saturations improved to 89-95% on room air with
extensive walking. Of note, she has never been symptomatic
during her desaturations (noted by home ___ initially) and
remains coherent/without signs of hypoxia.
#) ___
Most recent Cr in system was 1.1 in ___. It was 1.6 on
presentation, and increased to a peak of 2.0 with diuresis, at
which point her PO 20mg lasix daily was changed to every other
day. It was 1.9 on discharge. Lisinopril was continued.
#) Chronic issues:
- HTN: continued home amlodipine 5mg, metoprolol tartrate 25mg
BID
- HLD: continue home pravastatin 80mg q day
- CAD: continue home aspirin 81mg
- GERD: continue home omeprazole 20mg q day
- hypothyroidism: continue home levothyroxine 100mg q day
- dementia: continue home donepezil 5mg q HS and memantine 10mg
BID
#) Contact: Daughter ___ ___
==================================
TRANSITIONAL ISSUES
==================================
Ms. ___ is a ___ yo lady with PMH significant for HTN, HLN,
CAD s/p RCA stenting and DES to LAD, type II DM and
hypothyroidism who presented with signs of heart failure and
desaturations with ambulation.
[ ] Chem 7 checked within one week ___ to draw on ___ and
fax to Dr. ___, as she was started on lasix 20mg
PO every other day.
[ ] Heart Failure: Likely due to diastolic dysfunction given EF
of 50-55%. Started on lasix.
[ ] Desaturations while ambulating: After diuresis, she had O2
sats between 89-95% while ambulating. Asymptomatic, no shortness
of breath or limitations on ambulation distance.
[ ] Renal dysfunction: Baseline is unclear (one measurement of
1.1 recently, otherwise has been ~1.5. Her Cr was 1.9 on
discharge, and stable x 3 days on the PO lasix 20mg every other
day regimen.
[ ] Dry weight 59.1 kg
[ ] Alzheimer's Disease: Prior to her knee surgery
hospitalization/rehab she was living alone. She will go to live
her her daughter now. | 163 | 409 |
18065731-DS-23 | 29,649,612 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were feeling dizzy
WHAT HAPPENED IN THE HOSPITAL?
- You had imaging of your brain that did not show any changes
that would cause your dizziness
- You were given a collar to wear at night to help with
dizziness
- You were started on a medication, Meclizine, that should help
with your dizziness
WHAT SHOULD YOU DO AT HOME?
- Make sure you continue drinking lots of water and fluids. We
think that some of your dizziness may be from dehydration
- Go to your appointment with Dr. ___ on ___.
- Continue taking medications
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | Patient Summary:
==================
Mr. ___ is a ___ yo M h/o renal cell carcinoma Stage IV (s/p
right nephrectomy and partial hepatectomy), DVT, cerebral palsy,
and hypercholesterolemia who presented to the ED with one day of
vertigo and weakness, and headache. He had a negative
___ test and had CTA head/neck, MRI/MRA of brain that
were negative for acute pathology. Neuro consulted and thought
pathology may be related to cervicogenic dizziness/headache and
started symptomatic treatment with Compazine and Meclizine given
no acute intracranial pathology and symptoms consistent with
previous episodes. Plan for outpatient Neurology follow up with
Dr. ___ on ___.
Active ISSUES
=============
#Dizziness/Vertigo
#Headache
Presented with vertigo symptoms/headache and shortness of
breath. Had CTA head/neck and MRI/MRA of brain that were
negative for acute intracranial processes. Negative ___
test. Some element of orthostatic hypotension present and
received IVF. Known h/o of DJD in cervical spine and admission
physical exam reproducing vertigo on palpation of SCM are
consistent with past determination of "cervicogenic dizziness"
by outpatient neurologist. Questionable polypharmacy though
patients symptoms did not improve through a trial of holding
home depression/anxiety medication. Neurology consulted and
recommended a soft collar at night and started on meclizine and
Compazine PRN for dizziness/headaches, although patient did not
feel that Compazine was helping so was discharged on meclizine
alone for dizziness. Plan for outpatient follow up with Dr.
___ as below.
#Leukocytosis- On day of discharge, patient had elevated WBC in
the setting of mild generalized abdominal pain and an episode of
diarrhea. No new cough, sputum production and negative UA for
UTI. No risk factors for C.diff such as immune suppression or
recent antibiotic use. Likely a viral gastrointestinal process.
Please monitor symptoms at rehab.
Chronic Issues
==============
#Cerebral palsy, spastic paresis: Patient not on Baclofen and
did not require treatment during this hospitalization.
#Renal Cell Carcinoma Stage IV with liver metastases, s/p
resections:
MRI kidney scheduled for ___. Brain imaging without evidence
of metastasis.
#Depression/anxiety: Continued on duloxetine, buspirone,
lamictal.
#h/o DVT- Concern for PE on admission given shortness of breath
but with negative CTA chest. Was continued on Xalrelto.
TRANSITIONAL ISSUES:
===========================
- New Meds: Meclizine 12.5mg TID
- Stopped/Held Meds: None
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed:
- Incidental Findings:
1) stable 7 mm focus of abnormal enhancement at the right
vertex favored to represent a vascular malformation
2) Stable 3 mm right middle lobe nodule in the lung
3) Stable size of a 1.6 x 1.5 cm soft tissue nodule along the
superior aspect of the right nephrectomy bed.
[] follow up with outpatient Neurologist, Dr. ___, ___
01:30p.
[] Evaluate patient's diarrhea symptoms. If worsening, consider
repeat CBC to evaluate WBC. Low concern for C. Diff
*) CODE STATUS: Full (presumed)
*) CONTACT:
Health care proxy chosen: Yes
Name of health care proxy: ___
Phone number: ___ | 125 | 463 |
12030982-DS-3 | 27,087,844 | Dear Ms. ___,
You were admitted to the ___
after a blood clot was found in your abdomen. You had a
procedure that removed the clot which you tolerated well. You
were also started on blood thinning medications called "Lovenox"
and "Coumadin". Please continue to take these medications as
prescribed and stop the lovenox once your INR is therapeutic on
the Coumadin. You are being discharged to rehab now to continue
your recovery. Please monitor your INR carefully and adjust the
dosage of medication as ordered. Make sure to keep all follow up
appointments.
It was a pleasure taking care of you, we wish you all the best!
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. | Ms. ___ is a ___ year old female who was recently
discharged on ___ after laparoscopic appendectomy for
appendiceal polyp. She presented to an outside hospital with
complaints of abdominal pain. She underwent a CT scan where a
SMV thrombus was identified and she was sequentially transferred
to ___ for further management.
#SMV thrombus: Patient was started on a heparin drip that was
titrated based on every 6 hour PTT results. The patient reported
that her abdominal pain improved with initiation of heparin.
However, the abdominal pain progressively got worse. So the
heparin drip was temporarily stopped when she was brought to
interventional radiology and was restarted while in the ICU.
Once out of the ICU, she was transitioned to therapeutic Lovenox
(160mg SC BID) and a Coumadin bridge.
=================================
FICU COURSE: ___ - ___
=================================
# SMV thrombosis, s/p catheter-guided thrombolysis:
Found to have stable SMV thrombosis on CT AP w/contrast, arrived
to the FICU post-TIPS approach lysis catheter placement into SMV
clot. No compromised bowel noted on CT. Relevant risk factors
for SMV thrombosis include recent surgery and history of PE;
clinical picture not suggestive of infection/inflammation in the
abdomen, no known malignancy, and no obvious anatomic
compression. Given recurrent ___ likely warrant a
hypercoagulability workup in OP setting. Patient was started on
tPA and heparin gtt while in the ICU, ultimately discontinued
after SMV thrombectomy ___. Prior to transfer, her abdominal
pain had resolved.
# Fever--resolved
# Hematuria--resolved
# C/f CAUTI: neg UCx
New hematuria and intermediate dirty UA, CRS agreed with
starting Cipro given PCN allergy. Hematuria iso heparin and tPA,
grossly resolved by AM. UCx returned negative. Continued on
Ciprofloxacin x5 days per Colorectal Surgery.
# Intubation:
# Sedation:
# Stridor
Sedated for two days given 2-step procedure. Extubated ___ (per
___ and CRS) and weaned to room air. Developed concern for
stridor, however not clearly volume overloaded on exam. Gases
suggest no oxygenation issues; increased PEEP given body
habitus; chronic retention due to possible obesity
hypoventilation. Known OSA. Received one dose of 20mg IV Lasix
for optimization, Racemic epi, and Decadron x1 with improvement
in symptoms. Ultimately weaned to RA prior to transfer.
# HTN: Did not require pressors during her stay in the ICU. Was
continued on her home Losartan. Her home Atenolol was converted
to IV Metoprolol while NPO - ultimately restarted prior to her
transfer to the floor.
=================================
Patient transferred back to floor on ___..
#s/p TIPS: Patient mental status remained clear once on the
floor, interventional radiology has a concern for encephalopathy
so the patient will follow up with hepatology as well as
interventional radiology. The patient had a CTA/CTV post TIPS
and will repeat a CTA for monitoring.
#Hemoptysis: patient had one episode of hemoptysis, chest xray
done that was unremarkable. Will need to follow up with PCP for
possible bronch. | 264 | 459 |
18043576-DS-22 | 27,350,436 | You were admitted at ___ for difficulty breathing and it
turned out you were having wheezing. Your wheezing improved
with breathing treatments and prednisone, treatments that you
will continue at your rehab.
You voiced a lot of frustration over your ongoing medical
treatments, and, in discussion with your family, you decided to
be a DNR/DNI. If you continue to want to focus on comfort and
minmize treatment, I would recommend that you seek palliative
care services at your rehab, and consider not returning to the
hospital. | Assessment and plan: ___ with multiple medical problems
including recurrent CVA, Htn, DM with recent admission for
septic shock, CVA, seizure and GI bleed, admitted from rehab
with respiratory distress and hypoxemia.
# Bronchospasm: She had significant wheezing on exam consistent
with "cardiac asthma" or wheezing triggered by her CHF. She was
started on prednisone and standing bronchodilators and improved
dramatically. She should finish one additional day of
prednisone at 40 mg on ___ and then taper by 10 mg every two
days. She will be discharged on standing nebulizers, but,
these, too should be tapered when she improves fully.
# Acute on chronic diastolic heart failure:
BNP was 11K on arrival. CXR showed fullness in pulmonary
vessels. She received IV lasix, but when she started to refuse
lab tests and IV she was put back on oral lasix. Her weight on
discharge was 75.4 kg.
# Cough: She continued to complain of cough despite resolution
of her wheezing and diuresis. NO pneumonia on CXR. She
responded well to dextromethorphan.
# H/O recurrent CVA: Continue aspirin
# Seizures: ON lacosamide, since having seizures last
hospitalization. Has f/u with neurology.
# Delirium: She was delirious during the hospitalization, but
improved significantly. She was mostly oriented and could
describe her symptoms well, but would easily get frustrated with
more formal mini mental status testing.
# Anemia:
Improved from prior admission.
# CKD stage III:
At baseline. Renally dose medications.
# DM2, poorly controlled, complicated.
Required additional insulin given that she was receiving
prednisone. Will be discharge on glargine as well as a sliding
scale.
# HTN:
___ need to continue to uptitrate anti-hypertensives as they
were doing at rehab prior to her hospitalization, as blood
pressures were elevated here during her hospital stay (BPs in
160s, so her amlodipine was uptitrated).
# Weakness: Patient refused to participate in strength testing,
but per RNs she requires two person assist to get from bed to
chair. Left sided weakness as a result of her CVA was noted in
her last admission. She was frequently incontinent of urine
# Breast Cancer: Letrozole held during last admission as a
result of her CVA; depending on her goals of care, re-initiation
of this should be reconsidered.
# Hypothyroidism: ON synthroid
# Goals of Care: Patient frequently refused blood draws, IVs,
stating that she was "tired of all of it". I discussed this
with her and her son (now her health care proxy) and husband
(alternate health care proxy). She clearly stated that she did
not wish to be resusciated and intubated, and was made a
DNR/DNI. Given her frustration and reluctance to undergo
medical treatments she and her family should continue be engaged
in conversations regarding her goals of care. IF she is to
deteriorate at rehab, consultation with a palliative care
service can be considered. | 89 | 496 |
19454978-DS-22 | 26,537,547 | Dear Ms ___,
It was a pleasure taking care of you at the ___
___. You were admitted for fever and
confusion. You were found to have bacteria in your blood and
your urine. You will need a 14 day course of IV antibiotics to
treat this infection. | ACTIVE ISSUES:
==============
# Bacterial UTI and bacteremia causing septicemia and metabolic
encephalopathy: h/o complicated UTIs and GNR sepsis, most recent
episode of bacteremia in ___ of this year. Does have history of
cholangitis, but LFTs normal and abdominal scan was unrevealing
for any infectious source. Given her very complex resistant
organism including resistant pseudomonas she intially was
treated emperically with gentamycin. Cultures from ___
___ on ___ grew Klebsiella and E.coli in the blood, both
sensitive to gent as well as ceftriaxone (see lab results for
full sensis). On ___ patient was transitioned to IV CTX with
plan to complete a 14 day course of antibotics. At the time of
discharge, urine culture sensitivities were not back, but it was
felt that at this point, a UTI would have been appropriately
treated with >3 days of gentamycin. Urine culture eventually
grew enterobacter, sensitive to gentamycin (though not
ceftriaxone).
# Hypoxemia: Became hypoxic in ED after recieving 1 L NS bolus
and appeared volume up on exam. Does have history of PE, but CTA
in ED was negative for PE or other pulmonary process. She was
placed on standing 20mg PO lasix daily (which she takes "prn" at
home) with resolution of hypoxia.
# ___'s Disease: c/b recurrent cholangitis, on suppressive
antiboitics. On cefuroxime BID at home, but this was d/c in
setting of IV cefepime. Continued home ursodiol.
# Thrombocytopenia: chronic, likely in setting of liver
dysfunction.
# Benign Hypertension: continued home amlodipine and lasix.
Initially held home losartan for nomrotension on these other
agents,
# Osteoarthritis: patient on standing tramadol, lidocain patc,
tylenol, gabapentin and as needed liquid morphine. Also on bowel
regimen.
TRANSITIONAL ISSUES:
====================
# Losartan held in setting of normotension on amlodpine alone;
can be reinitated as OP as needed
# Plan for 2 weeks of IV CTX (day ___ for treatment of
UTI and bacteremia
# Plan to reinitiate prophylactic antibiotics (cefpodoxime) once
IV antibiotics are completed
Full Code
Contact: ___ (son) ___/ ___
(granddaughter) ___ | 47 | 329 |
12104929-DS-36 | 28,857,881 | Dear ___,
___ was a pleasure participating in your care. You were
admitted for lethargy and found to have a UTI. You were treated
with antibiotics and IV fluids with improvement in your symptoms
and energy level. You continue to be deconditioned and will go
to rehab to continue improving your strength.
.
Of note, your lasix was held because you have become dehydrated.
Please discuss with your gerontologist if you should restart
this medication in the future. | ASSESSMENT & PLAN: ___ year old woman with h/o HTN, recurrent
UTIs, SSS s/p pace___, falls, TIA on Plavix p/w lethargy.
# AMS/Lethargy: The pt presented with worsening ams and lethargy
in the setting of insufficiently treated UTI, and increasingly
cloudy urine. The pt had a UTI with ESBL attempted treatment
initially with cefpodoxime and then was macrobid (which is was
sensitive to) 2 days prior to admission. Upon admission the pt
was started on imipenem (ucx was zosyn sensitive but there is
inducible resistance) and treated with 1L NS x3days. His mental
status improve significantly and per her daughter she returned
to her baseline. She completed a total of 6 days of imipenem.
Lasix was held on discharge bc pt already has poor PO intake. In
addition, the pt should drink ensure shakes with protein daily
to TID as she tolerates, and she should be encouraged to eat and
drink as she is reluctant to do so on her own.
# UTI: As above, pt with ucx +ESBL ___, UCx now with GBS,
however while on macrobid, so urine might have been sterilized
of ecoli. F/u ucx from ___ grew GNR, but apparently was a
contaminated specimen. The pt completed a 6 day course of
imipenem and was straight cathed BID for a few days. For the 2
days prior to discharge the pt was urinating on her own and not
did not requiring further straight cath.
# Deconditioning: Pt appears deconditioned, difficulty with
standing and pivoting. Per ___, pt will require rehab.
# Urinary retention: followed by urology as outpt. Initially
straight cathed however voiding on her own by discharge.
Follow-up with urology as outpt as previously planned.
# Hx fall with back pain (prior to admission): no fx, tylenol
prn
# HTN/CAD: continued home plavix, held lasix, will continue to
hold lasix on dc as pt has poor po intake.
.
# Hypothyroidism: continued synthroid. TSH 8, free t4 wnl.
.
# CKD: Baseline creatinine is 1.0-1.3. stable
.
# Thoracic Aortic Aneurysm: Seen on admission CXR. Stable from
prior CXRs.
.
# Osteoporosis: continued home Vit D and Ca++. | 79 | 359 |
19769489-DS-2 | 28,712,243 | Dear Ms. ___,
It was a pleasure meeting you during your recent
hospitalization. You came to the hospital with confusion and
were found to have low sodium levels in your blood
(hyponatremia) and a urinary tract infection. Your sodium levels
improved with hydration; it is important that you keep hydrated
at home. You should have your sodium checked outpatient next
week and the results will be faxed to your PCP. For your UTI,
you will complete your course of antibiotics as an outpatient.
While in the hospital, our monitors showed that your heart rate
becomes slow intermittently and your oxygen saturations become
low when you sleep. The cardiology team saw you and your
diltiazem dose was decreased. Please take the first dose
tomorrow ___. The sleep team also saw you and recommend that
you have a sleep study outpatient; this is the way to diagnose
sleep apnea. In the meantime, you will be discharged with oxygen
to use at home while you sleep. We will send a nurse, physical
therapy, and speech therapy to visit you at home.
Sincerely,
Your ___ Team | Ms. ___ is a ___ with multiple sclerosis c/b chronic pain
and quadriplegia/spasticity with chronic indwelling baclofen
pump last revised ___ and suprapubic catheter who initially
presented to ___ ___ with confusion and
poor PO intake, transferred for hyponatremia and concern for
infection at the site of recent baclofen pump revision.
ACTIVE ISSUES
==============
# Toxic-metabolic encephalopathy:
Encephalopathy at presentation was likely multifactorial in the
setting of hyponatremia, suprapubic-catheter-associated UTI, and
postoperative narcotic use. Noncontrast head CT and CXR were
unremarkable at the outside hospital and there was no evidence
of intra-abdominal infection on outside hospital CT
abdomen/pelvis or RUQ US in the ___ ED. She was evaluated by
neurosurgery in the ___ ED, with low suspicion for local
infection at the site of her recently revised baclofen pump. Her
mental status improved to baseline after treatment of her UTI
and hyponatremia.
# Hyponatremia:
She presented to an outside hospital with Na of 115. Na improved
to 125 at the time of admission to ___ after 2L of IV NS at
the outside hospital. Hyponatremia is likely hypovolemic in
etiology in the context of nausea and poor oral intake. There
may be some degree of chronic hyponatremia per her report for
unclear reasons; indeed, Na was 128 on ___, though there are
no other measurements available.
# Intermittent hypoxia:
Patient was found to be intermittently hypoxic on monitors
during sleep. Hypoxia was consistently in the ___ but at
times decreased as low as ___. Most likely is a chronic issue
and is due to obstructive sleep apnea in the setting of her
multiple sclerosis and anatomy. She was seen by the sleep team
and will follow up outpatient for a sleep study for definitive
sleep apnea diagnosis. She was discharged with oxygen to wear at
night.
# Bradycardia:
Patient was noted to have intermittent episodes of bradycardia,
as low as 30. ECGs show junctional rhythm although patient is
generally in normal sinus rhythm. EP was consulted. Because she
is asymptomatic and bed-bound at baseline these episodes are low
risk and likely from autonomic dysfunction in setting of likely
OSA and MS. ___ her dose of diltiazem and set up
outpatient sleep follow up to treat her OSA.
# Suprapubic-catheter-associated UTI:
Although pyuria is difficult to interpret in the setting of
chronic indwelling urinary catheter, complicated UTI is presumed
in the setting of associated constitutional symptoms and mental
status changes. Treatment is indicated per current ___
guidelines. There was no evidence of SIRS/sepsis (tachycardia
only).
She was treated with ceftriaxone and later transitioned to
levofloxacin based on outside hospital sensitivity data of
citrobacter. After discharge, the patient called in to ___
complaining of diaphoresis but was afebrile. She felt this was a
side effect and asked to switch antibiotic agents. She was
switched to ciprofloxacin to complete her antibiotic course.
# Nausea:
Nausea at home was perhaps opioid-induced, given temporal
association with hydrocodone use and improvement following
transition to opioid-sparing analgesics. Nausea also may reflect
underlying catheter-associated UTI. There was low suspicion for
intraabdominal pathology in the setting of normal LFTs and
unrevealing CT abdomen/pelvis and RUQ US. Noncontrast head CT
was negative at the outside hospital, hence low suspicion for
centrally mediated nausea, at least due to large intracranial
mass. Her nausea resolved after discontinuation of opioids.
CHRONIC ISSUES
================
# Multiple sclerosis:
She is quadriplegic due to multiple sclerosis with chronic
indwelling baclofen pump and suprapubic catheter. According to
the neurosurgery consult note, she is not receiving intrathecal
baclofen yet post-op.
# Incidental radiographic findings:
Bilateral ovarian cysts and bulky uterus were noted on outside
hospital CT abdomen/pelvis, and IPMN was observed on admission
RUQ US.
# Hypertension:
She was mildly hypertensive to 150s-160s systolic on arrival.
Continued home diltiazem XR 240mg daily and valsartan 320mg
daily
# Noninsulin-dependent diabetes mellitus:
Hold home metformin in favor of Humalog insulin sliding scale.
# Gout:
Continued home allopurinol ___ daily.
TRANSITIONAL ISSUES
====================
- Obtain pelvic US in the outpatient setting for further
evaluation of ovarian cysts and bulky uterus
- Obtain MRCP in 6 months for further evaluation of IPMN | 178 | 665 |
10485315-DS-4 | 21,131,281 | You were admitted for shortness of breath and dyspnea on
exertion. This was related to your existing porcine mitral valve
replacement and your underlying severe COPD. Your Coumadin was
held and multiple studies were done to assess your valve and
whether this could be repaired by conventional means versus a
newer less invasive procedure. Extra fluid was removed from your
body using Lasix. Your shortness of breath improved and you
continued with your home inhalers. You were seen by the
Electrophysiology Team who adjusted your device to improve
filling time of blood in your heart. Your home inhalers were
restarted on ___. You resumed Coumadin on ___ and
because your INR was not therapeutic and you were at risk of a
stroke, you were continued on a Heparin drip and then bridged
back to a therapeutic INR level on Coumadin. You were seen by
the Cardiac Surgery Service and risk stratified given your
co-morbidities for the less invasive repair of your valve. Once
you were therapeutic with your INR you were discharged to home
with ___ services so that your Coumadin could be managed as it
was prior to admission. New ___ services were established for
you by Case Management since you were no longer on ___
___ prior to your admission to ___.
You eventually decided to pursue a mitral valve replacement
under less invasive means with the Structural Heart team. Many
of these studies were completed during your stay. The Structural
Team will be contacting Dr. ___ to discuss planning for your
new mitral valve replacement. Your procedure may be completed as
early as ___. ___ and Dr. ___ will be in contact with
you to plan for your procedure.
Continue all of your home medications, including your daily
Lasix and Coumadin. Your Carvedilol was discontinued and you
were started on a new medication called Toprol or Metoprolol
which helps your heart beat more effectively and also helps with
blood pressure. This has been sent to your pharmacy and can be
picked up on your way home from the hospital. Your home Lasix
dose of 20 mg Daily was increased to 40 mg Daily. A new
prescription for the 40 mg dose was sent to your pharmacy.
Your INR should continue to be monitored and you should take
your Coumadin as you had prior to your admission. Your PCP, ___.
___ continue to manage your INR. These checks can be
done once per week or as ordered by her office. Your first INR
check will be ___ since your INR ws checked prior to your
discharge from ___.
Continue to follow a low sodium diet (2 grams) and limit fluids
to 2 liters daily, you should include anything that melts at
room temperature (popsicles, jello, etc.). Weigh your self
daily. If your weight increases by ___ lbs. in ___ hours,
contact your Cardiologist as your Lasix may need to be adjusted
to prevent worsening fluid overload and admission to the
hospital. Contact your PCP if any symptoms worsen. | ___ year old man with a history of HFrEF (LVEF 40-45%), COPD (on
home O2), MVP/MR ___ bioMVR (___), TR ___ annuloplasty (___),
valvular AF, hypertension, dyslipidemia
who was transferred from ___ on ___ for evaluation for
MVR for severe mitral stenosis, being evaluated by structural
team for TMVR. He was initially followed by the Heart Failure
Service and transitioned to the ___ NP service on
___. Structural Heart service continued to follow him during
this time. Given his co-morbidities and his frail status, he had
been seen by Geriatrics who weighed in on his risk for
intervention to repair his mitral valve which was felt to be
causing some, but not all of his symptoms. Given his severe
COPD, he will continue to have symptoms of shortness of breath
and dyspnea on exertion. His Coumadin was held while his
testing was completed in the event he moved forward with an
intervention during the admission. He was maintained on a
heparin drip during that time given his history of AFIB and
porcine valve replacement. He restarted Coumadin on ___ and
his INR responded appropriately after one 5 mg dose of Coumadin
on ___ and 7.5 mg on ___. He was given 2 mg on ___ after a
repeat INR was 1.9. His hospice services were terminated by the
family prior to his admission at his daughter's request. His
PCP ___ continue to manage his INR at discharge (weekly INR
checks recommended) and ___ Services will be coordinated by Case
Management given he is no longer on hospice services at this
time.
A number of family meetings occurred where risks and benefits of
intervention with a new minimally invasive valve procedure could
be performed and provide some benefit and relief of his
symptoms. Initially, the daughter and patient declined to move
forward. On ___, the patient was again seen by Dr. ___
the ___ Service and the patient indicated he was
interested in the procedure if it could benefit his symptoms. He
is sedentary at home, and primarily uses a computer. His
daughter works during the day. The current plan is for the
Structural Team to coordinate his planned procedure with his
cardiologist, Dr. ___. Much of the preoperative workup
(imaging studies) were done while he was an in-patient here.
#) DYSPNEA ON EXERTION: Likely some contribution from severe
mitral stenosis and also his underlying lung disease (on
nighttime O2 @ home) and ongoing smoking. Management of these
issues as below. It is unknown/unclear how much incremental
benefit a mitral valve intervention would have in terms of his
dyspnea given his coexistant lung disease, however, the
Structural Team does feel there will be incremental benefit.
Further discussion will continue with his cardiologist. He was
seen by the Cardiac Surgery team and deemed high risk for
conventional surgery.
# DYSPNEA ON EXERTION, MV STENOSIS MVA 0.4 cm2 by TTE
(___): Likely some contribution from severe mitral stenosis
and also his underlying lung disease (on nighttime O2 @ home)
and ongoing smoking. Management of these issues as below. It is
unknown/unclear how much incremental benefit a mitral valve
intervention would have in terms of his dyspnea given his
co-existant lung disease.
- Family meeting held ___ and ___. Initially
felt he would not have TMVR but has since indicated he would
move forward. Dr. ___ to review imaging studies with Dr.
___. Will possibly have procedure ___
- Therapeutic INR of 2.1 today. Managed by PCP, next draw ___
- Lasix was restarted on ___ at a 40 mg dose. He was
closely monitored with dietary control on a low 2 gram sodium
diet and a 2 liter daily fluid restriction with daily weights.
