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15508517-DS-10 | 27,509,615 | Dear Ms. ___,
It was a pleasure taking care of you at ___! You were
hospitalized because you had chest pressure and dizziness that
we think was due to your fast, irregular heart rhythm called
atrial fibrillation. We increased your Metoprolol to 75mg every
night. It is important to take this medication every night
because it prevents you from going back into the fast rhythm.
The Metoprolol will not lower your heart rate too low because
your pacemaker will prevent that from happening. Please keep
your appointments as listed below. Go by the ___
___ clinic tomorrow, ___, to have your INR checked.
Take care and we wish you the best,
your ___ team | Ms. ___ is an ___ yo woman with a history of
paroxysmal atrial fibrillation on warfarin, sick sinus syndrome
s/p PPM placement ___, CKD, HTN and HLD who presented with
chest pressure ___CTIVE ISSUES:
==============
# Atypical Chest Pain: Pt presented with substernal chest
pressure upon waking in the setting of not taking her
Metoprolol. Resolved with rate control and thought to be ___KG without acute changes, TTE without evidence
of pericardial effusion or wall motion abnormalities. Did
initially have troponemia, however, mild and in the setting CKD,
thought to be demand ischemia. CK-MB did not elevate. PPM site
c/d/I. Recently hospitalized with similar chest pressure and
afib with RVR, as well as SSS, PPM implanted with success,
discharged on ___. Her Metoprolol was uptitrated to 75mg XL
QHS, which she tolerated well.
# ___ on CKD: Baseline creatinine 1.6-1.8. 2.0 on admission,
came down to 1.5 with increased PO intake. Likely prerenal in
the setting of hypovolemia, patient does not appear volume
overload on exam. | 117 | 171 |
16194637-DS-13 | 23,370,117 | Dear Mr. ___,
You came to the hospital because you felt short of breath.
While you were here:
------------------
- The interventional pulmonary doctors and the ___ doctors
looked at your trach to see if a problem with the trach was
causing your shortness of breath. Your trach looked ok.
- The sleep doctors also saw ___. They recommended lung function
tests, a blood test (ABG), and a sleep study to figure out if
you have obesity hypoventilation syndrome in addition to your
sleep apnea. The treatment for this would be ventilation at
night but you said you could not do this.
- The reason you experienced shortness of breath and weight gain
is most likely from fluid overload due to your heart failure and
your diet at home. You received IV medicine (Lasix, Diuril) and
saw the heart doctors to help get rid of extra fluid.
When you leave the hospital, please:
- Get a referral for a sleep study (should be in a sleep lab,
not at home), and the other testing to diagnose obesity
hypoventilation syndrome and see how your sleep apnea is doing.
- Continue taking Ambien for sleep apnea.
- Keep your trach open at night and blow humidified air on it.
- If you become open to testing and treatment for your sleep
problems, have your doctor connect you to the sleep clinic at
___.
- After you have a sleep study, you need to see the
Interventional Pulmonary doctors to exchange your trach.
- Follow a low salt diet and do not drink more than 2 liters of
fluids per day (including all the food you eat).
- Weigh yourself every day. Call the heart failure clinic if
your weight goes up by more than 3 pounds in one day or 5 pounds
in one week.
- Continue to see a nutritionist through the heart failure
clinic.
- Get a referral for a psychiatrist for anxiety and
claustrophobia.
- See below for your appointments.
- Take your medicines as prescribed below.
We wish you the best,
Your ___ Team | Mr. ___ is a ___ year old gentleman w HFpEF, DM2,
severe OSA s/p ___ cannula on nocturnal O2, B subclavian
DVTs on lifelong anticoagulation who presented with 1 week of
dyspnea and months of weight gain, initially thought to be
related to his tracheostomy, but more likely related to acute on
chronic diastolic heart failure, for which he had prolonged
hospitalization for diuresis. | 330 | 64 |
15593172-DS-29 | 24,706,598 | Dear Mr. ___,
You were admitted to ___ for fevers. You were found to have a
bacterial bloodstream infection. You were seen by the infectious
disease specialists and they do not think that your portacath is
infected, so it does not need to be removed at this time. You
were treated with IV antibiotics and your fevers resolved. You
will need to take an oral antibiotic called levofloxacin
[Levaquin] for 9 more days to finish a 2 week course of
antibiotics. If you begin to experience fevers or
redness/tenderness around your portacath, it is very important
that you call your doctor immediately. Once you have finished
your antibiotics, you can talk to your oncologist about resuming
chemotherapy.
Also, we will set up an appointment with the GI doctors in order
to replace the cap on your G-tube.
It was a pleasure taking part in your care, and I wish you all
the best in the future. | Mr. ___ is a ___ with h/o stage IIIB NSCLC and stage IIIB
laryngeal CA (poorly differentiated, likely ___)with multiple
brain mets s/p WBXRT and Cyberknife, currently on single agent
palliative docitaxel who presents with fever, found to have
strep pneumo bacteremia.
# Strep Pneumoniae bacteremia: Patient had no clinical evidence
of pneumonia. Likely etiology of his bacteremia is tumor
invasion, causing commensal strep pneumo to leak into the
bloodstream. There was erythema, warmth, and TTP over the
tunneled portion of his portacath, which was concerning
infection of his portacath or the tunnel of the portacath vs a
more superficial cellulitis. U/S showed no evidence of
subvlacian or IJ clot. Also no evidence of portacath pocket
abscess. Erythema around the portacath tunnel improved on
antibiotics throughout admission, though patient still with some
tenderness at site where tunnel crosses the left clavicle on
discharge. Surveillance BCx showed NGTD. Patient was initially
treated with vancomycin and cefepime. When speciation and
sensitivities of blood culture returned, coverage was narrowed
to ceftriaxone 2gm IV daily. He was evaluated by the central
line nurse ___ ID. ___ ID recs, patient was discharged on PO
levofloxacin 500mg daily to complete a 14 day course of
antibiotics for uncomplicated bacteremia. ID consultants
believed that there is a possibility that there is an infection
of patient's portacath tunnel or this could be a cellulitis as
it did not appear classic for a tunnel infection. Given the fact
that he already had one port removed and therefore it would be
difficult to place another port, ID recommended that he finish
his 14-day course of antibiotics and then monitored for evidence
of continued infection. From ID consultants perspective, after
patient finishes his course of antibiotics, it would be alright
to use the port for palliative chemo at the discretion of
patient's PCP and oncologist. He will need close monitoring once
his antibiotics are done to make sure the infection does not
return. The patient and wife are aware. He will need close
outpatient follow up.
# Brain mets: patient is s/p WBXRT and cyberknife. He currently
has no focal neurologic deficits. Continued Keppra and
dexamethasone.
# Lung/Laryngeal CA: patient is on palliative docitaxel chemo.
He receives infusions once weekly on ___ x 3 weeks then 1
week off. Last infusion was 1 week prior to admission. Decision
to resume chemo through portacath will be left to the discretion
of patient's PCP and oncologist as outlined above under
#bacteremia.
# Hypothyroidism: continued home Synthroid
# Hypertension: held home metoprolol in setting of hypotensive
episode in the ED. Resumed on discharge. | 153 | 435 |
17848200-DS-13 | 21,055,006 | Dear Mr. ___,
You were admitted to the hospital because you were nauseous and
had abdominal pain. Please see below for more information on
your hospitalization. It was a pleasure participating in your
care!
We wish you the best!
- Your ___ Healthcare Team
What happened while you were in the hospital?
- You were found to have too much fluid on board. This was felt
to be the cause of your nausea and belly pain.
- You received medications through the IV to help you pee off
the extra fluid.
- You were improved significantly and were ready to leave the
hospital.
What should you do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | =====================
SUMMARY:
=====================
___ with complex medical history significant for non-ischemic
cardiomyopathy with EF ___, awaiting LVAD with Lifevest, s/p
ICD explantation due to Staph bacteremia on home daptomycin,
pulmonary HTN, MR, and TR who presents with cough,
nausea/vomiting, and chest and abdominal pain, found to be in
acute on chronic systolic heart failure exacerbation. He
underwent IV diuresis with subsequent improvement of his
symptoms.
CORONARIES: no CAD noted on cor angio in ___
PUMP: EF ___ on last echo in ___
RHYTHM: sinus with PVCs | 148 | 84 |
10335293-DS-28 | 23,577,897 | Dear Ms ___,
You came to ___ because you were short of breath. You were
found to have some collapse of your lungs and possibly increase
in fluids in your lungs that cause your shortness of breath.
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!
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You were treated with IV lasix to remove excess fluid from
your lungs
- You had imaging of your kidneys as the function
- You improved considerably and were ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have chest pain, shortness of
breath, or other symptoms of concern.
Sincerely,
Your ___ Care Team | Ms. ___ is an ___ woman with a history of a fib/sick
sinus syndrom s/p PPM placement in ___, chronic pain,
hypertension, hyperlipidemia, GERD, diastolic heart failure,
chronic iron deficiency anemia, OSA, and osteoporosis, who
presents with acute onset shortness of breath, found to have ECG
with features consistent with possible atrial fibrillation w/
aberrancy vs. VT.
==================== | 187 | 57 |
11569076-DS-10 | 21,848,854 | Dear Ms. ___,
It was a pleasure participating in your care. Please read
through the following information.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had chest pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
While you were in the hospital we checked for some proteins in
your blood which show whether or not you are having a heart
attack. These markers showed that you were not having a heart
attack. Even though these were negative, we did a procedure to
look at in the arteries in your heart because your diabetes and
high blood pressure put you at risk for coronary artery disease.
The arteries in your heart did not have any blockages.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
-Your ___ Care Team | SUMMARY STATEMENT
Ms. ___ is a ___ yo F with a history of poorly controlled HTN
and T2DM (A1c 8.2% ___, obesity (BMI 36.2) presenting with
chest pain, left arm numbness, diaphoresis, concerning for
unstable angina in the setting of risk factors for CAD.
Throughout admission the patient had episodes of chest pain with
repeated negative troponins and unchanged EKG. Patient underwent
TTE which showed mild LVH but otherwise normal function. Patient
underwent left heart catheterization which showed clean
coronaries with no significant CAD.
# CORONARIES: no evidence of macrovascular CAD
# PUMP: mild LVH, normal function ___
# RHYTHM: NSR
#Non cardiac Chest Pain
Patient presented with significant risk factors for ACS and
story concerning
for unstable angina. She was given aspirin 324mg. Troponins were
negative x3 and was not found to have any EKG changes throughout
multiple episodes of chest pain during admission. HEART score is
5, TIMI ~2, ___ 49pts, low-moderate risk overall. Patient was
managed medically with ASA 81mg, Atorvastatin 80mg, Metoprolol
6.25mg q6, and Valsartan 320mg for BP control. TTE showed
grossly normal function. Patient underwent LHC which showed no
macrovascular CAD. Patient was discharged on ASA, atorvastatin
80mg. Metoprolol was stopped given no clear indication at this
time in the setting of clean coronaries and normal EF.
#HTN: Continued home Valsartan 320mg QD
#T2DM (A1c 10.3% ___, now 8.2% ___: held home oral agents
and gave 12u Lantus nightly + SSI while in house
TRANSITIONAL ISSUES
=====================
[] patient was felt to have noncardiac chest pain given TTE with
only mild LVH, LHC without macrovascular CAD. Could still have
microvascular disease. If continues to have anginal chest pain
without other explanation, could start Metoprolol as outpatient.
[] consider diagnosis of peripheral neuropathy given hand and
foot numbness/tingling/pain
# CODE: full code confirmed
# CONTACT: mom ___ ___ | 193 | 293 |
14061482-DS-26 | 29,466,940 | Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You came to the hospital because you were
having diarrhea. We tested your stool to see if you had c. diff
but the results were not available at the time of your discharge
so we decided to continue on your oral vancomycin. You were
fluid through an IV and your got better.
Your discharge medications and follow up appointments are
detailed bellow.
We wish you the best!
Your ___ care team | ___ yo man with AML/myeoloid sarcoma admitted with diarrhea 4
days after discharge for malaise.
#Diarrhea: Patient was recently discharged from ___ for an
episode of malaise, was never febrile. During that admission his
levofloxacin and Bactrim were discontinued as the patient was no
longer neutropenic, however his PO Vancomycin for previous C.
Diff was continued. Pt was seen by transplant ID on ___ for
evaluation of his malaise and subjective fevers. At that
appointment it was noted that he should have discontinued his
levofloxacin as he was not neutropenic after his last admission,
but had continued to take it. Further more he was noted to be
more than 2 months out from an isolated case of Cdiff and told
to discontinue his PO vancomycin. The patient reports that he
has had increased loose, yellow bowel movements x4 days PTA. No
fevers/chills or abdominal pain. Given recent abx use and
discontinuation of his PO vanco, there may be concern for
recurrent c. diff. Noro PCR negative. Patient quickly improved
after admission to the hospital and only had one episode of
diarrhea while inhouse. He was restarted on PO vancomycin for
presumed recurrent c. diff. C. diff PCR and other stool studies
were pending at time of discharge.
# AML/Myeloid sarcoma - s/p ___, C1 HiDAC ___. Pt
received 1u pRBC while in house for Hgb of 7.3
- cont acyclovir ppx
TRANSITIONAL ISSUES
[]assess pt's ongoing diarrhea
[]please follow up stool studies
CODE: Full
COMMUNICATION: Patient
EMERGENCY CONTACT HCP:
Name of health care proxy: ___
___: mother
Phone number: ___
Cell phone: ___ | 81 | 260 |
16909978-DS-15 | 24,489,674 | Dear Ms ___-
___ was a pleasure taking care of you during your
hospitalization. You were admitted after a fall because you were
having pain and a difficult time walking. You were given pain
medicine and see by physical therapy who felt you would benefit
from a short stay in rehab.
Please make a follow-up appointment to see your primary care
provider once you are discharged from rehab. Take all your
medications as prescribed, listed below.
Again, it was a pleasure being a part of your care-
-Your ___ Care Team | ___ with HTN, type 2 diabetes, asthma who presents after a
mechanical fall and is now being admitted for pain management
and difficulty ambulating.
#S/p fall: pt reports falling on steps after her shoe fell off
while descending. She reports landing on her knees, right elbow,
then her face, but denied any LOC. History appears entirely
mechanical without loss of consciousness, prodromal symptoms or
preceeding illness. She presented to the ED when she had
difficulty ambulating. EKG unchanged and labs WNL. Head, knee
and elbow imaging reveals no acute abnormalities. Patient
currently endorses adequate pain control. However, she does have
difficulty with ambulation and transfers after her fall.
Orthostatic vital signs were negative and ___ felt that the
patient would need short term rehab given her limited mobility
with pain.
# Sinus tachycardia: Believed to be secondary to pain. Treated
with adequate pain control and 1L NS bolus. EKG unchanged from
prior with RBBB LAFB.
CHRONIC ISSUES:
#HTN: Normotensive. Continue home amlodipine, lisinopril and
potassium
#TYPE 2 DIABETES: Well-controlled. HbA1c 6.3 in ___.