- Carvedilol discontinued earlier in his stay, escripted Toprol
to his pharmacy
- Continue 2 gram low sodium diet, 2 liter fluid restriction,
daily weights
- Dr. ___ will coordinate plan with Dr. ___
#) COPD/TOBACCO USE: On nighttime O2 at home. Actively smoking.
Currently on maintenance prednisone.
- Continue bronchodilators
- Continue maintenance prednisone
- Smoking cessation was counseled. He did not utilize a nicoderm
patch or gum while here.
#) ATRIAL FIBRILLATION: Valvular. Rate controlled currently.
His Carvedilol was discontinued and he was started on Metoprolol
Tartrate 12.5 mg every 6 hours and ordered for 50 mg Toprol at
the time of discharge. He was bridged to a therapeutic INR as
described above using heparin.
He worked with Physical Therapy and was ambulatory with
supervision (see ___ note for further information). He should
continue to be out of bed for meals and ambulate as tolerated at
home. He was voiding without difficulty and moving his bowels as
normal. His LFTs were elevated and was seen to have hepatic
congestion, and these values improved somewhat during his stay. | 500 | 792 |
15388421-DS-23 | 28,479,172 | Mr. ___,
You were admitted to the ___
for shortness of breath and coughing. You were found to have a
large collection of fluid in your left lung. All of our usual
imaging and laboratory testing was reassuring, however we did
not have a satisfactory answer for why you had this fluid. We
drained this fluid which provided you with some symptomatic
relief, however the fluid seemed to persist and possibly
reaccumulate. Our pathologists further reviewed the fluid which
showed that the fluid "effusion" had cells consistent with your
prior cancer and indicated to us that you likely have recurrence
of your esophageal cancer. At this time Dr. ___ there was
no surgery that could be performed at this time as you had
metastatic disease and would only create potential surgical
complications rather than provide any benefit. Dr. ___
___ further imaging to look for presence of cancer
elsewhere in your body. We did find evidence of tumor in some of
your lymph nodes and soft tissues of your abdomen and pelvis.
While this was not the news we wanted to hear, it did not
surprise us as finding cancer cells in the fluid of the lungs is
evidence of metastatic disease. What is important to note is
that this does NOT change any of our management plan.
To alleviate your symptoms of shortness of breath, as this
fluid is likely to recur, we had our Interventional Pulmonary
team place a catheter in the left lung called a Pleur-Ex tube.
This can be uncapped and fluid can be removed whenever you feel
symptoms of shortness of breath and/or coughing. You were
discharged to ___ as it is very important to try to
regain strength so that when you follow up with your primary
care physician and Dr. ___ can discuss all options
available to you including chemotherapy. Our nutrition team was
consulted to ensure that your tube feeds are given at the
appropriate rate. As your family requested to know the details
the goal is: Nepro tube feeds. Rate of 80cc/hr. Supplement diet
with ensure and protein with meals.
Please note the following medication changes:
Additionally, while admitted we exchanged your atenolol for
metoprolol for the benefit of long term safety. During this
transition you experienced an episode of your afib which we
treated. At the time of your discharge your heart rates were
normal again.
You should no longer take your sodium bicarbonate tablets.
It was a pleasure meeting you and your family, taking part in
your care, and we wish you the best.
-Drs. ___ and the entire ___
___ ___ Team | ___ year old man with a history of esophageal cancer (T3N2Mx) s/p
neo-adjuvant chemoradiation and s/p esophagogastrectomy on
___, DM2, CAD s/p CABG, post-op atrial fibrillation on
rivaroxaban, presenting with dyspnea and found to have large
left pleural effusion with pleural cytology showing malignancy
c/w prior cancer.
#Dyspnea
#Pleural effusion
Patient with chronic nonproductive cough following prolonged
complicated hospitalization for partial esophagogastrectomy and
drainage of previous right pleural effusion, who presented on
this hospitalization with subacute onset of dyspnea and
worsening exercise/activity tolerance.
CXR performed at ___ showing large effusion.
Transferred to ___ for further management. Initially
felt likely to hypoalbuminemia as no other objective evidence of
heart failure. Subsequent pleural fluid analysis (drained
___ pseudoexudate. Cytology returned cells consistent
with malignancy which when specifically compared to prior sample
with known esophageal cancer were identical. This represented
persistence of esophageal cancer. Interventional pulmonary team
placed left pleur-ex drainage system ___ without complication.
#Metastatic Esophageal cancer
History of esophageal cancer (T3N2Mx) s/p neo-adjuvant
chemoradiation and s/p partial esophagogastrectomy on ___.
Since procedure per patient and family patient has suffered many
set backs, emotionally and physically. Has never fully recovered
to functional status pre surgery. Now with recurrent malignant
pleural effusion with cytology consistent with prior malignancy
which represents persistence of metastatic microscopic disease.
Staging CT-Ab/Pelvis showing retroperitoneal infiltrative soft
tissue density and fat stranding surrounding the celiac and SMA
axis, with diffuse narrowing of the proximal SMA, although the
SMA remains patent. Additionally, some nonspecific bladder wall
thickening which was likely related to non distended bladder,
but could represent a drop metastasis. Bladder U/S was not
highly suspicious for malignancy, but non urgent follow up was
recommended with either cystoscopy or MR-U.
Will have close follow up with Dr. ___ previously had
treated cancer at time of initial diagnosis.
#Atrial fibrillation
On admission, pt on Atenolol. Transitioned to Metoprolol and
was previously controlled on lower dose. However, experienced
episode of Afib w/RVR ___ with mild flash edema. Uptitrated
metoprolol and converted back to sinus rhythm.
At time of discharge remained on Xarelto. Metoprolol Succinate
150mg daily at time of d/c.
#Orthostatic Hypotension
Likely ___ deconditioning with likely component of
hypoalbuminemia and capillary leak. Less likely dysautonomia
related to prior chemotherapy as carboplatin. Pt was not
symptomatic with orthostasis and predominant VS abnormality was
increase in HR. Pressures were refractory to albumin boluses. We
increased tube feeding rates after consultation with nutrition
and have plan for close follow up. Deferred initiation of
midodrine, but could consider if became symptomatic.
#Failure to thrive
Pt with lack of functional recovery s/p esophagectomy. Found to
be significantly hypoalbuminemic. Multiple contributing factors
included TF not being at goal rate previously. Nutrition was
consulted who recommended increasing rate (see below for
summary). Additionally, there is a component of ageusia,
declining his mirtazapine and now recurrence of malignancy.
Liberalized diet to encourage PO and made any adjustments to
insulin sliding scale as needed. Discussion with daughter and pt
about role for mirtazapine and started taking on a regular
basis. At time of d/c still significant difficulty with PO
intake.
-Nutrition Recommendations: Glucerna 1.5 Cal Full strength;
85cc/hr. 6pm-12pm. Residual Check: q4h Hold feeding for residual
>= : 200 ml
Flush w/ 100 ml water q4h.
-Recommendations for Nepro: 80cc/hr. Cycle over 16 hours.
Residual Check: q4h Hold feeding for residual >= : 200 ml Flush
w/ 100 ml water q4h. Continue supplementing with ensure with
meals TID and protein.
#Pericardial Effusion
Very small on CT. Confirmed on Echo ___. Resolved JVP. No
tamponade physiology clinically or echocardiographically. Stable
on other imaging performed on admission.
================
CHRONIC ISSUES:
================
#CAD, HTN, HLD
S/p CABG ___. As above, transitioned to Metoprolol Succinate
150mg daily. Otherwise continued on home ASA and pravastatin.
#Diabetes mellitus type 2
Insulin: glargine 24U QHS (substituted for levemir) with SSI
#GERD
-Pantoprazole 40 mg PO Q12H (from home omeprazole 20mg BID)
#Asthma/Reactive Airway
No signs of asthma exacerbation on admission. Cont home meds.
*****TRANSITIONAL ISSUES*****
# CONTACT/HCP: Wife- ___ number: ___
# CODE STATUS: full code
# Held Lasix at time of discharge. If short of breath would
first drain pleur-ex, if persistent would obtain CXR, can trial
small dose of Lasix (prior home dose 40mg daily) and if concerns
for pleur-ex contact interventional pulmonology at ___.
# Non urgent urology evaluation of bladder-cystoscopy vs MRU
# Changed Atenolol to Metoprolol Succinate 150mg daily
# Discontinued sodium bicarb
# Cont ___ and increasing PO intake as tolerated
# Nepro tube feeding recommendations for Nepro (converted from
Glucerna 1.5 as inpatient) 80cc/hr cycled over 16 hours with
residual check q4h Hold feeding for residual >= : 200 ml Flush
w/ 100 ml water q4h. Continue supplementing with ensure with
meals TID and protein.
# Note disease burden surrounding SMA and should consider
ischemic bowel if develops abdominal pain
#Recommend follow-up CT chest in 3 months per previous
recommendation.
#Pt has had ongoing orthostasis while admitted which we expect
will improve with ongoing nutrition and mobilization
#J tube evaluated per ___ and is in correct place and functional
#Can consider adding daytime stimulant if persistent lethargy.
Tolerated AM 2.5mg Ritalin x1 while inpatient
___ increase Mirtazapine to 45mg if issues with sleeping
___ PleurX Orders
Standard Pleurx orders: Left
1. Please drain Pleurx every other day (___) and
symptomatically
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. Keep a daily log of drainage amount and color, have the
patient bring it with him to his appointment.
6. You may shower with an occlusive dressing
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
Pleurex catheter sutures to be removed when seen in clinic ___
days post PleurX placement.
Please call ___ if there are any questions
#Discharge bed weight: 80.5 kg, last standing weight: 74.6kg | 442 | 965 |
13475033-DS-66 | 20,643,042 | Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with chest
pain, which was probably related to your coronary artery diseae
and also your gastroesophageal reflux. You underwent a cardiac
catherization on ___, and had a stent (drug-eluting) placed
in one of your arteries (the right coronary artery). Per Dr.
___ will need to remain on aspirin and clopiodogrel
(Plavix) for the rest of your life.
We did not change any of your medications. Please see attached
for a list of your medications. See below for information
regarding your follow-up appointments.
Wishing you all the best!
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Patient is a ___ y/o M PMH significant for CAD s/p PCI to RCA,
ESRD s/p renal transplant with rejection on hemodialysis MWF
with recent admission for chest pain/hyperkalemia a month ago,
who presents with onset of chest pain yesterday morning during
dialysis, with planned cath already scheduled for ___. | 116 | 50 |
11970424-DS-7 | 24,970,283 | Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
-Viral infection of tissues around brain called meningitis
WHAT HAPPENED IN THE HOSPITAL?
==============================
-You are given antibiotics and antivirals
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | SUMMARY STATEMENT
=================
___ without significant PMH presenting with headache and AMS,
transferred from ___ with symptoms and LP findings
concerning for viral meningitis/meningoencephalitis.
TRANSITIONAL ISSUES
===================
[] please follow up on patient's headache, mental status, and
vision changes to ensure these resolve
[] Incidentally found sub 6 mm pulmonary nodules. Patient has
possible TB exposure. Nodules require follow up CT in 12 months
[] Microscopic hematuria noted while inpatient. Please repeat UA
at follow-up appointment and consider workup for microscopic
hematuria if persistent.
[] Incidentally found possible 1-2 mm left ACA aneurysm based on
CT head from ___ prior to transfer. Neurosurgery
follow-up ___ weeks post discharge. Patient instructed to
schedule with Dr. ___ in ___ weeks for continued management
of aneurysm. Please call ___ to schedule this
appointment if needed.
ACTIVE ISSUES
=============
#viral meningitis/encephalitis
#pleocytosis w/lymphocytic predominance
CSF w/ lymphocytic pleocytosis, high protein, low glucose c/w
viral process, she has risk/exposure as high school ___.
Confusion and delayed response to simple questions increased
suspicion of parenchymal involvement. CSF negative for HSV.
Arbovirus serum serologies were negative. Followed by ID consult
team, who recommended a 2 week course of acyclovir. She was
treated with 2 week course of IV acyclovir which she received
inpatient. The patient's HA and photophobia improved and she had
no more episodes of confusion; vitals stable throughout
admission. She should follow up with her new PCP ___ 1 week
of discharge, scheduled for ___.
#Pulmonary nodules
CT neck with incidental finding of sub-6 mm pulmonary nodules
within the right upper lobe.
Follow-up CT of the chest is recommended in 12 months.
#Small left ACA aneurysm
CTA head with incidental finding of 1-2mm outpouching arising
from the left ACA may represent small anterior communicating
artery infundibulum or possibly small aneurysm. Reviewed
informally with neurosurgery who recommended outpatient
follow-up in ___ weeks post discharge.
# Microscopic hematuria: Microscopic hematuria demonstrated on
UA x2 (on ___ and ___. UCx was ordered but not processed
given absence of pyuria. She has no symptoms of UTI. UA should
be repeated as outpatient and, if persistent microscopic
hematuria, pt should be referred to urology for further
evaluation. | 99 | 339 |
13409093-DS-9 | 23,548,037 | Dear ___,
___ were admitted for shortness of breath and fluid collection
around your lungs, called a pleural effusion. While ___ were
here, ___ had a large amount of fluid removed from around your
lungs to help ___ breath better. ___ also had a port placed in
anticipation of starting chemotherapy with Navelbine. However,
___ had worsening shortness of breath, which was felt to be due
to many reasons, but a large part due to spread of cancer into
the small airways in your lungs. At this time ___ are not
getting further chemotherapy. Since ___ have had multiple
pleural effusions that have a tendency to recollect after being
drained, ___ had a procedure to help prevent fluid from
recollecting in the same space ("pleurodesis"). After that
procedure, we monitored ___ to make sure that ___ remained
stable. ___ were seen by many other teams to help with your
symptoms, including pulmonary and palliative care. The pulmonary
team recomended steroids, and ___ will be on a taper of steroids
for the next 2 weeks. We also started ___ on nebulizers.
Finally, we started ___ on morphine. This medication helps with
shortness of breath. ___ found that it helped your symptoms.
___ are being discharged to a rehab facility. ___ will continue
to receive all of your medications there. If ___ have any change
in your sypmtoms, feel free to call (or have the facility call)
the ___ emergency number at ___ and ask
for the oncologist on-call. They will be happy to speak with
___, your family, or your medical team. Additionally, please
call Dr. ___ office on ___ to arrange for follow-up
with her.
___ have an appointment with the pulmonologists who did the
procedure on your lung (pleurodesis and chest tube placement and
removal) on ___. This is to remove the sutures. If ___ cannot
make this appointment, please call their office (as below).
Another physician should be able to remove the sutures.
It has been a pleasure taking care of ___. | ___ with PMH of stage IV poorly differentiated lung
adenocarcinoma with malignant effusion admitted with acute on
chronic dyspnea.
Active Diagnoses:
=================
# Acute on chronic dyspnea
Evidence of recurrent right-sided malignant pleural effusion
with thoracentesis performed ___, serosanginous fluid
removed (1.4L). IP was consulted and the patient underwent
right-sided thoracoscopy, talc pleurodesis, chest tube and
pleur-x placement on ___ and removal on ___ without
complications. The effusion resoved but she continued to have
significant dyspnea and hypoxia requiring supplemental oxygen.
The cause was multifactorial including pulmonary emboli (treated
with enoxaparin, see below), tumor burden, and likely most
contributed to by lymphangitic spread of cancer noted on CT
scan. Pulmonary and palliative care followed her. She was
treated with scheduled bronchodilators, corticosteroids, and
morphine. The morphine helped her dyspnea significantly. She
will continue on a prednisone taper for 2 weeks. Can consider
palliative BiPAP in the future for worsening symptoms or
hypercarbia.
# Stage IV lung adenocarcinoma
Diagnosed in ___, s/p chemotherapy, but disease progression
noted with malignant right-sided pleural effusion despite being
on maintenance chemotherapy. There had been plans to start
Navelbine chemotherapy as an outpatient. She underwent
uncomplicated right-sided port-a-cath placement this admission
on ___. Given need for talc pleurodesis, chemotherapy was
deferred. Atrius ___ oncolgoy followed while hospitalized. They
had extensive discussions wwith her and her family regarding her
rapid decline, and futher chemotherapy is unlikely to be of
benefit. They will continue to follow upon discharge and will
help with any further patient or family needs. The idea of
hospice in the future was discussed with the family, but she is
not yet ready. The patient remains full code at this time, but
discussions regarding code status and futher goals should
continue.
# Pulmonary Emboli
CTA on admission showed small segmental and subsegemental PEs.
She was started on a heparin drip and transitioned to enoxaparin
which will continue upon discharge.
# Pericardial effusion
Incidentally noted on imaging. TTEs x2 performed this admission
showed small to moderate-sized effusion without tamponade
physiology. She remained hemodynamically stable.
# Sinus Tachycardia
She initially presented with sinus tachycardia that improved s/p
thoracentesis. However, this recurred after pleurodesis.
Systemic absorption of albuterol and dyspnea were likely
contributors. Once dyspnea resolved with morphine and
corticosteriods, tachycardia improved, but she remains in sinus
tachycardia with HR in the 100s. | 333 | 382 |
18221103-DS-13 | 22,528,722 | Dear Mr. ___,
You were admitted to the hospital after what appeared to be a
seizure. You also had very high blood pressure.
We did several tests to find out what causes the seizure, but
didn't find anything. You should follow up with the neurologists
outside the hospital.
Your had very high blood pressure in the hospital. The scans of
your brain showed many small strokes in the brain that were
likely caused by high blood pressure. We started you on aspirin,
a statin (to lower cholesterol), and two blood pressure
medications (amlodipine and losartan) to decrease the risk of
this worsening.
It is very important to see your new primary care doctor to
monitor your blood pressure in the future.
Because you had a seizure, you cannot drive for 6 months (first
day ___.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team | HOSPITAL COURSE
===============
___ with a PMH of HTN who p/w episode of syncope c/f seizure in
setting of extreme hypertension.
ACUTE ISSUES
============
# Syncope: History c/f new onset seizure, corroborated by
elevated lactic acid in the. No prodrome symptoms to indicate
syncope. Does not seem induced by toxic ingestion, TBI,
infection, metabolic abnormality or acute stroke given
history/physical/labs/imaging. Patient was hypertensive to 240's
systolic after events, raising possibility of PRES as component.
MRI with old strokes but nothing acute, no sign of PRES. EEG
w.n.l. TSH and A1c nl. Lipids high/normal. No events on
telemetry. Inpatient workup completed, no longer needs ___,
___ f/u in neurology clinic.
# HTN emergency (inducing seizure): Maximal systolic SBP 240s,
dropped to 160's in ED with no intervention. Started amlodipine
10mg QD ___, losartan 25mg ___, discharged on these
medications. Received PRN labetolol 100 mg PO QD:PRN for SBP >
160 in the hospital.
# Chronic Lacunar Infarctions: CT Head showed bilateral basal
ganglia hypodensities c/w chronic lacunar infarctions likely ___
HTN. Started ASA 81 and statin on ___ for secondary prevention.
# Type I Ventricular Conduction Delay. PR 203. Otherwise normal.
TRANSITIONAL ISSUES
===================
[] New appointments
- PCP (patient to call)
- Neurology (scheduled)
[] New medications
- amLODIPine 10 mg PO/NG DAILY
- Aspirin 81 mg PO/NG DAILY
- Atorvastatin 40 mg PO/NG QPM
- Losartan Potassium 25 mg PO/NG DAILY
[] PCP to titrate up / add new HTM medications to strictly
regulate, given patient already has lacunar strokes.
[] Patient cannot drive for 6 months (Day 1 = ___ due to
seizure | 150 | 252 |
10888963-DS-15 | 23,686,022 | Dear Ms. ___,
You have undergone a laparoscopic appendectomy, recovered in the
hospital and are now preparing for discharge to home with the
following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal
pain. Admission abdominal/pelvic CT revealed acute
appendicitis; patient had a mild leukocytosis with WBC of 16.
Given presentation and CT scan results, the patient was taken to
the operating room where she underwent laparoscopic
appendectomy; please see operative note for details. After a
brief, uneventful stay in the PACU, the patient was transferred
to the general surgery ward.
Post-operatively, the patient remained afebrile with well
controlled pain. She was mildly hypotensive (SBP 90-102), but
asymptomatic. Therefore, only her home metoprolol was resumed
and she will monitor her BP at home and restart her valsartan
and hctz pending results. Ms. ___ diet was advanced to
regular and well tolerated without pain, nausea or vomiting.
Additionally, she was ambulating and voiding without assistance
and subsequently discharged to home on POD1. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 316 | 167 |
10317694-DS-18 | 26,269,966 | Discharge Instructions:
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.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
not resume this medication until cleared by Dr. ___ in the
outpatient Neurosurgery office.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. You will only need to take
Keppra for 7 days (starting ___.
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. | ___ y/o F with history of VP shunt placement in ___ for NPH
presents with headaches. She reported that she hit her head on
the car door a couple days ago and head CT confirms R SDH. She
was admitted to the ICU for close monitoring. She was
neurologically intact on exam. On ___, patient remained intact.
Repeat head CT showed redistribution of R SDH. Her diet was
advanced and she was OOB with assistance. Transfer order to the
floor were written.
___, the patient remains stable. She was started on a short
course of anti-epileptic medication. She was discharged home in
stable condition after walking with her nurse who felt she
stable. | 188 | 113 |
14796020-DS-13 | 23,998,550 | Dear ___,
___ was a pleasure caring for you on your recent hospitalization
to ___. You came to the hospital because you were having blood
in your urine. While you were here we found that you had a mass
in your bladder. You underwent cystoscopy for biopsy and removal
of the mass. We are awaiting results of the biopsy which you
should follow up with urology and your oncologist. You can
expect to have pink urine for the next week. If your urine
becomes bloody or you can't urinate please call Dr. ___
office at ___.
The following changes were made to your medications:
1. Added oxybutinin 5mg three times per day as needed for
bladder irritation.
2. Docusate Sodium 100 mg by mouth twice per day for
constipation | Ms. ___ is a ___ year female with PMH of left breast DCIS
s/p lumpectomy/radiation in ___, and recently diagnosed right
breast grade I invasive ductal and lobular carcinoma (estrogen
receptor positive, HER-2 negative) in ___ who presents with
hematuria and was found to have an exophytic mass in her bladder
associated with hemorrhage. | 125 | 56 |
18143616-DS-7 | 26,607,180 | Mrs. ___ you were admitted to the inpatient colorectal
surgery service with difficulty pouching the ileostomy from your
prior surgery. The Ileostomy was so retracted that you have
severe skin breakdown around the stoma, so much so that Dr.
___ the ileostomy early as the connections in the
pouch he surgically created had healed. We slowly advanced your
diet and you may now return home.
You have an open wound where the ileostomy was in place and this
will be a VAC dressing that will be changed at home. This
dressing will be changed every 3 days by the visiting nurse.
Please call us for any issues with the VAC dressing: increased
pain, leaking of the vac dressing, fever, bleeding from the
wound. Call with any questions.
Atrial Fibrillation: you have additional atrial fibrillation
which you had after your initial surgery. For now we will keep
you on the anticoagulation that you had been on at home until
you see the cardiology team as listed below. The cardiology
separtment took the event monitor and a report will be available
to the cardiology team soon. Please call if you have any of the
following symtpoms: weakness, feeling faint, fluttering in your
chest, palpitations, or fast heart rate when the ___ checks your
vital signs >100 beats per minute. Please continue to take the
metoprolol. | Mrs. ___ was admitted to the inpatient colorectal surgery
service with severe irritation around the ileostomy. This
irritation was so severe that the pouching system would not stay
in place. A pouchogram showed that there was no leak of the
pouch. After much consideration, Dr ___ that an
ileostomy reversal was indicated. The ileostomy takedown was
preformed on ___. There was a larger wound at the ileostomy
takedown site given the prior infection and a VAC dressing was
applied. The patient's did well in her recovery from the
ileostomy takedown and she advanced her diet to regular and was
emptying the pouch without issue. Visiting nursing services were
arranged for home. Cardiology recommended continuing
anticoagulation until follow-up with them as she had additional
atrial fibrillation. She will follow-up with cardiology as an
outpatient. | 223 | 134 |
11666440-DS-3 | 21,712,007 | DISCHARGE WORKSHEET INSTRUCTIONS:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You fainted and fell, hitting your head
WHAT HAPPENED IN THE HOSPITAL?
- You had imaging of your head that showed a small bleed in your
brain and were evaluated for this by the neurosurgery team
- You had an echocardiography (ultrasound of the heart) that did
not show any heart related reason for fainting but showed small
decrease in activity of one wall of the heart
- You were given fluids that made your dizziness/lightheadedness
better and improved your blood pressure
WHAT SHOULD YOU DO AT HOME?
- If you have worsening headache or any changes in your mental
status, feel weakness, numbness or tingling in your body, please
report immediately to the ER but otherwise can go to the
concussion clinic as needed
- Please continue to drink plenty of water and fluids to avoid
dehydration
- Please follow up with your primary care doctor in ___ week
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | This is a ___ year old male with past medical history of
hypertension, diabetes type 2, admitted ___ following a
syncopal episode in the setting of diarrhea, found to have
parietal subarachnoid hemorrhage, subsequently cleared by
neurosurgery, workup for syncope only notable for orthostasis,
which resolved with volume resuscitation, able to be discharged
home.
# Syncope secondary to orthostatic hypotension -
Patient presented with syncope with headstrike that occurred
following an episode of diarrhea. Reported a preceding
sensation of feeling "unwell" and diaphoretic. Cardiac workup
including EKG, telemetry and TTE did not reveal signs of ACS,
severe valvulopathy or new severe heart failure. Neurologic
exam was nonfocal as below. Vitals notable for orthostasis,
likely secondary to dehydration from self-resolving diarrheal
episode he had (which did not recur while inpatient). He
received volume resuscitation and subsequent vitals were
normal. Patient ambulated safely without symptom recurrence.
# L parietal Subarachnoid hemorrhage
On admission patient was found to have a small parietal SAH
that remained stable on NHCT x2. Neurosurgery evaluated patient
and felt no acute surgical intervention was indicated. Patient
had nonfocal neurologic exam. Was recommended that he could
follow-up at ___ as needed. Continued on
ASA per neurosurgery.
# Hypertension
Home atenolol and lisinopril were initially held, then
restarted due to hypertension.
#Hyperlipidemia
Continued home simvastatin, ASA
#DM2
Held metformin during admission; restarted at discharge
TRANSITIONAL ISSUES:
- Discharged home
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: Echo as below
[] Echo with "Overall left ventricular systolic function is low
normal (LVEF = 50%) secondary to hypokinesis of the inferior
and posterior walls." Currently on ASA, statin, bblocker and
Ace inhibitor. Would consider cardiology referral for whether
or not additional optimization is indicated;
# CODE: Full code | 181 | 312 |
19054786-DS-15 | 25,399,972 | Dear Ms. ___,
You were admitted for worsening kidney function noted on your
labs. It is unclear if this worsening kidney function is due to
worsening of your IgA nephropathy. You were started on steroids
with some improvement in your kidney function. You were feeling
well so you were discharged with close follow-up with Dr.
___. Please have your blood drawn on the morning of your
appointment so that these results will be available at the time
of your appointment. You should continue to hold all of your
blood pressure medications. You were also started on new
medications including prednisone, protonix, Lasix, and calcium
acetate. We wish you all the best in your recovery.
Sincerely,
Your ___ team | This is a ___ year old female with history of IgA nephropathy
recent admission ___ with GN with nephrotic range
proteinuria and negative work-up including Hep B/C, HIV, ANCA,
complements, and anti GBM.
# Acute on chronic renal failure- Patient was admitted for
ongoing worsening creatinine since most recent discharge with
admission Creat 4.6, from 3.3 on discharge likely IgA relapse.
However other possibilities include FSGS, membranous, lupus,
amyloid, LCDD. She was treated with 500mg IV methylprednisolone
X 3 days (500mg IV daily) and then transitioned to 120mg po
prednisone every other day. She was also started on protonix and
atovaquone for GI and PCP ___. She was started on
calcium acetate for hyperphosphatemia.
# Hyperkalemia: Labs were also notable for hyperkalemia as high
as 5.7 in the setting of worsened renal function for which she
was maintained on telemetry and started on Lasix 60mg po daily
on discharge.
# Fatigue/malaise- No evidence of infection; CXR negative, no
fevers, no leukocytosis (elevated WBC following steroids).
Fatigue is likely secondary to worsening renal function,
elevated BUN. No evidence of consolidation or edema on CXR and
negative DVT on LENIs so low suspicion for PE with normal O2
saturations. Lungs clear on exam and patient is complaining more
of fatigue than true SOB. She has ___ edema secondary to
significant proteinuria.
# Anemia- Stable from last admission. Suspect acute blood loss
anemia in perimenopausal female. Patient reports extensive
bleeding x 1.5 weeks, worsened with heparin on last admission.
Also likely component of anemia of chronic disease. Heparin SC
was held during admission as patient was ambulatory throughout
the majority of the day.
# Rash, improved by discharge- Present on chest and left lower
extremity. Appeared to be solar rash, possibly contact
dermatitis from sunscreen. She denied new medications,
detergents, soaps. No warmth or induration to suggest
cellulitis. Vasculitic rash was considered given history of HSP
but less likely gien rapid improvement over short hospital
course.
# HTN- home HCTZ, valsartan and nifedipine held during last
admission given ___ and ___ normotensive off all agents.
These medications continued to be held in the setting of acute
renal failure. Patient was discharged on lasix.
#Transitional issues
- f/u in ___ clinic ___ with repeat CHEM10 in morning to
assess renal function
- continue new medications: Lasix, pantoprazole, prednisone,
atovaquone, calcium acetate, Ca/Vit D supplementation
#CODE: Full CODE
# EMERGENCY CONTACT HCP: Sister ___ ___ | 116 | 396 |
15155703-DS-13 | 29,617,336 | Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
======================================
You were admitted to the hospital because you had been having
some shortness of breath and leg swelling.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
=============================================
- While you were in the hospital you had a test that found a
blood clot in your lung (Pulmonary Embolism) which required
treatment with an intravenous (IV) medication called Heparin.
- You were initially found to have low oxygen levels in your
blood. You received oxygen through a nasal cannula and your
levels improved.
- We transitioned you from the intravenous medication (Heparin)
to an injectable medication (Lovenox or enoxaparin).
WHAT SHOULD I DO WHEN I GET HOME?
================================
Please follow up with your oncologist, and take your new
medication, enoxaparin (injection), as prescribed.
We wish you the best!
Your ___ Care Team | ___ with history of recently diagnosed cholangiocarcinoma ___, mets to lung, liver, and bilateral pleural effusions
requiring chest tubes, who recently completed 2 cycles of
gemcitabine/cisplatin and presented to ___ clinic (___) for
worsening shortness of breath, orthostasis, and inability to
care for himself at home. Patient was found to have submassive
PE treated with heparin gtt and then transitioned to lovenox.
# PE: Lysis was deferred since patient's bleeding risk
outweighed the potential benefit. He was on a heparin gtt for 3
days, and then we started him on lovenox. His right chest tube
drainage was notably amber fluid approx. 600cc (compared to his
left chest tube drainage approx. 300cc clear). Patient noted
this was a change from baseline, however, patient's hemoglobin
and vital signs were stable so we just continued to monitor.
# Cholangiocarcinoma: Patient has oncology appointment on
___. He had a repeat CT here for staging, which showed
progression of disease and a new liver lesion.
#Nutrition was consulted for patient's report of poor PO intake
and 7% weight loss in 2 months. They recommended small, frequent
meals throughout the day and high calorie/protein foods with
supplemental Ensure Enlive Frappe TID.
#Physical Therapy: Consulted given his recently depressed
ability to function independently. ___ worked with him using a
walker, which greatly improved his mobility. They also monitored
him walking up a flight of stairs, which he was able to tolerate
on 3L nasal cannula and minimal (___) dyspnea.
#Social work: Consulted given recent diagnosis of cancer and
change in independence and high cost of lovenox for
consideration of Mass Health. | 146 | 259 |
16983840-DS-12 | 22,290,540 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- Please remain in your bi-valve cast until your post operative
visit.
- Please keep the cast clean and dry
- 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.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing left lower extremity
Physical Therapy:
NWB left lower extremity
Activity as tolerated within this restriction.
Treatments Frequency:
Please remain in your bivalve cast until your 2 week post
operative visit
Please keep the cast clean and dry
Any sutures or staples will be removed at your post op visit. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left pilon fractureand was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF left pilon fracture, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non-weight bearing in the left
lower extremity in bivalved cast, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up in two
weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge. | 170 | 239 |
16730443-DS-18 | 20,893,078 | Dear ___,
___ was a pleasure to take care if you at ___. You came to us
for abdominal and rib pain, and nausea. We found an increase in
your white counts and a lot of bacteria in your urine. We
treated you with antibiotics for 2 days. Also took xrays and CT
scan of your ribs which did not show a fracture or something
wrong with your ribs. It may be that you have progressing
disease and so it will be very important for you to follow up
closely with Dr. ___ Dr. ___, as well as your primary
care doctor.
We wish you a fast recovery.
Take care,
Your ___ team | Mrs. ___ is a ___ woman with a history of metastatic
thyroid cancer, hypertension, and a remote history of PUD who
presented with RUQ pain and nausea.
# RUQ pain and nausea: Patient presented on ___ with 9 days of
nausea and anorexia and 5 days of RUQ pain. In the ED she was
afebrile with labs notable for leukocytosis, normocytic anemia,
lipase and LFTs within normal limits, and negative troponins. A
urinalysis showing WBCs, nitrites, and bacteria. A RUQ
ultrasound showed sludge but no evidence of cholecystitis or
bile duct dilatation. Acute care surgery was consulted and
decided that no surgical intervention was indicated. PA and
lateral chest radiographs were negative for bone involvement.
Despite a lack of urinary symptoms, she had mild right CVA
tenderness and suprapubic pain as well as nausea, so she was
started on a three-day course of ceftriaxone to empirically
treat a urinary tract infection. On the floor on ___ she was
given ondansetron for nausea and acetaminophen with codeine,
which she takes for chronic migraines, for the RUQ pain. Given
her history of metastatic thyroid cancer, occult pathologic rib
fracture was high on the differential, so rib unilateral and AP
chest radiographs were performed which showed known nodular
opacities but no evidence of rib fracture.
On ___ she had a CT without contrast that showed no rib
lesions or rib fractures but interval increase in the size of
her mediastinal mass and pulmonary nodules since ___
___s new bilateral pleural effusions. Given her persistent
pain and severe nausea and anorexia despite the Zofran and
acetaminophen with codeine, she was started on metoclopramide,
dronabinol, and oxycodone in addition to the Zofran. On ___
she reported feeling much better, and her RUQ seemed
significantly less tender on exam. She was ambulating and able
to eat a regular diet for breakfast. Her rib pain though to be
secondary to rib contusion or due to mass effect from growing
pulmonary masses.
# Leukocytosis: On admission she had a WBC of 16.6 this was
initially attributed to her urinary tract infection, however
upon completing the three day course of ceftriaxone, the
leukocytosis had neither diminished nor resolved. ___ be
secondary to neoplastic process.
# Anemia: She presented with an H/H of 9.5/30.1 decreased from
her last H/H in ___ of 11.6/35.3. Given initial concern for
intra-abdominal bleed, her blood was typed and screened. Her
stools were not Guiac tested given lack of bowel movements x 5
days. Her H/H was trended and iron studies were ordered. The
ferritin of 676 suggested an anemia of chronic disease
consistent with her known malignancy and metastases. Her low
reticulocyte index also suggested she was not appropriately
compensating for the anemia. Her anemia was stable throughout
her stay. Patient should have this anemia worked up more in more
depth.
# Eosinophilia: The patient presented with 10.5% eosinophils
with a history of 9.1% in ___ and normal levels in the
interval. Eosinophils could be elevated secondary to progressing
malignancy, rheumatologic disorders, asthma, helminthic
infection. Given patient's significant malignancy history, this
is the most likely cause for the eosinophilia. Infection of
liver less likely given normal LFTs. Of note, patient has an
incidental 1.4cm echogenic lesion of liver on RUQ ultrasound
which is likely a hemangioma. | 112 | 538 |
19438264-DS-40 | 27,950,792 | It was a pleasure taking care of you during your recent
admission.
You were admitted with worsening pain in your back, in addition
to nausea, vomiting, diarrhea, and fever.
Your diarrhea and vomiting resolved on its own and was likely
due to a virus. You had no infection on urine culture, so your
antibiotics were stopped.
Your pain was controlled with dilaudid every 6 hours, and you
should continue this at rehab, with additional dilaudid for
breakthrough pain.
You were seen by vascular and podiatry for the changes on your
feet. Podiatry recommended that you wear a surgical boot on
your right foot and apply hydrocortisone cream to the rash on
you feet. You will follow-up with the vascular surgeons, but
the studies they did were all normal.
The following changes were made to your home medication regimen:
- START 2mg dilaudid every 6 hours, except while sleeping
- you can also take ___ dilaudid every 4 hours for
breakthrough pain
- START valium 5mg at night before bed
- you can also take 2.5mg of valium during the day for muscle
spasms
- apply hydrocortisone cream to the rash on your feet for no
more than 2 weeks | ___ yo M with h/o IDDM, chronic indwelling foley, chronic low
back pain with severe spinal stenosis, presenting with worsening
low back pain in the setting of fever, nausea, vomiting and
diarrhea.
# Low back pain- There was no evidence of acute changes
concerning for cord compression on exam. Patient had no
worsening numbness or tingling, weakness in lower extremities,
nor did he has bowel incontinence. On exam, strength was intact
on right, mildly diminished on left secondary to pain. Likely,
in setting of acute illness, back pain was exacerbated. In
addition, patient has been resistant to taking pain medications,
which has made it difficult to assess his true pain medication
needs.
He was started on standing dilaudid 2mg q6h, with ___ q4h
prn breakthrough. This controlled his pain well. In addition,
for muscle spasms, he was given vicodin 5mg qHS and vicodin
2.5mg daily as needed during the day.
# Fever, nausea, vomiting, diarrhea- Likely related to urinary
tract infection given positive urinalysis or a viral
gastroenteritis. C.difficile and stool cultures were negative.
Patient was treated for UTI with ciprofloxacin, however urine
culture was negative and ciprofloxacin was discontinued. Foley
catheter was changed by urology on ___. Nausea, vomiting
and diarrhea resolved and patient was able to take normal oral
intake.
# Foot erythema, ulceration- Patient had several concerning
lesions on bilateral feet. On the left, the ___ toes were
ecchymotic consistent with trauma, however x-ray showed no acute
fracture. On the right, the ___ toe was cyanotic, concerning
for chronic ischemia related to peripheral vascular disease, and
had a non-healing eschar on the distal aspect of the toe, which
did not appear infected. X-ray showed soft tissue swelling
related to severe osteoarthritis and bone spurs. Patient had
palpable pulses bilaterally and non-invasive arterial studies
were normal. Patient will follow-up with vascular as
outpatient, and they did not recommend any further intervention
at this time.
# Urinary retention- Indwelling foley since ___, changed
every ___ weeks. Changed during admission on ___.
Continued finasteride and tamsulosin.
# IDDM- Complicated by neuropathy, retinopathy, nephropathy.
Continued lantus 19 units qHS with insulin humalog sliding
scale. Continued diabetic diet.
# Diastolic CHF- Euvolemic during admission. Weights were
checked daily and on day of discharge weight was 166.4kg.
Patient was continued on torsemide 50mg po daily, however he
will need to be increased to 100mg if weight starts to increase.
Also continued home metoprolol.
# Hypertension- Continued home losartan, metoprolol and aspirin.
# OSA- Continued CPAP during admission.
# Transitional issues-
- Standing dilaudid 2mg q6h should continue; may consider
titrating up to 4mg if requiring lots of breakthrough
- Blood cultures pending with no growth to date
- Please repeat urinalysis and urine culture within one week | 194 | 474 |
19590214-DS-15 | 20,374,882 | Dear Ms. ___,
It was a pleasure taking care of you during your stay. You were
admitted for a port infection. You were treated with IV
vancomycin and your port was removed. An echocardiogram did not
show any infection on the heart valves. A PICC line was placed
for IV therapy at home. You ___ need to be on antibiotics until
___ and have an appointment with the infectious disease team
on ___. We wish you the best!
Your ___ care team | ___ y/o woman with a pmhx. significant for Her2+ inflammatory
breast cancer with bony disease Taxol and Herceptin, recent L
port infection treated with 14 days of IV vanc and vancomycin
locks in ___ (discontinued on ___, who presented
with fever and erythema around port site due to recurrent port
infection.
# Port infection: The patient initially presented from clinic
due to fever along with erythema and tenderness around her left
side Powerport while receiving chemotherapy. She was initiated
on IV vancomycin through her port along with vancomycin locks in
the port. Her vancomycin levels were checked and titrated
accordingly thorughout admission. Her blood cultures grew out S.
epidermidis which was the same organism as the prior port
infection. Infectious disease was consulted and recommended
removal of the port since both infections were caused by the
same bacterial organism. In addition, ID recommended a TTE which
did not show any vegetations. She was taken to the
interventional radiology suite on ___ and had her Powerport
removed. Following port removal, she had a PICC line placed by
___ on ___ in order for her to continue her IV chemotherapy
regimen and her IV vancomycin. She was discharged with follow up
in ___ (infectious disease) clinic for managing her IV
antibiotics. Her course of vancomycin ___ end on ___. She was
discharged home with ___ services to help with wound dressing
changes of the former port site as well as nursing services for
her IV antibiotics. She ___ receive weekly labs for CBC and
vancomycin levels and results ___ be faxed to the ___ clinic.
# Stage IV breast cancer: on Taxol and herceptin, normally
follows with Dr. ___ as an outpatient. She was discharged with
instructions to follow up in Dr. ___ for continued
management of her breast cancer and administration of her
chemotherapy.
# Hypertension: Continued Hctz, lisinopril, atenolol
# Transitional issues:
- Stop antibiotics on ___
- Keep PICC following completion of antibiotics for chemotherapy
- Can place new port upon completion of antibiotics
- Infectious disease appointment on ___
- Wound care nurse ___
- ___ need weekly CBC with differential, BUN, Cr, Vancomycin
trough. Fax results to ___ CLINIC - FAX: ___
- All questions regarding outpatient parenteral antibiotics
after discharge should be directed to the ___
R.N.s at ___ or to the on-call ID fellow when the
clinic is closed | 80 | 388 |
13811510-DS-11 | 21,463,989 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with the flu. After getting IV fluid and Tamiflu, you began to
feel better, were able to eat, and are ready to discharge home.
Please wear a mask in public or when sharing a room with another
invidual until you are free of fevers for 24 hours (fever is a
temperature greater than 100.6). Please wash your hands well to
prevent spreading the infection to others. We are discharging
you on Tamiflu to treat the infection. You can use saline spray
for your nasal congestion. Please remember to stay hydrated with
fluids like gatorade, and call your doctor if you can't keep
food down. Also call your doctor if your breathing is getting
worse, as some people can develop pneumonia after having the
flu. Make sure to take your inhaler if your breathing feels
tight. We are giving you some nausea medications as well. You
can take this prior to the tamiflu if you feel this medication
is making you nauseous.
Please continue to take your HIV medication every day and
followup with Dr. ___ as scheduled. We checked your viral
load and CD4 count, which were still pending at discharge. Dr.
___ will address any changes that might be necessary based
on these results as an outpatient.
We wish a speedy recovery, | ___ yo M with hx of HIV on HAART (VL ___, CD4 ___
presenting with body aches, fevers, HA, GI sx, found to be
influenza A positive.
# Influenza A: Patient presentsed with symptoms consistent with
ILI, fount to be flu A positive. Vital signs were stable,
defervesced, clinically improved. Labs unremarkable. No e/o
viral pneumonia or sepsis. Started on Tamiflu 75 mg BID for 5
day course (w/ prn zofran for N, QTC 390). Given Tylenol prn.
Instructed about contagion precautions. Tolerated a diet prior
to discharge. Given saline nasal spray for congestive sx.
# Tachycardia: Likely ___ hypovolemia/poor PO intake and
low-grade fever. Resolved with APAP and 2L IVF
# HIV: On HAART (VL ___, CD4 ___, takes every day. On
no prophylaxis (previously on atovaquone/azithromycin when VL
was higher). Continued home HAART regimen. Checked HIV VL and
CD4, pending at d/c. Will f/u w/ ID/PCP as ___.
# Asthma: Pt notes some recurrent sx in the setting of acute
illness. CXR clear. Did not desat below 92 on ambulation.
Continued albuterol prn and home montelukast.
# Allergic Rhinitis; Restarted home cromolyn at d/c, saline
spray and montelukast as above.
# Hypertension: BP elevated to 140-150s. Per OMR has a h/o HTN,
not currently on therapy. Tx of this should be considered as an
___ if continues to be elevated.
# HSV: ___, on suppressive regimen. Continued home
Famciclovir
# OSA: Pt will continue CPAP at home.
# EKG findings: EKG on admission inferior Q waves, possibly old
inferior MI, recommend CAD work up as ___ and medical
optimization (ASA, statin, BP control, etc.). Is at risk for CAD
given HIV and chronic HAART therapy. | 228 | 273 |
12385894-DS-7 | 27,201,076 | You were hospitalized after having witnessed seizures first at
___ and then while in the emergency department at ___
___. In the hospital, you underwent
head imaging and lab evaluation which did not demonstrate a new
cause for your seizure. You were started on a second
anti-seizure medication, Dilantin (also known as phenytoin) to
help control the seizures short term. It will likely be possible
to increase your Lamictal dose so you will only need to take
Lamictal, and eventually stop taking the Dilantin.
You should follow up with your neurologist, ___, MD,
who we have made attempts to contact as to our plan for seizure
prophylaxis. | # Seizure
- Patient was transported to hospital following Witness Tonic
Clonic Seizure. He has another episode in the ED (lasting 45
sec) and recieved Ativan and was loaded with Dilantin. His
labwork and Head CT did not note any possible acute inciting
cause for this event and it was felt to be likely ___ to his
previous stroke. His Lamictal was increased to 75mg PO BID and
he was maintained on Dilantin 100mg TID. He subsquently did
well and was safe for d/c. On his discharge he was sent with
instruction to gradually increase his Lamictal dosing according
to the following schedule:
- Lamictal 75mg BID through ___
- Lamictal 100mg BID through ___
- Lamictal 150mg BID ongoing.
His d/c Dilantin was 100mg TID ___. Though this must be
guided by his outpatient neurologist, the plan on discharge was
to continue dilantin while patient was uptitrating on Lamictal.
WHen he was on Lamictal 150mg PO BID and seizure free, he can
likely be tapered off Dilantin. | 109 | 171 |
15624384-DS-6 | 20,898,627 | You were struck by a vehicle while riding your bike. You
sustained a small bleed in your head,bilateral rib fractures,
sternal fracture, cervical and thoracic spine fractures, and a
dislocation to your left hip. You were taken to the operating
room to have the left hip repaired and underwent a cervical
spinal fusion. It is recommended that you remain in the
cervical collar for neck support and stabilization. You were
evaluated by physical therapy and recommendations made for
discharge to rehabilitation facility where you can further
regain your strength and mobility. You have appointments to
follow-up in the Orthopedic and Spine clinic. You are being
discharged with the following recommendations:
* Your injury caused Right ___ and Left ___ rib fractures which
can cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Additional instructions include:
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.
*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. | ___ male with past medical history significant for
diabetes (on insulin) who was reportedly hit by a car which was
traveling ___ miles an hour. The patient
landed on the windshield. There was a head strike and initial
loss of
consciousness. At the scene, his GCS was 14 and he was
hemodynamically stable. He was transported to the emergency
department of the ___. Upon
arrival at the hospital, his GCS was 15 and he was
hemodynamically stable.
Upon admission, the patient was made NPO, given intravenous
fluids and underwent imaging. He sustained a head laceration
which was stapled in the emergency room. A cervical collar was
placed for neck stabilization. The patient sustained abrasions
to the arms and face. On review of the imaging, the patient
was reported to have the following injuries: a left acetabular
fracture with femoral head fracture and posterior dislocation, a
C5-C6 middle and posterior column fracture, bilateral rib
fractures, and a intra-parenchymal hemorrhage. Because of his
injuries the Orthopedic, Neurology, and Spine services were
consulted.
Neurosurgery was consulted for the patient's IPH. No surgical
intervention was indicated. The patient was not started on
keppra. The patient was admitted to the intensive care unit for
hourly neurological examinations which remained stable. Among
the patient's injuries, he was reported to have a C7 teardrop
fracture with vertical split of the C7 vertebra and facet
injury. There was concern that this was a unstable fracture and
because of this, the patient was taken to the operating room by
the Spine service where he underwent a fusion laminectomy
cervical posterior with instrumentation C4-T1. The operative
course was notable for a 500cc blood loss. The patient remained
intubated after this procedure and returned to the intensive
care unit for monitoring. The patient's vital signs remained
stable and he received 1 unit of PRBC's. The patient was
extubated in 24 hours with anesthesia on stand-by. His
respiratory status remained stable.
On ___, the patient returned to the operating room with the
Orthopedic service where he underwent an ORIF of a left
posterior acetabular fracture. The operative course was notable
for a 400 cc blood loss. The patient was extubated after his
procedure and monitored in the recovery room. The patient's
vital signs remained stable and he was transferred to the
surgical floor. He was started on a course of lovenox for DVT
prophalaxsis.
In preparation for discharge, the patient was evaluated by
physical and occupational therapy and recommendations were made
for discharge to a rehabilitation facility. The patient's vital
signs were stable and he was afebrile. He was tolerating a
regular diet and voiding without difficulty. His bowel function
had been slow to return despite the addition of a bowel regimen.
He was instructed in the use of the incentive spirometer and
maintained an oxygen saturation >90 %. His hip and rib pain
were controlled with oral analgesia. Hematocrit at discharge was
25.4.
The patient was discharged to rehab on ___ in stable condition.
Discharge instructions were reviewed and questions answered.
Follow-up appointments were made with the Orthopedic, Spine, and
the acute care clinic. | 468 | 538 |
13265883-DS-15 | 23,606,388 | Dear Mr. ___,
You initially presented to ___ with a deficit in
appreciating the left visual space. There an MRI was done, and
revealed a stroke in the right occipital lobe, a region
important for vision. Vessel imaging demonstrated no clearly
contributory changes (such as blockages or narrowing). Heart
rhythm monitoring showed no obvious abnormalities. An
echocardiogram (an ultrasound of the heart) revealed a patent
foramen ovale (an opening between the two sides of the heart).
Accordingly, ultrasounds of the lower extremities were done to
evaluate for blood clots that could have travelled to the brain.
The study showed that there were no clots.
.
At this time, the cause of the stroke is unclear. It is
recommended that cardiac monitoring be performed over 30 days to
evaluate for an arrhythmia. To help prevent future events, the
aspirin was discontinued in favor of plavix. The lisinopril was
transiently stopped to allow your blood pressure to
autoregulate; you can restart the medicine tomorrow (___). We
measured your cholesterol levels, and your LDL (bad cholesterol)
returned at 74, which is excellent. We recommend that you
continue to take your simvastatin as you have been in the past.
.
Please make an appointment with Dr. ___ in the next week.
Please ask him to help coordinate an appointment with an
ophthalmologist.
Regarding the issue of DRIVING: We strongly recommend that you
refrain from driving until you visit with an ophthalmologist
(for formal visual field testing) and/or the ___ Drivewise
program. We provide you with an informational booklet about this
service, which can provide a comprehensive evaluation of your
ability to safely drive.
.
MEDICATION CHANGES
- aspirin was discontinued
- plavix was started. | Mr. ___ was transferred from ___ to the ___ campus
of ___ for the management of his acute stroke. Earlier that
morning, he had developed a left visual field deficit and also
had reported some problems with peripheral visual field
blurriness. An outside hospital MRI/MRA confirmed his right
occipital lobe stroke in the PCA distribution. MRI brain also
show a punctate FLAIR hyperintensity in the right cerebellar
hemisphere with a small amount of hemorrhagic transformation -
this was not bright on DWI imaging and thus seemed most likely
to be chronic.
He was transferred to ___ for the further work up of
this stroke. A code stroke even though he was outside the
window, and his exam confirmed a subtle left homonymous
hemianopia. He had a subtle right arm ataxia. No acute brain
lesion was found to account for this right arm ataxia.
The work up for his stroke was largely unrevealing. The MRA
showed no major intracranial or extracranial stenosis. His lipid
panel was within goal limits with a relative high HDL and low
LDL, and A1c was normal. An echocardiogram (TTE) identified a
PFO but LENIs were negative. The etiology of his stroke was
unclear - this may have been due to embolism, but no embolic
source was found. He does not have intracranial atherosclerosis
making large vessel thrombosis improbable (though the MRA was
limited by motion artifact). The infarct size was of unusual
location (and slightly too large) to be a lacunar infarct. His
aspirin was switched to a daily plavix for secondary prevention.
TRANSITIONAL ISSUES
At the time of discharge, in conjunction with the remainder of
the stroke neurology team, a number of recommendations were
made.
- We asked Mr. ___ to without fail seek ophthalmological
evaluation with formal visual field testing prior to driving.
- We referred him to the ___ DriveWise program for a
comprehensive evaluation of his driving abilities
- We request that his PCP perform ___ 30 day holter monitor
testing looking for paroxysmal asymptomatic atrial fibrillation
as a possible source for his stroke.
His discharge physical examination was unchanged from previous.
He was well appearing and was able to ambulate independently
without difficulty. He will follow up with his PCP as well as
Dr. ___ the division of stroke neurology | 291 | 378 |
12028861-DS-11 | 29,792,703 | Dear Mr. ___,
You were admitted to ___ on ___ after you had worsening
pain in your back and hips. Your pain regimen was changed many
times and we hope the current regimen will keep you comfortable
at home. You had scans of your spine done which shows existing
compression fractures and bone pain from myeloma, but no new
signs of new problems.
During your stay, you received another cycle of chemotherapy.
Please follow up with your outpatient appointments.
We also adjusted your diabetes medications as you changed
steroid doses. At home you will be taking Lantus (injections)
25 Units in the MORNING, along with Metformin (increased to 1000
mg BID) and Glipizide (10 mg BID). You will follow-up at ___
___.
Sincerely
Your ___ care team | Mr. ___ is a ___ year old male, with past history of Multiple
Myeloma treated with CyBorD and XRT, with multiple lytic
lesions/compression fractures, severe aortic stenosis, Type II
DM, HTN, and hyperlipidemia, recently discharged on ___ from
___ service for long-hospital course, presented from home with
increased pain.
#Pain management: He was previously discharged on MS ___ 60
mg TID, hydromorphone 6 mg q4 hours PRN and Lyrica 150 mg TID.
Source for worsening pain was likely from known lytic lesion and
compression fractures, with imaging showing no new fractures
(plain films and lumbar MRI). His myeloma labs also were
improved during this time (Free Kappa 226.4, Fr K/L 19.52).
There were no signs of acute cord compression. The pain service
was involved during his course, and recommended initiation of
fentanyl patch (uptitrated to 200 mcg), standing dilaudid, up to
8 mg q4 (initially required dilaudid PCA), and Lyrica at 75 TID
(decreased dose due to transaminitis). Palliative care was
consulted and did not recommend any acute changes in pain
regimen, happy to see patient again once discharged from the
hospital. ___ was consulted and there was no role for kyphoplasty
in subacute, chronic pain exacerbation. Orthopedic surgery was
consulted and there was no role for surgical intervention.