#HLD: Continue atorvastatin
#ASTHMA: Continue home flovent with prn albuterol
TRANSITIONAL ISSUES
Code status while inpatient: Full (confirmed)
EMERGENCY CONTACT HCP: ___ ___
Pt will take home tylenol dose for pain
Pt HR has been between 85-100, pt has been asymptomatic, this is
likely secondary to pain and should resolve with APAP PRN | 89 | 229 |
17944165-DS-11 | 29,348,944 | Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with confusion. You were seen by the
neurology and psychiatry teams. You had a brain MRI which was
unchanged from your last MRI. It is important that you follow up
with the cognitive neurologist at the appointment below.
We wish you the best,
Your ___ Care team | ___ year old female with h/o memory loss and difficulties with
executive functioning who presents with an acute on chronic
decline in functioning.
#Cognitive deficit NOS
The patient presented with worsening confusion in the setting of
at least ___ years of cognitive difficulties. She had a underwent
CT scan and MRI of her brain which showed volume loss more
pronounced in the frontal lobes. The patient was seen by
psychiatry who recommended a slow taper of Clonazepam and
outpatient follow up with a psychiatrist, perhaps in the
cognitive neurology clinic. The patient was seen by neurology
who recommended repeating a brain MRI as noted above, which was
unchanged from MRI in ___. She was started on b12 repletion
given her borderline B12 levels. The patient was seen by OT who
felt the patient was safe for discharge home but would need help
with IADLs. The patient was counseled not to drive until follow
up with cognitive neurology- She has follow up scheduled in
approximately one month.
#DEPRESSION/Anxiety
As above, the patient was seen by psychiatry who felt there was
no indication for inpatient admission and recommended weaning
Clonazepam. No other changes were made to the patients
medication regimen.
#Headaches
The patient had ongoing complaints of headache. She was
continued on Imitrex and advised to discontinue Fiorocet. | 63 | 214 |
12640368-DS-18 | 26,859,638 | Dear Ms. ___,
You were hospitalized at ___ for symptoms of Lower
extremity sensory change. You were sent in from Neurology
clinic and admitted to the Neurology Service.
While inpatient, you underwent Brain MRI, Spinal Imaging and
lumbar puncture as part of your evaluation. Based on your
history, examination and lab studies, your doctors have
___ with Multiple Sclerosis.
Multiple Sclerosis is an Neurologic inflammatory condition
where the myelin (a material insulating the nerves in the brain
and spinal cord) is attacked by your immune system by mistake.
It is a treatable, but chronic condition. There are many
different medication and treatment options for you.
You were treated in the hospital with IV steroids to help
improve your sensory changes. You were improving and doing
well. Your doctors think your ___ continue to improve
with time. Following the lumbar puncture you did have a
significant headache, but this was improving. Your doctors ___
___ were safe and that you did not need a blood patch. Should
your headache fail to improve over the next ___ days, you may
require a blood patch.
You have been scheduled outpatient neurology follow-up with
an MS specialist. They will be able to answer your questions
and discuss more long term medications.
It was a pleasure taking care of you.
Your ___ Care Team | ___ woman with a past medical history of distant opiate abuse
on methadone who was referred in from clinic for bilateral leg
sensory changed. She underwent expedited inpatient evaluation.
MRI revealed a T-spine lesion (most likely demyelinating) at the
level of T10 which likely explained her sensory symptoms.
Imaging of her brain confirmed multiple lesions of different
ages consistent with demyelination. The clinical picture was
consistent with transverse myelitis secondary to a new diagnosis
of multiple sclerosis. She was treated with 3 days of IV
solumedrol with moderate improvement in her sensory symptoms. He
had a post-LP headache, which was improving prior to discharge.
She was scheduled for outpatient follow-up with an MS
specialist. Conversation regarding initiation of longer term
agents can be discussed at that appointment.
Transitional Issues.
- Outpatient Neurology follow-up with Dr. ___.
- Should her post-LP headache fail to improve in ___ days, she
may need to present to the ED for a blood patch. She was clearly
improving during hospital stay.
- Consideration for longer term agents on outpatient basis. | 242 | 172 |
18553055-DS-15 | 20,602,088 | You were admitted to the hospital with pain in your left arm and
a non-function av graft. Your graft developed a clot and was no
longer functioning. A temporary dialysis line was placed and you
underwent dialysis.
You developed a fever, which was concerning for infection. We
strongly recommended that you stay in the hospital for further
evaluation. We discussed that you could become very ill if you
leave the hospital. You declined further workup and decided to
leave against medical advice.
The following changes were made to your medications:
-percocet for pain | ___ with ESRD on HD with who presents with left upper arm pain
and found to have left thrombosed brachiocephalic fistula and
admitted for placement of tunneled HD catheter and hemodialysis.
# Thrombosed Fistula - AV fistula became non-function at his
outpatient HD session. There was pain over the site of the
fistula. His pain was treated with oxycodone. Initially, there
was no sign of superimposed infection with no fever or
leukocytosis but he received 1 dose of vancomycin. A tunneled
line by ___ on ___. He developed a fever prior to discharge and
it was recommended that he stay for further fever work-up but he
left AMA. He was given a follow-up appointment with transplant
surgery.
# Hyperkalemia - Initially 6.1 on admission which improved to
5.5 after kayxelate. There were no EKG changes (peaked T waves
were present on previous and unchanged). He was monitored on
telemetry and his potassium improved with HD.
# ESRD - Creatinine and BUN very elevated on arrival. He
received HD on ___ and ___ to make up for his missed HD
session on ___. He was continued on phoslo.
# hypertension - He was continued on lisinopril 40 mg po daily. | 93 | 207 |
12338051-DS-22 | 24,484,178 | Dear ___,
You were hospitalized due to symptoms of right leg weakness
resulting from your prior ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-pre-diabetes
-elevated cholesterol
We are NOT changing your medications.
Please take your medications as prescribed previously.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ right-handed man with history notable for HTN, HLD,
CAD s/p stents, RPLS (___), and prostate cancer s/p recent
(___) radical prostatectomy recently admitted (___) with
a left basal ganglia/IC and right frontal infarcts presented
with worsening right leg weakness. Repeat CT head shows prior
infarct without evidence of new lesions. Therefore the right leg
weakness was likely a sequela of the prior stroke. Foley
catheter was removed during this hospitalization per the
patient's outpatient urologist Dr. ___. He voided voluntary
s/p removal without any issues. | 230 | 86 |
18653131-DS-26 | 23,515,807 | Dear Ms. ___,
You were admitted for an episode of freezing in place, and L
sided numbness. You had some abnormal eye movements in the ED so
you were evaluated for stroke, and MRI brain showed that you did
NOT have a stroke. You should follow up with Dr. ___
neuro-opthalmology to further evaluate your abnormal eye
movements. However, it is possible these are due to medication
effect, or a congenital nystagmus which is not an issue for you.
You should follow up with Dr. ___ your seizure control as
previously scheduled.
Your creatinine was increased on admission suggesting that your
Lasix dose may be high. We arranged a PCP appointment to follow
this up. Please have your creatinine level drawn next week and
faxed to your PCPs office.
It was a pleasure caring for you at ___
___. | The patient had an atypical episode of freezing in place and L
sided numbness. Exam showed ocular misalignment and ? upbeat
nystagmus, with L sided subjective numbness and L sided give way
weakness. She was admitted and MRI ruled out stroke. She
improved back to baseline. Her Cr was elevated and improved back
to 1.5 with gentle IVF. She will get her Cr checked next week
and faxed to her PCP's office.
She should follow up with her epileptologist as previously
scheduled, and Dr. ___ neuroopthalmology to evaluate her
abnormal eye movements.
[ ] follow up creatinine, will be faxed to PCPs office
[ ] A1C elevated at 6.5, requires PCP follow up
[ ] F/U pending lipid panel | 136 | 115 |
13975682-DS-19 | 22,580,820 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital because of heart failure
causing weight gain and difficulty breathing.
What happened while you were in the hospital?
- You were briefly admitted to the intensive care unit because
you needed extra oxygen support to help your breathing.
- You were started on IV diuretics to help remove excess fluid
from your body.
- You were maintained on a low-salt diet.
- You were given vitamin K because your blood was too thinned
from the warfarin. You were then restarted on your warfarin when
safe.
- You were found to be in an abnormal rhythm, atrial
fibrillation. Your metoprolol was increased to help lower your
heart rates to a safe level. You then went into a different
abnormal heart rhythm called atrial flutter and you were started
on another medication digoxin to better control your heart rate.
- You were feeling better and were ready to leave the hospital.
What should you do after leaving the hospital?
- Weigh yourself daily. If your weight increases by more than 3
pounds in one day, make sure to take a dose of metolazone and
follow up with your doctor.
- Please take your medications as listed in your discharge
summary and follow up at the listed appointments.
We wish you the best in the future!
Sincerely,
Your ___ care team. | Ms. ___ is an ___ y/o woman with PMH of heart failure
borderline EF 45%, atrial fibrillation w/ RVR (on Coumadin s/p
DCCV x 3 (most recent ___, CAD s/p PCI to LAD (stents x3,
most recently in ___, COPD/Asthma, HTN, who presented with
weight gain and dyspnea consistent for HF exacerbation. She was
briefly admitted to CCU for BiPAP but improved with IV diuresis.
Course complicated by atrial fibrillation/flutter. | 231 | 71 |
15648706-DS-2 | 24,306,156 | You were admitted with diffuse lymphadenopathy and a biopsy was
performed. Unfortunately the biopsy results were not available
at the time of discharge, however the hematology/oncology team
that saw you in the hospital will follow up the results and
contact you about next steps. If you feel sick, please consider
going to the emergency department. If you are not feeling sick
but have other questions, you can call the hospitalist who took
care of you in the hospital, his phone number is below. | ___ year old man with a history of well controlled HIV (CD4 359,
VL undetectable) on ART, melanoma (resected), and colon polyps,
who presented with abdominal pain and was found to have diffuse
mesenteric and RP lymphadenopathy, admitted for expedited
biopsy.
The patient felt well on the day of discharge. We were all
frustrated by not having a preliminary biopsy result but
Heme/Onc agreed it was safe for him to be discharged and they
will call him with the result.
#Abdominal Pain
#L supraclavicular and axillary, retroperitoneal and mesenteric,
and left inguinal lymphadenopathy
-noted to have B-symptoms (chills, drenching sweats)
-very concerning for malignancy, usual lymphoproliferative
disorders seem more likely than HIV-associated lymphoma given
excellent viral control, do not have significant suspicion for
TB
-however, Radiology's read raised abdominal TB as a possible
cause. Case was discussed with ___ and ACS, but both services
requested TB be ruled out prior to any biopsy. PPD was placed
and was negative, and core biopsy was performed (rather than
excisional biopsy) to assess for any signs of TB.
-LDH and uric acid were elevated so he was started on
allopurinol
-Heme/Onc was consulted and will follow-up the results
-they recommended EBV viral load (pending), hepatitis B and C
serologies (consistent with Hep B immunity due to natural
infection), and quantitative immunoglobulins (IgG and IgM were
low)
#Constipation
-resolved with prune juice
# HIV: Well controlled for years.
-Home Biktarvy (Bictegravir, Emtricitabine, Tenofovir) is
non-formulary, so here he was on emtricitabine/tenofovir and
dolutegravir instead of bictegravir
-his outpatient infectious disease attending was aware of these
changes
# BPH: Continued home tamsulosin
# HLD: Continued home rosuvastatin
# AMD: No AREDS vitamins on our formulary
#Pulmonary nodule
- 6 mm right lower lobe perifissural nodule is most likely an
intrapulmonary lymph node. An optional CT follow-up in 12
months is recommended in a high risk patient, as described
below.
-RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT in 12
months is recommended in a high-risk patient.
-See the ___ ___ Guidelines for the Management
of Pulmonary Nodules Incidentally Detected on CT" for comments
and reference: ___
#Advance care planning
-Desired amount/detail of information about medical problems:
[x] All the details
-Preferred involvement of others in decision making: [x] Makes
important decisions alone
-Evidence of prior advance care planning in WebOMR: [x] No
-Care preferences in the setting of serious illness: [x] Yes,
has preferences: Patient stated that he has no one that he could
choose as his healthcare proxy, saying that the person he had
previously chosen has since passed away. He says he has no
friends/family or other people that he could pick. When asked
if he has any preferences for the kind of care he would want if
he got very sick he says "yes, just pull the plug." He has not
really talked with anyone about these wishes before. He states
there is not really anyone who would miss him if he were to go.
Interpretation of above data: Full code, presumed. It would be
optimal if the patient could select a proxy, however he seems
relatively on befriended. I noted that occasionally healthcare
professionals can become proxies for patients, but they cannot
serve in their capacity is a healthcare professional at the same
time that they are serving as a proxy.
-SW provided information about role/function of HCP, and
guardianship process if a pt does not have a HCP and needs
alternate decision making. SW suggested living will--pt states
he has one that is very old, and indicates a person who has
passed away.
-SW encouraged pt to call PCP at ___ to ask for
referral, and also provided pt w/ contact information for
Therapy Matcher referral service.
[x] The patient is safe to discharge today, and I spent [ ]
<30min; [x] >30min in discharge day management services.
___, MD
___
Pager ___ | 86 | 638 |
19311354-DS-29 | 24,062,469 | Dear Mr. ___,
You came into the hospital from your ___ facility because
the fistula on your left arm clotted and you were unable to get
dialysis on ___.
In the hospital, the interventional radiology team attempted to
remove the clot, but the fistula in your left arm was unable to
be used for dialysis. As a result, a new dialysis catheter was
placed in your left arm so that you could continue with
dialysis. You received dialysis on ___ and ___
___. You will be able to continue with your dialysis
appointments as scheduled.
Please follow up with Dr. ___ you leave the hospital.
Please also follow up with your podiatrist when you leave the
hospital to monitor your foot wound. Please changes the
dressings according to the instructions from your
podiatrist/vascular surgeon.
Continue to take all your medicines and keep your appointments.
It was a pleasure caring for you at ___
___. We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with a PMH of CAD s/p
CABG, HFrEF (45%), PVD s/p multiple interventions, ESRD on HD
___ who presented from ___ clinic with concern for AV fistula
thrombosis and hyperkalemia s/p AV fistulogram with ___
thrombolectomy on ___, now with persistent AV fistula
thrombosis and s/p tunneled HD line placed on ___. He has
resumed dialysis.
============= | 161 | 64 |
11597448-DS-20 | 25,700,496 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so 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:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
WBAT LLE
Treatments Frequency:
Dry sterile dressing daily or as needed for staining
Staples to be removed at first follow up appointment | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left hip fracture and was admitted to the orthopedic
surgery service. She also sustained a R thumb metacarpal base
fracture, which was managed by Plastic Surgery in a thumb spica
splint. The patient was taken to the operating room on ___
for L 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. She received 1u PRBC postoperatively for Hct 23.5.