#Multiple Myeloma: Patient initiated another cycle of CyBorD on
___ with great improvement of pain initially, though acute
exacerbation overnight on ___, most likely due to effects of
steroids wore off. Patient was scheduled for subsequent cycle on
___, though this was delayed in setting of transaminitis. He
was started on Dexamethasone in setting of persistent pain,
decreased to 1 mg BID at time of discharge.
#Transaminitis: Suspected medication toxicity, without abdominal
pain. Acetaminophen, Crestor, Lyrica, and omeprazole were
initially discontinued in addition to switching from Bactrim to
Atovaquone. RUQ US was normal except for hepatic steatosis. MRI
liver did not reveal etiology for transaminitis. LFTs
subsequently improved. Lyrica was resumed at lower dose, 75mg
TID. Patient started Pantoprazole 40mg PO qd in setting of
ongoing steroid use but discontinued at discharge. Crestor was
not restarted. Hepatitis B/C viral loads were negative. He was
briefly on atovaquone given Bactrim was thought to be
contributing to LFTs. He was discharged off PCP prophylaxis, to
be readdressed as outpatient.
#Type II Diabetes Mellitus: Patient followed by ___ Diabetes
Service throughout admission. Blood sugars relatively well
controlled, difficult in setting of fluctuating steroid doses.
Patient discharged on Lantus 25U qAM. Given patient's desire to
not use short acting insulin, he is being discharged on Lantus
25U in AM, with Metformin 1000 mg BID and Glipizide 10 mg BID.
Patient will follow-up with ___ as outpatient on ___.
# Cardiac History: Patient with initial presentation on prior
admission (___) with symptomatic hypotension, and prior
chest pain, now resolved. Patient underwent stress at that time,
was placed on therapy for suspected CAD.
- Continue aspirin
- d/c'd statin given abnormal LFTs
- Continue metop with holding parameters
# BPH: Held alfuzosin while in house, monitor for symptoms, can
consider restarting as outpatient.
# Eye Complaints: patient with no known glaucoma, several
different eye drops.
- Continue Latanoprost in place of Travatan
- Prednisolone 0.12% drops in left eye QHS in place of Lotemax
(non-formulary)
- Restart home eye drops on discharge
# Hyperlipidemia (CK normal):
- d/c'd statin in setting of abnormal LFTs
# Leukopenia: Mild, likely ___ to marrow suppressive underlying
disease.
# Normocytic Anemia: Likely ___ to marrow suppression and
underlying disease myeloma. | 128 | 572 |
13478959-DS-12 | 29,846,799 | Dear Ms ___,
You were admitted to ___ from
___ - ___ for abdominal pain and constipation. We feel
that these symptoms are likely to the tumor in your belly and
pelvis.
WHAT HAPPENED WHILE YOU WERE HERE?
- You had a CT scan of your abdomen, while showed growth of the
tumor since your last CT scan. There was no evidence that the
tumor was actually blocking your colon, but it more than likely
putting pressure on your colon.
- You were seen by the gynecology-oncology and ___
surgery teams, as well as Dr ___ Dr ___. All agreed
that the best plan going forward is to continue with
chemotherapy to see if the tumor will start to shrink.
- We discussed your case with our gastro-intestinal team, who
felt that putting a stent in your colon would not be successful
in improving your constipation.
- You received several medications for your constipation,
including senna, Colace, MiraLax, bisacodyl.
- You had increased swelling in your legs, especially your left
leg, so we did an ultrasound of your left leg, which confirmed
that there is no blood clot in your leg that is causing the
swelling.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will see Dr ___ Dr ___ in the office on
___ at 9am.
- You will continue to take senna and Colace every day. You will
take Miralax and bisacodyl at your discretion to keep your
bowels moving.
- You will continue to take tramadol (instead of exycodone) for
your belly pain.
If you have any further questions regarding you care here,
please do not hesitate to contact us at ___ (___
front desk). We wish you the very best with your health going
forward.
Your ___ Oncology Team | ___ w/ PMH of hypothyroidism recent Dx of endometrial
carcinosarcoma on ___, recently admitted to ___ for ___
___ obstructive uropathy requiring ___ PCNs, now s/p first round
of ___ ___ p/w ABD pain thought to be secondary to
enlarging pelvic mass.
#ABDOMINAL PAIN: likely ___ colonic distension ___ compression
from pelvic mass. Still passing liquid stool and flatus, so not
completely obstructed, but is likely on her way to obstruction
in the seting of enlarging pelvic mass. PCNs are in correct
position and there is no evidence of stone on CT and UA is
bland. CT without evidence of SBO or LBO. C. diff negative. Case
discussed with GI, gyn onc, and colon&rectal surgery for
management of impending obstruction - GI deferred colonic stent
for low likelihood of success (given external compression of the
colon), gyn onc will not debulk until tumor is smaller,
colon&rectal will not intervene at this time as she is not
completely obstructed, but would potentially consider a
diverting ileostomy if she becomes obstructed; however, this may
not be an option due to large tumor burden in pelvis/abdomen.
Given senna, Colace, PRN polyethylene glycol TID, bisacodyl PRN.
Treat pain with 600mg ibuprofen q6hrs PRN for pain (takes this
at home), simethacone, tramadol 25mg BID:PRN. On a clear liquid
diet while admitted, tolerated small amounts of PO. Can advance
diet at her discretion at home.
#STAGE IV ENDOMETRIAL CARCINOSARCOMA: CT on ___ showed
interval growth and progression of pelvic disease, plus ground
glass nodules in pulmonary bases. Confirmed PCN placement. Dr
___ outpatient oncologist) following inpatient.
Given single dose of ___ thus far, will not consider this a
failure of chemotherapy, and will allow another dose of current
regimen to attempt tumor shrinkage. ___ need temporizing measure
to treat impending colonic obstruction in order to give time for
___ to shrink tumor, see above for discussion. CA 125 on
___ 208 from 337 on ___.
#PSEUDOMONAS UTI: Dx ___ and started on ___ outpatient for a
10 day course. Last day on ___.
#Malignant ureteral obstruction s/p percutaneous nephrostomy
tubes: renal function stable throughout admission.
#HYPONATREMIA: Na 132 on admission, likely hypovolemic
hyponatremia in setting of Lasix and poor PO intake. Concern on
last admission for SIADH of malignancy and possibly hypervolemic
hyponatremia in setting of acute renal failure. TSH WNL and no
steroid use to implicate adrenal insufficiency. Volume status
appeared volume up, but this is localized in the setting of mass
compression; her MM are dry and JVP is not elevated. FeUrea is
negligible, which could indicated a pre-renal etiology. Home
Lasix restarted prior to discharge, Na 131.
#TRANSAMINITIS: AST/ALT elevated on admission with normal
tbili/alk. Likely secondary first round of ___. Now
down-trending. Also has elevated INR, likely of the same
etiology. INR from 1.7 to 1.2 following vit K. Should follow-up
as outpatient.
#HYPOTHYROIDISM: Continued home levothyroxine | 283 | 475 |
16394197-DS-17 | 23,141,341 | Why were you hospitalized?
You were having diarrhea after taking too much senna.
What did we do?
We monitored you overnight to ensure that your bowel movements
return to normal. We also find that you likely have emphysema
and will require outpatient follow-up and to quit smoking.
What should you do when you leave the hospital?
You should follow-up with your new primary care doctor next week
to establish care and start working on taking care of some
concerns about your health. | SUMMARY/ASSESSMENT: ___, chronic smoker, presenting with
intermittent constipation ___ year and now senna-induced
diarrhea,
also with an episode of asymptomatic hypoxemia in the ED, now
resolved.
#Abdominal Pain
#Diarrhea
#Constipation
One year of intermittent constipation that he has treated with
large doses of senna, often inducing diarrhea. He had one such
episode today and called an ambulance due to concerns about
soiling his living space. He received Imodium in the ED and
diarrhea has slowed down. No blood in stool or other warning
signs (weight loss, change in stool shape); however he has never
had a screening colonoscopy. His diarrhea improved, and he was
advised to use psyllium daily for bulking, and miralax as
needed, with recommendations for colonoscopy as outpatient.
#Hypoxemia, likely emphysema
#Chronic Smoking
Significant smoking history (>120 pack years) without formal
diagnosis of emphysema (though currently out of care). He
desaturated to 88% in the ED without respiratory symptoms. At
home he is active, no limiting SOB, no cough or sputum. CXR with
chronic changes consistent with emphysema. In the ED he
received a dose of IV solumedrol, which was not continued after
admission in the absence of acute exacerbation. Smoking
cessation was recommended, and he was given an albuterol inhaler
at ___. Smoking cessation was advised. His O2 sat was in the low
___ throughout hospitalization. He will benefit from formal
PFTs and COPD management after discharge.
#Complex social situation
He is in significant financial need, after tumultuous life after
return from ___ to take a position at ___, at the time of
___. He was evacuated to ___, and then friends
relocated him to ___ housing at ___
___. He was displaced from there - he says because he values
living over dying - and is now living at ___ in ___, as he
attempts to find permanent housing. He may have some chronic
trauma from these recent events.
#Transitional issues:
- set up with new PCP ___ 1 week to establish primary care
- Will need clothing (his was soiled when he arrived in the ED)
- Consider outpatient CT Chest for follow-up of "linear opacity"
likely due to parenchymal markings seen on CXR | 80 | 340 |
19240268-DS-22 | 26,078,018 | You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that may
be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | Mr. ___ was admitted to Dr. ___ from the ED
with intractable abdominal pain and cramping and dysuria. She
took an ambulance to the ED and was admitted for a bowel regimen
for constipation and pain medications. Overnight, the patient
was hydrated with intravenous fluids and received appropriate
home medications and laxatives. Medications were again titrated
for better pain control (limited options given multiple allergic
concerns) and she was eventually feeling well enough to
discharge home. She was offered an enema prior to discharge as
well. Repeated urine cultures with + staph (as previously). At
discharge her pain was controlled with oral pain medications,
tolerating regular diet, ambulating without assistance, and
voiding without difficulty, although some frequency and dysuria.
She was explicitly advised to follow up as directed.
Of note, Dr. ___ the patient the day of discharge,
noted her lack of a BM, inquired as to when she was going to
have her enema (she stated after lunch) and examined her,
noticing a SNT abdomen. | 270 | 166 |
11816641-DS-17 | 23,768,138 | Ms. ___, you were admitted to ___
___ after presenting to the Emergency Department with
confusion for several days. You were found to be dehydrated and
to have high sodium levels which were treated with intravenous
(IV) fluids. You also had a CT scan of your belly which showed
a mass in your abdomen.You underwent EGD/EUS with a biopsy of
the mass and the results of the biopsy showed that this is
cancer.
The Oncologists feel that it would be too dangerous to pursue
treatment for this cancer. The focus at this point is to keep
you feeling well and comfortable.
Please see below for you follow-up appointments.
It was a true pleasure taking care of you, Ms ___. | ___ year old female with PMH of COPD, CAD, and heart failure who
presents with somnolence and hypercarbia who was started on NIV
in the ED with worsening mental status.
# Pancreatic head mass- On presentation the patient was noted to
have new thrombocytopenia, DIC, transaminitis, and chronic
portal vein thrombosis, raising concern for underlying
malignancy, to tie all this findings together. At CT abdomen and
pelvis was performed and was notable for a 1.2 x 1.0 cm
hypodense hypoenhancing lesion within the pancreatic head highly
suspicous for malignancy likley cause of pt's DIC, and portal
vein thrombus. CA ___ was done and elevated at 4120. The
patient underwent an EUS with biopsy that confirmed
adenocarcinoma of the pancreas. After speaking with Oncology,
the patient is not a good candidate for surgery or radiation
given her lack of symptoms, comorbidities, and frail stature.
The patient has been discharged with Oncology Follow-up.
# Subsegmental PE- The patient had an episode of tachypnea. An
ABG was done, and notable for hypoxia and an A-a gradient. At
subsequent CTA of the chest was performed and notable for
pulmonary emboli within the segmental arteries of the right
upper and middle lobe. The patient's PE likely from
hypercoagulable state in the setting of likely pancreatic
cancer. She was started on a heparin gtt and will be discharged
to rehab on lovenox.
# Chronic Portal vein thrombus: The patient was noted to have
portal vein thrombosis on right upper quadrant ultrasound.
Likely from hypercoagulable state in the setting likely
pancreatic malignancy (see above). Hepatology was consulted and
thought that her portal vein thrombosis was likely chronic in
nature. However, given her acute PE she was anticoagulated as
above.
#) ___: Hypovolemic ___ with pre-renal azotemia. She was total
body volume depleted. Her creatinine was 1.8 at her PCPs office,
with improvement to 1.3 with IVF. She had an initial 2L free
water deficit. Again, TTP unlikely given improvement clinically
and by labs without intervention aside from fluid resuscitation.
Her diuretics were held and she was treated with initial bolus
of LR then free water repletion. Her creatinine remained normal
during the remainder of her hospital stay and diuresis was
restarted.
#) Acute Confusional State: She was somnolent on arrival to MICU
with asterixis on exam, though she was answering questions
appropriately and following commands. Her somnolence was thought
to be a multifactorial problem consisting of hypernatremia,
hypovolemia, hypercalcemia, and possibly hypercarbia though she
was close to her baseline based on her elevated bicarb. No focal
signs of infection, though cultures were sent. She was treated
on NIV overnight with a decrease in her oxygen from when she
arrived as she appeared to have times of apnea related to high
oxygenation. She improved and was weaned off NIV overnight. She
was then transferred to the floor where patient remained alert
and at her baseline mental status.
#)DIC/ Thrombocytopenia: New thrombocytopenia She presented with
a significant drop from her prior admission. She was in DIC,
likely related to underlying pancreatic head mass and suspected
malignancy see on CT abdomen (see below). Prior to CT findings,
the initial hypothesis was severe volume depletion ending in end
organ dysfunction (transaminitis, ___, and AMS). She had no
focal signs of infection. 4T's with a score of ___ placing HITT
risk at intermediate given her heparin exposure within the past
30 days and drop of >50% with a nadir >50k. However P4
antibodies were negative making HITT unlikely. TTP was
considered given the anemia, mental status changes, acute kidney
injury and thrombocytopenia, however her symptoms improved with
hydration and her low fibrinogen and elevated coags was
indicative of DIC. Hematology was consulted and felt that TTP
was less likely as there were few schisctocytes seen on
peripheral smear. Her initial fibrinogen was 76 and was given 1
unit of cryo. Her fibrinogen and FDP were trended daily and
continued to improve and were normal prior to discharge.
#) Hypernatremia: The patient was found to be hypernatremic on
admission with Na of 153, and was likely Hypovolemic
hypernatremia. Her hypernatremia was corrected with D5W and BID
Na checks to ensure that the Na was not corrcted > 10mEq/24
hours.
#) Hypercalcemia: Corrected with fluid resuscitation.
#) Chronic Hypercarbic Respiratory Failure: The patient was
initially noted to have hypercarbia, with peak CO2 level in
~70s. She required NIV fio2 26% overnight int he MICU, with
improvement in her mental status. It is unclear what her
baseline is, though she does have a history of COPD and it is
possible that she is a retainer at her baseline. Subsequent ABGs
done during acute episodes of tachypnea demonstrated stably
elevated CO2 ( 40s-50s).
# CAD/systolic CHF (EF < 20%): While in the MICU the patient had
a 40 beat runs of NSVT, was asymptomatic and spontaneously
converted to sinus. While on the floor she was monitored on
telemetry and had intermittently had short runs of NSVT while
admitted.The patient's diuretics ( lasix and spirnolactone) were
initially held while in the MICU in the setting of hypovolemia.
Her diuretics were restarted on the floor once her BPs were able
to tolerate. The patient had a repeat echo on ___ which was
notable for left ventricular cavity moderately dilated with
severe global hypokinesis (LVEF <20 %) and right ventricular
cavity dilated with moderate global free wall hypokinesis.
There was concern for right heart strain in the setting of her
new PE. Given her ___ CHF At___ cardiology was
consulted regarding recommendations for medical optimization of
her heart failure. Her home lasix was increased from 40 to 60 mg
daily, she was continued on metoprolol tartate 25 mg BID, and
losartan 25mg daily, as her home irbesartan was not on
formulary. The patient is to be discharged on metoprolol
succcinate and irbesartan 75mg daily. Her atorvastatin was held
in the setting of transaminitis. It was restarted at discharge.
# elevated LFTs: The patient was noted to have a new elevated
LFTs, with increased T Bili, elevated INR, and hypoalbuminemia.
On review of Atrius records, LFTs were increased on labs from
___ checked at PCPs office, and consistent with admisison
LFTs. Differential diagnosis considered in this pt include
included congestive hepatopathy ,cirrhosis and obstructive in
the setting of pancreatic head mass and CBD dilatation.
Cirrhosis was considered in the setting of initial coagulopathy
and hypoalbuminemia. However CT abdomen and pelvis suggest no
evidence of cirrhosis. Hep serologies, alpha-1 ___,
and anti-smooth muscle antibody were also negative making
cirrhosis less likely. The patient's pancreatic head mass
unlikely contributing to her LFT abnormalities, although you
would expect to see elevated T. Bili, which has down trended
while admitted. The patient LFTs, INR and bili continued to
down trend on admission in the setting of resuming her diuresis,
supporting congestive hepatopathy as the underlying cause of her
abnormal LFTs.
# COPD: She was continued on her home medications, including
albuterol and fluticasone
# DM2: She was not on any medications and was continued on a
diabetic diet
# GLAUCOMA: Continued her home latanoprost eye drops, betaxolol
eye drops
# ANEMIA: Patient noted to have anemia in the past on iron. Of
note, MCV has been in ___. Moreover, haptoglobin was low, LDH
and Tbili were elevated, which were consistent with hemolytic
process. Her reticulocyte count was not appropriately elevated
given degree of anemia, likely ___ malnutrition. She was
continued on her ferrous sulfate and her hematocrit was stable
throughout. | 118 | 1,250 |
13134704-DS-22 | 25,878,910 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after having several episodes of
diarrhea and missing HD due to your symptoms
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received HD while admitted.
- Your diarrhea improved making this likely caused by viral
gastroenteritis.
- Given the difficulty of doing an outpatient colonoscopy, we
had this done while inpatient which showed 3 polyps that were
removed and 2 smaller polyps that were not removed given risk of
bleeding.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please follow up with your PCP regarding INR.
- You will need a follow up colonoscopy in 6 months to remove
the other small polyps.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with past medical hx of ESRD on
dialysis MWF, HIV on ARV, DMII c/b nephropathy and neuropathy,
PAD s/p b/l BKA, atrial fibrillation on coumadin, who presents
with acute on chronic diarrhea likely from viral
gastroenteritis.
ACUTE/ACTIVE PROBLEMS:
# Acute on chronic Diarrhea
# Elevated anion gap metabolic acidosis
Patient with 5 days of copious diarrhea about ___ BM per day,
anorexia. Per further history, appears to be acute on chronic
diarrhea with baseline ___ bowel movements. His HIV has been
well controlled for many years, with most recent CD4 at ___
in ___ WNL. His workup included negative cdiff, norovirus,
crypto, giardia, O&P. DDx included protease inhibitor reaction
but less likely given he has been on the
medication for years. Most likely viral gastroenteritis as
symptoms improved with addition of psyllium wafers and
immodium:prn.
#Colorectal cancer screening
Given his functional limitations, he had a colonoscopy while
inpatient for ___ screening. 3 polyps were removed with
pathology pending with 2 additional smaller polyps identified
but not removed given risk of bleeding. Will need repeat
colonoscopy in 6 months given fair prep and polyps that were not
removed. Warfarin was held for 24hours and restarted on ___.
#Hypertensive Urgency
Patient had elevated BP to 208/100 and asymptomatic. Likely
occurred iso holding BP meds due to anorexia and missing HD. BP
remained hypertensive after restarting home medications and
lisinopril was uptitrated and metoprolol was switched to
carvedilol. Discharge regimen was amlodipine 10mg daily,
lisinopril 40mg daily, and carvedilol 12.5mg BID.
#End stage renal disease (MWF HD)
#Electrolyte abnormalities
Initiated HD on ___. Renal failure felt due to ischemic ATN
with possible cardio-renal component. Acidosis, hypokalemia
likely combination of diarrhea and missing HD which improved
after restarting HD. Continue calcium acetate. Last had HD on
___.
#Atrial fibrillation:
#Coagulopathy
Hx of paroxysmal Afib. CHADS-VASc score 4 (CHF, hypertension,
diabetes, age). Patient on Warfarin 2.0 at home, goal INR ___.
INR elevated to >5 on admission iso of poor PO intake. INR
downtrended and warfarin was held for colonoscopy. We continued
carvedilol for rate control. Warfarin was restarted on discharge
at 2mg daily.
#Anemia: Appears to be baseline. Iron supplement held during
admission.
#Hepatitis B c ab positive. Hepatitis B serologies checked in ED
and hepatitis B core ab positive, surface ab positive likely
reflecting immunity ___ natural infection.
CHRONIC/STABLE PROBLEMS:
=========================
#Type II DM:
Last A1C was 5.1 and oral diabetes medications have been stopped
as outpatient
#HIV:
Last CD4 on file 273 in ___. CD4 during admission was 274.
We continued home ART regimen.
#Hypothyroidism
Continued home levothyroxine
#HLD
Continued home atorvastatin
#GERD
Continued home omeprazole | 177 | 427 |
14251620-DS-21 | 23,786,977 | Dear Ms. ___,
You were hospitalized due to symptoms of left arm numbness and
weakness and were found to have some small strokes. Thankfully,
your left arm sensation and strength has returned back to
normal.
You presented to the hospital on aspirin 81 mg daily and
pravastatin 40 mg daily for secondary stroke prevention. We
have discussed with you and have changed your secondary stroke
prevention in order to try to prevent further strokes. We will
have you take aspirin 81 mg daily and clopidogrel 75 mg daily
together for 21 days total. You on ___ will stop taking
aspirin 81 mg daily and only take clopidogrel 75 mg daily
thereafter. We have discontinued your pravastatin 40 mg and
have started you on atorvastatin 40 mg daily. Your LDL level
was about 120 and we want to get that level below 70. The
atorvastatin is a stronger medication compared to pravastatin in
lowering LDL levels.
We will call you next week to schedule a follow up appointment
with a stroke neurologist in ___ months.
Please take all of your other medicines as prescribed.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Patient summary: Ms. ___ is a ___ right-handed woman
with multiple vascular risk factors including HTN, HLD, cervical
and lumbar spinal disease, s/p L4/5 fusion, multiple prior
strokes and TIAs attributed to ASD/embolic versus small vessel
disease who is admitted to the neurology stroke service with a
transient episode of left arm weakness/numbness, dysarthria, and
ataxia secondary to acute ischemic strokes in the precentral
gyrus, frontal lobe, and cerebellum.
Her strokes were most likely secondary to an embolic event given
the multiple cortical infarcts. Ms. ___ presented on aspirin
81 mg daily. We will have her take aspirin 81 mg daily and
clopidogrel 75 mg daily for 21 days total per the CHANCE trial.
Ms. ___ has been instructed on ___ to stop taking aspirin 81
mg daily and to then thereafter only take clopidogrel 75 mg
daily indefinitely or until instructed otherwise by her
outpatient neurologist. Ms. ___ LDL was 120. We switched her
from pravastatin 40 mg daily to atorvastatin 40 mg daily. We
wanted to put her on atorvastatin 80 mg daily because goal LDL
is less than 70, but she did not want to do this right away. We
have sent her out with a ziopatch to monitor for atrial
fibrillation. Ms. ___ will follow up with Dr. ___ with
stroke neurology in ___ months. Ms. ___ will continue to
participate in outpatient physical therapy.
Her stroke risk factors include the following:
1) LDL 120
2) A1c 5.7
3) MRI reviewed and notable for scattered embolic-appearing
infarcts in the cerebellum, precentral gyrus, and frontal lobe
consistent with proximal source of embolization.
4) TTE did not identify PFO/ASD, in contrast to previous
studies, nor any intracardiac source of thrombus.
5) CTA demonstrates patent arteries in the head and neck and no
stenosis.
TRANSITIONAL ISSUES
1) Added Plavix (clopidogrel) 75 mg to aspirin 81mg daily (dual
antiplatelet therapy for 21 days), followed by aspirin
monotherapy for secondary stroke prevention.
2) Stopped pravastatin and started atorvastatin 40 mg daily for
LDL 120
3) Ziopatch (ambulatory cardiac monitor) for 2 weeks
post-discharge to evaluate for atrial fibrillation given
suspected cardioembolic etiology of stroke
4) Her deficits improved greatly prior to discharge; notably,
there is there was no residual left arm or hand weakness/sensory
deficits at the time of discharge.
5) She was evaluated by ___ with plan for home ___ services.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 120) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A | 286 | 669 |
16421543-DS-8 | 23,108,631 | Dear Ms. ___,
You were admitted to ___ for
management of your pain. While you were here, you had a biopsy
taken, a procedure done called pleurodesis, and a pleurex
catheter placed to help drain your lungs of build up of fluid.
For information regarding follow up appointments and discharge
medications, please see below. Please start the dexamethasone on
___, the day before chemotherapy.
It was a pleasure taking part in your care!
Your ___ Team | ___ female with history of chronic pain syndrome and
newly diagnosed metastatic non-small cell lung cancer likely
adenocarcinoma (T2 N3 M1b, stage IV), admitted for pain control
and s/p thorascoscopy, pleurex placement, pleural biopsy and
pleurodesis.
#Pain: Presented initially to the ED in significant pain with
reported loss of her pain medication. Pain is described and
sharp, diffuse over right chest and right back. Patient
describes the pain in her R shoulder blade, R shoulder, R
subcostal area. Pain was worse with deep breaths and movement.
Most likely initially secondary to tumor and extensive thoracic
metastatic disease combined with pleurisy secondary to R pleural
effusion. For further pathology, IP conducted pleural biopsy.
Further, they conducted pleurodesis and placed a pleurex
catheter to assist in drainage of the ongoing pleural effusion.
Patient was transferred to the medicine floor after IP procedure
for pain management. She also has a component of longstanding
fibromyalgia and chronic pain syndrome requiring long term
narcotics. CTA (-) for PE, cardiac work up (-). Her pain regimen
was adjusted, with adequate control of her pain. Chronic pain
management followed her during her hospital course.
#Hypoxia: Likely multifactorial due to effusion, atelectasis and
heavy burden of disease. CTA negative. CXR without evidence of
infection and improved pleural effusion after pleurex drained
effusion, and pleurodesis performed. Patient continued to need
O2 through her stay however and will be discharged with home O2
services in place.
# Leukocytosis: Resolved at discharge. Likely due to
pleurodesis. UCx and blood cultures negative.
#NSCLC: Initial presentation with right arm, shoulder and
thoracic back pain as well as cough and dyspnea. Recently found
to have adenocarcinoma of the lung with a right pleural effusion
and metastatic carcinoma involving a 4R lymph node confirmed
pathologically. PET-CT with evidence of multiple bone
metastases. Clinical stage IV (T2 N3 M1b). The case was
discussed with Dr. ___ primary oncologist), who will
begin chemotherapy on ___. IP was consulted to complete a
thoracoscopy, obtain additional tissue for pathology/mutation
analysis, and pleurex catheter placement on ___. After the
procedure, patient was transferred from the medical oncology
service to general medicine for pain management. Pathology
results are pending at discharge. Her pleurex catheter had < 5cc
drain over 3 days, and prior to discharge IP pulled pleurex. | 74 | 375 |
16078344-DS-8 | 27,437,700 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because there was concern that your mental
status was not at your normal.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given antibiotics to treat a possible urinary tract
infection
- You were given fluids because your blood pressure was low
- Your heart rates were fast, so we restarted a previous
medication ("digoxin") which improved your heart function
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | This is an ___ year old female with past medical history of
paroxysmal afib, hypothyroidism, hypertension, recent admission
___ - ___ for posterior ___ complicated by severe MR and
cardiogenic shock requiring IABP, Vtach, readmitted ___
with confusion, hypotension, atrial flutter, treated for
metabolic encephalopathy, restarted on previously discontinued
digixon, subsequently stabilizing and able to be discharged to
rehab.
# A-flutter with variable block and paroxysmal Afib w/ RVR
Patient with history of pAfib with recent hospital stay during
which her digoxin was discontinued due to concern that it could
be contributing to mental status changes. Patient re-admitted
within 24 hours of discharged with a-flutter with uncontrolled
rates. Worked up for infectious or other general medical causes,
but none identified. Patietn was seen by cardiology consult
service who recommended restarting digoxin 0.25mg ___ for RVR.
Patient subsequently with improved rate control, remaining
stable on maintenance digoxin with rates controlled. Continued
metoprolol 50mg XL daily, digoxin 0.0625 daily, apixaban 2.5 BID
# Hypotension:
Patient referred for readmission after found to have SBP ___ at
___. Workup for infection was without positive
findings. Appeared euvolemic. Normal lactate. Course notable
for afib/flutter with poorly controlled rates as above.
Hypotension was thought to relate to poorly controlled rates in
setting of her low EF. Repeat TTE ___ showing stable EF of
___ in comparison to TTE on ___. Lisinopril and Lasix were
held on admission. Continued to hold lisinopril given risk for
hypotension. Continued to hold lasix given stable weights over
5 day hospital course without any diuretic. Discharge weight
and transitional issue as below.
# Acute metabolic encephalopathy
Patient referred for admission with agitation and confusion.
Infectious workup was negative and neurologic exam without focal
abnormalities. Sedation worsened following a dose of seroquel
(given due to agitation). Patient subsequently managed with
delirium precautions, avoiding sedating medications. Her mental
status returned to baseline over 48 hours. Initial presentation
thought to be due to being transferred to ___ at ~1am, lack of
sleep, medical illness as above, overlying chronic mild
cognitive impairment. She received several days empiric
antibiotics before all cultures returned without growth. Prior
to discharge family confirmed patient at her baseline mental
status.
# Recent ___ c/b cardiogenic shock (resolved) with cardiac
balloon pump placement: IABP removed ___
# Severe MR
# Chronic ___ ___, elevated BNP (around
baseline)
# CAD
Admitted with elevated troponin, but overall decreased from
recent admission. Did not endorse any chest pain on arrival and
EKG was without significant ischemic changes. Did not appear
volume overloaded. Continued Metoprolol 50 daily, continue
Plavix 75 daily (started at prior hospitalization), continue
atorvastatin 40mg. Lasix and lisinopril held as above.
#Subacute infarct in the left posterior frontal lobe
On review of data from recent admission, noted MRI ___ showing
possible subacute stroke. Neurology consulted during this
admission felt probable punctate L frontal infarct, potentially
occurring during her severe illness last admission, but unlikely
to have contributed to her presenting symptoms. Recommended to
continue on her maximum medical therapy (clopidogrel, apixiban,
atorvastatin). Family was made aware of this diagnosis.
#Dysphagia - Kept on aspiration precautions per prior admission.
# Hypothyroidism: Continued home Synthroid 75mg daily. | 137 | 536 |
17195386-DS-21 | 21,177,910 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why were you hospitalized?
You were hospitalized because you suffered a fall at home and
hit your head, and while being evaluated in the emergency room,
you were found to have elevated kidney function tests.
What was done for you in the hospital?
-We scanned your head and neck and did not find any broken bones
-We checked your urine. Initially it looked like you had an
infection, which we treated with antibiotics. Your final urine
tests did not show infection, so we stopped the antibiotics
early.
-Your kidney function was higher than normal, which we think is
because of not eating and drinking as much as you need to. We
gave you fluid through the IV to help your kidneys. Your kidney
function partially improved with IVF. We also obtained an
ultrasound which showed kidney stones in both your kidneys, with
interval worsening of your known kidney stone burden on the
left. No intervention was planned by urology or nephrology,
however you will be seen in clinic by both urology and
nephrology to continue to monitor your kidney function
longitudinally to ensure that it does not worsen.
-We had Physical Therapy come and evaluate you for safety
-We checked your pacemaker, and it showed that your heart rhythm
had been normal.
-All these checks revealed that your fall was probably
mechanical because you stumbled or because of weakness.
What should you do after you leave the hospital?
-Please work with physical therapy in rehab to get stronger and
prevent further falls.
-Follow up with your doctors as listed below.
-Keep taking your medications as before.
-Make sure you eat and drink enough and don't skip meals.
Please also take your medications as prescribed below, and also
followup at the appointments listed below that have been
arranged on your behalf.
We wish you the best!
Sincerely,
Your ___ Team | Mr ___ is a ___ man with BPH, dementia, hypertension, atrial
fibrillation not on anticoagulation, who came in after a fall,
found to have orthostatic hypotension and ___.
# Acute Kidney Injury
# Bilateral staghorn calculi:
Patients creatinine was notably elevated at 2.3 on arrival, with
patient's baseline in the past year ranging from around 1.1-1.5.
However, patient has had elevated Cr on prior admissions from
1.1-2.3 over past ___ year period. Nevertheless, given history of
dementia and initial response to IVF, etiology was thought to be
pre-renal secondary to poor PO intake. Patient was fluid
resuscitated with improvement of Cr to 1.7. He was bladder
scanned to ensure that he was not retaining urine. Cr continued
to remain at 1.7-1.9, currently 1.9, not further improving with
IVF. Urine lytes were obtained and notable for FeNa of 1.5%
concerning for possible intrinisic pathology. Renal U/S was
notable for persistent extensive stone burden on the left with
moderate left hydronephrosis, and interval decrease in stone
burden in the right kidney w/o hydronephrosis, with numerous
stones in the bladder. Pt continues to have PVRs persistently in
~150s. Urology consulted, deferring intervention as pt is a poor
surgical candidate, and temporary nephrostomy tube would only be
a bridge to surgery. Furthermore, his stones are likely chronic,
and patient has had improvement in Cr function with IVF and
produces good urine currently, making post-obstructive uropathy
less likely. Case was discussed with renal for further
assessment of chronic pathology, who noted that pts calculated
eGFR is not significantly changed from prior, with patient
having evidence of multiple insults with bilateral stones and
uric acid crystals in the past resulting in his elevated Cr, and
is currently per baseline. Plan was made for patient to followup
as an outpatient with urology and Nephrology for close
monitoring to ensure no further worsening of his kidney
function, and further for patient to be monitored with
bladderscans/post-void residuals to ensure that patient does not
develop signs of obstructive uropathy.
# Abdominal hernia: on admission, large hernia noted surrounding
ostomy. Nontender and reducible, low concern for strangulated or
incarcerated hernia.
# Fall: Patient with history of mechanical falls prompting
hospitalizations in the past year. Head and C-spine CT, as well
as CXR negative for new fractures or bleed. EP interrogated
patient's pacemaker but did not find any evidence of arrhythmia.
Patient was notably frail and inattentive, and his orthostatic
vital signs were positive with >20 point drop in systolic
pressure from lying to standing. He received fluid resuscitation
per above, with improvement in his BPs, however he remains
orthostatic with changes in position, likely multifactorial in
nature (see below). Patient was seen by ___, who recommended
rehab for strengthening, and was advised regarding making slow
changes in position to allow blood pressures to adjust
appropriately and prevent light-headedness with position
changes.
# Orthostatic Hypotension: positive orthostatic vitals signs on
both ___ and ___, with SBP on ___ decreased from 148->125.
Etiology may be in setting of hypovolemia, medication effect (as
on tamsulosin), or autonomic dysfunction given age. IVF was
given per above, and patient was further evaluated and
progressed by ___, who noted that patient will benefit from rehab
to aid in strengthening and would benefit from slow transfers to
allow blood pressures to equilibrate with changes of positions.
# Pyuria: UA in ED concerning for UTI given few bacteria, WBC
25, RBC >182, leuks trace. Unable to obtain corroborating
history given patient's baseline dementia. Received 1 dose of
Bactrim in ED, switched to ceftriaxone given ___ once on the
floor. Final urine cultures were negative for UTI, however, thus
ceftriaxone was continued.
# Dementia: inattentive, AAOx2. No focal neurologic deficits, CT
head w/ e/o bleed. Appears to have declined steadily in the last
6 months but without acute decline leading up to this fall.
Currently living in a dementia unit. Patient was continued on
ramelteon 8mg qhs prn for sleep, and acetaminophen 1000mg q8h
prn for pain.
# Hypertension: during this admission, pt was not on home
anti-hypertensive medications. Is on tamsulosin qhs for BPH. SBP
120s-170s. Asymptomatic. No additional blood pressure medication
given.
CHRONIC ISSUES:
===============
#Hypothyroidism: continued home levothyroxine
#BPH: continued home tamsulosin
#Depression: continued home sertraline
#Abdominal hernia: large hernia noted surrounding ostomy.
Nontender and reducible, low concern for strangulated or
incarcerated hernia. | 308 | 716 |
14049067-DS-13 | 23,139,829 | Dear Mr. ___:
You were admitted to ___ for evaluation and treatment of your
diverticulitis. Interventional radiology attempted to place a
drain in ab abscess that you developed in association due to
your diverticulitis however this was not possible given the tiny
size of the abscess. You were thus treated with antibiotics and
bowel rest until you were feeling better. You are now ready to
continue your recovery at home.
Medications: You will be discharged on your home medication
regimen. You will also be discharged home on antibiotic
medications. It is very important that you complete the entire
course of these medications regardless of whether you are
feeling better. Otherwise your infection is likely to come back.
Diet: You may resume your regular home diet.
Activity: You may resume your regular home activities without
activity restriction.
Please do not hesitate to contact our clinic ___ if
you experience fevers/chills, nausea/vomiting, worsening of your
abdominal pain, changes in your bowel movements or any other
symptoms that concern you. | Ms. ___ was admitted to ___ on ___ following
presentation in the ED with abdominal pain which on CT done in
the ED appeared to be due to active diverticulitis with a very
small pericolonic fluid collection. He was started on IV Cipro
and IV flagyl and bowel rest with fluid resuscitation. An
attempt was made by the interventional radiology team to
percutaneously drain the abscess however this was aborted. It
was ultimately felt that the fluid collection was likely too
small and resolving sufficiently such that it does not require
additional drainage. Mr. ___ diet was gradually advanced
over the following 24 hours to regular, which he tolerated. His
abdominal pain continued to improve and was nearly completed
resolved at the time of discharge.
Mr. ___ at the time of discharge was ambulating, eating,
tolerating oral medications, and toileting himself. He was
discharged on 2 weeks of oral cipro and flagyl with scheduled
follow up. | 164 | 156 |
11673166-DS-10 | 24,088,788 | Dear ___,
___ was a pleasure taking care of you at ___. You were admitted
for shortness of breath and cough. This may be in part caused
by your asthma, however, we are also concerned about obstructive
sleep apnea and/or COPD (chronic obstructive pulmonary disease).
We are discharging you with a new steroid inhaler for your
asthma symptoms. We are in the process of scheduling an
appointment with a lung doctor ___ below), who can refer you
for further lung testing for asthma and COPD. You should
complete your scheduled sleep study to test for sleep apnea. We
strongly encourage you to stop smoking. | ___ yo female with history of asthma, chronic hepatitis C,
depression, anxiety presenting with shortness of breath and
cough.
ACTIVE ISSUES
-------------
# Shortness of breath/cough: Differential includes asthma
exacerbation, COPD, pulmonary hypertension. Patient has a
history of asthma but has not responded to repeated prednisone
tapers over last several weeks or to increasing her
albuterol/ipratroprium use, suggesting there may be another
process contributing to current presentation. Her history of
snoring and witnessed apneic episodes are concerning for
obstructive sleep apnea which can result in pulmonary
hypertension. A TTE performed this admission showed mild
pulmonary hypertension. COPD is also possible given her smoking
history. She had no fever, leukocytosis, sick contacts or recent
travel to suggest an infectious etiology. Her TTE showed no
evidence of heart failure. No household or occupation exposures.
She has not started any new medications and is not an ACE
inhibitor or ___. Her GERD is well controlled on pantoprazole
with no heartburn symptoms. Peak flow 205-230 this admission.
Her lung exam was relatively benign, with mild expiratory
wheezes and slightly decreased air movement on admission that
improved with albuterol and ipratroprium nebulizers as well as
initiation of advair. She was given guaifenasin and benzonatate
for cough. She should follow up with a pulmonologist as an
outpatient; pulmonary function testing is strongly recommended
to evaluate asthma and possible COPD. A sleep study is also
recommended to evaluate for obstructive sleep apnea. She was
discharged with a prescription for advair to help better control
her asthma symptoms.
# Tobacco use: She is motivated to quit smoking and has set a
quit date of ___. She was discharged with nicotine patches.
INACTIVE ISSUES
---------------
# Depression/anxiety: Stable. Continued home fluoxetine,
trazodone, gabapentin, alprazolam.
# GERD: Stable, asymptomatic. Continued home pantoprazole.
.
## Transitional issues:
- started advair discus inhaler for better control of asthma
symptoms
- started benzonatate and guiafenesin for cough
- recommend sleep study to assess for OSA
- recommend Pulmonology f/u and PFTs to confirm asthma diagnosis
and assess for COPD
- please encourage smoking cessation, she is discharged with
nicotine patches and has set a tentative quit date of ___
# CODE STATUS: Full
# EMERGENCY CONTACT: ___ (daughter) ___, ___
(son) ___ | 108 | 359 |
14184360-DS-15 | 29,735,087 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
on ___ after you were found to have fallen at home. This may
have been due to a seizure-like episode in response to stress.
You had several similar stress-related episodes in the hospital
but were felt safe to go home and follow up with your doctor in
clinic.
Please continue to take your medications as prescribed and
follow up at Healthcare Associates as listed below.
Best wishes,
Your ___ Medicine Team | Hospital course: Ms. ___ is a ___ with past medical
history of T2DM, HLD, anxiety and history of pseudoseizures who
presents with pseudoseizures and fall, admitted over safety
concerns, and also reporting history of unintentional weight
loss associated with early satiety. She had multiple
pseudoseizures while admitted. She was evaluted by psychiatry
who recommended outpatient psychiatry referral although patient
declined. She further declined ___ for home safety eval.
# Pseudoseizures: Per ___ in OMR, manifestations of her prior
pseudoseizures include neurological symptoms such as grimacing,
inability to speak, and lip smacking. She was also noted to have
rhythmic movements of her extremities, both upper and lower. No
hypoglycemia. No focal neuro deficits on my exam, no report of
tongue biting, incontinence of post-ictal state to suggest
seizure. Not likely hyponatremic (see below). Stress about being
estranged from her children, especially on Mother's day, and
stress about decreased energy and weight loss may have
contributed. We continued her home clonazepam for anxiety. She
was evaluted by psychiatry who recommended outpatient psychiatry
referral although patient declined. She further declined ___ for
home safety eval.
# Fall in the ED: Patient reports not remembering her fall. Do
not think this represents cardiac syncope as trop < 0.01, no EKG
changes, and prior history of falls associated with episodes of
pseudoseizures. She was monitored on telemetry, which was
unremarkable. Had normal stress echo in ___. Head CT
unrevealing for any sustained head injury.
# Weight loss: Has been evaluated twice in ___ clinic with no
clear etiology except for hypothyroid state, which is now
improved. Early satiety is concerning and, EGD in ___ showed
fundic gland polyp with chronic inflammation. She may benefit
from a repeat EGD, which may be done on an outpatient basis.
Though she endorses depression, she reports that she has had
this her whole life and it was not associated with weight loss
in the past. No hx of emesis to suggest obstruction. She may be
due for a mammogram per PCP ___. At the time of discharge,
continued outpatient work-up was recommended.
# T2DM: In the setting of pt reporting poor PO intake, decreased
lantus to 10U with standard inpatient sliding scale.
# Hypothyroidism: TSH WNL. Continued home levothyroxine.
# HLD: Continued atorvastatin.
# CODE STATUS: full, confirmed
# CONTACT: ___ (daughter) ___, ___ (son)
___ | 84 | 391 |
18576427-DS-15 | 27,652,047 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Discharge Instructions:
INSTRUCTIONS:
-Your in the hospital for pain management and evaluation of your
function after a pelvic fracture. Your fracture does not need
surgery.
- 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 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.
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
- 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.
Please also discuss an incidentally found right upper lobe
nodule that was noted on your chest CT with your primary care
physician.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right lateral compression type I fracture and was
admitted to the orthopedic surgery service. The patient was
treated nonoperatively and worked with physical therapy who
determined that discharge to rehab was appropriate. The patient
was given anticoagulation per routine, and the patient's home
medications were continued throughout this hospitalization. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is weightbearing as tolerated and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. [] 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. | 474 | 175 |
12232510-DS-48 | 22,072,963 | Dear Mr. ___,
It was a pleasure taking care of ___ during your recent
admission to ___ came to us after a fall,
and we found that ___ had broken your right arm. We gave ___ a
sling and pain medications, and ___ will follow up in clinic
with orthopedic surgery. We also found that ___ had a temporary
worsening of your kidney function, which improved after we gave
___ some fluids. We also performed an infectious work-up and it
was negative. ___ will be going to rehab, where ___ can regain
your strength and continue your recovery.
We held a number of your heart failure medications this
admission including lasix, metoprolol, isosorbide, and
hydralazine. These should be restarted sequentially by your
doctors at your rehab.
We wish ___ the best of health.
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Non-weightbearing right upper extremity. Please continue to wear
the cuff and collar sling. | Mr. ___ is a ___ man with h/o AML in ___ s/p BMT
in ___, secondary hemachromatosis, chemo-induced cardiomyopathy
(EF=20%), CKD (baseline Cr 3.5-4), HTN, BOOP on 3L home O2, who
presented after mechanical fall and was found to have right
shoulder fracture and ___ on CKD.
============== | 159 | 48 |
16780307-DS-9 | 27,741,871 | Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You presented after passing out at your rehabilitation facility.
It is most likely that your epsiode was most likely due to an
acute drop in blood pressure while urinating. You will now need
to be helped to and from the bathroom when urinating to ensure
you do not pass out and hit your head again. In addition, your
blood pressure was found to be low when you stand up. You will
need to take a new drug called Fludrocortisone to help keep your
blood pressure higher. You will need to take neupogen
injections daily while your white cell counts are low. In
addition, you will be started on a new antibiotic, Levaquin, to
help prevent inections. Please follow up with your scheduled
follow up with your primary oncologist, Dr. ___, as an
outpatient ___ at 10:30AM.
New Medications:
Fludrocortisone 0.1 mg by mouth every morning
Neupogen 480 mcg subcutaneous injection daily
Levaquin 500 mg by mouth daily
Stopped medications:
Allopurinol ___ PO daily | ___ year old M with refractory Hodgkin's lymphoma on salvage
chemotherapy presenting after a syncopal episode at rehab | 179 | 19 |
14919793-DS-3 | 26,857,567 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital after having intractable abdominal pain while at
home. Here, you underwent imaging which showed inflammation of
the large intestine, or colitis. We believe the reason you have
inflammation is actually intermittent reduced blood supply to
that organ. You also underwent a partial colonoscopy which
showed this as well, and given that your pain was still not
improving fully, you underwent a full colonoscopy on ___ which
showed the same type of injury. While your pain has been
improving, it may take some time to fully become pain free as
your large intestine recovers from this insult.
The following changes were made to your home medication regimen:
1. START Nicotine Patch
2. START Oxycodone 5 mg every ___ hours as needed for pain
3. START Dicyclomine 10 mg three times daily for 2 weeks
4. START pantoprazole 40 mg every day
Please continue to take your other home medications as
prescribed. Please follow-up with your primary care doctor, and
a gastroenterologist for follow-up visit and full colonoscopy at
that time. Please keep up the good work by NOT smoking in the
future as well.
Take Care,
Your ___ Team | Mr. ___ is a ___ year old male who presents with acute onset
LLQ abdominal pain, bloody diarrhea and imaging concerning for
ischemic colitis.
.
>> ACTIVE ISSUES:
# Abdominal Pain: Patient was seen in the ED, after sustaining a
very acute onset of ___ left lower quadrant pain, accompanied
with bright red blood per rectum. In the ED, patient underwent
CT scan which was concerning for colitis in a vascular
distribution, most likely concerning for an ischemic type
colitis. Patient was evaluated by both the Gastroenterology and
Acute Care Surgical (ACS) service, at which point patient was
admitted to medicine for further workup. Other differential
diagnoses included infectious type colitis, and therefore stool
studies were sent for microbial etiologies including C. diff, E.
Coli O157:H7, and stool culture. Patient was empirically started
on IV Ciprofloxacin and Metronidazole to ensure coverage of
these organisms, and C. diff returned negative. Further, it was
discussed that patient's imaging may be consistent with
ulcerative colitis, however thought to be less likely given no
involvement of the rectum, and vascular distribution of disease.
Therefore, it was recommended that patient undergo serial
abdominal exams, bowel rest, IVF, and was pain controlled.
Throughout hospital stay, patient continued to have severe
abdominal pain requiring IV hydromorphone for symptomatic
relief, and patient continued to have bouts of melena and
hematochezia. Patient was evaluated daily by the ___ and GI
services, and over the hospital stay, patient continued to have
non-recovery of pain symptoms, and abdominal exam remained
continously out of proportion. Therefore, given slower clinical
recovery and unchanging abdominal exams, patient underwent a
dedicated CTA scan which revealed unchanged colonic wall
thickening, edema in the transverse colon, inflmmatory fat
stranding consistent with an ischemic etiology . Further, ___
and SMA remained patent, and no pneumatosis, gas, free fluid or
air was seen. Patient continued to have non-improvement in
clinical symptoms and pain, and given prolonged course of
abdominal pain without much relief, patient underwent flex
sigmoidoscopy on ___, which revealed mild proctitis with
normal colonic mucosa type for 50 cm of exam. Biopsy of colonic
mucosa also consistent with ischemic type injury as well, and
therefore given normal appearing colonic mucosa on
sigmoidoscopy, patient was trialed on diet on ___. Given
biopsies consistent with ischemic type injury, patient completed
a 7 day course of IV Cipro/Flagyl, and pain control was weaned
to oral medications, with advancement of diet. Patient tolerated
food on ___, however then developed again worsening abdominal
pain. KUB at that time did not reveal any signs of obstruction,
perforation, free air, and lactate 1.5. Therefore, unclear
picture given no signs of ischemia on laboratory values. Patient
was started on oral dicyclomine per GI recommendations to help
with pain, and thought that patient may have component of hyper
algesia given prior pain clinic history. Patient was given IVF,
IV hydromorphone for symptomatic relief, and then trialed on
transition back to PO oxycodone. Patient continued to have
episodes of melanotic stools, however discussed with GI that not
uncommon given injury. However, as acute care surgery still
concerned for possible missing other etiologies, patient
underwent a colonoscopy on ___. Findings from colonoscopy
include diffuse continous ulceration, granularity, friability
and pseudopolyps with congestion, compatability with colitis
most likely ___ to underlying ischemia. Patient also had several
sessile polyps ranging in size, and therefore would require
colonoscopy for screening purpose in several months. Patient
continued to have abdominal pain, although improving, however
was not improving at rate consistent with ischemic colitis. To
further evaluate, patient underwent a repeat CT scan which
showed interval improvement in his colitis, without perforation,
and therefore surgical intervention was not indicated. Patient
to continue conservative management with pain control and
follow-up with ACS in 2 weeks for further evaluation.
.
# Left Ulnar Neuropathy: Patient with past history of ulnar left
neuropathy, however no changes in past pain regimen. Patient was
continued on home gabapentin. Of note, patient has had several
episodes of neuropathic pain requiring pain clinic at ___.
However, patient eventually was referred to other specialists
for chronic pain complaints.
.
# Asthma, controlled: Continued on albuterol PRN while
inpatient.
.
# Tobacco Cessation: Given ischemic type injury, discussed with
patient need for smoking cessation. Patient was very interested
in this, and was started on nicotine patch while inpatient, to
be continued while outpatient.
.
# Insomnia/Depression: Patient was continued on home
amitriptyline while inpatient.
.
>> TRANSITIONAL ISSUES:
# Ischemic Colitis: OK for patients to continue to have mild
episodes of melena as colon mucosa recovering. Patient to have
full colonoscopy as both nvestigatory and screening (age ___,
found to have polyps on colonoscopy while inpatient) at follow
up appointment. Will need follow up in 2 weeks with ACS
# Pain Regimen: Prescribed 5 mg Oxycodone q ___ hours x 24 tabs
; also given dicyclomine anti-spasmodic to take short term
# Smoking Cessation: Encouraged, and patient was prescribed
nicotine patch 21 mcg (please taper as outpatient)
# HIV Test negative while inpatient. | 207 | 829 |
12882985-DS-43 | 28,588,627 | You presented to the hospital with fevers, back pain and pus
draining from your nephrostomy tube, consistent with a
genitourinary tract infection. You were placed on IV
antibiotics. You were seen by the Infectious Disease Consult
team and the Urology Consult team. You had a PICC line placed
and will need to complete a course of IV antibiotic (Ertapenem).
.
Your blood cultures returned positive for bacteria, but this is
likely a contaminant. However, we do recommend that you have
blood cultures re-checked by your PCP 1 week after completing
your IV antibiotic course.
.
An incidental 5 millimeter (less than 1 cm) lung nodule was seen
on your CT scan by the radiologist. It is recommended that you
have a repeat CT scan of the lungs in 3 months to make sure this
is nothing more than an incidental scar. Your PCP has been
informed and a copy of Dr. ___ letter to Dr. ___ this
matter is being sent to your home address. | ___ year old Male with T12 paraplegia, bladder incontinence s/p
ileal conduit and L nephrourostomy with recurrent
pyelonephritis, seizures, CKD IV presenting with infection of L
nephrostomy tube.
.
# Abscess adjacent to Percutaneous Nephrostomy Tube # UTI #
Bacteremia
No evidence of abscess on ultrasound and CT scan. Responding to
antibiotics with resolution of fever and elevated WBC. Likely
true polymicrobrial UTI with GAS and E.coli. CoNS Bacteremia is
likely contaminant. Per Urology, would not change PCNT during
active infection. Followed by ID consult service not this
admission. Initially on Meropenem, but will transition to
Ertapenem via PICC line for 2 week course from ___. He
was also seen by Wound Care for management of dressing around
his PCNT. For his CoNS bacteremia, likely contaminant. ID
recommends repeat blood cultures 1 week after completion of IV
antibiotic course. Will need to follow-up with Urology and they
indicated they would f/u with him before his antibiotic course
is over (apptmt pending).
.
# Acute Renal Failure on CKD Stage IV, improving, Cr back to
baseline. Likely pre-renal ___ in setting of infection.
- Renally dose medications
- Avoid nephrotoxins
- continued NaHCO3 and Sevelamer
.
# Benign Hypertension
# Anemia of CKS
- On iron supplementation
- Consider outaptient Epogen
- stable H/H during hospitalization.
.
# Epilepsy
- stable, continue home Keppra
# Chronic Pain
- Oxycontin, PRN PO dilaudid when able
. | 166 | 227 |
13360415-DS-12 | 22,553,288 | 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:
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.
For blisters near incision:
Commercial wound cleanser or normal saline to cleanse blisters
surrounding left hip superior incision.
Pat the tissue dry with dry gauze.
Leave intact blisters intact.
Apply Adaptic dressing to unroofed blisters (non adherent
dsg)
Cover entire area with large Sofsorb sponge
Secure with Medipore tape
Change daily
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 left lower extremity
No range of motion restrictions
No braces or splints needed
Upper extremity assist as needed
Treatments Frequency:
Dry sterile dressing overlying surgical incisions closed with
staples
Once surgical dressing falls off, no need to replace unless
incisions are actively draining
For blisters near incision:
Commercial wound cleanser or normal saline to cleanse blisters
surrounding left hip superior incision.