Her Hct responded appropriately and remained stable. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated on the left lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. The patient
should also follow up with Dr. ___ (Hand Surgery). The
patient was given written instructions concerning postoperative
precautions and the appropriate follow-up care. The patient
expressed readiness for discharge. | 198 | 273 |
10764017-DS-23 | 24,001,931 | Dear Mr. ___ Mrs. ___,
___ you for choosing the ___
for your daughter's care.
___ was admitted with a fever and pneumonia.
While she was in the hospital, we gave her IV antibiotics to
treat her pneumonia and continued all of her other medications.
Over the course of admission, she also developed a urinary tract
infection. We gave her separate antibiotics to treat her urinary
tract infection.
Once ___ leaves the hospital, she will transition to an
LTAC. At this facility she will continue to work with therapists
and doctors who ___ continue to evaluate her and try to help
her. We communicated with an accepting physician and the
nursing director and told them about ___ care. We conveyed
our perspectives on aspects of her care that are of particular
concern, including fevers and managing her tracheostomy. She
will be connected to outpatient neurology for after discharge.
We wish your family the best. It was a pleasure caring for
___ and we will miss her.
Your ___ Care Team | PLEASE NOTE THIS PATIENT JUST HAD AN EXTENSIVE HOSPITALIZATION
___ AND FOR CONVENIENCE THE PREVIOUS HOSPITAL COURSE IS
COPIED BELOW. That discharge summary in its entirety will also
be provided. | 170 | 30 |
15400576-DS-15 | 29,548,073 | Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with an infection in your bladder and
you developed urinary retention (inability to urinate). You were
started on antibiotics. Unfortunately, the bacteria in your
urine can not be treated with oral antibiotics. You have been
set up to receive intravenous antibiotics at home.
For you urinary retention, you will require indwelling catheter
until you follow up with your urologist. (see below) | ___ y.o M with CAD s/p CABG, prostate CA s/p radiation on
leuorplide, recent TURP on ___, history of ___, presenting
with dysuria, chills, and left flank pain, consistent with
pyelonephritis
# Pyelonephritis: Pt presenting with flank pain, leukocytosis,
fever, and LLQ pain radiating toward the left flank concerning
for pyelonephritis. Per ED exam, no prostatic tenderness to
suggest prostatitis. Urine culture obtained from
___ on ___ with resistant E.
Coli. The patient was initally treated with ceftraixone but
given resistant urine culture he was transitioned to Meropenem.
Blood and urine cultures at ___ were negative. He was
discharged on Ertapenem to complete a 14 day course.
#Urinary obstruction secondary to prostate cancer,
recently s/p TURP:
The patient was noted to have urinary retention with increased
post-void residuals.Discussed with urology who recommended Foley
placement and outpatient follow up which was placed, and
recommended (see below)
# Hypertensive urgency: Patient presenting with elevated BPs to
the 230s/110s, decreased to 210s/110s. Improved with two doses
of labetolol, and initiation of amlodipine. I called ___
pharmacy and reviewed his current meds and reconciled his list.
Amlodipine was not mentioned as an active medication by them or
in the CHA list of active records, and he had not filled his
amlodipine rx since ___. On review of CHA notes, Lasix
appeared to have been very effective in improving his bp on
prior occasions, and as such pt. was given one dose of Lasix on
___, and his bp improved dramatically. It was in the
110-120 range the following day (day of discharge) and he felt
well, no complaints, and was not orthostatic. Given this
improvement, did not plan to continue the amlodipine on
discharge, rather to resume his pre-admit meds, and pt. will
have ___ follow up.
# Prostatic adenocarcinoma: Patient with a history of prostate
adenocarcinoma, with recent TURP as above, on Leuprolide as an
outpatient. The patient's oncologist, Dr. ___ PSA
which is stable from prior
# CAD:
- continued Metoprolol Succinate XL 50 mg PO DAILY
- Continued aspirin 81 mg daily
- Continued home Atorvastatin 20 mg PO QPM
# Chronic Anemia: Admission H/H of 10.8/33.7, within recent
baseline. No evidence of active bleeding.
- Continued ferrous sulfate
# Asthma:
- Continued albuterol sulfate 90 mcg/actuation inhalation Q4H
- Continued Fluticasone Propionate NASAL 2 SPRY NU DAILY for
management of allergies
# Atrial fibrillation: Admission EKG in atrial fibrillation.
Continued Coumadin 5 mg daily, INR subtherapeutic-- follows with
___ clinic with PCP. INR on discharge was---
# Back pain:
- Gabapentin 300 mg PO QHS
# GERD:
- Continue omeprazole 20 mg daily
# Osteopenia:
- Continue vitamin D 1000 units daily | 78 | 429 |
15015778-DS-15 | 26,722,654 | Dear Mr. ___,
You were admitted for acute low back pain and found to have L2/3
discitis. You did spike a fever so a bone biopsy was recommended
to rule out infection but you needed to leave the hospital for
personal reasons so declined inpatient biopsy and left against
medical advice. You understood and were able to verbalize the
potential health risks without doing the biopsy including severe
spine and nerve damage. Please follow up with your PCP. | ___ with hx of chronic intermittent lumbar back pain, htn, HLD,
gout presenting with
progressive lumbar back pain, with MRI findings concerning for
discitis.
# Back pain, discitis: MRI findings concerning for L2/L3
discitis, without cord signal abnormalities or evidence of
critical stenosis. No symptoms of cord compression. CRP
elevated. Spiked one fever to 100.7 on ___ but none since. BCx
negative to date. Ortho spine consulted and recommended bone
biopsy to rule out infectious cause but patient declined
inpatient biopsy as he needs to leave the hospital to see his
son in ___ before he is deployed. Patient fully
understands and verbalized risks of leaving without definitive
diagnosis including permanent spine and nerve damage. He decided
to leave ___. He will follow up with
his PCP when he returns from ___.
# Fever: Raises concern for infectious discitis as discussed
above but may also be inflammatory reaction. No other signs of
infection. BCx negative to date.
# Hypertension: Continue home anti-hypertensives.
# Gout: Continue home allopurinol
# Contact: wife, ___ ___ | 77 | 166 |
15544487-DS-17 | 20,275,614 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed results as above, no
leukocytosis. The patient underwent laparoscopic appendectomy,
which went well and without complication (please see the
Operative Note for full details). After a brief, uneventful stay
in the PACU, the patient arrived on the floor tolerating clear
liquids, on IV fluids, and with IV pain meds for pain control.
The patient was hemodynamically stable.
When tolerating a diet, the patient was transitioned to oral
pain medication with continued good effect. Diet was
progressively advanced as tolerated to a regular diet without
nausea/emesis. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
The patient is discharged to home on ___ with appropriate
information, warnings, prescriptions, and plans to follow up in
clinic. | 729 | 231 |
12040844-DS-20 | 20,056,276 | You were admitted with diarrhea and abdominal pain. A CT exam
was consistent with a flare of Crohn's disease. You were started
on IV steroids, and you were much improved overnight and able to
eat a regular diet. I am discharging you on oral steroids
(prednisone), which you will take until you see Dr. ___
in clinic. If you have not heard from his office ins two days,
please call ___ to schedule. | On admission, Mr. ___ was noted to have a CT scan
consistent with a Crohn's flare, as well as continual diarrhea
and abdominal pain. A C Diff was negative, CRP was elevated
above his baseline, and a stool culture was sent, which is no
growth to date. His vital signs were stable. Gastroenterology
was consulted, who diagnosed a Crohn's flare. He was started on
IV methylprednisolone, his budesonide and mesalamine were
stopped, and his diet was advanced. By HD#1, his abdominal pain
and diarrhea had completely resolved. Therefore, he was
discharged on prednisone 40 mg, which he will continue for two
weeks until he sees Dr. ___ in gastroenterology.
Hepatitis serologies and a quantiferon and TPMT were sent in
preparation for starting TNF-a antagonist in the outpatient
setting for his Crohn's disease (work up negative so far).
1. Crohn's flare.
- prednisone 40 mg x 2 weeks (provided three weeks in case there
is delay in seeing GI)
- f/u with Dr. ___ in two weeks for steroid
taper/discontinuation and consideration of TNFa blockage
- HOLD mesalamine and budesonide while on systemic steroids
2. Hiccough. Resolved. Likely d/t recent EGD.
3. HTN. Continued home metoprolol.
4. HLD. Home statin
5. DM2. Holding home oral agents, on ISS.
6. CAD s/p CABG. On home metoprolol and aspirin. | 73 | 209 |
12584779-DS-12 | 27,387,568 | Dear ___,
___ was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted after you had a fall at your nursing
facility
What was done for me while I was in the hospital?
- You were found to have a bladder infection, which was treated
with IV antibiotics
- You were found have a fracture of your right hip, for which
you had surgery to repair it
- You had CT scans of your head and abdomen that did not show
any signs of bleeding from your fall
- You were started on lovenox injections to prevent blood clots
after your hip surgery, which you will continue for one month
until ___.
What should I do when I leave the hospital?
- You should continue doing physical therapy
- Resume your regular activities as tolerated, and use Tylenol
(650mg every six hours as needed) to manage any pain from the
hip surgery
- You should take all your medications as prescribed
- You should go to your appointments listed below
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.
Sincerely,
Your ___ Care Team | HOSPITAL COURSE
--------------------
___ woman with hx dementia presented to the ED after a
mechanical fall, treated for a Klebsiella UTI with 3 days of
ceftriaxone, found to have an impacted and mildly medially
displaced right femoral neck fracture s/p R hemiarthoplasty
___, with course complicated by intermittent hypoxia likely in
setting of atelectasis/mucous plugging.
TRANSITIONAL ISSUES
--------------------
[ ] Monitor Hg in 1 week ___ (had downtrending Hg in setting of
hemodilution and arthroplasty, required one unit of pRBCs,
discharge Hg 10.0 on ___
[ ] Started on lovenox for prophylaxis in setting of
arthroplasty, discontinue in month ___, monitor for any
signs of bleeding
[ ] follow up with orthopedics on ___
[ ] Has R lobe thyroid nodule seen on CT, ultrasound follow-up
recommended if within ___
[ ] 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.
ACTIVE ISSUES:
# Right femoral neck fracture s/p R hemiarthroplasty ___
Patient found to have right femoral head fracture ___ fall at
nursing facility. s/p R hemiarthroplasty ___ w/o complications.
Her pain was managed with scheduled tylenol. She was started on
lovenox 40qHS for DVT prophylaxis for one month. End date
___.
# Intermittent hypoxia
Pt with 2 episodes of hypoxia to the ___, with swift recovery to
room air. First episode occurred in the immediate post-op
period, at which point a CXR was repeated that did not show
worsening pulmonary congestion or PNA. Second episode occurred
overnight and resolved without specific intervention. These
episodes were determined to likely be ___ mucus plugging vs mild
chronic aspiration vs atelectasis. There was low concern for
pulmonary edema given CXRs and euvolemia on exam. At the time of
discharge, the patient was back on Room Air for > 48 hours.
# Anemia
Came in with Hg 12.4 and downtrended over the first several days
of her hospitalization, with nadir at 7.6. This likely occurred
in the setting of hemodilution, followed by bleeding from her
arthroplasty. She had a normal abdominal/pelvis CT, ordered
given concern for possible intraabdominal/retroperitoneal
bleeding from her fall and her inability to express pain due to
dementia. She received one unit of pRBCs per ortho protocol to
transfuse for Hg<8 in elderly. Hg responded appropriately,
discharge Hg 10.
# Fall
# AMS at dementia baseline, resolved
Per ED collateral, baseline mental status worsened as she was
non verbal and had bouts of aggressiveness. This was attributed
to her UTI, treated as below. A non-con CT head was performed in
the ED and was unremarkable. Her mental status returned to her
normal baseline during hospitalization.
# Klebsiella UTI
# leukocytosis, resolved
# lactic acidosis, resolved
Pt has a leukocytosis to 14 on admission and slightly elevated
lactate with tachycardia, all of which resolved with IV fluids
and abx therapy. urine culture grew Klebsiella and she was
treated with IV ceftriaxone for 3 days. Discharge wbc 8.6.
# CKD 3
Per review ___ labs, pt with baseline Cr 0.9-1.1. She is at
her baseline. She was discharged with a Cr 0.8.
# Thyroid nodule, right lobe
Visualized on CT Spine with normal TSH. Ultrasound follow-up
recommended if within ___
CHRONIC ISSUES:
# Dementia - alzheimers per hx, continued home memantine 10mg
BID and performed delirium precautions
# Oropharyngeal phase dysphagia - on soft diet per instructions
from nursing home. on aspiration precautions
# Glaucoma - continued home eye drops per formulary
#CODE STATUS: Confirm DNR/DNI?
#CONTACT: ___ (___) | 255 | 596 |
16649269-DS-17 | 29,291,653 | It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation of your pain and
nausea. The pain was felt to be related to your reccent nulasta
infusion and improved with ibuprofen, tylenol and oral morphine.
Your nausea was felt to be related to your chemotherapy, you
were given IV fluids and these symptoms improved with
medication.
The following changes were made to your medications:
-STOP Allopurinol ___ mg twice daily
-START Ibuprofen 800 mg every 8 hours until pain is resolved
-CONTINUE Acyclovir 400 mg every 8 hours
-CONTINUE Tylenol ___ mg every 4 hours as needed
-CONTINUE Ondansetron 8 mg every 8 hours as needed for nausea
-CONTINUE Prochlorperzaine 10 mg every 6 hours as needed for
nausea
-CONTINUE Lactulose 10g/15mL 1 to tablesppons every 2 hours
until bowel movement
-CONTINUE Oxycodone 5 mg every ___ hours as needed for pain
-CONTINUE Ativan 0.5 mg twice daily as needed | A/P: ___ w/ h/o follicular lymphoma diagnosed in ___
presents with total body joint pain, fatigue, nausea and
vomiting which improved over the course of her stay with
supportive management.
#Joint pain: Patient presented with ___ diffuse myalgias and
arthralgias soon after Neulasta injection similar to prior
episodes. The patient was given IV morphine initially and
transitioned to standing ibuprofen 800 mg TID and oxycodone for
break through pain. Patient appeared weak and had difficulty
ambulating, ___ consult recommended that patient was not safe for
home discharge. Patient refused additional hospital stay and
was discharged home aware of her risks for fall. She was given
a rolling walker to use and instructed to have close assistance
when climbing stairs.
.
#Lymphoma: Patient is s/p 3'rd cycle of R-CHOP, her acyclovir
was continued and allopurinol held per the ___ attending.
.
#Leukocytosis -Patient found to have a leukocytosis of 35K on
admission, felt to be due to demargination from neulasta
infusion, trended down over the course of her hospitalization.
.
#Nausea: related to reccent chemo given zofran and compazine.
.
TRANSITIONAL ISSUES:
-___ did not clear patient for discharge, felt was unsafe to go
upstairs, patient was made aware of her fall risk, but insisted
on discharge. She was given a rolling walker to use prior to
discharge. | 154 | 220 |
15558486-DS-6 | 27,324,298 | Dear Ms. ___ were hospitalized for symptoms of dizziness most likely
caused by a condition affecting your inner ear: VESTIBULAR
NEURITIS. This condition will resolve on its own, but may take
several days. We recommend limiting your activity, and treating
your symptoms with the prescriptions we will provide ___ with.
Please make sure to get adequate fluid intake.
It was a pleasure taking care of ___ during this
hospitalization. | ___ F w PMHx HTN, HLD presents with vertigo and right facial
droop. NCHCT and MRI negative for acute infarct. Symptoms are
improved, predominately provoked with movement and changing
positions. Most likely peripheral in etiology given +head
impulse test, +past pointing to the right, and absence of
findings consistent with central location (direction changing
nystagmus, acute changes on imaging). Will treat symptomatically
with IVF, zofran, clonazepam, and limited activity. Will
discharge to home as patient has family members to care for her
- with recs to limit activity and to use above medications to
treat her symptoms on an as needed basis.
Pt was found to have TSH 0.24, T3 62, T4 7.6 on admission labs.
Recommend follow up as outpatient.
Patient also found to have HgA1c of 6.2. Prediabetes education
and diet recommendations were given during hospitalization.
Recommend outpatient follow up. | 67 | 140 |
12759982-DS-3 | 29,005,946 | Dear Mr. ___,
You were admitted to ___ from an outside hospital for workup
of your kidney stones, urinary tract infection, and intestinal
obstruction. We gave you IV antibiotics for your infection, that
will require continued treatment on an outpatient basis. Your
kidney stones and obstruction were managed medically without
surgical intervention.
Please note the changes to your home medications as detailed in
discharge paperwork. Please follow up with your outpatient
doctors as ___ below.
It was a pleasure taking care of you!
Your ___ Team | Mr. ___ is a ___ yo man with a PMH significant for
paraplegia ___ spina bifida, massive ventral hernia with loss of
domain, Fournier's gangrene s/p debridement with diverting
colostomy and SPT, recurrent nephrolithiasis s/p multiple PCNLs,
and recurrent UTIs, transferred from OSH with obstructing right
UPJ stone, suspected SBO, and urosepsis. He was medically
managed for SBO with good effect, tolerating PO well with good
colostomy output on discharge. He was started on IV abx therapy
to be continued as outpatient for his UTI with sepsis. He was
seen by urology, who rec completion of abx therapy and follow up
as outpatient for potential intervention on nephroliths.
#) UTI with sepsis: Patient was admitted with an elevated WBC
count and a dirty UA (>1000 WBC, + Nitrite, + ___. There was
question about possible C. diff abdominal source, but PCR
results came back negative. He was also found on OSH CT to have
several nephroliths, making his UTI complicated, and met SIRS
criteria with tachycardia and elevated WBCs. At OSH, he was
given ertapenem and transitioned to meropenem and daptomycin (hx
of multiple drug allergies) empirically to cover for MDR
pseudomonas and enterococcus, which he has grown in the past.
This was narrowed to meropenem to cover pseudomonas per culture
data and sensitivites on UCx from ___ ED. BCx was negative.
His total abx course will be 14 days given complicated nature
___ first dose - ___ last dose), to be completed as outpatient
at ___ through LUE MIDD line. He has remained afebrile and in
good clinical condition with a WBC that has trended downward
prior to discharge.
#) Possible SBO: Patient has had a massive ventral hernia with
loss of domain for years but this is his first episode of
intense abdominal pain. Per CT scan at OSH, he had severe
dilation of his stomach and first three portions of his duodenum
with obstruction at the Ligament of Treitz. He was managed
conservatively with NG tube decompression to good effect. He
also likely has decreased abdominal wall strength, and
subsequent decreased ability to increase intra-abdominal
pressure to make stool. For this, he was given abdominal binder
to enhance his intra-abdominal pressures and facilitate GI
peristalsis. Prior to discharge, ___ to evaluate nephroliths
showed abd distention still to be present (verified with
radiologist over the phone), but his pain and abd distention has
since disappeared and he was found to be in good clinical
condition, tolerating PO diet well on discharge. He was
instructed to follow up on any issues following discharge with
his doctor at ___.
#) Nephrolithiasis: Patient has significant history of
nephrolithiasis requiring multiple interventions as well as
potential vesicocutaneous fistula (not found on exam), followed
by several urologists as an outpatient. On admission, he had
multiple nephroliths in his bladder and a partially obstructing
stone at his right UPJ, with associated worsening right
hydronephrosis. Urology saw patient, ___ medical management with
IVF and treatment of UTI with no immediate intervention. He was
rec to have follow up with Dr. ___ at ___ after
hospitalization for re-assessment of stones, which was
scheduled. Management of UTI with sepsis as above.
#) IDDM: He was admitted form OSH, where he had ketones on UA
and FSBG >500, likely as he did not receive any insulin despite
being on impressive home regimen. Following 12u regular insulin
in ___ ED, FSBG fell to 280s and he was started on lower
regimen of insulin (Glargine 15u qAM and qHS with ISS) given NPO
status (vs. home regimen of detemir 32u qAM and 26u qPM with
ISS). His FSBG were WNL ranging 100's to 150's throughout
admission, despite advancing diet. He was discharged on this new
regimen with instructions to follow up as outpatient.
#) Multiple decubitus ulcers: Patient has chronic decubitus
ulcers, notable for stage 3 ulcer on sacrum, and unstagable
ulcers on his left dorsal foot. He was managed with wound
consult throughout hospitalization.
#) HTN: BP well controlled with pressures 110-130's in the ED,
but with spiking pressures during admission. His BP's remained
elevated throughout hospitalization to 180's systolic despite
reinitiation of home metop, amlodipine, and lasix (half dose).
He was discharged on new regimen of home metop, uptitrated
amlodipine, lasix, new initiation of lisinopril, and
instructions to potentially uptitrated further/alter regimen as
outpatient. On discharge, his systolic blood pressure was
140's/WNL. | 82 | 718 |
18901656-DS-12 | 26,170,764 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You had shortness of breath. We found that your blood count was
life-threateningly low (anemia).
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You received blood transfusions, and your blood counts
improved.
-Our gastroenterologists looked at your digestive tract with a
camera from above and below (upper endoscopy and colonoscopy),
but did not see any active bleeding.
-You swallowed a capsule, which took pictures of your digestive
tract. Our gastroenterologists are still reviewing those
pictures.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Take all of your medications as prescribed.
-Alert the nursing staff if you have black or bloody stool.
-Weigh yourself every morning, and call your primary care
physician if your weight goes up more than 3 pounds.
We wish you all the best!
Sincerely,
Your ___ care team | ___ female with a history of colon cancer status post
resection, heart failure with preserved ejection fraction, and
type II diabetes admitted for profound anemia in the context of
shortness of breath and visualized melenic, guaiac positive
stool concerning for chronic gastrointestinal losses, though EGD
and colonoscopy non-diagnostic.
#) Chronic blood loss anemia: hemoglobin 2.8 on arrival, which
then appropriately responded, and stabilized in the 8-range,
after transfusion of five units pRBCs in total. Initially, with
end-organ damage by virtue of lactic acidosis and acute kidney
injury, both of which resolved after said transfusions.
Hemodynamic stability and magnitude in keeping with chronicity.
Consensus was gastrointestinal losses, especially in the context
of prior colon cancer; however, both EGD and colonoscopy were
non-diagnostic. Colonoscopy otherwise remarkable for severe
diverticulosis without stigmata of bleeding, internal
hemorrhoids, and single subcentimeter ___ sessile
polyp. Capsule endoscopy then performed. Image interpretation,
however, were not available at the time of discharge. The
gastroenterology team will contact the patient and health care
proxy, should that prove informative. Capsule confirmed to be in
the colon at time of discharge. An unappreciated small bowel AVM
is possibly causative. Not evoking hematologic malignancy in the
absence of differential or peripheral smear aberration.
Inappropriate reticulocytosis is a probable consequence of
chronic iron depletion, which was repleted with intravenous
formulation. 50-percent decline in platelets noted after
admission, but suspect this is reactive and dilutional in the
context of transfusions. Nadir 103, stable thereafter. Of note,
no heparin administered. At discharge, hemoglobin = 8.3
#) Acute on chronic diastolic heart failure: volume status
initially equivocal, then more hypervolemic after transfusion,
which improved with active diuresis. BNP excursion and stable,
mild pulmonary congestion in keeping with relatively minor
exacerbation. Suspect her sense of dyspnea was derived from
profound anemia. Surface echo with small pericardial effusion
but otherwise unchanged from prior. Transient hypoxemia unlikely
related to vague retrocardiac opacity. Home Lasix 20 mg and
Toprol XL 25 mg resumed.
#) Bacteremia, contaminant: GPCs noted in one set of blood
cultures. Empiric daptomycin initiated in the context of
vancomycin allergy, but then discontinued when culture speciated
as CONS and Micrococcus sp., another skin commensal organism.
Surveillance blood cultures remained negative thereafter.
#) Knee pain, left: with relative immobility of uncertain
duration, initially concerning for septic arthritis in the
context of leukocytosis and undifferentiated positive blood
culture. Per health care proxy collateral, pain is reportedly
chronic, on the order of years. Timeline, unremarkable plain
film, and normal ESR thus rendered septic arthritis unlikely.
Moreover, exonerated after blood culture clarified as
contaminant. Orthopedic surgery in agreement.
#) Acute kidney injury: on probable chronic kidney disease by
virtue of age. Creatinine 1.8 on admission; baseline not
definitively known, but suspected to be 1.2-1.4. Creatinine fell
to 1.0 with normalization of oxygen carrying capacity and
optimization of volume status.
#) Hypernatremia: sodium briefly 148 in the context of repeated
NPO for endoscopy preparation. Free water deficit about one
liter. Resolved with gentle hypotonic fluid and diet resumption.
#) Asymptomatic bacteriuria: urine culture obtained in the
emergency department speciated as pan-sensitive K. pneumoniae.
Antibiotics deferred in the absence of sepsis or symptoms. | 138 | 514 |
17506585-DS-22 | 28,794,819 | Dear Mr. ___,
You were admitted to ___ and
underwent non-operative management/obervation for a suspected
duodenal perforation. You are recovering well and are now ready
for discharge. Please follow the instructions below to continue
your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | Mr. ___ was admitted On ___ to the acute care surgery service
for further observation of a suspected duodenal perforation.
Given his vital signs were normal and his white blood cell count
and lactate are also normal it is believed that he may have
sealed this perforation. Therefore, he was admitted for further
monitoring and serial abdominal exams. He is made n.p.o., given
maintenance IV fluids, and started on IV antibiotics including
ciprofloxacin and metronidazole. He required doses of IV
Dilaudid for breakthrough pain and Zofran for nausea. He was
started on Protonix 40 mg twice daily. ___ his abdomen remained
rigid however his abdominal exam was not worse just stable to
the prior day. On ___ his abdominal exam improved with
decreased pain especially over the right lower quadrant he was
started on a clear liquid diet. His Foley was discontinued at
this time he voided without issues. On ___ his H. pylori
antibody came back as negative. CT scan of the abdomen and
pelvis demonstrated a small volume of free air in the abdomen
however significantly improved from prior imaging from outside
hospital. His stress study while patient also improved,
consistent with his improving abdominal exam. On ___ he was
tolerating regular diet with further improvement of his
abdominal pain. His blood cultures returned as no growth. On
___ he was tolerating his regular diet and he was deemed safe
for discharge with planned antibiotic course of 14 days. He
will follow-up in clinic in the next few weeks and should also
undergo endoscopy to further evaluate potential ulcers.The
patient received subcutaneous heparin and ___ dyne boots were
used during this stay and was encouraged to get up and ambulate
as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan | 230 | 348 |
10527032-DS-2 | 27,909,870 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You came to the hospital because you developed
low oxygen levels and appeared more tired in your home facility.
In the hospital, we found that you had bacteria growing in your
blood. We briefly treated you with antibiotics. This bacteria
may have represented a true infection or may have been
contaminant from your skin. We also found that you had a
"hernia" in which some organs from your belly are in your chest.
Because of this, it has been difficult for you to breathe and
you will be given oxygen supplementation when you leave the
hospital.
Please continue to take your medications as prescribed and to
follow-up with your doctors as ___.
We wish you all the best,
Your ___ care team | SUMMARY STATEMENT
==================
___ year old woman with a past medical history of dementia
(normally oriented to person only), hypothyroidism, CAD, HTN,
and GERD presenting with hypoxia and hypotension, found to have
coagulase negative staph bacteremia s/p 5 doses of vancomycin,
large hiatal hernia, and pulmonary consolidation concerning for
malignancy. Problems addressed during her hospitalization are as
follows:
#Coagulase negative staphylococcus bacteremia:
Overall low suspicion for true infection. Initially presented
with leukocytosis x1 (WBC 12.3), fever x1 (100.9), cough. No
clear infectious source, chest imaging with low suspicion for
infectious process, fever possibly related to underlying
malignancy (see #hypoxia below). Found to have gram positive
cocci in blood culture, subsequently started IV vancomycin. No
source for her bacteremia was suspected. On return of culture
speciation, was found to have coagulase negative staph isolated
from one set, thought to represent skin contaminant. As such, IV
vancomycin was discontinued after receiving 5 doses. Remained
afebrile and hemodynamically stable >24 hours off antibiotics.
#Hypoxia
#Hiatal hernia
#Left cardiophrenic consolidation with central calcification:
Unclear what patient's baseline oxygen requirement is.
Throughout admission, required up to 3L supplemental oxygen on
nasal cannula, maintaining saturations in the mid-90s. At time
of discahrge was saturating high ___ on room air. Etiology of
her hypoxia is likely multifactorial. Patient with known left
lung mass with concerning for malignancy, hiatal hernia with
abdominal contents in chest, and concern for aspiration
pneumonitis, all of which are contributing to her poor
oxygenation. After discussion with health care proxy, PET CT to
further investigate concern for lung malignancy was not within
goals of care.
#Hypothyroidism
Continued levothyroxine
#GERD
Continued omeprazole
#Dementia
Held sedating medications in setting of poor baseline mental
status (AAOx1) (Zolpidem, mirtazapine, LORazepam)
#CAD
Continued ASA, held metoprolol, furosemide, and acetazolamide
#Glaucoma
Continued latanoprost and timolol | 132 | 278 |
10668217-DS-25 | 29,765,303 | You presented to ___ for abdominal pain and were found to have
elevated liver function tests. The GI team preformed an ERCP and
dilated the ducts in your liver. Your liver blood tests improved
some after this procedure but remained elevated. The
interventional radiology team preformed a liver biopsy in order
to take a cellular look at your liver in hopes to find the cause
of your abdominal pain and elevated labs.
During your hospital stay, you had a chest CT to rule out a
blood clot in your lungs, as you were having shortness of
breath. The CT did not show a blood clot, but it did show a
nodule on your right lung. Your PCP (Dr. ___ was contacted
about this finding. You should follow-up with her and plan on
getting a repeat CT in ___ year to assess for grow of the nodule.