Pat the tissue dry with dry gauze.
Leave intact blisters intact.
Apply Adaptic dressing to unroofed blisters (non adherent
dsg)
Cover entire area with large Sofsorb sponge
Secure with Medipore tape
Change daily | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have a left intertrochanteric hip fracture and was admitted
to the orthopaedic surgery service. The patient was taken to the
operating room on ___ for ORIF left hip intramedullary nail,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate.
On postop day 2 patient was transfused 2 units of packed red
blood cells for hematocrit of 22.8 with appropriate response.
Wound care was consulted for development of ___
blisters from Tegaderm dressing. The following recommendations
were made:
Commercial wound cleanser or normal saline to cleanse blisters
surrounding left hip superior incision.
Pat the tissue dry with dry gauze.
Leave intact blisters intact.
Apply Adaptic dressing to unroofed blisters (non adherent
dsg)
Cover entire area with large Sofsorb sponge
Secure with Medipore tape
Change daily
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
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 694 | 353 |
16732638-DS-10 | 23,044,818 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for worsening of your heart function which caused fluid to
accumulate in your lungs and legs. We gave you strong
medications to help you remove the excess fluid, but
unfortunately we were not able to help you improve and your
kidneys failed. Given your poor condition, we decided, along
with you and your family, to primarily pursue comfort as opposed
to aggressive measures. We will continue diuretics and will
focus on relieving your shortness of breath with opiates such as
oxycodone. | ___ with PMH COPD, CHF unknown EF, presents with likely demand
ischemia given symptoms (despite elevated troponins with flat
MB), acute on chronic CHF exacerbation, and hyperkalemia likely
from supplemental K (tough did not take on day of presentation),
now improved
# CORONARIES: Patient has known CAD s/p multiple stents and CABG
likely having demand ischemia from acute on chronic CHF. Patient
was already on plavix, started on high dose aspirin, and high
dose statin (80 atorva), and carvedilol. Troponins were flat at
0.3. Patient was initially on heparin drip which was stopped in
the setting of likely demand ischemia, as trops were flat.
Patient underwent pharmacologic stress adn perfusion imaging
which showed an irreversible defect. Decision was made to
_______ .
# PUMP: Patient presented with acute on chronic CHF
exacerbation. Per his daughter, his weight was DC from rehab was
201 and on admission was 204. Patient was diuresed wtih 40 IV
lasix x1-2 qd until his peripheral edema decreased, his crackles
decreased, and his breathing improved. He went to Echo which
showed 4+MR, inferolateral and inferior hypokinesis,
concerningfor RCA territory ischemia. Patient went to
pharmacologic stress with perfusion imaging which showed
irreversible defect ____. Decision was made to _________ re:
catheterizstion.
# HTN: No evidence of HTN on admission. Patient was on labetalol
which was switched to carvedilol to heart failure as above
# ___: Trend creatinine. Admitted at 1.7, and stable at 1.7
durnig hospitalization. Lisinopril was held ______
# COPD: Patient was continued on singulair, spiriva and prn
duonebs.
# Gout: Patient was continued on allopurinol and percocet. | 96 | 257 |
15140113-DS-19 | 27,659,903 | Dear Ms. ___,
You were admitted for evaluation of palpitations and jaw
pain. We were initially concerned about a heart attack. However,
your lab tests and the stress test were both reassuring that you
did not have a heart attack.
While you were here you were also noted to have elevated
blood pressure to the 200s which is quite high! We increased
your lisinopril and added on another drug called
hydrochlorothiazide.
The following changes were made to your medication regimen:
STOP lisinopril
START Lisinopril/Hydrochlorothiazide 20mg/25mg daily
Otherwise, take all of your medications as prescribed. | Ms. ___ is a ___ year old with a history of DM, HTN, and
COPD who presented with neck pain/palpitations concerning for
acute coronary syndrome.
# Chest pain/Palpitations: Ms. ___ certainly has risk
factors for ACS, and a rule out was performed with troponins x 2
which was normal. A myocardial perfusion scan was performed
which was within normal limits with a small area of questionably
decreased tracer uptake in the inferior wall likely due to soft
tissue interference. ACE inhibitor, BB, and ACE were continued.
# Hypertension: Ms. ___ blood pressures were quite high
while she was admitted reaching 200s/110s. Ms. ___
pressures were controlled with PRN captopril. While she was
admitted, her daily lisinopril was increased to 20mg daily and
HCTZ was started at 25mg daily. One potential explanation for
Ms. ___ poorly controlled hypertension is untreated OSA.
Ms. ___ has been ___ to her CPAP therapy for OSA
as this has been causing her sinus trouble. She may benefit from
mask re-fitting.
# DM: Lantus was continued.
# GERD: Omeprazole was continued.
# Allergic rhinitis: Fluticasone was continued. | 98 | 181 |
19908221-DS-25 | 27,717,842 | Dear Mr. ___,
It was pleasure to take part in your ___ during your stay here
at ___. You came to the hospital after your family was
concerned about you being confused and having a fever. You were
treated upon your arrival with antibiotics for an infection in
your lungs and for your confusion using a medication called
lactulose. You were started on IV antibiotics and then
transitioned to oral antibiotics prior to discharge. You will be
given one dose of antibiotic (levofloxacin). You will take this
last pill after your next outpatient hemodialysis apt.
Your lactulose regimen was increased during you hospital stay.
It is vital that your take your lactulose at home every day. You
should titrate the amount you take in order to have at least 2
BMs per day. If you start to feel confused or begin to have
recurrent fevers you should call your Liver Doctor immediately.
You will follow up with your Liver Doctor and your Primary ___
Physician.
Thank you for allowing us to participate in your ___ during
your stay in the hospital.
Sincerely,
Your ___ Team | ___ with HCV cirrhosis, diastolic CHF, diabetic neuropathy and
ESRD from MPGN and cryoglobulinemic vasculitis presents with
fever and confusion. Per wife's report, the patient has had
confusion on and off for the past few days in the setting of
refusing to take his lactulose. The patient also presented with
a fever. CXR at OSH read as pneumonia. Patient started treatment
for HCAP on presentation with vanc/cefepime. Pt fever curve
trended down and CXR did not show large consolidation, CT showed
evidence of chronic aspiration but no evidence of active
infection. Patient transitioned to Levaquin on ___ and
received his last dose of antibiotics on ___. Patient was
counseled on making sure to take his Lactulose daily and
titrating BMs in order to avoid worsening encephalopathy.
Patient will follow up with his Liver team and with his Primary
___ Physician.
ACUTE ISSUES
# ACUTE HEPATIC ENCEPHALOPATHY. Pt presented with confusion,
which has improved with lactulose suggesting HE as etiology.
Pt's fever overnight suggests infection as contributing
component as well. Mental status improved since fevers broke.
We titrated lactulose to ___ per day; Dr. ___
conversation with patient and he agreed to take his lactulose at
home after explanation of why it prevents confusion. At time of
discharge patient was A+Ox3 and mentating well.
# FEVERS. Fever to 102 on evening prior to presentation. No
clear source of infection. CXR without new consolidation to
suggest interval development of infectious process. No UA given
anuria. LP unsuccessful. History of cellulitis, but no sources
on exam. CBC without leukocytosis. No ascites on CT seen to
evaluate for SBP. Patient started on Vanc/cefepime/flagyl on
admission for broad coverage. Was transitioned to levofloxacin
for treatment of community aquired pneumonia. CT did not show
focal consolidation prior to discharge, but did show evidence of
chronic aspiration.
# HYPOXIA. Requiring CPAP in ___, and weaned down to room air
with clearance of his delirium. Was likely due to acute
confusion vs OSA vs opiate use. Patient will need outpatient
follow up for possible CPAP with sleep study.
CHRONIC ISSUES
# HEP C CIRRHOSIS: MELD score of 22 on admission. Child's ___
B, due to Hepatitis C s/p failed treatment with IFN. Not
eligible for new treatments due to ESRD per hepatology. No
history of esophageal varices or SBP, however he has had hepatic
encephalopathy in the past and is on daily lactulose, but did
not take it at home. Restarted lactulose, rifaximin.
# TYPE 2 DIABETES. HbA1c 6.1% in ___. Cont home NPH,
glargine, HISS
# CRYOGLOBULINEMIA: Previous labs in support of cryoglobulinemia
with RF 325, C4 levels <2. Most likely due to Hepatitis C, and
would benefit from treatment if he were eligible. He had no
other evidence of other organ involvement related to
cryoglobulinemia.
# CHF, DIASTOLIC, CHRONIC. Euvolemic on exam. Cont torsemide,
metoprolol and HD as scheduled.
#ESRD: Cont HD while in patient.
# CAD. Continue aspirin and atorvastatin.
# ASTHMA. Continue Advair.
# SEIZURE DISORDER. Continue Keppra.
# CHRONIC PAIN. Held opiates for now given acute confusion on
admission. Restarted after patient's mental status cleared.
TRANSITIONAL ISSUES
-Pt will be discharged on Lactulose 30ml PO TID (titrate to ___
BMs per day)
-pt will be discharge on Rifaximin 550mg PO BID
-pt will take last dose of levofloxacin 500mg PO x1 after his
next hemodialysis apt (after leaving the hospital)
-pt will need to go to his regularly scheduled dialysis apts
after leaving the hospital
-pt will f/u with the ___ after discharge | 185 | 593 |
17829563-DS-7 | 22,747,869 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted because your blood was too
thin on your Coumadin, and because you fell, had a fracture of
your tailbone, and had a small bleed in your brain. You were
seen by our orthopedic surgeons and our neurosurgeons, and you
did not require immediate surgery. You will be seeing an
orthopedic surgeon after discharge.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below. We wish you
the very best!
Warmly,
Your ___ Team | ___ is a ___ y/o woman with a PMH of MVR and a fib on
Coumadin, cirrhosis, CHF, hemolytic anemia, UC s/p colectomy,
who presented from OSH s/p mechanical fall with coccygeal
fracture and subarachnoid hemorrhage in the setting of
supratherapeutic INR from fluoroquinolone use.
# Sacrococcygeal fracture. This occurred in the setting of a
mechanical fall at home. She was evaluated by orthopedic
surgery, who recommended no acute surgical intervention. Her
pain was well controlled with Tylenol ___ mg q8h PRN and
tramadol ___ mg q6h PRN, as well as with a lidocaine patch.
She is scheduled for outpatient orthopedics follow-up.
# Subarachnoid hemorrhage. As above, in the setting of
mechanical fall at home; evaluated by neurosurgery, who
recommended no acute surgical intervention. Her neurologic
examination was normal. She was started on a 7 day course of
Keppra, to be completed ___. Repeat head CT after restarting
warfarin demonstrated no new bleed.
# Coagulopathy. Ms. ___ had supratherapeutic INR (13 at OSH),
likely from inconsistent warfarin use in conjunction with
fluoroquinolone use. She is anticoagulated for atrial
fibrillation and mechanical mitral valve. She received Vitamin K
and Kaycentra at OSH. She was bridged to Coumadin with a heparin
drip. She was restarted on warfarin on ___, and was
therapeutic goal range (INR 2.5-3.5); INR of 3.3 on ___.
Repeat head CT demonstrated no new bleed.
# Cough. Ms. ___ was previously on levofloxacin at OSH in the
setting of her bronchitis, however this may have contributed to
her supratherapeutic INR. She grew MRSA in her sputum, however
she had no fevers; no increased shortness of breath. No evidence
of consolidation on examination. No fever or leukocytosis. CXR
without evidence of pneumonia. Cough was treated symptomatically
with benzonatate 18h PRN and guaifenesin 600 mg q12h PRN.
==============
CHRONIC ISSUES
==============
# Chronic systolic CHF. Chronic systolic heart failure, with EF
40-45% s/p St. ___ mitral valve replacement, with severe TR.
She is followed by Dr. ___ in ___. She had no
decompensation, and was continued on her home furosemide 20 mg,
metoprolol tartrate 12.5 mg BID, and sprinolactone 50 mg daily.
# Atrial fibrillation. CHA2DS2-VASc score of 5 for age, sex,
CHF, and HTN history. She was continued on metoprolol tartrate
12.5 mg bid. Anticoagulation was undertaken as above.
# Chronic wounds. Wound care was consulted.
# Hemolytic anemia. Chronic per PCP, in the setting of
mechanical valve, with Hb of 8.0 g/dL, indirect
hyperbilirubinemia, and haptoglobin <5. She required no
transfusions.
# Cirrhosis. Likely congestive hepatopathy; per PCP, no evidence
of viral or alcoholic hepatitis. She was compensated, with no
ascites or encephalopathy. Diurses was continued as above. At
this point, is compensated, with no ascites or encephalopathy.
# COPD. Home albuterol, montelukast, and tiotropium were
continued. Oxygen saturations were 96-100% on RA.
# Glaucoma. Continued timolol 0.5% BID.
# GERD. Continued omeprazole 20 mg daily.
# Gout. Continue allopurinol ___ mg daily.
# Osteoporosis. Continued home calcium and vitamin D
# Seasonal allergies. Continued loratadine 10 mg daily.
# Hypothyroidism. Continued levothyroxine 50 mg daily.
===================
TRANSITIONAL ISSUES
===================
# Anticoagulation. INR of 3.3 on discharge. Started on warfarin
4 mg daily; anti-coagulation will be managed by Dr. ___.
Next INR check should be ___, with goal INR of 2.5-3.5
(mechanical mitral valve).
# Respiratory infection. Pt has a history of COPD and was
previously treated with Levaquin for bronchitis (this was
stopped). She has had productive cough with sputum that was
treated symptomatically. She was found to be colonized with MRSA
in her sputum, but had no consolidation on her CXR. Would
recommend low threshold to re-image chest if she clinically
worsens.
# Medication changes. Keppra was started for intracranial bleed
for one week (end ___. Warfarin was decreased to 4 mg daily.
# Code status: FULL
# Contact: Sister, ___ Daughter, ___ (h);
___ (c)
Billing: >30 minutes spent coordinating discharge from the
hospital. | 91 | 632 |
16724859-DS-10 | 24,319,768 | Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ with generalized
weakness and loss of appetite. Your blood counts were found to
be very low, and required transfusions of blood products.
Because you reported coughing up blood, our lung doctors
___. Based on studies of your sputum and a CT scan of
your chest, you do not have TB or another lung infection called
PCP. We restarted you on an anti-retroviral regimen to treat you
HIV. Your liver enzymes were also elevated, and you will need
follow up with a liver specialist after discharge to continue
treatment of your liver disease. Our physical therapist
evaluated you and felt that you would benefit from improving
your strength and functionality further at a short term rehab.
Thank you for allowing us to participate in your care.
- Your ___ Team | ___ hx of active AIDS (CD4 of 59 ___ presents with weakness,
cough w blood tinged sputum, diarrhea and poor PO intake
requiring ICU transfer for hypotension.
# Hypotension: Likely hypovolemia in setting of poor PO intake
versus sepsis (SIRS positive WBC and BP) given active AIDS (CD4
count 59) but no obvious source. Hypovolemia from bleeding
unlikely given no evidence of significant bleeding. Per history
pt does have cough, dyspnea, diarrhea, generalized weakness and
therefore possible source is very nonspecific (see failure to
thrive below). BP remained stable during remainder of hospital
course.
# Hemoptysis: Unclear history of hempotysis, as patient intially
reported history of, but now says he has only had clear sputum.
After further exploration of history, hemoptysis may have been
in the setting of preceding epistaxis. CT chest showed basilar
changes consistent with aspiration, however there were no
radiographic signs of tuberculosis and PCP. Sputum AFB smears
were negative x 3 ___s negative for PCP. Preliminary MTB
cultures are negative. No hemoptysis was observed during this
hopsitalization, and the pt's respiratory status remained stable
on room air.
# HIV/AIDS: last CD4 59, viral load 23,000. Not compliant with
retrovirals. Continued azithromycin prophylaxis and restarted
dapsone with careful monitoring of CBC. Started on antiretoviral
therapy with emtricitabine-tenofovir, darunavir, ritonavir and
raltegravir prior to discharge.
# Failure to thrive: Progressive functional decline as well as
generalized fatigue and weakness. This is likely secondary to a
combination of worsening HIV infection, and myelosuppression.
Nutrition was consulted for meal supplementation and dronabinol
started to increase the pt's appetite. ART restarted as above.
# Pancytopenia: Likely etiology is active AIDS vs medication
effect. Has not been on HAART therapy for unknown period of
time and has never been consistently compliant. He received a
total of 3U PRBCs and 1U platelets during this admission. His
cell counts was stable at the time of discharge and he was no
longer neutropenic. He will follow-up with PCP to discuss
restarting ART. Given his allergy to bactrim and
contraindication in the usage of atovaquone in liver
dysfunction, pt was restarted on dapsone for PCP prophylaxis and
___ need careful monitoring of his CBC after discharge.
# Transaminitis: Does have evidence of both liver injury and
synthetic dysfunction. LFTs stable form previous admission.
Significant alcohol history prior to ___. Had recent admission
with liver biopsy showing alc hep on ___. Does have positive
smooth muscle antibody. Viral hepatitis serologies negative.
AST/ALT pattern during this admission seems to be consistent
w/etoh abuse but he denies any recent use. MRCP one month showed
no obstructive pathology. Ct abdomen/pelvis on admission showed
ascites, homogeneous liver architecture, patent portal/hep vasc,
no pancreatits, but did not visualize GB. His liver function
remained stable during this admission and he will need follow-up
with hepatology after discharge for further management.
# L hip hematoma: No fracture on x-ray.
# R arm hematoma: Unclear inciting injury, possibly IV
placement. Hematoma stable in size on serial ultrasounds.
Managed conservatively.
# Alcohol abuse: Not currently using. Did not require CIWA. | 146 | 500 |
15749643-DS-26 | 20,102,954 | Dear Ms. ___,
IT was a pleasure meeting you and caring for you here at ___
___. You presented to us with chest
pain and increased urinary frequency. We believe your chest pain
is most likely musculoskeletal (costochondritis). You received
workup for cardiac causes of chest pain, and they were negative.
You were found to have a urinary tract infection, and you were
treated with IV antibiotics for 3 days.
Please take your medications as instructed. Please attend all
your follow up appointments as instructed.
All the best,
Your ___ team | Ms. ___ is an ___ woman with a history of CAD and
recurrent UTI who presented with chest pressure (relieved by ASA
and NTG) and was found to have a grossly positive UA.
# UTI: Pt presented with increased frequency. UA was grossly
positive. She was treated with cefepime 1gm Q12hr x3 days given
her previous urine cultures and sensitivities. Repeat UA was
clean (4 WBC). Urine culture grew less than 10,000 organisms.
Antibiotics discontinued after 3 days. Given history of
recurrent UTI and ? labial fusion, we arranged an appointment
for her with urogyn.
# Chest Pain: most likely musculoskeletal/costochondritis as
pain lasts a few seconds, does not worsen with exertion, and is
located along ___ rib and reproducible with palpation. EKG was
at baseline and unremarkable for any ischemic changes. Cardiac
enzymes negative x2. treated with tylenol with improvement.
Continued on home cardiac medications - Atorvastatin 80 mg daily
and metoprolol 25 mg BID.
# HTN: Pt bradycardic to 50-___symptomatic. Based on records, this is chronic. We continued
metoprolol given her history of CAD s/p PCI. We leave dose
adjustment in discretion of outpatient cardiologist.
- Continue metoprolol
- Continue HCTZ
- Continue losartan
# A. fib: In NSR but bardycardic to 50's throughout hospital
course. On rate conrol with metoprolol and AC with rivaroxaban
as CHADS score 3.
- Continue rivaroxaban
- cont. metoprolol
# DM: poorly controlled.
- Continue lantus 22 units HS
- Hold glipizide
- Add ISS
# Depression:
- Continue citalopram
# GERD
- Continue famotidine (renally dosed at 20 mg daily) | 89 | 280 |
15738458-DS-5 | 23,017,935 | Dear Mr. ___,
It was a pleasure taking care of you while you were a patient at
___. You were admitted for
alcohol intoxication and trouble with your balance. Your balance
improved after you withdrew from alcohol. It is very important
that you stop drinking alcohol. While you were here, you were
evaluated by our neurosurgeons. They found nothing concerning on
your CT scans and recommended that you follow-up with Dr. ___
in 1 month. We scheduled an appointment for you as listed below. | ___ yo M with PMH of cerebral palsy, alcohol abuse, and traumatic
subdural hemorrhage s/p craniotomy and re-do craniotomy in
___ here from OSH for possible acute on chronic subdural
hematoma. Neurosurgery consulted and found no need for any acute
intervention. Admitted for alcohol withdrawal.
ACTIVE ISSUES
# Falls: Patient reported more frequent falls over the last 2
weeks. Denied LOC. Neurologic exam consistent with cerebellar
etiology. Differential diagnosis for gait instability is broad.
Symptoms are most likely due to alcohol intoxication in the
setting of known cerebral palsy. Syphilis and vitamin B12
deficiency were also considered but serum vitamin B12 was normal
and RPR were non-reactive. Patient was kept on fall precautions.
He was evaluated by Physical Therapy who determined that he
could ambulate safely.
# Chronic subdural hematoma: Head CT from ___ and ___ were
reviewed by Neurosurgery who determined that there was no need
for acute intervention. Overall, changes seem stable per
reports. Plan is for repeat CT head and follow-up with Dr.
___ in 1 month.
# Alcohol abuse: Patient drinks ___ pints of vodka daily. Last
drink was day prior to admission. No history of withdrawal
seizures or delirium tremens per the patient. He reports
withdrawing in prison without issues. Scored to 12 on CIWA in
hospital and receiving diazepam accordingly. He was not scoring
on discharge. He was started on thiamine, folate, and MVI which
were continued on discharge.
CHRONIC ISSUES
# Cerebral palsy: Right-sided weakness was at baseline.
# Chronic back pain: Continued home ibuprofen with food.
TRANSITIONAL ISSUES
- Patient to return to ___
- Started thiamine, folate, and MVI
- Repeat non-contrast CT head arranged
- Follow-up with new PCP in ___ scheduled
- Follow-up with Neurosurgery scheduled | 83 | 274 |
17172702-DS-18 | 26,855,308 | You were admitted with acute onset of severe shortness of breath
and were initally treated in the ICU. You had pulmonary function
tests which show that you have emphysema and you were started on
a new medication called Advair. You will need to follow up with
Dr. ___ in clinic next week.
You were also treated for congestive heart failure with some
extra doses of lasix. You are now at your dry weight of 271
lbs. Weigh yourself every morning, call the PACT program or Dr
___ weight goes up more than 3 lbs, because you will
need some extra lasix. It is very important you follow a low
salt diet. | Mr. ___ is a ___ with history of atrial fibrillation on
Coumadin, systolic and diastolic HF (LVEF 40-45%), hypertension,
and IDDM who presents with acute-onset shortness of breath and
chest pain.
# Respiratory distress/Hypoxia/COPD: He presents with
acute-on-chronic shortness of breath and hypoxia, required
transient noninvasive ventilation. Hypoxia was associated with
fever, leukocytosis to 21 (which has been chronic), and
scattered ground glass opacities new since ___, Initially
there was concern this was infectious and he was treated for
HCAP but the following day he was doing well clinicaly without
fevers and normalization of WBC count therefore antibotics were
stopped. CTA was negative for PE and the patient had no acute
EKG changes or elevation in tropoinin. In the setting of known
systolic/diastolic dysfunction, there was no evidence of volume
overload clinically or radiographically, though proBNP was
slightly elevated and pt has known MR. ___ afterload reducers
were restrated the day following admission. Imaging showed
low-grade lymphadenopathy in the mediastinum and right hilum
with associated groung glass opacities concerning for early
infection. He had PFTs done on ___, with results showing a
mixed restrictive and obstrutive picture. He was see by the
pulmonary consult service who recommended starting Advair. The
patient will need to follow up with Dr. ___ week. He can
be referred for a new CPAP mask at that time.
The patient's acute dyspnea is likely related to a number of
factors including acute diastolic CHF and COPD. By the time of
discharge, he reported that his dyspnea was much improved
compared to admission, but that he was not yet 100%. However,
medical management for his conditions had been maximized - his
treatment of emphysema had been continued with spiriva and
advair, he was diuresced to dry weight and he continued CPAP
mask for OSA. His wife will reschedule his pulmonary followup.
# Chest pain: His chest pain is described as
chest-wall-associated and has been attributed in the past to
costochondritis. As above, CTA was negative for PE, and lack of
acute EKG changes or troponinemia is reassuring against ACS.
Chest pain responded to morphine in the ED and was controlled
with tylenol while on the general medical floor.
# Chronic systolic and diastolic HF: Most recent LVEF was >55%
on TTE in ___, though EF was previously reduced. He also has
known Mitral regurgitation. He appeared slightly dry to
euvolemic on admission, with mildly elevated proBNP and no
radiographic evidence of volume overload. Despite this, on
transfer to the medical floor his weight was up 10 lbs from a
weight taken at home 3 days prior to admission. This may be
from the fluids he received to prevent contrast induced
nephropathy. He was treated with PO lasix for diuresis and
improvement in his symptoms. His weight was 271.7 lbs on
discharge. He was discharged on lasix 40 mg a day in the
morning, with 20 mg in the afternoon, with instructions to take
another lasix tablet if his weight increases by more than 3 lbs.
# Hypotension: He was transiently hypotensive to ___ systolic in
the ED, with spontaneous improvement to 100s systolic, after
which he received 500cc IV fluids. Iatrogenic hypotension in the
setting of multiple anterhyptensive agents is also possible and
on discussion with the patient's PACT nurse his
antihypertensives were being titrated down due to hypotension at
home. He had no further hypotension while on the floor. | 112 | 574 |
12756788-DS-34 | 29,531,769 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You came to the hospital because you were
having fevers after a recent switch to your antibiotic regimen.
You were seen by our infectious disease doctors and also
received an MRCP which did not show any suspicious findings.
After discussing with infectious disease and the liver team, we
decided to treat you with 10 full days of ertapenum and then
switch you to augmentin to try and suppress your infection.
Your discharge appointments and medications are detailed bellow.
We wish you the best!
Your ___ care team | ___ with history of ampullary carcinoma s/p Whipple, c/b
recurrent cholangitis due to secondary sclerosing cholangitis,
most recently growing ESBL E. Coli, who now presents with fever.
#Fever: Pt reportedly had fever to 101.4F 2 days PTA. This is
concerning for cholangitis in the setting of his history of
recurrent cholangitis which typically manifests with fever
alone. Of note, patient had been on ertapenum suppressive
therapy for his ESBL E. coli and was changed on ___ to rifaximin
and fosfomycin to avoid resistance. Given quick recurrence of
fevers in setting of antibiotic change, recurrence of ESBL E.
coli cholangitis is the most likely diagnosis. Patient has no
dysuria or cough which would exclude urinary or pulmonary
sources, respectively. He does have a history of ESBL E. Coli
(never grown here, but per OSH cultures), which has been
sensitive to carbapenems recently. In house blood cultures
pending at time of discharge. MRCP to evaluate for increasing
stricture/fluid collection showed no fluid collection or e/o
cholangitis. Per ID will continue ertapenem for 10 total days
(___) and then start augmentin 875mg BID for suppressive
therapy.
#Secondary sclerosing cholangitis: S/p Whipple ___ years ago for
ampullary cancer c/b ESBL cholangitis (see above). LFTs wnl
-cont ursodiol 600mg po BID
#Macrocytic Anemia: Hb 9.6, stable.
TRANSITIONAL ISSUES
blood cultures from OSH: ___ which have all grown ESBL E. coli. | 97 | 232 |
11047238-DS-17 | 20,457,539 | You were admitted for evaluation and management of shortness of
breath and coughing due to an asthma exacerbation as well and
pneumonia. Your symptoms improved with steroids (prednisone) and
antibiotics (levofloxacin). These medications were complete
during your admission. In addition, you reported increased
stress urinary incontinence. You have been set up with an
appointment to see a urogynecology doctor. See below.