You were also found to have high blood pressure and acid reflux.
Your amlodipine was increased to 5mg daily, and you were started
on omeprazole 20mg daily to help with your acid reflux symptoms.
Please follow-up with your PCP for management of these medical
conditions.
You pain continued to improve and you are being discharged home.
Please call your doctor or return to the ED if you have
persistent abdominal pain, nausea, vomiting, yellowing of your
skin, dark/black urine. | The patient presented the ED on ___ with abd pain. She was
found to have persistent transaminitis (LFTs elevated at last
admission in ___. She was admitted for pain management and
evaluation of transaminitis.
She had an ERCP done that showed poor return of contrast through
the hepatic ducts, and balloon dilation was preformed. Her LFTs
improved some after dilation but remained elevated. She was also
evaluated by the hepatology service who recommended liver
biopsy, preformed ___, results pending at time of
discharge.
During her stay, her pain was treated symptomatically and
improved. At the time of discharge, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a bariatric stage 5 diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Neuro: The patient was alert and oriented throughout
hospitalization. Pain was very well controlled.
CV: The patient was hypertense during her stay. Her amlodipine
was increased to 5mg and she was asked to follow-up with her PCP
regarding management. She remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
Of note, patient had CTA chest in ED which found a pulmonary
nodule in the right lobe. Radiology recommended 12 month
follow-up for monitoring. Patient was notified of finding and
PCP (Dr. ___ was contacted.
GI/GU/FEN: Abd pain improved with pain management. Tolerated
regular diet. She experienced some acid reflux and was started
on a PPI.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin during
this stay and was encouraged to get up and ambulate as much as
possible. | 221 | 323 |
18962557-DS-32 | 29,418,778 | You were admitted for confusion, found to be related to a kidney
stone on the right side and an associated infection. These
symptoms have improved with antibiotics and drainage of the
right kidney. You will go home with this drain in place and
follow up with urology on ___. Continue to take
Cefpoxodime twice daily for 10 more days. The last day will be
___.
Given your atrial fibrillation and high risk of stroke, your
apixaban (eliquis) should be restarted on return home. Be aware
that this will increase the risk of bleed and there might be
some mild bleeding into the tube. If you are experiencing anemia
symptoms - lightheadedness, confusion, shortness of breath on
exertion - pause the medication and talk to your doctor.
You have been given a medication for pain that is called
tramadol. This is related to the opiate class of medications and
can cause confusion and lightheadedness at times. Be sure to
take care to avoid driving or other situations in which you
could have an accident.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | TRANSITIONAL ISSUES:
PCP:
- monitor for resolution of UTI Sx
- monitoring for signs of biliary cholic; has incidental
gallstones
- referral for abnormal uterine bleeding, noted prior to
admission
- continued tobacco cessation counseling/resources
- discuss risk and benefit of apixaban if patient continues to
have bleeding issues while Percutaneous nephrostomy is in place
- for pulm sarcoid, emphysema, consider start of LAMA
Urology:
- management of nephrolithiasis, ___
HOSPITAL COURSE:
#UTI, sepsis:
On admission confused/somnolent and w/ leukocytosis; qSOFA of 2.
No obvious pyelonephritis by imaging, but given an obstructive
stone, an upper tract infection should be presumed. She has been
coughing recently, so clinically there had been suspicion for
PNA
as the source of infection; however, her CT does not suggest any
acute pulmonary process. Cx growing proteus. Initially CTX -->
keflex; day one ___. Planning 2 week course given sequestered
infection. Improved encephalopathy. Will f/u with Urology
outpatient.
#Right-sided ureteric stone
#Obstructive uropathy
___ (resolved) on CKD:
There is really only a very mild ___. Presenting Cr of 2.1 with
baseline of 1.6. Now down to 1.5 after drainage. S/p R PCN tube
on hospital day zero, more for presumptive sequestered upper
tract infection than for renal function. Urology saw patient
briefly but wanted outpatient follo wup for ostone management.
Will go home with PCn and ___. Last Cr on DC 1.4. For pain -
standing Tylenol and Tramadol PRN; continued on DC
#HFrEF
LVEF is only marginally low at 45%. Cards feels that much of her
left-sided failure is diastolic failure. BNP is up but looks
euvolemic; continued home regimen for diuresis, torsemide 120 mg
daily. Did not give any of her PRN metolazone
#A-fib
Has a history of CVA and a very high CHA2DS2-VASc (8). Initially
holding apixaban but restarted once urine clearing. On DC
continued despite the risk of some bleeding given her high
CHADS. Continue Toprol XL 150 mg
#DM2: some hyperglycemia initially, now overcorrected - home
insulin (Lantus 32u qHS + Novolog ___ prandial plus sliding
scale) moved to 38u QHS and uptitrated ___ return to her
prior on DC as she had intermittent mild low's
#CAD, PAD
- continue Pravachol
#COPD, pulmonary sarcoid
Clinically she does not have wheezing or worsened air movement,
but her report of cough for two weeks suggests acute-on-chronic
bronchitis symptoms. Completed a Z-pack during admission but no
e/o bacterial pneumonia. Felt her cough was resolving prior to
DC. Continue home Flovent, PRN albuterol MDI.
#Neuropathy
- continue Neurontin
#GERD
- continue Zantac qHS
#Tobacco dependence: offered nicotine patch during admission but
did not want Rx on DC.
#Post-menopausal bleeding
The patient has been reporting some brown discharge from the
vagina for months. She has also had pelvic pain. Needs a TVUS as
an outpatient and gyn referral with probable endometrial
sampling.
#Adrenal nodule
Trivial increase in size since ___ (2.2 -> 2.7 cm in ___
years).
Per guidelines, a routine endocrine workup would be indicated,
but this would be of a lower priority than her many other
unaddressed issues.
>30 minutes spent on day of DC planning | 185 | 471 |
13105864-DS-14 | 22,978,484 | Mr. ___,
You were admitted to the hospital after you had an episode of
vomiting blood at ___. You had no further episodes while
in the hospital and your blood counts remained stable. While it
is not exactly clear what caused this bleeding, it may have been
from a stent which was previously placed in your bile ducts
which came out.
It was a pleasure participating in your care, thank you for
choosing ___! | Mr. ___ is a ___ with recent episode of acute necrotizing
gallbladder pancreatitis with course complicated by sepsis and
respiratory failure, as well as DVT on anticoagulation, who
presented from SNF with hematemesis.
#Hematemesis, acute upper GI bleed
Patient presenting after single episode of hematemesis in the
setting of vomiting up NGT. He presentead with his HCT at recent
baseline which remained largely stable during his
hospitalization. He had no further episodes of bleeding and
remained hemodynamically stable. The patient was treated with
twice-daily pantoprazole. Source of the hemetemesis is unclear,
possible secondary to trauma sustained from migration and
eventual regurgitation of a previously-placed biliary stent.
Given no further episodes of hemetemesis, the patient did not
undergo endoscopy. He was continued on pantoprazole at
discharge.
#Deep venous thrombosis on anticoagulation, subacute
Patient on warfarin for DVT identified on LENIs two months prior
to admission. No concern for pulmonary embolus at the time.
Given his supratherapeutic INR and concern for further bleeding
at the time of admission, his warfarin was held during his
admission. Despite holding anticoagulation, INR remained
elevated likely secondary to malnutrition. ___ was repeated
without evidence of DVT, thus warfarin was discontinued at
discharge.
#Gallstone pancreatitis, transaminitis, malnutrition
ALT and AST minimally elevated upon admission compared to most
recent baseline with mildly increased alkaline phosphatase
compared to prior. Unclear etiology in setting of recent
hepatopancreobiliary illness. Mild diffuse tenderness on exam
which remained stable. No nausea or other symptoms. JP drain in
place. This was trending during his admission. A follow-up CT
abdomen was performed which demonstrated improvement compared to
prior. After discussion with Surgery, it was determined that
patient's tube feeds could be held to allow him a trial of
regular diet with supplementation. The patient was started on
Ensure Plus with meals. On day of discharge patient had slight
metabolic acidosis with lactate of 2.8, likely from dehydration.
He was given 500mL NS.
#Hyponatremia
Chronic mild hyponatremia. Patient appeared euvolemic on exam.
On sodium chloride tabs at SNF. Likely secondary to ongoing
illness. His sodium was trended during his hospitalization and
his sodium was continued.
#Thrombocytosis
Chronic platelet elevations, likely reactive in setting of
inflammatory processes.
#H/o ventricular tachycardia
The patient was continued on metoprolol.
TRANSITIONAL ISSUES
-Please trend INR every three days. Once less than 1.5, consider
performing repeat ___ one week later to ensure no evidence of
previously-identified DVT. If repeat ___ negative, it is likely
reasonable to continue holding anticoagulation. If repeat LENIs
demonstrate DVT, please restart anticoagulation.
-Patient discharged on trial of regular diet with Ensure Plus
supplementation. Please monitor calorie intake to see if patient
can get enough nutrition without replacement of the Dobhoff
tube.
-Patient should follow-up with Dr. ___.
-Please recheck chemistries and lactate on ___ AM to ensure
resolution. | 72 | 446 |
11277578-DS-10 | 24,608,350 | Dear Mr. ___,
It was a pleasure taking care of you.
Why you were admitted?
- You were admitted to receive HD.
What we did for you?
- You received HD.
What should you do when you leave the hospital?
- We recommend that you stay given your outpatient HD center has
not been set up; however you left AGAINST MEDICAL ADVICE to
attend your mother's cremation. We recommend that you come back
___ so you can receive dialysis on ___.
- Please continue taking all your medications as prescribed.
We wish you the best,
Your ___ team | ___ is a ___ woman with HBeAg-negative HBV cirrhosis
(c/b ascites, chronic hepatic hydrothorax, and hepatic
encephalopathy) s/p TIPS that was c/b right heart failure
requiring TIPS closure and aggressive diuresis, recently listed
for transplant who re-presented to receive HD as she is
difficult to place for outpatient HD given insurance and Hep B
status. She left AGAINST MEDICAL ADVICE to attend her mother's
funeral/cremation with plans to return to the hospital to
continue HD.
ACTIVE ISSUES
=============
# Disposition: Patient very difficult to find HD center given
her
insurance and hepatitis B status. She left AGAINST MEDICAL
ADVICE to attend her mother's funeral/cremation with plans to
return to the hospital to continue HD.
# ATN
# HD Dependent
# Chronic kidney disease stage 4 (eGFR ~18 by cystatin C)
Baseline CKD secondary to longstanding diabetes and hypertension
per ___ biopsy. Her renal function was complicated by
episodes of ATN in the setting of overdiuresis. She was
monitored for renal recovery however remained persistently
uremic with symptoms and HD was initiated. S/p tunneled line
placement. Had difficulty in being accepted by an outpatient HD
center due to Hep B status/insurance. Has been trialed off HD
several times in the past and becomes volume overloaded with
large hepatohydrothorax requiring chest tube. She therefore
continued receiving hemodialysis while inpatient. She received
vein mapping in preparation for fistula.
# HBV cirrhosis (MELD 22, Childs B on admission)
Cirrhosis decompensated by ascites, refractory hepatic
hydrothorax s/p chest tube, and hepatic encephalopathy, s/p TIPS
___ with revision ___ due to right heart failure. EGD w/o
varices. She remains on the transplant list. Entacavir was
increased to 1mg weekly given on HD and has decompensated
cirrhosis. Repeat HBV VL was undetected. Continued
lactulose/rifaximin
#Abdominal pain
#Leg pain
#Tunneled HD line site pain
Chronic. Unchanged. No e/o infection around HD line site.
Continued Tylenol and oxycodone PRN
CHRONIC ISSUES
==============
#Nocturnal hypoxia
Intermittent desats to ___ overnight during prior admission.
Suspect undiagnosed OSA.
#Hypertension
Continued home amlodipine. Re-started losartan
#Asthma
Continue albuterol nebs PRN.
#GERD
Continue home pantoprazole.
TRANSITIONAL ISSUES
======================
[ ] FYI: patient has PFO diagnosed on ___ bubble study.
[ ] Will need repeat Cystatin C 12 weeks after initial was
checked (initial checked ___.
[ ] Patient will benefit from liver-kidney transplant.
[ ] Outpatient sleep study given episodes of desaturation at
night
[ ] Gabapentin held iso renal failure, patient wasn't requiring
so continued to hold at discharge.
[ ] Triple phase CT scan to evaluate prior liver lesions on
re-admission to liver service | 89 | 384 |
13400375-DS-6 | 27,040,549 | Wound Care:
- Keep Incision clean and dry.
- Do not get the splint wet.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be NO weight bearing on your left leg
- You should not lift anything greater than 5 pounds.
- Elevate left leg at all times while in bed or sitting to
reduce swelling and pain.
- Do not remove splintrace. Keep splint dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room. | Mr. ___ was admitted to the Orthopedic service on
___ for left calcaneal tuberosity fracture after being
evaluated and treated with closed reduction in the emergency
room. He underwent open reduction internal fixation of the
fracture without complication on ___. Please see
operative report for full details. He was extubated without
difficulty and transferred to the recovery room in stable
condition. In the early post-operative course he did well and
was transferred to the floor in stable condition.
He had adequate pain management and worked with physical therapy
while in the hospital. The remainder of his hospital course was
uneventful and he is being discharged to home in stable
condition. | 257 | 115 |
17884424-DS-9 | 21,399,039 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because you presented to ___
___ where you were found to have fevers, labs
concerning for infection, and swelling and redness in your hand
in the area you had injected into. You were transferred to ___
to be evaluated by our hand surgeons who did an incision and
drainage of the abscess. You were treated with IV antibiotics
and given IV fluids. You were also given Tylenol, morphine, and
Toradol for pain control.
- You were also found to have low red blood cells and platelets
that may be due to your hand infection or due to chronic liver
disease. You also some abnormalities in your labs that show your
ability to clot blood, as well as your liver enzymes. We are
concerned you may have chronic liver disease and you should
follow up with your primary care doctor.
- You were tested for HIV which was negative. You were also
tested for hepatitis C virus, but this result was not back yet
when you left the hospital.
What should I do after leaving the hospital?
- Please take your antibiotic called clindamycin 300 mg every 6
hours for 7 days.
- Please call the Hand Surgery clinic for follow-up by this
___.
- Please have repeat labs drawn on ___ to evaluate your
liver and your platelets.
- Please see your primary care doctor within the next week.
- Change the dressing on your hand daily and keep the area
cleaned. Also, please keep the splint on as much as possible.
- Follow-up with detox and rehabilitation. You have done well
without heroin over the past few days and have done well on
suboxone in the past. We believe you can get back on the right
track!
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | Outpatient Providers: SUMMARY: ___ male with a history
of IV drug use, Hepatitis C, and anxiety who presents with four
days of redness, swelling, and pain on the dorsal surface of his
right hand accompanied by fevers, chills, and generalized body
aches found to have cellulitis and an abscess on his right palm
status-post drainage by hand surgery.
=======================
ACUTE MEDICAL PROBLEMS
=======================
# Cellulitis and abscess of right hand secondary to IVDU
Patient initially presented to ___ with fevers, hand
pain, and swelling in the area of injection. The outside
hospital did an MRI which showed no focal fluid collection or
evidence of osteomyelitis. He was transferred to ___ to be
evaluated by hand surgery. A hand x-ray in the emergency
department showed soft tissue swelling. He was started on IV
vancomycin and Unasyn and given a 1L bolus of normal saline. He
had a bedside debridement of the site done by the hand surgery
team. He was treated with IV Toradol and IV morphine for pain
and placed on scheduled Tylenol. The cultures from his abscess
grew MRSA sensitive to clindamycin, Bactrim, and doxycycline.
Blood cultures from ___ drawn on ___ showed no growth
when checked on ___ and blood cultures from our hospital also
showed no growth. On the day of discharge, he was transitioned
to PO oxycodone for pain relief and agreed to not be sent home
on narcotics, as he is trying to go to rehab. He was sent out
with a prescription for clindamycin 300 mg q6h PO for 7 days
with follow-up in Hand Clinic by ___.
# IV heroin use
Patient states he last used 4 days before admission and denies
current symptoms of withdrawal. Toxicology screen was positive
for cocaine and opiates, however, he had already received IV
narcotics for pain before this was drawn. He denies history of
endocarditis and had no growth to date on all blood cultures
collected (see above). HIV was checked and was negative. Patient
will be sent home with a script for Narcan. Social work was
consulted but were unable to see the patient before discharge.
He states he is planning to go to detox at ___ or ___
in ___, which his girlfriend is supposedly helping to
arrange for him. He also says he has a bed at a rehab in ___
that he would like to go to.
# Acute normocytic anemia
Patient presented with H&H of 12.8/12.7, thought to be secondary
to his acute infection. He had no signs/symptoms of acute
bleeding. Discharge hgb was 13.3.
# Thrombocytopenia
Patient presented with platelets 132, thought to be secondary to
chronic liver disease vs. his acute infection. Discharge
platelet count was 136.
# Coagulopathy
Patient's INR on admission was 1.2, thought to be due to
underlying liver disease. INR on discharge was 1.1
#Transaminitis
#Hx of hepatitis C
Patient presented with elevated ALT 62 and rest of LFTs normal.
He has a reported history of hepatitis C that reportedly clear
per the patient. Denies history of recent alcohol use but
previously binge drank regularly. Hepatitis C antibody was
checked and was positive. Hep C viral load was pending on
discharge.
========================
CHRONIC MEDICAL PROBLEMS
========================
# A fib. Patient noted history of a fib that was diagnosed at
___ when
presented with overdose previously. States he was on warfarin
temporarily while in
hospital but was told he didn't need to take it at home. Patient
was placed on telemetry and remained in sinus rhythm for >24
hours.
# ADHD. Patient declined to take his home Adderall during his
admission, but it was offered.
# Anxiety. Continued home dose of Xanax 2 mg q8h.
# Neuropathy. Continued home gabapentin 800 mg TID
# Tobacco use. Offered nicotine patch 21 mg but patient
declined.
========================
TRANSITIONAL ISSUES
========================
[] Narcan script written
[] Ensure patient has support to attend detox/rehab
[] Repeat LFTs in ___ weeks. If still elevated, may consider
work-up
[] Work-up of anemia, thrombocytopenia, and coagulopathy
[] Follow-up of blood cultures from ___ drawn on ___
[] Repeat labs - BMP, CBC, LFTs on ___
[] Follow-up with primary care provider ___ 7 days
[] Follow-up in hand clinic within 7 days
[] Hep C viral load pending
[] Smoking cessation counseling
Code Status: Full code, presumed
Surrogate/emergency contact: Father, ___
___ | 334 | 693 |
11735378-DS-13 | 26,347,295 | Dear Mr. ___,
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of left sided visual
disturbances and generalized weakness resulting in falls. Your
neurological exam shows no clear abnormalities. You also had an
MRI of your brain that showed no evidence for stroke. The most
likely cause for your visual disturbances and falls is thought
to be related to multiple problems: dehydration, alcohol
intoxication or withdrawal, and increased vagal tone aka
fainting. You were maintained on a heart monitor during your
stay that showed frequent extra beats (PVCs - premature
ventricular contractions) but no arrthymias. A TTE, a heart
ultrasound was done that showed no abnormalities.
During your stay your blood pressure was high, 140-160s/80-90s.
Please have your PCP ___ this in the next ___ weeks and
discuss with your PCP whether you need to make any medication
adjustments.
Please do your best to avoid alcohol and maintain good fluid
intake to keep hydrated. Please also quit smoking as this will
greatly increase your risk for strokes and heart disease in the
future.
Please make an appointment to see your PCP and discuss these
issues with him/her.
Of note, your bloodwork shows liver damage from alcohol. Please
stop drinking now to keep this from progressing. | Mr. ___ is a ___ yo ambidextrious man with a history of
hypertension and alcohol use who presents with transient
episodes of left visual field disturbances and falls.
Neurological exam showed only end-gaze nystagmus, and patchy
sensory loss. The etiology is most likely vasovagal syncope,
likely complicated by dehydration, as well as alcohol
intoxication. MRI imaging shows no evidence for stroke. On
telemetry, the patient had frequent PVCs but no arrthymias. TTE
showed no abnormalities. The patient's blood pressure was
somewhat elevated during his stay, SBP 140-160s, despite
continuing his home BP medication, losartan 50mg po daily. We
will ask his PCP to monitor this and increase his medication as
needed.
We started the patient on aspirin 81mg po daily for overall
cardiac and stroke protection. His other vascular risk factors
were assessed as well: HbA1C- 5.8, LDL 103, HDL 38, ___ 156.
The patient was maintained on a CIWA scale throughout his stay
given his alcohol history. He showed no signs of withdrawal. His
bloodwork shows evidence of liver damage from alcohol. We
counseled him on the benefits of alcohol cessation.
We also counseled him on tobacco cessation and provided him with
a prescription for nicotine patches.
We ask his PCP to please follow up on these issues. | 215 | 211 |
10469621-DS-23 | 21,154,724 | Dear Ms. ___,
You were admitted to ___ with headache, cough, and high INR
level. You underwent CT head imaging which was found to be
normal. We treated your headache with fioricet. You should not
take this medication more than three days a month because you
may become dependent on it. You can discuss other medication
options and management of your headaches with your primary care
doctor. You were also found to have a pneumonia for which you
were started on antibiotic called levofloxacin. Please take this
antibiotic every other day, your last dose will be ___. Your
INR level was also found to be high. Please do not take your
coumadin again until told to do so by your primary care doctor.
Please have your bloodwork taken on ___. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs. We wish you
all the best.
Sincerely,
Your ___ team | Ms. ___ is a ___ year old female with history of Afib, CHF,
CAD s/p CABG, and Rt MCA CVA who presents with headache in the
setting of supratherapeutic INR and productive cough.
# HEADACHE: Likely secondary to tension headache. Reassuring
that CT head was negative in the setting of supratherapeutic
INR. Meningitis and influenza were thought to be less likely
given lack of fevers and persistent symptoms for 5 days.
Temporal arteritis was also thought to be less likely given lack
of jaw claudication. Lastly, cluster headaches were considered,
but patient described constant pain rather than attacks.
Furthermore, she did not have associated lacrimation and
conjunctival infection. Patient had immediate relief with
fioricet suggesting this is tension headache. Patient was
maintain on fioricet while hospitalized and discharged with
short course of fioricet as well.
# RML Pneumonia, CAP: Patient reports 1 day of productive cough.
No fevers though admission labs notable for leukocytosis. CXR
with right middle lobe opacity. Received ceftriaxone/azithro on
admission and was transitioned to levofloxacin to complete 7 day
course (day1: ___, last dose ___.
# AFIB, reverted to sinus: Patient triggered for Afib with RVR
with HR 160 and stable blood pressure though systolics with
20mmHg decreased from admission vitals. Afib with RVR resolved
with diltiazem IV. Etiology thought to be likely secondary to
pain causing increased sympathetic tone and volume overload from
fluid administered in ED. Patient was diuresed as below and
restarted on home carvedilol. Coumadin was held in the setting
of supratherapeutic INR.
# CHF: Patient reported dyspnea on exertion, orthopnea,
peripheral edema, and weight gain. Clinically she appeared
overloaded though CXR was without pulmonary edema. Patient did
have dyspnea and decreased SpO2 during Afib with RVR, suggesting
a component of flash pulmonary edema. Patient also received 1L
NS in ED. Patient was dosed with 40mg IV lasix on admission with
rapid improvement in dyspnea. She was also restarted on home
carvedilol and valsartan. On discharge, she was restarted on
home po lasix. | 151 | 329 |
14496738-DS-21 | 27,064,576 | Dear Ms. ___,
You were admitted to the hospital with pain and nausea. A CT
scan revealed kidney stones, fluid build up around your right
kidney and dilation of your bowels and remnant stomach. You
were placed on bowel rest, given intravenous fluids and a
medication called tamsulosin to help you eliminate the kidney
stone; intravenous antibiotics were also given for one day.
Your pain and nausea have resolved and you are having normal
bowel and bladder function. You 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, urinate or
have a bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge or have inability to urinate.
*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.
Please strain all urine. | The patient presented to the Emergency Department on ___ with pain, nausea and po intolerance. Upon arrival,
she was placed on bowel rest, given intravenous fluids and
underwent a CT scan which was significant for dilated bowel
loops, right sided hydronephrosis and nephrolithiasis. Given
findings, the patient was admitted to the ___
service and followed by Urology who had recommended IV
ceftriaxone and monitoring with potential need for urgent
intervention with any evidence of worsening symptoms.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intravenous
hydromorphone. However, by HD3, the patient's abdominal pain
had resolved. Her home amitriptyline, celexa and clonazepam
were resumed on HD2.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On HD2, given
resolution of her nausea and pain and ongoing evidence of normal
bowel function, the diet was advanced to stage 5 which was
tolerated. Patient's intake and output were closely monitored
and the patient voided without difficulty through the
hospitalization; ceftriaxone was discontinued given no growth on
urine culture. On HD2 a renal/bladder ultrasound was
significant for persistent right sided hydronephrosis without
stones. Urology cleared the patient for discharge to home
without intervention and scheduled outpatient follow-up with
repeat ultrasound in ___.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged
ambulate. At the time of discharge, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a diet, ambulating, voiding without assistance, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 311 | 350 |
19360045-DS-21 | 21,787,934 | Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital
after you fainted and fell down. We did a CT scan of your head
and neck which were normal. We felt that this might have
happened either because of your atrial fibrillation (afib) or
because your heart rate is slow. You were monitored on telemetry
over the weekend, and did not have any episodes of atrial
fibrillation. A Linq device was placed to continue to monitor.
You can take off the dressing in 3 days.
Medication changes: Please stop taking digoxin.
We have scheduled you an appointment with your primary care
doctor and are working on scheduling you an appointment with
your cardiologist (see below)
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team | ___ with hx of pAFib on coumadin, HTN, CKD III, HLD, who
presents after syncope and fall I/s/o bradycardia w/ paroxysmal
Afib.
# Syncope:
# Paroxysmal atrial fibrillation:
Patient presents with syncope preceded by prodrome. Presentation
is highly suggestive of vasovagal reaction, perhaps triggered by
pain from leg cramps. However given she felt similarly when
presenting with pAF and was found to be in sinus brady to the
___, may be ___ RVR vs bradycardia. Orthostatics negative on
___. No suspicion for seizure, no significant carotid
stenosis, has had recent TTE without severe valvular disease.
Per Atrius records her HR has been difficult to control, with
episodes of RVR as well as sinus bradycardia limiting her rate
control options. Atrius cardiology and the EP service were
consulted for management of tachy-brady syndrome. Her home
digoxin was held, and the patient was monitored on telemetry
through the weekend. Tele significant only for stable sinus
bradycardia throughout hospitalization. Her home warfarin was
continued. Ultimately the decision was made for LINQ placement
and f/u with cards as outpatient.
# Acute Kidney Injury: Admission Cr of 1.8, up from a baseline
of 1.0. Resolved following 1L LR in ED. Her chlorthalidone and
losartan were initially held, then restarted once ___ resolved.
# Hypertension: chlorthalidone and losartan as above, continued
home amlodipine
# Cataracts, glaucoma: Continued latanoprost 0.005% eye drops,
brimonidine 0.2% eye drops
# Hyperlipidemia: Continued home atorvastatin 40 mg daily
===================================
TRANSITIONAL ISSUES
===================================
- The patient had linq placement for cardiac monitoring on
___. This will be followed by her cardiologist.
- The patient's home digoxin was stopped.
- The patient's INR downtrended while in the hospital due to
being on a smaller dose than her outpatient dose. She was on her
home dose at time of discharge. An INR should be checked at her
next appointment to ensure that it is therapeutic.
# CODE: Full confirmed
# CONTACT: son ___ ___ | 144 | 314 |
19008705-DS-18 | 25,749,397 | You were admitted to the hospital after sustaining mutliple
gunshot wounds to your abdomen and thigh. You underwent an
operation to repair injuries that resulted from your trauma. You
developed a wound infection and now require dressing changes
until the wound heals. You also developed a blood clot inthe
vein in your right leg and will now require a blood thinning
medication called Wafarin (Coumadin) to help keep your blood
from becoming too thick. Your blood levels called INR will need
to be followed by your primary care doctor ___.
It is important that while taking these medications that you do
not take other blood thinners such as aspirin, ibuprofen
(Motrin), advil, aleve, naprosyn unless otherwise directed by
your health care provider. It is being recommended that you
either wear a medical alert bracelet and/or carry a card in your
wallet indicating that you are on blood thinners in case of an
emergency.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites. | Mr. ___ was admitted to the Trauma SICU s/p exploratory
laparotomy and small bowel resection with primary anastomosis.
During postoperative assessment he was noted to have diminished
Doppler signals relative to his ___ and ABI 0.7. A CT angiogram
was done showing intimal defect and pseudoaneurysm of Right
SFA. He was taken back to the OR on the same day by Vascular
Surgery for exploration of right thigh and ligation of the
femoral vein and superficial femoral artery to superficial
femoral artery bypass using greater saphenous vein graft.
Post operatively his K was 6.3 which resolved with insulin. His
hemodynamics were stable and he was weaned and extubated
uneventfully. His exam revealed significant thigh swelling but
compartments remained soft and pulses palpable. His hematocrit
trended down to 17 and he was given 2u packed red cells; serial
hematocrits were followed and stabilized at range ___. His
thigh exam remained unchanged and pulse exam stable and he was
started on a diet and transferred to the floor.
Once transferred to the floor he continued to progress. He had
an episode of nausea with emesis on HD #5 and was made NPO; his
exam was unremarkable at the time. Once his symptoms resolved
and he had return of flatus he was started on clears and
advanced slowly to a regular diet.