.
You experienced blood in your stool. You were evaluated by the
gastroenterology service and were placed on an acid suppressing
medication (omeprazole) which you should continue to take after
you are discharged. You will need to follow up with a
gastroenterologist after discharge to have an endoscopy and
colonoscopy scheduled.
.
You developed significant abdominal pain and constipation. You
were given an aggressive bowel regimen. You should continue to
take this medication upon discharge. | ___ y.o female with h.o asthma, ___ disease, HTN who
presented with SOB, cough, chest tightness c/w asthma
exacerbation
.
#acute asthma exacerbation/community acquired pneumonia/chest
tightness/hypoxemia-Pt with symptoms of asthma exacerbation in
days preceding admission. However, symptoms acutely worsened and
pt with chest tightness and 1 day of n/v prior to admission. Pt
could have had viral illness as a trigger, especially given her
reports of sore throat and rhinorrhea. However, CXR with
bronchograms possibly suggestive of early PNA. BNP and troponin
unrevealing. Pt was started on prednisone 60mg daily x5 days for
an asthma exacerbation and levoflox 750mg daily x5 days. Course
completed during admission. She was given albuterol and
ipratropium nebs and her flovent inhaler with good effect. She
was given benzonatate for symptomatic relief. BNP and troponins
were unrevealing. Pt's symptoms markedly improved and she was on
room air by ___. Pt will be following up with her PCP for
ongoing care.
.
#acute blood loss anemia/gastrointestinal bleeding/abdominal
pain:Pt reported epigastric pain and was very constipated prior
to aggressive bowel regimen ___ that also lead to vomiting x1.
Since the onset of bowel movements (2 large on ___ pt reports
initially small amounts of blood in the stool and then began to
have bright red blood ___ am and x1 bloody stool ___ am. DDx
included PUD/gastritis/duodenitis from ASA and prednisone vs.
LGIB from hemorrhoids/fissure/straining and severe constipation.
The GI service was consulted who followed the pt. She was placed
on a BID PPI with good effect. HCT was followed an slightly
downtrended, but overall remained stable. Pt never had
hemodynamically significant bleeding. Pt did have some mild
epigastric pain and nausea at times and also could have
gastritis from asa/prednisone. She had been taking a BID H2
blocker on admission. Her asa was stopped when bleeding started
as was her SC heparin. Given that her HCT remained stable and
her diet was able to be advanced on ___, plan will be for an
outpatient EGD and colonoscopy to be arranged. Given pt's
chronic constipation, she may need a several day prep. H.pylori
was negative.
.
#s/p fall ___. Report is that pt got tangled in her o2 tubing.
No LOC. Head and neck CT unrevealing. NO apparent sequelae due
to fall. ___ consult recommended ___ home without acute ___.
.
#stress urinary incontinence associated with coughing-Pt
reported that she wanted to establish care at ___ (see
appointment below). as she missed a previously scheduled outpt
appointment. No other neurologic red flags noted during
admission, but incontinence much worse due to coughing.
.
#constipation with nausea, vomiting-pt developed significant
constipation on ___. She was given an aggressive bowel regimen
and then developed an episode of vomiting. KUB did not show
evidence of obstruction. Pt's symptoms improved after several
BMs. Pt does have a history of chronic constipation in the
outpatient setting and has never had a colonoscopy. She will
need to be scheduled to have an outpatient colonscopy that may
require a several day prep. The GI service will be arranging for
this procedure.
.
#L.calf ___ negative for DVT, improved.
.
___ disease-continued home regimen of sinemet
.
#GERD-continued BID H2 blocker, but discontinued when bleeding
started. PPI BID started at that time.
.
#osteoporosis-weekly fosamax as outpt
.
#FEN-low sodium diet
.
#ppx-hep sc TID
.
#access-PIV
.
#communication- pt reports her HCP is her son ___
___
.
___, d/w pt
.
___ care:
1.Pt will need f/u after her hospitalization to monitor the
status of her asthma.
2.pt will need to f/u with urogynecology for her stress urinary
incontinence (appt made).
3.bowel regimen
4.Pt will need to have an EGD/colonoscopy arranged to evaluate
for the cause of bleeding as above and also to evaluate her
chronic constipation. This will be arranged by the GI service. | 133 | 645 |
13322229-DS-4 | 25,418,975 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain and
distention. We also noticed that you had pneumonia on your chest
X-ray. We treated you for an infection of both your abdomen and
pneumonia. Your symptoms gradually improved during your
hospitalization. We also started you on Warfarin for your portal
vein thrombosis. Your goal INR level is ___ for this. Your
primary care physician ___ on your INR level. We will
also discharge you with some anti-fungal cream for the rash on
your foot. It will be very important for you to follow up on the
appointments listed below. You will also need to have your blood
drawn for your INR check on ___. Please take
your antibiotics through ___.
You should eat bland, easy to digest food for the next week
(plain rice, boiled chicken, mashed potatoes).
It was a pleasure to be a part of your care!
Your ___ treatment team. | Mr. ___ is a ___ Year old gentleman with a history of ETOH
cirrhosis who presents from clinic with abdominal pain, new
onset ascites and radiographic evidence of community acquired
PNA.
# Abdominal pain: Physical exam was notable for abdominal pain
in the LLQ. Initial exam notable for rebound and transplant
surgery was consulted, though rebound tenderness resolved
without need for intervention. He was initiated on antibiotics
for presumed diverticulitis. CT abdomen with IV contrast was
unremarkable though was not obtained with PO contrast. There was
no evidence of hernia or prostatitis on physical exam. His
symptoms gradually improved during his hospitalization and
resolved prior to discharge. He was able to tolerate a low
residue diet. He had persistent bloating on exam though passed
stools without difficulty. It is expected that his bloating will
resolve with discontinuation of antibiotics. He is discharged to
complete a 10 day course of levo/flagyl.
# CAP: Patient presented with low grade temperature and
radiographic concern for pneumonia in the LLL. Patient received
Ceftriaxone and Azithromycin on admission. He was transitioned
to Levofloxacin, given that it would also cover an
intra-abdominal infection. He is discharged to complete a course
of antibiotics as above.
# PV thrombus: Patient noted to have portal vein thrombus near
the confluence of splenic vein. Given its proximal nature, the
decision was made to anticoagulate with warfarin, with goal INR
___. He was bridged with Lovenox and is discharged on Warfarin
2.5. The team opted for a lower dose given a relatively rapid
rise of INR with Warfarin 5 mg and the expectation that it will
exceed the therapeutic goal while the patient is on antibiotics.
He will likely need an increased dose of Warfarin once he
completes his antibiotics course. It was confirmed that his PCP
___ be managing his anticoagulation. He will have his next INR
drawn on ___, with results faxed to his PCP.
# Cirrhosis: EtOH, MELD 24 (12 on admission) though artificially
increased due to elevated INR in setting of anticoagulation.
There was no evidence of encephalopathy on exam during his
hospitalization. He was continued on Lactulose, rifaximin,
lasix, nadolol, pantoprazole and ursodiol.
# Leukopenia: Patient noted to have leukopenia to ___ of 2
during his hospitalization. ___ have been contribution from
hemodilution as all cell lines dropped. He otherwise looked
clinically well, did not have a fever during his stay.
No evidence of neutropenia during his stay. Recommended to
follow up on ___ count on PCP follow up to ensure stability. | 153 | 417 |
10570315-DS-4 | 25,165,954 | You were admitted to the hospital for a pacemaker implantation
to treat your abnormal heart rhythm. This abnormal rhythm
started after your TAVR procedure. Originally, your abnormal
rhythm was stable, and you were sent home with remote
monitoring. However, shortly after your return home, you became
symptomatic and developed a dangerous heart rhythm. You had a
pacemaker placed in order to prevent your heart from beating too
slowly.
Instructions regarding the care of the implant site have been
reviewed and are included in your discharge packet.
Please follow up in the device clinic next week as scheduled. | Ms. ___ is an ___ yr old woman with a PMH of HTN,
hypothyroidism, severe aortic stenosis who underwent placement
of a 23 mm LOTUS valve in the aortic
position on ___. Post-procedure the patient was noted to
have
new left bundle branch block but with no evidence of high
degree
AV block. She felt well and discharged home on ___ monitor
the next day
showed today a few episodes of complete heart block with
episodes
of up to 6sec pause. She was called and asked to come to the ED
by EP.
Pt reports that she was feeling unwell since discharge. She was
re-admitted to the hospital and monitored on telemetry. She
continued to have episodes of CHB, that occurred mainly with
activity, so she remained on BR She remained hemodynamically,
stable. On ___, she underwent a dual chamber pacemaker implant.
On ___ she was restarted on atenolol and evaluated by physical
therapy. She was discharged home with services. | 97 | 173 |
17542845-DS-14 | 26,307,309 | Dear ___,
It was a pleasure taking care of you at ___ in ___. You
developed fevers and shaking chills shortly after receving a new
medication for your CLL called Campath. You were not given
antibiotics, as the blood, urine tests and chest x-ray did not
suggest tha tou had an infection. We gave you your 2nd dose of
Campath as planned, which you tolerated much better without
fevers and chills. Prior to your discharge, you were given your
3rd dose and tolerated it well. | ___ year old male with a history of CLL with 17p deletion on
___ ___
who is presenting with fevers and chills after recent
administration of Campath + ofatumumab.
.
# Fevers: Pt presented without overt localizing source, although
review of systems is positive for mild diarrhea upon admission
and mild dysuria. Diarrhea was C diff negative and UA was
negative for infection. BCx were no grwoth to date at discharge.
The patient reported feeling malaise even prior to the
administration of these medications in clinic - supporting that
the current fever could be secondary to a viral syndrome
antecedant to these medications. In addition, pt started getting
a new administration of subq campath, thus it is possible that
his fevers and rigors were prolonged from the ongoing delivery
from ___ depot. While in the hospital, pt did not spike, and
was given an additional 2 doses of campath with premedication
without symptoms. Pt was discharged with instruction to continue
benedryl and tylenol after receiving ___ campath administration.
.
Of note, pt has terrible dentitio, though did not report any new
tooth pain. Since BCx were no growth to date, and patient
improved clinically, we did not give any abx. Pt only received
2g Cefepime x1 in the ED upon presentation.
.
# CLL - Pt continued to received campath per protocol under
close monitoring in the hospital after consultation with
outpatient oncologist.
.
# Cytopenia - Pt was admitted with cytopenia ___ was stable at
discharge and likely related to chemotherapy.
.
# Code Status - FULL (confirmed) | 84 | 251 |
16833478-DS-37 | 20,719,342 | You were admitted after a fever with abdominal pain. You had no
further fevers and felt well and were discharged home.
You might have been exposed to influenza while you are here and
should complete the 10-day course of Tamiflu to prevent you from
getting the flu. | Mr. ___ is a ___ male with complex past medical
history including ___ overlap syndrome c/b
multiple GIB ___ AVM requiring intermittent RBC transfusions and
chronic iron infusions, cerebral AVMs with
history of seizures, protein losing enteropathy/TPN dependent
since ___ c/b multiple line infections, stage IA adenocarcinoma
of the duodenum/ampulla s/p Whipple ___ c/b DVT/PE with
retained IVC filter, and chronic diastolic CHF, who presents
today w/ abdominal pain and fever to 101.6 with negative
abdominal CT, with negative work up thus far, and clinical
stability for discharge. | 47 | 87 |
19864612-DS-21 | 22,167,702 | Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with nausea, abdominal pain and diarrhea. You underwent testing
that showed elevation of several of your liver function blood
tests. Testing of your liver and gallbladder was reassuring you
did not have any blockages of your bile ducts or acute
gallbladder problems. You were treated with IV fluids and
nausea medications. You improved.
We think that the most likely explanation for your symptoms is
that you had a viral infection impacting your liver and GI
tract, that then resolved on its own.
You are now ready for discharge home.
Of note while you were in the hospital, testing showed that you
might have chronic problems with your gallbladder. You were
seen by surgeons who recomemended seeing them as an outpatient
to discuss having your gallbladder removed in the future.
It will be important for you to see you primary care doctor to
your blood and urine tests rechecked. | This is a ___ year old male with past medical history of seizure
disorder, alcohol use disorder currently on naltrexone,
depression and anxiety admitted ___ with 1 week of
worsening nausea and abdominal pain, found to have abnormal LFTs
in a mixed pattern (AST>ALT, elevation of direct and indirect
bilirubin), thrombocytopenia, HIDA scan without acute
cholecystitis and cleared by general surgery, thought to have
had a ___ viral infection, spontaneously improving
and able to be discharged home
# Abnormal LFTs
# Generalized Abdominal Pain
In setting of generalized abdominal pain, patient was found to
have elevated LFTs in a mixed atypical pattern: ALT 102 AST 146
AP 100 Tbili 3.3 Dbili 0.8 ibili 2.5. In ED, RUQUS showed
echogenic liver consistent with steatosis, and sludge within a
somewhat distended gallbladder without signs of biliary
obstruction. Workup otherwise notable for HIDA scan showing
"The gallbladder is not seen within the first hour of imaging.
The patient returned at 4 hours to show tracer uptake in the
gallbladder." thought to represent chronic cholecystitis. Per
discussion with general surgery consult team, given atypical
LFTs and imaging, his symptoms were not felt to represent acute
cholecystitis. Suspect more likely he had acute viral infection
resulting in cramping, mild transaminitis and (given ibili
predominance without signs of intravascular hemolysis, normal
hapto) either mild extravascular hemolysis or a ___
syndrome. Patient initially given empiric antibiotics on
admission, this was stopped once HIDA results returned. His
pain and LFTs rapidly improved. Prior to discharge he was able
to tolerate a regular diet without any pain or nausea. At
discharge LFTs were ALT 59 AST 53 AP 57 Tbili 0.8. Would
consider recheck at ___. Anaplasma serologies pending at
discharge.
# Abnormal imaging gallbladder
Admission RUQUS showed mild distension of gallbladder, and
subsequent HIDA scan consistent with chronic cholecystitis. As
above, clinical picture and imaging were not felt to represent
acute cholecystitis. However, given chronic findings seen on
HIDA, general surgery recommended outpatient ___ for
discussion re: elective cholecystectomy. Scheduled at
discharge.
# Thrombocytopenia
Course notable for thrombocytopenia, nadiring at 134k. Smear
not suggestive of ongoing hemolysis, coags normal. Felt to fit
with suspected viral infection. Platelets rapidly improved to
178k prior to discharge.
# Proteinuria
Noted to have trace proteinuria on admission. Could consider
repeat UA as outpatient
# Alcohol use disorder
Held Naltrexone during admission. Of note, naltrexone can cause
mild elevations of transaminases, or abdominal pain, but would
not typically cause bilirubin elevations seen in this
patient--not felt to be related to his acute presentation.
Restarted at discharge.
# Anxiety
Continued clonazePAM
# Seizure disorder
Continued keppra
# ADHD
Continued Adderall
Transitional issues
- Discharged home with PCP ___ consider repeat check of CBC and LFTs at ___
discharge platelets were 178k; discharge LFTs were ALT 59 AST 53
AP 57 Tbili 0.8
- Incidentally noted to have mild proteinuria on admission urine
dipstick; would consider repeat at ___
- Ultrasound incidentally showed "Echogenic liver with no focal
lesions identified. Echogenic liver consistent with steatosis.
Other forms of liver disease and more advanced liver disease
including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study." Radiology
recommended "Radiological evidence of fatty liver does not
exclude cirrhosis or significant liver fibrosis which could be
further evaluated by ___. This can be requested via the
___ (FibroScan) or the Radiology Department with either
MR ___ or US ___, in conjunction with a
GI/Hepatology consultation"
- Ultrasound showed "Sludge within a somewhat distended
gallbladder. No other sonographic evidence of acute
cholecystitis." HIDA scan showed "Abnormal hepatobiliary scan
consistent with chronic cholecystitis." Per discussion with
___ general surgery, recommended for outpatient ___ for
discussion re: elective cholecystectomy
> 30 minutes spent on discharge | 168 | 628 |
19022227-DS-21 | 26,324,649 | Dear Mr. ___,
You came to ___ because you were feeling feverish and had a
hard time using your straight catheter. Please see more details
listed below about what happened while you were in the hospital
and your instructions for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- You were found to have a urinary tract infection, given your
use of intermittent straight catheterization. You were started
on an IV antibiotic which improved your symptoms and completed
your course while in the hospital.
- You were also having severe knee and ankle ulcers. A bone
biopsy of your right knee showed involvement of the infection in
your bone. You had a surgery to remove infected material from
your wounds (debridement) and you were started on a 6 week
course of antibiotics.
-Finally, you were found to be at increased risk for these
ulcers given your severe psoriasis. You were started on a
steroid ointment called clobetasol for 2 weeks which improved
your symptoms.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Please continue monitoring your symptoms and seek medical
attention if you have any difficulty with urination, fevers,
chills, or worsening spasms
- Please follow up with your primary care physician, infectious
disease physician, and dermatologist
- Please continue taking all of your medications as prescribed
It was a pleasure taking care of you. We wish you the best.
-Your ___ care team | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ year old male with a significant past
medical history of spina bifida, complicated by neurogenic
bladder requiring intermittent straight catheterization, who
presents with fever and UTI, along with worsening lower
extremity ulcers with concern for osteomyelitis
#Complicated UTI: The patient presented with a urinary tract
infection in the setting of chronic use of intermittent
catheterization. He stated he had difficulty advancing his
catheter over the last few weeks. The patient did not have any
systemic signs of infection including fevers or leukocytosis. He
did however have suprapubic pressure and grossly positive UA in
the ED. His urine culture grew K. pneumoniae. He completed a
course of IV ceftriaxone and tolerated it well. At the time of
discharge, he was asymptomatic, without any suprapubic pressure,
or difficulties advancing his catheter.
#Lower extremity ulcers: The patient presented with multiple
painless lower extremity ulcers with eschar on his R knee and
ankles b/l, that had been developing over the past few months.
In addition he had been experiencing general malaise and
subjective fevers over the past 6 weeks. He described sleeping
on his knees, which likely resulted in pressure ulcers. On
admission, the ulcers were concerning for necrosis vs.
osteomyelitis. He had bilateral ankle, bilateral foot, and right
knee xrays in ED, with no evidence of osteomyelitis. Of note,
the CRP was elevated to 114. MRI of the R knee ___ and b/l
ankles ___ showed no definite evidence of osteomyelitis,
however his bone biopsy was positive for rare S. aureus and
mixed flora from the wound culture. He has a wound debridement
of his R knee and R ankle ulcerations. He was started on IV
vancomycin and was modified to IV daptomycin and ciprofloxacin
at the time of discharge for 6 weeks.
#Severe Psoriasis: The patient was not taking any medications
for his psoriasis in the past, and was initially fearful of
starting a PO medication, given his weakened immune system from
spina bifida. Given the severity of his plaques on admission,
that were likely also contributing to his skin breakdown and
ulceration, he was started on a 14 day course of topical
clobetasol 0.05% ointment BID. His plaques improved
significantly during his hospital stay. He will be following up
as an outpatient with dermatology.
#Spina bifida: During his hospitalization, the patient had an
increasing frequency in back spasms which were interrupting his
sleep. The patient tolerated his current pain regimen well, and
felt better with stretching and exercises. He will be dicharged
on his home baclofen and oxybutinin. His home breakthrough
tizanidine was held given the interactions with ciprofloxacin. | 248 | 440 |
14504439-DS-19 | 21,349,633 | Ms. ___,
It was a pleasure taking care of you here at the ___
___. You were admitted to our hospital for
acute inflammation of your appendix. You had a laparoscopic
appendectomy during this admission without complications. You
tolerated the procedure well and are ambulating, stooling,
tolerating a regular diet, and your pain is controlled by
medications by mouth. You are now ready to be discharged home.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the surgery.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- You are being discharged with a prescription for oxycodone for
pain control. You may take Tylenol as directed, not to exceed
3500mg in 24 hours. Take regularly for a few days after surgery
but you may skip a dose or increase time between doses if you
are not having pain until you no longer need it. You may take
the oxycodone for moderate and severe pain not controlled by the
Tylenol. You may take a stool softener while on narcotics to
help prevent the constipation that they may cause. Slowly wean
off these medications as tolerated.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
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.
WOUND CARE:
-You may shower with any bandage strips or Dermabond that may be
covering your wound. Do not scrub and do not soak or swim, and
pat the incision dry. If you have steri strips, they will fall
off by themselves in ___ weeks. If any are still on in two weeks
and the edges are curling up, you may carefully peel them off.
-Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
-Notify your surgeon is you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
Good Luck | Ms. ___ is a ___ with acute appendicitis who was admitted to
the ___ on ___. The
patient was taken to the OR and underwent an uncomplicated
laparoscopic appendectomy. For details of the procedure, please
see the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the surgery floor where he
remained through the rest of the hospitalization.
Post-operatively, she did well without any major issues. She was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. He was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions. | 770 | 129 |
19969918-DS-19 | 25,664,596 | You were admitted for increased oxygen requirement, low blood
pressure and increased respiratory secretions that were
secondary to a pneumonia. You were treated with strong
antibiotics initially to cover for urinary and respiratory
sources. Ultimately, bacteria was isolated from your
respiratory secretions and you will require a total of fourteen
days of antibiotic therapy.
Your hospitalization was complicated by a fast heart rate which
was treated with increased doses of your metoprolol. You also
developed volume overload, which was treated with a diuretic,
furosemide. Lastly you were noted to have blood in your stomach
so you were started on 6 weeks of anti-acid medication.
The following changes were made to your medication list:
1. CONTINUE Lasix (furosmide): 10mg-20mg IV for goal urine out
put 1 liter per day for several days
2. CONTINUE Meropenem 500 mg IV every 6 hours for 6 more days
3. INCREASE Metoprolol to 12.5mg three times a day
4. START Pantoprazole 40mg IV twice a day for four additional
weeks | HOSPITAL COURSE
___ y/o M with PMH progressive multiple sclerosis ___ trach and
G-tube placement for recurrent aspiration PNA, recent
Enterobacter and ___ transferred from an OSH with hypoxia,
hypotension and focal consolidation on CXR. He was treated for a
pneumonia with IV antibiotics and transferred to an LTAC for
further care. His hospital course was complicated by tachycardia
and volume overload.
.
ACTIVE ISSUES
# Septic Shock: At outside hospital, patient met SIRS criteria
with tachycardia, bandemia and tachypnea. He was afebrile, but
hypotensive and not responsive to fluid boluses, and had a
lactate of >9. CXR at outside hospital, and confirmed at ___
showed new right lower lobe opacity. In addition, he had a
positive urinalysis. Patient was started on broad spectrum
antibiotics with vancomycin, levofloxacin and meropenem to cover
hospital acquired pneumonia and urinary tract infection, with
history of ESBL e.coli UTIs. Lactate trended down, was 3 on
arrival to ___, and was normal by HD1. Patient required a
total of 6L NS in fluids, and then was placed on phenylephrine
for blood pressure support. Pressors were weaned on HD1.
Patient had a PICC line placed on HD1 for antibiotic
administration, with plan to continue broad spectrum antibiotics
for 14 days, day 1= ___. At the time of discharge, urine
culture was positive for both enterococcus and ecoli, which were
speciated to VRE however < 3000 colonies so therfore not
treated. Sputum cultures were contaminated but speciated to
pseudomonas and ecoli. Blood cultures were still pending or
negative at the time of transfer. At the time of transfer he was
day ___ of meropenem for esbl pneumonia. He completed 7 days
of vancomycin which was discontinued prior to transfer given
absence of culture driven data.
- Continue IV Meropenem for 6 additional days to complete 14 day
course
.
# Hypoxic respiratory distress: Thought to be due to recurrent
pneumonia, likely aspiration despite tube feeds through PEG. On
arrival to ICU, sat's were in the ___ on tach mask at FiO2 35%.
ABG 7.44/___. Patient was treated with broad spectrum
antibiotics as above, with plan to treat for 14 days. Patient
was at his baseline at the time of discharge. Interventional
pulmonology saw patient while in-house and were concerned about
recurrent aspirations and recommended that G-tube be changed to
J-tube. Head of bed was elevated to prevent aspirations in
addition to frequent suctioning of oral secretions. He was
diuresed prior to transfer given total fluid balance during his
hospital stay was over 10 liters. He was placed on a lasix drip
prior to transfer in an effort to achieve relative ___.
- He should be continued on bolus lasix 20 IV for goal net
negative 1 liter per day.
- At the time of discharge he was 7 liters up total length of
stay.
.
# Tachycardia: Documented initially as sinus, with rates in the
120s. He went into atrial fibrillation with short bursts into
the 190s that were felt to be supraventricular. As blood
pressure was stable, home metoprolol was restarted on the
evening of admission and was titrated up for improved heart rate
control. Tachycardia coincided with aggressive diuresis. He
flipped back into sinus rhythm and his metoprolol was ultimately
down-titrated to tid dosing.
- Increase metoprolol to 12.5 mg tid
. | 165 | 554 |
15742492-DS-17 | 23,510,705 | Dear Mr. ___,
It was our pleasure to take care of you during your admission to
___. You came into the hospital due to
fevers, muscle pain and were noted to have double vision. The
ophthalmologists (eye specialists) evaluated you and saw changes
in your pupils concerning for increased pressure in your brain.
We performed three spinal taps during your hospital stay to help
diagnose the cause of this elevated pressure and to track
changes in it as we treated you. You were evaluated by the
infectious disease and neurology doctors who ___ that your
symptoms were concerning for meningitis. We treated you with IV
antibiotics and antivirals and your symptoms improved. You are
discharged on a course of oral antibiotics.
Your lumbar puncture on day of discharge showed persistent
elevated pressures in the brain. This is concerning for an
ongoing viral meningitis. If you develop any concerning
symptoms including confusion, fatigue, lethargy, changes in
vision, double vision, headache, fevers, or any symptoms that
are concerning you, please return to the emergency department as
soon as possible. Finally, please follow-up with your PCP, the
eye doctors, and neurology.
We wish you a speedy recovery,
Your ___ Care Team | === SUMMARY ===
Mr ___ is a ___ year old male without significant past
medical history who developed acute mental status changes
associated with meningismus in the setting of two weeks of
fever, myalgias, and headache. Found to have elevated ICP and
taken for urgent LP and MRA before transfer to the ICU,
transferred back to the medical floor the following day for
continued medical management. He most likely had viral
meningoencephalitis causing encephalopathy and cranial nerve
palsy, which resolved by the time of discharge.
****** After discharge, his CSF returned positive for ___
virus IgM (confirmed at 1:20).****
=== ACUTE ISSUES ===
# Likely viral meningoencephalitis causing encephalopathy:
Patient presented with subacute course of fevers, headache, and
diplopia. Patient was urgently evaluated by ophthalmology on day
of admission who noted bilateral blurring of optic discs and L
CNVI palsy. Throughout course of hospital day #1, patient was
noted to become increasingly somnolent (arousable but with
distracted speech). ___ performed urgent LP under fluoroscopy
with elevated ICP to 25mmHg noted. ID consulted who felt CSF
chemistry was suggestive of a viral/ rickettseal, spirochete
process. Patient was urgently started on empiric vancomycin,
ceftriaxone, ampicillin, acyclovir and doxycycline. He was taken
for urgent MRI/MRA that day with no evidence of dural venous
sinus thrombosis or brainstem infarct. Patient was transferred
to MICU overnight for observation and was transferred back to
the floor the following day. Patient received a repeat LP on
___ with elevated ICP to 24mmHg. Acyclovir was discontinued
___ after HSV PCR returned negative. EEG was performed per
Neurology recommendations which demonstrated slight frontal and
temporal slowing suggestive of encephalopathy but not specific
for elevated ICP. Given unclear etiology of persistently
elevated ICP with improving CSF WBC, Neurology recommended MRI
with gadolinium, however patient refused. Patient was monitored
on telemetry with no events noted. Vancomycin, ceftriaxone,
ampicillin were discontinued ___ per ID given repeatedly
negative cultures and very mild pleiocytosis. Patient reported
improved headache and resolution of diplopia and neck stiffness.