He was noted with purulent exudate from his midline incision -
several staples were removed and the wound opened for irrigation
and packing. He will require daily packing of the wound through
___ services which has been arranged.
On HD#7 he was noted with right calf swelling and pain. LENIS
were performed showing a deep vein thrombosis seen within the
right popliteal vein and also within the two right posterior
tibial veins. Heparin drip was initiated and adjusted per PTT.
Coumadin was started - he received 5 mg on ___ and ___ and his
INR was 2.2 on ___ prompting discontinuing his Heparin drip.
He was seen by Social Work due to the nature of his trauma and
provided information on reactions to trauma and contact
information for the ___'s office and
Victims Advocacy Department to ascertain whether they can
provide protection for patient and his family at home. He was
also given Victims Compensation information and contact numbers
for the ___ Violence Prevention and Recovery here at ___
___.
He is being discharged to home w/ services and has appointments
for follow up with his PCP, ___ and Acute Care Surgery in
place. | 415 | 410 |
18549207-DS-18 | 27,044,416 | Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You came to the hospital because you were having pain in your
abdomen.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were diagnosed with an infection of your gallbladder and
you had surgery to remove your gallbladder.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
-Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency. -You may climb stairs.
-You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
-Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap. -You may start
some light exercise when you feel comfortable.
-You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL: -You may feel weak or "washed out" for a
couple of weeks. You might want to nap often. Simple tasks may
exhaust you.
-You may have a sore throat because of a tube that was in your
throat during surgery.
-You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
-You could have a poor appetite for a while. Food may seem
unappealing.
-All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
-Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you may have small plastic
bandages called steri-strips. Do not remove steri-strips for 2
weeks. (These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay). If
your incisions are closed with dermabond (surgical glue), this
will fall off on it's own in ___ days.
-Your incisions may be slightly red. This is normal.
-You may gently wash away dried material around your incision.
-Avoid direct sun exposure to the incision area.
-Do not use any ointments on the incision unless you were told
otherwise.
-You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
-You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
-Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription. -If you go 48 hours without a
bowel movement, or have pain moving the bowels, call your
surgeon.
PAIN MANAGEMENT:
-It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
-Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
-You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
-Your pain medicine will work better if you take it before your
pain gets too severe. -Talk with your surgeon about how long you
will need to take prescription pain medicine. Please don't take
any other pain medicine, including non-prescription pain
medicine, unless your surgeon has said its okay.
-If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
-Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises. If
you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS: Take all the medicines you were on before the
operation just as you did before, unless you have been told
differently. If you have any questions about what medicine to
take or not to take, please call your surgeon.
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.
Warm regards,
Your ___ Surgery Team | The patient was admitted to the Medicine service on night of
___ due to her abdominal pain. Right upper quadrant
ultrasound demonstrating thickened
distended acalculous gallbladder. ACS was consulted for
evaluation and treatment of cholecystitis. Given initially
benign exam, but concerning imaging, further work up with HIDA
scan and MRCP were ordered. on ___ HIDA scan demonstrated
findings consistent with acute cholecystitis and patients RUQ
pain acutely worsened. On ___ the patient underwent
laparoscopic cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears, on IV fluids,
and acetominophen for pain control. The patient was
hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. Patient was initially
started on ceftriaxone and flagyl post op given concern for her
gangrenous gallbladder, however the patients WBC remained normal
and gram stain was unrevealing. The patient was then evaluated
by physical therapy to determine disposition on ___. Evaluation
was finished on ___, and they recommend acute ___ rehab.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged to acute ___
rehab. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 807 | 284 |
13913641-DS-5 | 27,028,669 | Mr. ___,
You were admitted to the hospital with a very serious infection
of your right arm called necrotizing fasciitis. Your arm had to
be surgically incised in order to provide adequate drainage of
the infection. A vaccuum-assisted closure device was placed
over the incision to ensure timely healing of the extensive
wound. Subsequently, you required a skin graft to your right
upper extremity that we took from your right thigh. We now feel
comfortable sending you to a rehabilitation facility, where you
shall continue with your ongoing recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
sites.
*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. | Mr. ___ presented to ___ with pain, swelling, and
erythema of the right upper extremity. He was initially
hypotensive requiring levo as well crystalloid and albumin
boluses. CT scan of the right upper extremity was concerning for
necrotizing fasciitis in the right upper extremity with
extensive foci of gas extending in the soft tissues and fascial
planes from the level of the elbow to the axilla. A central and
peripheral arterial line were placed and he was taken emergently
for exploration and debridement given the concern for
necrotizing fasciitis. He underwent incision and debridement of
the RUE for three consecutive days (please see Operative Notes
dated ___ through ___ for further details), during
which time he remained intubated in the ICU. On the last of
these procedures, wound was deemed appropriate for
vacuum-assisted closure. He was extubated without issues. An
echocardiogram was performed to rule out endocarditis, with
reassuring results. Patient initially received broad-spectrum
antibiotics until speciation of cultures allowed for tailored
therapy. Joint fluid cultures were negative. On POD#1 from the
final debridement, patient was transferred to the floor.
Once tolerating a regular diet, patient was transitioned to oral
therapy. He completed a two-week course of cipro/clinda. VAC
changes were performed every 3 days as directed. Swelling and
tenderness improved daily. He worked daily with occupational and
physical therapy, making great progress. Nine days after his
last procedure, decision was made to take the patient back to
the operating room for a split-thickness skin graft (please see
Operative Note dated ___ for details). Skin was taken from
the right thigh. He tolerated the procedure well. A VAC was
placed over the wound and left in place for four days, after
which the wound was evaluated. The graft appeared to take
nicely, and wound was thus dressed with non-adhesive dressing
and Kerlix.
Anticipating discharge, he continued to work with ___. Case
management was involved in the screening process for a rehab
bed. Upon discharge, patient was doing well. His pain was under
control, although his elbow has a limited range of motion due to
pain. He was ambulating and voiding without assistance,
tolerating a regular diet. He received teaching and follow-up
instructions with verbalized understanding and agreement with
the discharge plan. | 352 | 371 |
15678150-DS-14 | 21,960,731 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for weakness.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We found that you had abnormal labs.
- Your weakness was likely to too much fluid being removed from
your body.
- You received some fluids and you were less weak on discharge.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines on discharge.
We wish you the best!
Sincerely,
Your ___ Team | ___ is an ___ man with CAD, PAD, DMII, AAA, CKD,
HFpEF, aortic stenosis, severe mitral regurgitation, peripheral
artery disease, bladder cancer s/p BCG, and recently diagnosed
NASH cirrhosis complicated by ascites and new diagnosis
multifocal ___ who presented for evaluation of ongoing weakness
and abnormal labs, iso initiation of diuretics 7 days ago. In
his previous recent hospitalization, he was discharged off all
diuresis in the setting of ___, and was told to resume as an
outpatient on ___. He started taking aldactone and torsemide,
which did not help him and rather caused him to feel weak. He
was admitted for an acute kidney injury ___ to overdiuresis in
the outpatient setting. | 107 | 114 |
18971123-DS-15 | 29,270,210 | Dear Ms. ___,
You were admitted to ___ with electrolyte abnormalities
related to your alcohol use. You were given IV fluids and your
electrolytes were replaced. You were able to start eating again.
Initially you were having "coffee ground" colored vomiting. T
This was likely related to your alcohol use and has now
resolved.
We recommend that you get treatment for your alcohol use
disorder.
It was a pleasure taking care of you!
Your ___ Team | ___ with PMHx restrictive eating behavior requiring multiple
hospitalizations, depression, anxiety and alcohol use disorder
presenting with two episodes hematemesis iso recent EtoH binge
and alcoholic/starvation ketoacidosis with current hospital
course notable for electrolyte abnormalities attributed to
refeeding and resolution of acidosis:
# ALCOHOLIC/STARVATION KETOACIDOSIS: On admission, patient
presented with severe AG metabolic acidosis with HC03 11
secondary to ketoacidosis secondary to alcohol consumption,
starvation ketosis with minimal PO intake, and lactic acidosis.
Patient also with underlying metabolic alkalosis on
presentation, likely due to contraction alkalosis given emesis.
Initial hospital course complicated by electrolyte derangements
including hypokalemia, hypomagnesemia, hypophosphatemia, likely
in the setting of refeeding and hyponatremia, likely in the
setting of hypovolemia. Patient was given Thiamine prior to 1L
D5NS in ED and given IVF resuscitation while inpatient. Patient
is status post high dose IV thiamine x 3 days and continued on
oral thiamine, multivitamin, and folate. During her hospital
course, her electrolytes were aggressively monitored and
repleted and electrolytes had normalized prior to discharge.
# REFEEDING SYNDROME: Patient with hypophosphatemia and
hypokalemia in the setting of restricted PO intake and alcohol
binge. Also with LFT abnormalities that can be explained by
referring versus EtOH hepatitis. No evidence of rhabdomyolysis,
seizures, heart failure or other complications of referring this
admission. Electrolytes were repleted and monitored as above.
Given thiamine, multivitamin, and folate.
# THROMBOCYTOPENIA: Nadir 90K this admission with uptrend prior
to discharge. Etiology likely secondary to EtOH use. Did not
suspect HIT (4T score 3).
# COFFEE GROUND EMESIS: Patient with three episodes of small
volume coffee ground emesis with retching in ED in setting of
EtoH binge prior to admission. During admission, H/H and
hemodynamics stable, without further episodes of emesis. Given
PPI BID. Likely ___ tear in setting of alcohol use and
retching or alcoholic gastritis. No previous history of GI bleed
or history of PUD. Stool guaiac negative in ED. RUQ to eval for
cirrhosis on ___ showed echogenic and mildly coarsened liver
consistent with steatosis. On discharge, patient to follow up
with GI for further evaluation of hepatic findings noted on
ultrasound and for possible EGD.
# ETOH Use Disorder: Last drink ___ at 8PM with recent binge
on gin in the background of relapsing from sobriety and drinking
one bottle of wine per day for the past two weeks. She has
undergone detox program at ___ in ___. She has
been enrolled in outpatient alcohol treatment program until one
week prior to admission. This admission, patient monitored on
CIWA without evidence of withdrawal. Given thiamine, folate,
MV. Social work consulted and patient has intake appointment at
___ Addiction Program for Intensive
Outpatient Program on ___. Patient plants to contact
outpatient therapist and psychiatry for follow up outpatient.
Patient, husband, and primary team in agreement with this plan
on day of discharge.
# HX ANOREXIA NERVOSA: Previous hospitalization and ICU
admission in ___, formerly enrolled in residential eating
disorder program until ___. After discharge and improvement
in her eating, her alcohol abuse disorder worsened. Patient had
been gaining weight prior to her relapse of alcohol abuse 2
weeks ago. Patient intake monitored this admission and adequate
per Nutrition.
# DEPRESSION/ANXIETY: Longstanding history, likely contributing
to alcohol abuse/eating disorder. Continued on SSRI &
gabapentin. Olanzapine was held this admission given patient
report that she does not take this regularly.
# TOBACCO ABUSE: Given nicotine patch. Counseled on smoking
cessation. | 73 | 589 |
17096318-DS-21 | 20,781,972 | Dear ___,
___ was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of your transient memory
loss. During your evaluation it was determined that it is
possible that you had an episode of transient global amnesia,
although your presentation is not quite typical. Your imaging
showed no signs of stroke and no active white matter lesions at
this time. We also did an EEG to look at your brainwaves, for
which the prliminary read is normal. Given that you are back at
your baseline, we feel that it is safe for you to return home.
For your chronic daily headaches, please continue to use moist
warm heat to the neck and shoulders. Additionally we advise that
you start a medicine called nortriptyline. Please start taking
10mg (1 pill) at night. If after 1 week your headaches have not
improved, please go up to 20mg nightly and continue on this
dose. Please continue to take this medicine for at least 4 weeks
as it will take time for it to achieve the proper levels in your
system.
In the future, if your headaches continue, you may also wish to
inquire about a pain medicine referral for the consideration of
trigger point injections for headaches.
Given the concern for MS vs neurosarcoidosis, we have made an
appointment for you to follow up with a MS ___, Dr.
___. Please see the appointment information below.
Lastly, during your stay it was discovered that you have a
urinary tract infection. We started treating this with an
antibiotic called macrodantin. Please take 1 tab by mouth every
6 hours for the next 2 days or until the pills are gone. If you
have any fever, pain with urination, or frequent urination after
completing these antibiotics, please see your PCP ___ an
urgent care ___ further evaluation.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | This patient is a ___ year old female with a past medical history
of pulmonary sarcoidosis, and questionable neurosarcoidosis vs.
multiple sclerosis, along with fibromyalgia, chronic daily
headache and anxiety who presents with multiple syncopal
episodes, headache, and memory loss. Her syncope sounds highly
likely to be cardiac/orthostatic in nature. The episode of
amnesia day is more difficult to explain and the story is not
very consistent with TGA. Routine EEG was normal and the story
does not sound very typical for a complex partial seizure. Brain
imaging negative for stroke. Given that she remained at her
baseline during her stay, we will discharge her home with follow
up in Dr. ___ in regard to her MS vs ___.
We also started nortriptyline 10mg (with plan to increase to
20mg in 1 week if well tolerated) for her chronic headaches. We
also advised moist heat and in the future, considering trigger
point injections in pain clinic if medical therapy is
ineffective.
Of note, she was found to have a UA suspicious for UTI so she
was sent out with macrodantin to complete 3 days of treatment. | 322 | 182 |
18724860-DS-13 | 29,908,275 | Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight bearing on your left leg but do not
place your full body weight on your right leg; however, you may
rest the toes of your right leg on the ground
- You should not lift anything greater than 5 pounds.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity as tolerated
Right lower extremity: Touchdown weight bearing
Left lower extremity: Weight-bearing as tolerated
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment:change daily by RN; please overwrap any dressing
bleedthrough with ABDs and ACE | Mr. ___ was admitted to the Orthopedic service on ___ for a
right acetabular, inferior pubic ramus and iliac wing fractures
after being evaluated and treated with closed reduction in the
emergency room. He underwent open reduction internal fixation
of the fracture without complication on ___. Please see
operative report for full details. He was extubated without
difficulty and transferred to the recovery room in stable
condition. In the early post-operative course Mr. ___ did
well and was transferred to the floor in stable condition.
He had adequate pain management and worked with physical therapy
while in the hospital. The remainder of his hospital course was
uneventful and Mr. ___ is being discharged to home in stable
condition with strict touchdown weight bearing restrictions on
his right leg. He will follow-up in clinic in 2 weeks with
repeat pelvic films. | 341 | 143 |
15560355-DS-7 | 27,397,216 | Dear Mr. ___,
You were admitted to ___ after having some confusion and
altered mental status. After extensive testing, we found several
blockages in your heart. We placed several heart stents to open
the blockages. It is VERY IMPORTANT THAT YOU TAKE YOUR ASPRIN
AND PLAVIX EVERY DAY. DO NOT MISS ___ DAY. Please follow with a
PCP and cardiology for additional treatment.