A number of CSF and serum studies were sent and were negative
including HSV PCR, routine culture, Cryptococcal Ag. Remainder
of viral cultures, serology, PCR were pending at time of
discharge. Lumbar puncture performed on date of discharge ___
showed persistent elevated ICP of 24mmHg. Given clinical
improvement with regards to headache, neck stiffness, and
occular symptoms, patient was discharged on 14 day total course
of doxycycline (day ___ with neurology follow up.
****** After discharge, his CSF returned positive for ___
virus IgM (confirmed at 1:20).****
#Transaminitis: Patient noted to have slight elevation in
AST/ALT and alk phos that was thought to be due to antibiotic
side effect. Uptrending at time of discharge but without
associated abdominal pain.
=== CHRONIC ISSUES ===
#Anemia: Patient noted to have stable anemia during hospital
stay. Iron studies performed revealing nonelevated ferritin,
decreased TIBC, and decreased transferrin saturation consistent
with iron deficiency anemia.
=== TRANSITIONAL ISSUES ===
****** After discharge, his CSF returned positive for ___
virus IgM (confirmed at 1:20).****
#Diplopia: Patient presented with diplopia and was noted to have
bilateral optic nerve blurring on ophtho evaluation. His ocular
symptoms resolved by the end of his hospital admission. Please
follow up vision symptoms. Patient is scheduled for follow up
with ophtho.
#Meningitis: Patient presented with fevers and with elevated ICP
noted on LP. Patient empirically treated with antibiotics and
acyclovir with resolution of ocular, neck, and headache
symptoms. LP on day of discharge with persistent elevated
pressures. Patient discharged on 14 day total doxycycline course
with neurology follow up. Please follow up and ensure resolution
of symptoms.
#Transaminitis: Patient noted to have slight elevation in
AST/ALT and alk phos without other symptoms. Thought to be due
antibiotic side effect. Antibiotics were discontinued by ID by
the day of discharge except for doxycycline per above. Please
follow up to assess for resolution of these findings. | 202 | 641 |
12831424-DS-11 | 27,625,345 | You were admitted with joint pains, fever, and confusion. Your
confusion was largely related to your medications. Rheumatology
evaluated you for your joint pains and your knee was aspirated;
there was no infection present. You were started on steroids
and will complete a taper as an outpatient. You were seen by
physical therapy and they recommended you go to rehab to work on
balance and strength prior to going home.
Please take all medications as prescribed and follow up closely
with your PCP. | ___ with hx of MMP including DM2, asthma, bipolar d/o presenting
with AMS, fever, leukocytosis and L knee pain, initially with
___ SIRS criteria but without clear source for infection.
# Polyarthritis and fever: Documented temp to 101.8 in ED, WBC
20, tachycardic. Only localizing symptom is L knee, although no
erythema or warmth compared to R knee, and gram stain negative,
decreasing likelihood of septic arthritis. Culture was NGTD. CXR
and urine culture negative and no other signs of bacterial
infection. Rheumatology consulted for assistance. Several
serologies sent and prednisone empirically increased to 30mg
daily in case of an inflammatory process. Suspected crystalline
disease vs other autoimmune or post infectious process.
Rheumatology recommended steroid taper and followup as
outpatient.
# Acute encephalopathy: Largely related to over medication with
opioids and benzos. Improved during this hospitalization. Odd
affect at baseline. No evidence of trauma. TFTs consistent
slight overdosing of thyroid medication. ___ also be related to
rheumatologic process above. If recurrence after steroid taper
would consider hashimotos encephalitis/SREAT.
# Asthma: No wheeze on exam. Continued home medications.
# Bipolar disorder: Stable. Continued home medications.
# Hypothyroidism: TSH low and equivocal symptoms for overactive
thyroid. It is possible she was taking too much thyroid
replacement. Thus, her thyroid dose was decreased slightly.
Recommend repeat TFTs in 4 weeks. | 86 | 215 |
12586254-DS-5 | 21,875,574 | Dear ___ you for coming to the ___
___. You were in the hospital because you had several
enlarged lymph nodes and a blood clot in your leg. We treated
you with IV antibiotics and then switched you to oral
antibiotics. We also treated you with a blood thinner called
heparin and then switched you to enoxaparin (lovenox) so that
you can provide yourself with the medication.
Medication Recommendations
-Please START:
-Bactrim 800mg twice daily for 8 days
-Enoxaparin (lovenox) ___ mg injection daily for at least three
months. Please discuss the duration of treatment with your
primary doctor and hematologist.
-Oxycodone 5 mg every 6 hours as needed for pain. Do not drive
while taking oxycodone
-Acetaminophen (tylenol) ___ mg every six hours as needed
for pain
Please continue to take all other medications as you have been | ___ with complex medical history including h/o
thrombocytopenia, leukopenia, portal vein thrombosis and
lymphedema, chronic RLE DVT presenting with LLE DVT and
lymphadenopathy
.
ACTIVE ISSUES
#Left lower extremity DVT: The patient has a history of a right
sided DVT and a portal vein thrombosis though her
hypercoagulability work up has been negative. She presented with
a new L lower extremity DVT in the setting of a new lympadenitis
of her femoral lymph nodes. Hematology-oncology was consulted
who recommended ___ months of anitcoagulation for a DVT which
was provoked by her infection. She was initially treated with iv
heparin and then transitioned to lovenox ___ sc daily prior to
discharge.
.
#Lymphadenitis, acute: Th etiology of her recurrent
lymphadenitis was unclear. She did not appear to have an
overlying or distal cellulitis that would be draining to this
lymph node group. She did have fevers and an elevated wbc count.
She was started on vancomycin which was later transitioned to
bactrim. Hematology and Infectious Diseases were consulted.
Infectious work up including HIV, HCV, GC/Chlamydia, blood and
urine cultures was unrevealing. Test for filariasis, HTLV,
Lymphogranuloma venereumand shistosoma were pending at time of
discharge. | 134 | 190 |
17032851-DS-18 | 22,781,592 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Mr. ___ presented to ___ with chest pain. Given his
past medical history of aortic dissection, he was transferred to
___ for surgical evaluation. Upon arrival he underwent a chest
CTA which showed a Type A dissection extending from the root to
the level of the SMA. He was emergently taken to the operating
room where he underwent replacement of ascending aorta and arch
aorta, and closure of atrial septal defect. Please see operative
note for surgical details. Following surgery he was transferred
to the CVICU for invasive monitoring in stable condition. He has
a presumed factor 7 deficiency and was given multiple blood
products in the OR and also in the ICU, including factor 7. The
hematology service was consulted. He had persistent high chest
tube output, and was therefore taken back to the operating room
on ___ for mediastinal exploration. The chest tube drainage
slowed after his take-back and he extubated without incident. On
post-operative day two his chest tubes and wires were removed.
He was given Lasix and diuresed toward his pre-operative weight.
He was given Lopressor, but went into atrial fibrillation on
post-operative day two. As his INR is elevated at baseline, it
was recommended that he not start Coumadin. Epixiban was started
and a TEE was done to assess for clot before he was electrically
cardioverted into sinus rhythm. His hematocrit drifted downward
and he received a transfusion. His apixiban was discontinued. On
post-operative day 16 he was discharged to ___
Rehab. His Hematocrit should be checked periodically while at
rehab. An appointment has been made for follow-up with Dr. ___
___ Hematology but it is for ___, and the inpatient
Hematology service felt that because of his high stroke risk he
should be seen sooner. Dr. ___ will be calling
___ with an appointment for ___ weeks from now. | 132 | 305 |
15263567-DS-19 | 20,445,930 | Dear ___,
___ was a pleasure taking care of you at ___. You were admitted
because you had a fall, and you had been feeling weak, confused,
and with worsening right knee pain. Your fall was most likely
due to taking sedating medications (ativan, vicodin). Several
weeks ago you had another fall in which you hurt your right
knee, which became red, swollen, and painful. This was due to an
infection in your knee. We gave you antibiotics and it improved.
Please continue to take the following antibiotics for 7 days:
- Cephalexin 500 mg PO/NG Q12H (last day ___
- Doxycycline Hyclate 100 mg PO Q12H (last day ___
Please follow up with your primary care doctor. We recommend
that you stop taking ativan, which can put you at increased risk
of continuing to fall. Vicodin is also very sedating and you
should consider stopping it.
We wish you the ___,
Your ___ team | ___ with PMH of hypertension, asthma, diabetes, and multiple
falls presenting after mechanical fall and progressive confusion
likely due to medication overuse, found to have right knee mild
septic bursitis vs soft tissue infection (?cellulitis). | 148 | 35 |
11490406-DS-13 | 20,314,682 | You were admitted to ___ with abdominal pain, nausea, and
vomiting. You were found to have a recurrence of your small
bowel obstruction. You were kept nothing by mouth and a
nasogastric tube was placed for stomach decompression. You were
managed conservatively, and your bowels have started working.
You are now tolerating a regular diet and your pain has
resolved. You are ready to be discharged home 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.
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. | ___ hx of lap chole, transverse colectomy for colon cancer
recently discharged after conservative management of small bowel
obstruction presents back 3 days after discharge with abdominal
distention, nausea, vomiting, leukocytosis up to 16, Cr 2.1
concerning for recurrent small bowel obstruction.
NGT placed at bedside with immediate drainage of 1000cc bilious
fluid. Patient clinically appears much better despite her
notable laboratory derrangement
and her imaging. She was kept NPO, ivfs and conservative
managment was initiated.
After return of bowel function, the patient's nasogastric tube
was removed. She was started on clears and advaced to a regular
diet.
Her hospital course was uncomplicated. Her vital signs remained
stable and she was afebrile. Her abdominal exam was benign by
the time of d/c.
The patient was discharged home on HD6 in stable condition. An
appointment for follow was made with the ACS. The patient was
also instructed to continue follow-up with her PCP for MRI
findings notable for a pancreatic tail cyst. | 267 | 161 |
11865356-DS-7 | 29,884,101 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital with cough and fevers. We found that
you have pneumonia.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You were started on antibiotics for your pneumonia.
-Additionally, you have a history of anemia and were found to
have low blood levels, so we gave you a blood transfusion .
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- If you have worsening fevers, please return to the hospital.
We wish you the best!
Sincerely,
Your ___ Team | ==================
Transitional issues
==================
[ ]Antibiotic course: Cefpodoxime and doxycycline to be
completed on ___ (inclusive) for total 10 day course for
pneumonia
[ ]Acute on chronic anemia
Patient and patient's daughter report that her anemia is
currently being worked up as an outpatient with hematology as
well as evaluation for GI bleeding with FOBT and possible
colonoscopy by PCP.
[ ]Aspirin: Consider dc in the setting of anemia and on it
appears she is on it for primary prevention
[ ] + HAV IgG: If diarrhea would evaluate for active infection
Ms. ___ is a ___ w/ ESRD on HD, HFpEF, and anemia of unclear
etiology, who is presenting with 1 month of cough and recent
fevers, found to have RLL consolidation on CXR, consistent with
pneumonia.
========================
Acute medical issues
========================
#Community Acquired Pneumonia
Patient presented with 1 month of cough and recent fevers and
was found to have a right lower lobe consolidation on chest
x-ray c/w community acquired pneumonia. She was treated with IV
ceftriaxone 1g and IV azithromycin 250mg. After starting
antibiotics her symptoms improved, leukocytosis resolved, and
she remained afebrile. She was discharged on PO doxycycline and
cefpodoxime to complete a total ___cute on chronic anemia
The patient has a history of chronic anemia of unclear etiology,
which is currently being worked up as an outpatient with
hematology. During this admission, she had a Hb of 6.5, so we
transfused one unit RBC with a subsequent increase in Hb to 7.8.
We have a low suspicion that the patient is actively bleeding,
as she denies any melana or bright red blood per rectum. She
does report some minor blood streaked sputum, but not enough to
explain her anemia. Likely multifactorial with ___, ACD/AI,
ESRD, and possible thalassemia trait. She has hematology
follow-up scheduled as an outpatient and plan for further-work
up with FOBT to assess for need for colonoscopy.
#NASH Cirrhosis
#Resolved mild transaminitis
Patient had a mild transaminitis that has resolved. The patient
was found to have an HAV Antibody c/w prior HAV infection. No
current diarrhea.
=============================
Chronic issues
=============================
#ESRD on HD
Continued home ___ schedule.
#HFpEF
Euvolemic. She is off of O2 supplementation and was sating well
on ambulation. Managed her fluids with hemodialysis.
#Type 2 diabetes mellitus
Not on home medications. Patient was on an insulin sliding scale
while in the hospital.
#HTN
We held the patient's home losartan and amlodipine in the
setting of acute illness which were restarted on discharge.
#Gout
Continued the patient's home allopurinol. | 112 | 404 |
19572643-DS-19 | 23,188,885 | You were admited after you passed out. This was likely due to
dehydration from the nausea you had and because you had not been
eating or drinking. | ___ yo w/ newly diagnosed triple negative breast CA admitted with
syncope 1 day after initiation of dose dense adriomycin and
Cytoxan.
# Syncope:
- She had an episode of syncope after not eating or drinking
anything all day due to nausea. The cause of her syncope is
likely related to dehydration. She was monitored on telemetry
and a head CT and both were unremarkable. Of note she does have
a cardiology appointment later this month due to the side effect
of chemotherapy and her age but there was not an indication for
an urgent cardiology evaluate while inpatient as there was no
indication that he syncope was cardiac in nature.
# Possible UTI:
- Had boderline UA in the ED but had no symptoms and the urine
culture was negative. She was started on ceftriaxone in the ED
but this was stopped. Of note she did have an elevated WBC but
this was likely a result of the neulasta she received.
#Breast Cancer
- Received chemotherapy the day prior to admission. This was
likely the cause of her nausea. Her nausea was treated with
zofran, compazine, and ativan. Electrolytes were replaced as
needed. She was also discharged with a prescription of oral
electrolyte replacement to complete this.
# Hyponatremia:
- Her hyponatremia on admission was likely due to volume
depletion and resolved with IV hydration. | 27 | 220 |
17663980-DS-9 | 23,079,800 | Dear Ms. ___,
You were admitted to the hospital with shortness of breath and
fatigue. We did an echocardiogram that showed that you have a
narrowing of one of your heart valves called aortic stenosis,
which is most likely causing your shortness of breath. The
surgery team evaluated you for a replacement of your aortic
valve but felt that it would be too high risk given your age.
However, you are still a candidate for the transcatheter aortic
valve replacement (TAVR.) The TAVR team will evaluate you as an
outpatient to follow up on this procedure.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | Ms. ___ is a ___ with history of hypertension,
hypothyroidism, osteoporosis and osteoarthritis who presents
with intermittent shortness of breath x2 weeks.
___ with history of hypertension, hypothyroidism, osteoporosis
and osteoarthritis who presents with intermittent shortness of
breath x2 weeks, echo showing severe AS and moderate MR,
declined by ___ pursue TAVR after discharge.
#Severe aortic stenosis
Echo showed severe AS, moderate MR, preserved EF. Cath with 70%
stenosis mid LAD, no intervention. Cardiac surgery evaluated and
said she was too high risk for aortic valve repair. Though she
is not significantly symptomatic (no angina, no evidence volume
overload, SOB but doesn't significantly impair daily
activities), she is quite active and relatively healthy for her
age and may likely benefit from an aortic valve intervention.
TAVR team evaluated patient and will follow up with her as an
outpatient for further work up. Discussed in detail with patient
her options and though she is anxious, she currently favors
TAVR.
#Shortness of breath
Likely secondary to worsening severe aortic stenosis shown on
echo ___. Mitral regurgitation may also play a role though
would expect to see signs of volume overload on exam; and
despite elevated BNP, she is without lower extremity edema,
crackles or elevated JVP. CXR also without overt pulmonary
edema, though does show some mild cardiomegaly. Restarted home
hyrdochlorothiazide 12.5 mg daily ___. Metoprolol started 12.5
mg BID ___ but not continued on discharge as patient not felt
to be volume overloaded or in CHF exacerbation.
#Troponin elevation
Patient with mildly elevated troponins to 0.03 on admission,
uptrending to 0.04 on repeat. Given minimal increase, lack of
symptoms, and lack of ECG findings, unlikely to be due to an
ischemic event. Outpatient provider may consider starting ASA or
statin given CAD found on cath ___.
# Acute on chronic kidney disease
Patient presenting with creatinine of 2.4, per ED records
obtained from ___, a previous
creatinine was 2.1. FeUrea 0%; pre-renal. Per daughter doesn't
take in much fluids due to difficulty pulling down pants to
urinate (due to arthritis.) Creatinine 2.1 on discharge.
#Macrocytic anemia
Patient with HCT 33.7%, though appears at baseline from ___
labs. MCV elevated to 101. No significant alcohol use and no
known liver disease. Vitamin B12 level 627.
#Hypertension
Held home losartan given ___, restarted on discharge.
#GERD
Continued omeprazole.
#Hypothyroidism
Continued levothyroxine. | 106 | 391 |
18383921-DS-2 | 26,944,098 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a low sodium
level and an overload of fluid in your body.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given intravenous medication (furosemide, a diuretic)
in order to remove excess fluid from your body, which had
accumulated due to problems with your heart and kidneys.
- Your cancer medication (regorafenib) was held as it may be
worsening several of your symptoms, including the sodium and
volume issues.
- You had a CT scan, which showed evidence of your cancer. This
is most likely the cause of your abdominal discomfort. You did
not have any signs of a bowel obstruction or a hernia requiring
need for surgery.
- You were evaluated by the kidney doctors ___ significant
amount of protein in your urine and will need to see a kidney
doctor outside the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please record your weight everyday. Should your weight
increase by more than 3lbs (>138 pounds), you may require more
torsemide and should call your doctor.
- Please continue to hold your cancer medication (regorafenib)
until you see Dr. ___ in clinic.
- Please limit the amount of salt in your diet to 2grams/day and
limit your intake of fluids to no more than 2liters/day.
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team | Patient is an ___ with history of metastatic GIST on regorafenib
(which has previously caused toxicities including HTN), CKD (?),
mild-moderate MR, ___ who presented with worsening DOE, ___
edema, hyponatremia, macrocytic anemia, proteinuria, and
elevated ___, admitted for worsening/persistent hyponatremia and
CHF exacerbation. Patient was diuresed with IV Lasix and
subsequently transitioned to torsemide 40mg qd. Regorafenib was
held given possible contribution to this presentation
(hyponatremia, volume overload, nephrotic range proteinuria).
TRANSITIONAL ISSUES
===================
-Discharge weight: 61.55 kg (135.69 lb)
-Discharge Cr: .9
-Discharge Na: 131
-Discharge Hb: 8.3 (MCV 100)
-Discharge diuretic regimen: Torsemide 40mg qd
-There will need to be discussion about risks/benefits of
continuing regorafenib, patient will have close follow-up with
her oncologist
-Patient will be set-up with an outpatient nephrologist given
nephrotic range proteinuria, appointment pending
-Patient should have repeat CBC in the next two weeks to ensure
stability, should be monitored for improvement after initiation
of vitamin B supplementation (will need to f/u Intrinsic Factor
Antibody, pending at time of discharge)
-Levothyroxine dose was increased to 125mcg qd, should repeat
TFTs in ___ and adjust as needed
-LDH elevated 515 on admission, downtrended to 313, should
continue to monitor as an outpatient as some degree of hemolysis
is possible
-Can consider HBV vaccination (surface Ab NEGATIVE, no signs of
current/prior infection)
# Hypervolemic Hyponatremia:
The patient's symptoms were thought to be most likely due to
effects of her VEGF inhibitor/TKI and possibly CHF exacerbation
and/or nephrotic syndrome. Regorafenib can also hyponatremia.
The patient's Na stabilized between 129-132 (126 on admission),
improved with diuresis and held regorafenib as below.
# Volume overload:
The patient's dry weight is ~60 kg. Lower extremity edema
improved significantly w/ diuresis as below. Etiology includes
acute on chronic HFpEF (see below), nephrotic
syndrome/hypoalbuminemia.
# Acute on Chronic HFpEF:
Exam w/ evidence of predominantly right-sided CHF with
impressive EJ distention and ___ edema but clear lungs. proBNP
2807. Decompensation likely due to uncontrolled hypertension
(required intermittent hydralazine earlier on this admission)
and holding off torsemide as outpatient, with additional
contribution of nephrotic range proteinuria/hypoalbuminemia. No
e/o ischemia, arrhythmia, or new valvular dysfunction on TTE
___ (LVEF 50-55%, mild symmetric LVH, mild TR/MR). Patient was
diuresed with IV furosemide up to 80mg, subsequently
transitioned to torsemide 80mg qd. She remained impressively
negative and so torsemide dose was decreased to 40mg qd.
- PRELOAD: Torsemide 40mg PO daily
- AFTERLOAD/NHBK:
* Labetolol 200 mg BID
* Losartan 50 mg PO BID
# Macrocytic Anemia:
Etiology unclear. B12 is low normal at 389, MMA mildly elevated.
SPEP/UPEP negative. Hemolysis labs suggestive of at least low
grade hemolysis, direct coombs negative. DDx includes
inflammation, medication (e.g. regorafenib), rheumatologic,
hypothyroidism, CKD, underlying myelodysplastic syndrome.
Patient was started on empiric Vitamin B12 supplementation,
intrinsic factor antibody pending at time of discharge.
# Abdominal pain:
CT A/P ___ with extensive intra-abdominal peritoneal and
omental metastatic disease, which is the likely etiology for her
symptoms. Patient has ventral hernia but reducible without exam
or imaging evidence of obstruction. Patient was having bowel
movements throughout her admission and complained of
intermittent loose stools associated with regorafenib.
# Metastatic GIST tumor:
The patient has been on regorafenib for her GIST tumor. The
patient's hyponatremia, volume overload and anemia are possibly
due to an effect of this medication. Unclear what other options
there are to treat her tumor and if these side effects warrant
discontinuing the drug. Regorafenib has been held and patient
will follow-up with her outpatient oncologist, Dr. ___.
# Positive ___:
Obtained in the setting of proteinuria. No signs of a
rheumatologic process other than anemia and nephrotic range
proteinuria. Titer 1:640 can be seen in healthy individuals,
rheumatology consulted and felt that this was non-specific and
that most of her lab values and symptoms were likely and effect
of her VEGF inhibitor/TKI. Anti-smooth, dsDNA, SSA-A/B, anti-RNA
were all negative.
# Nephrotic range proteinuria:
Spot urine protein 333 mg/dL, Pr/Cr ratio 5.7 w/ albumin 2.9 c/f
nephrotic range proteinuria. 24-hour protein only mildly
elevated but likely underestimated as per Renal given low
24-hour creatinine. Possible ddx includes adverse effect of
regorafenib, uncontrolled hypertension, or rheumatologic process
given elevated ___ (though less likely as above). Renal US was
unremarkable. ESR normal, SPEP/UPEP/free K:L unremarkable. Hep
B/C serologies negative. Renal biopsy was deemed to be NOT
indicated as per our nephrology consult service. Patient will
need to establish with an outpatient nephrologist, discuss
regorafenib continuation with her oncologist.
# Hypothyroidism:
On presentation TSH significantly elevated to 22 (sent iso
hyponatremia) but FT4 normal (subclinical hypothyroidism).
Levothyroxine 100 mcg was increased to 125 mcg. Repeat TSH 8.3,
total T4 8.7, Free T4 1.2 (stable). Direct dialysis free T4 2.1.
T3, TBG, Tuptake and T4 index were all borderline abnormal.
Anti-TPO antibody was NEGATIVE.
- PCP follow up as outpatient, may need endocrine referral
# GERD: Continued omeprazole 20 mg PO QD
Greater than 30 minutes spent on discharge planning and
coordination. | 299 | 796 |
12773640-DS-4 | 27,026,112 | INSTRUCTIONS AFTER ___ EXTREMITY SURGERY:
- You were in the hospital for care of your ___. It is normal
to feel tired or "washed out" after hospitalization, 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.
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.
--- you will start the antibiotic AUGMENTIN to be taken twice
daily for the next two weeks to treat/prevent infection, be sure
to take this medication
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
WOUND SOAKS:
- Please soak your ___ in dilute betadine three times
daily for ___ minutes at a time
- re-pack your wounds with gauze strips
-- be sure to dry your ___ and wounds meticulously between
soaks
-- you may replace dry dressings over your wounds between soaks.
-- keep your ___ dry otherwise
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
Treatments Frequency: | The patient presented to the emergency department and was
evaluated by the ___ surgery team. The patient was found to
have left thenar space abscess and was admitted to the ___
surgery service. The patient underwent I&D of left tehnar
webspace with decompression of abscess, which the patient
tolerated well. For full details of the procedure please see the
separately dictated procedure note. The patient was initially
given IV fluids and IV pain medications, and started on broad
spectrum antibiotics. The patient's home metformin was held and
he was placed on an insulin SS. The ___ hospital course
was otherwise unremarkable. He was transitioned to PO Augmentin
for abx at discharge.
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
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. | 344 | 195 |
16838641-DS-10 | 29,800,206 | Dear Ms. ___,
You came into the hospital because you were having chest pain.
We did some testing and a heart catheterization and found that
you had a blockage in your heart. We opened the blockage by
putting in a stent.
You improved after this and your chest pain resolved.
We started you on new medications for your heart.
Please continue taking your new medications.
Please get follow up blood work within one week of leaving the
hospital.
Please make sure you have an appointment with your cardiologist
and PCP within one week of leaving the hospital.
It was a pleasure caring for you at ___.
Sincerely,
Your ___ Medicine Team
Post-catheterization Wound Instructions
You may take the dressing off once you leave the hospital.
You may shower. Do not scrub at your wrist or groin sites. Let
warm soapy water run over the wound. Pat dry with towel.
Please notify your primary care doctor immediately if you notice
bleeding, if you develop severe pain in the R leg or R arm, or
notice any drainage. | ___ YO woman with h/o osteoarthritis diet-controlled DM2,
hypothyroidism, and depression/anxiety who presented with acute
onset substernal chest pain, admitted to ___ for NSTEMI.
# NSTEMI: Presented with one day of chest tightness, with
slightly elevated troponin, EKG without acute ischemic changes
concerning for NSTEMI. Was started on heparin gtt. Trop 0.02 ->
0.16 AM of ___. On ECHO ___ EF 55%, mild AR. S/p cardiac
cath on ___ with DES x1 to LAD. Given ASA 81, atorvastatin 80
mg, metoprolol 12.5 BID, and initiated on Plavix post cath.
# Hypertension: Review of outpatient BP's show typical readings
120-140/60-80. On presentation to ED, BP markedly elevated
215/74. Improved to 116-150s on ___. Concern for potential
contribution of patient's venlafaxine, recommend outpatient
discussion of indication for this med. Initiated Lisinopril 2.5
mg at this time.
#Thrombocytopenia:
Patient developed thrombocytopenia, with platelets downtrending
during admission from 120s -> 110s -> 108 at time of discharge.
Recommend outpatient f/u.
Patient was seen and evaluated by ___ Pharmacist while
inpatient to review medications.
=======================
Transitional Issues
- please follow up patient's cardiac symptoms s/p NSTEMI. Please
f/u groin and R wrist access sites
- patient initiated on Lisinopril for HTN at this visit. Please
monitor patient's BP and titrate medications accordingly. Please
evaluate venlafaxine for potential contribution to HTN and
consider changing this medication
- Patient started on metoprolol this admission
- Please follow up chemistry in 1 week given initiation of
Lisinopril
- Discharge K: 4.2
- Discharge Creatinine: 0.7
- Please f/u patient's thrombocytopenia. Patient will need
repeat labs within ___ days of discharge
- please consider transition to metoprolol succinate
- Code: Full
- Contact: ___ | 162 | 263 |
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