You were also started on medications for your diabetes
(glipizide 5mg and metformin 1000mg). Please follow up both with
your diabetes doctor at ___.
It was a pleasure taking care of you, best of luck.
Your ___ medical team | Summary
___ with history of T2DM (not on meds) who was admitted for
management of altered mental status.
Acute issues
# Encephalopathy
# Syncope
# Abnormal stress test
He described acute onset AMS with anterograde amnesia, headache
and persistent somnolence. Neurologic exam was nonfocal
throughout admission. He was afebrile and no meningeal signs
making meningitis unlikely. Unlikely seizure given no hx of
seizures and pt denies incontinence, tongue biting during
episode. Patient also described days of polyuria preceeding the
event which is is c/w hypovolemic syncope. EKG was wnl and trops
were negative. D-dimer neg making PE unlikely. He underwent
echocardiogram which was normal. An exercise stress test found
ST elevations and he underwent cardiac catheterization. He had
DES placed to the LAD and RCA. Post procedure he had some chest
pressure and elevated troponins (0.52) but EKG was stable and
unchanged from priors. Troponins peaked at 0.64 and then trended
down, consistent with his resolving chest pressure. He was
discharged on ___ after chest pressure resolved and troponins
were trending down.
# T2DM
His presentation was likely precipitated by dehydration and
untreated diabetes. His A1C was 10.2% on admission. He was
evaluated by ___ and started on glipizide 5mg and metformin
1000mg. He was discharged home in good condition.
Chronic issues
# Headache: Resolved. Was treated with Tylenol and toradol for
pain prn while in house.
# Anemia: normocytic, mild. No history concerning for bleed.
# ?EtOH use: Unclear EtOH history. Pt denies drinking heavily
prior to this episode. Works at ___ store. B12 469 (wnl).
Treated with multivit, folate, b12 while in house.
Transitional issues
- He does not have an active PCP and ___ new one was established
at Healthcare Associates at ___.
- Discharged on metformin 1000mg and glipizide 5mg and should
have repeat blood work checked at his new PCP. He has a glucose
meter and supplies at home. He should have yearly podiatry and
optometry follow up. Home ___ for diabetic teaching was set-up.
- Started on atorvastatin for primary prevention with DM.
- Started metoprolol, aspirin and clopidogrel which he will need
to continue for at least ___ year for ___.
- He will follow with PCP, cardiology and ___.
# CONTACT:
Name of health care proxy: ___
Phone number: ___
# CODE STATUS: full, confirmed | 99 | 381 |
14769658-DS-6 | 27,518,262 | Dear Ms. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital for diarrhea and kidney
failure.
For your kidney failure
WHAT HAPPENED WHILE I WAS HERE?
- You had a CAT scan and stool studies for your diarrhea, and
you were again found to have an infection called C. difficile
colitis which we are treating with a long course of oral
vancomycin (antibiotic).
- For your kidney failure, you were seen by the kidney doctors
here who ___ that this was likely related to your infection or
possibly from the dye / contrast that you got when you had a CAT
scan on your first day in the hospital. Because you had extra
fluid on board related to both your kidney failure and your
chronic heart failure, we gave you Lasix through the IV to get
the extra fluid off.
WHAT SHOULD I DO WHEN I GET HOME?
- For your C diff colitis / infection: To prevent repeated
infections, it is important that you continue to take this
medication for longer than just 14 days as outlined below.
Please make sure you see your PCP ___ 1 week of discharge and
remind them to make sure you have an appointment to be seen in
the ___ clinic to discuss treatment of your
infection.
- For your heart and kidneys, we have increased your dose of
torsemide which you should continue to take daily as outlined
below. It is very important that you see your doctor within 1
week of discharge to have your weight and blood work checked.
They may tell you to change the dose of torsemide (the water
pill) again when they see you. This is because while your
kidneys have improved, they are not yet back to where your
normal used to be. Makse sure you weigh yourself as soon as you
get home and then daily every morning.
Please call your doctor if you gain 3 or more pounds in 1 day or
5 or more pounds in 3 days. You have an appointment with the
heart doctors as ___ below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team | ___ F with history of CAD ___ CABG ___, HFrEF ___ on
___ TTE with moderate to severe MR ___ mitral annuloplasty,
IDDM2 with nephropathy, CKD stage 3 presenting with abdominal
pain and diarrhea, found to have pancolitis likely d/t recurrent
severe c.diff
# Recurrent Severe C.diff
Patient recently completed a 21 day course of PO vanc for severe
c.diff with resolution of abdominal pain, diarrhea, and
leukocytosis, but subsquently re-presented with leukocytosis to
17, fevers, diarrhea and CT scan showing pancolitis. Patient
was seen by GI service, had a positive cdiff PCR and was felt to
be demonstrating signs of severe recurrent c.diff. She was
treated with high dose PO Vancomycin. Patient slowly improved
over the course of 7 days and she was transitioned to po
vancomycin only with plan per GI to taper her vancomycin slowly
over the course of the next year as follows: 250mg QID x7 days,
250 BID x7 days, 125 QID x7 days, 125 BID x7 days, then 125mg
daily for the next year thereafter. She will need non-urgent
follow up in ___ clinic which can be arranged after
discharge. Per GI, her vancomycin can be managed by her PCP with
coordination with GI clinic as needed should any issues arise.
# Oliguric ___
# CKD stage 3
Patient with baseline Cr 1.2-1.5 whose hospital course was
complicated by ___. She was seen by neprhology who felt this
was likely ATN in setting above acute infection versus contrast
nephropathy. Cr peaked at 5.0 and then improved over the course
of her admission, initially with simply holding her diuretics
and all nephrotoxic agents. She developed volume overload by
___ and was started on IV Lasix with active diuresis and
continued improvement in her ___ which was thought to have a
cardiorenal component at that point. She was transitioned to
oral diuretic regimen on ___ and since she has required 120mg
BID of IV Lasix and given her strong preference to be discharged
today despite discussion that it would be safer to monitor on po
diuretic for 24 hours prior to discharge, decision made to
discharge her on 60mg po torsemide daily rather than previous
home dose of 40mg daily. She was advised to see her PCP ___ 1
week of discharge for CHF follow up along with repeat labs and
diuretic dose titration. Creatinine on discharge was stable at
1.9. Repeat renal function panel within 1 week of discharge is
advised.
# CAD ___ CABG:
Continued home BB, statin, aspirin
# Acute on chronic systolic CHF
In setting of oliguric renal failure, patient developed
significant volume overload. EF ___. As she clinically
stabilized from Cdiff, she was started on BID IV diuresis then
transitioned back to po torsemide as above. Conitnued home
imdur, hydralazine. Discharge weight 75.66kg.
# Diabetes type 2
Given hypoglycemia, renal failure and poor PO intake, her home
glargine was dose-reduced and metformin was held. As she
recovered renal function and her glucose levels trended up,
decision made that it was safe to discharge her on her previous
home dose of lantus 20U + metformin bid. | 374 | 519 |
16439081-DS-14 | 22,880,999 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital because you
were found to have another urinary tract infection. You will
need to take an antibiotic called cefpodoxime for the next ___
days. Additionally, your dose of lamivudine was increased on
this hospitalization. Your medication changes are as follows:
1.) cefpodoxime 100mg every twelve hours for twenty days
starting ___ and ending ___.
2.) You will now take one tablet of the 100 milligrams
lamivudine (instead of the 0.5 (one half) tablet each day). This
will account for a total of 100 mg lamivudine. This was a
recommendation from the pharmacists. Please discuss this with
Dr. ___ at your appointment on ___. Please call
your doctor for ___ refill when you run out of your home supply.
You will also need to have blood work on ___ and have
the results faxed to Dr. ___. You were given an order
prescription to have these labs drawn.
Please take all other medications as prescribed and follow up
with the appointments listed below. You will be seeing your
transplant doctor, infectious disease specialist, primary care
physician, and ___ urologist.
With the Urologist, it will be very important that you undergo
urodynamic studies, as well as bladder emptying studies. This
will help determine why you are experiencing recurrent
infections.
It is important you keep these appointments to prevent further
infections. If you develop any of the danger signs listed below,
please go the emergency room or call your doctors ___.
We wish you all the best!
Sincerely,
Your ___ Care Team. | ___ year old ___ lady with history of ESRD s/p DDRT and MDR
klebsiella UTIs, presented with recurrent urinary tract
infection after two days of dysuria, frequency, hematuria, and
nausea. Transplant ultrasound was normal and no ___ on labs.
# Urinary tract infection:
Patient with history of MDR Klebsiella infection in the past and
was previously on suppressive therapy with fosfomycin, which was
stopped due to intolerability (diarrhea). Patient also
previously scheduled for urodynamic studies, but deferred
invasive studies. On this visit, UA grossly positive for
leukocytes and blood. Urine Cultures speciated as MDR resistant
Klebsiella sensitive to cefpodoxime. She received one dose of
cefepime and was transitioned to PO ceftriaxone given
sensitivities. Her outpatient Infectious Disease doctor ___.
___ was contact who recommended transitioning to cefpodoxime
to complete a total 21 day course with end on ___. Added on
sensitivity testing for phosphomycin and tetracyclines and
organism resistant to both.
# Hematuria:
Likely secondary to UTI versus ruptured cyst. No recent
instrumentation. Patient will follow up with urology as
outpatient within the next few weeks.
# S/p kidney transplant:
Transplant renal ultrasound within normal limits and no ___.
Continued mycophenolate and tacrolimus without changes in
dosing. Tacro trough obtained after AM dose and thus level is
erroneously elevated. She was given a script and instructed to
have true trough drawn on ___ with results faxed to Dr. ___
___ Nephrology. Patient also continued Bactrim ppx and sodium
bicarb tabs BID.
# Hypertension:
Stable. Continued home amlodipine, hydralazine and metoprolol XL
with holding parameters.
# Atrial fibrillation:
___ score of 5.
Continued metoprolol XL for rate control. Continued apixaban 5mg
BID.
# Osteoporosis:
Continue home vitamin D, alendronate once weekly
TRANSITIONAL ISSUES
-Cefpodoxime 100 mg BID until ___ for a total 21 day course.
-Urine culture sensitivities added on for Fosfomycin and
tetracylcines to guide choice of suppressive therapy. Likely
resistant to both. (refer to pertinent results)
-Patient will need tacro level checked on ___ and
faxed to Dr. ___ at ___.
-Lamivudine: per Pharmacy was increased from 50 mg daily to 100
mg daily.
-Assess for ongoing hematuria at upcoming urology visit.
-Full Code (confirmed). | 265 | 352 |
14299919-DS-21 | 22,397,878 | WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You fainted at home and were found to have low blood pressure.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given albumin, a protein mixed in fluid, through the
IV because you were dehydrated.
- Once your blood pressure became more normal and your kidney
injured was fixed, we restarted your diuretics (water pills) at
a lower dose than you were on previously.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- Weigh yourself every day, as you do. If your weight goes up or
down by more than 3 lbs in 1 day, or 5 lbs in 3 days, please
call Dr ___. | ___ with history of alcoholic cirrhosis presenting after a fall,
found to be in hypotensive, likely in the setting of
hypovolemia/over-diuresis. Improving with colloid resuscitation. | 118 | 26 |
17096102-DS-5 | 28,432,108 | Dear Mr. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital from your nursing
home because your oxygen level dropped, and you were found to
have an worsening in your kidney function. While you have been
in the hospital, we have been giving you antibiotics to treat a
lung infection, as well as an infection in your urine.
.
You initially had a worsening of your renal function, but we
think that this was related to an antibiotic that we were giving
you. We stopped this antibiotic, and switched you to another
antibiotic to treat your infection.
.
We did further studies to evaluate your kidney function and we
think that, overall, your worsening kidney function is likely
due to a progression of your baseline high blood pressure and
diabetes. It will be VERY important for you to follow-up with
your kidney doctor as an outpatient (see below).
.
We also did an ultrasound of your heart, and your heart function
is normal and pumping well.
.
We made the following changes to your medications:
STOP atenolol
STOP chlorthalidone
START cefpodoxime 400 mg daily (LAST DAY = ___
START azithromycin 250 mg by mouth once daily (LAST DAY =
___
START guaiefenesin cough syrup by mouth every six hours as
needed for cough
START Miralax by mouth one time daily as needed for constipation | Mr. ___ is a ___ with DM, HTN, s/p CVA, and CKD admitted for
an elevated creatinine and volume overload, as well as likely
UTI.
.
# Acute on chronic renal failure: The patient has history of
chronic renal failure, with previous baseline in the mid 1s.
However, for the last two months, his baseline has been 2.3-2.5
after starting an ace inhibitor, and on this admission, creat
2.7. The patient had this creat increase worked up as an
outpatient, and was found to be ___, ANCA negative. While in
patient, renal was consulted, as the patient's creat trended up
to 3.2. He had a renal ultrasound with dopplers done that ruled
out renal artery stenosis, with evidence of an atrophic right
kidney. It was thought that the patient's creat bump while in
patient was related to the cipro he was receiving for his UTI
(see below). Urine eos were positive, but there was no evidence
of peripheal eosinophilia. The patient's FeUrea was also
consistent with an intrinsic etiology, and the patient's Cipro
was stopped out of concern for AIN. He was then switched to
Cefpodoxime and Azithromcyin to also cover for pneumonia (see
below). Upon discharge, the patient's creat began to trend
down; 2.9 on day of discharge.
.
The patient's ___ was held while in patient, and it will be
restarted as an outpatient. The patient's atenolol and
chlorthalidone were both discontinued, as well. He will follow
up with Dr. ___ as an outpatient.
.
# Volume overload: The patient had desaturation event while at
his NH, and initially had 2L O2 requirement when he first came
to the hospital, in the context of a CXR that showed evidence of
pulmonary edema. He was given Lasix 20 mg IV, to which he made
good urine, and O2 requirement improved; now satting high ___ on
RA. Unclear etiology of this volume overload, but given
presence ___ edema on admission, and slight cardiomegaly on
CXR, an ECHO was done to evaluate for CHF. Echo, however, was
normal and there was no signs of congestive heart failure.
.
# Urinary tract infection: The patient was found to have a dirty
UA, and was initially started on renally dosed Cipro for a total
7 days course to treat urinary tract infection. However, repeat
CXR showed an evolving RLL consolidation, and the patient was
transitioned from Cipro to Cefpodoxime and Azithromycin to treat
this pneumonia, as well as UTI. The patient was also found to
have urine eosinophils and Fe urea consistent with intrinsic
renal disease, and the Cipro was stopped, as above.
.
# Pneumonia: The patient was found to have evolving RLL
consolidation, which was thought to be consistent with
pneumonia, especially given his cough productive of a yellow
sputum. He was started on Cefpodoxime and Azithromycin, and
will complete a 5 day course. Upon discharge, he was breathing
comfortably on RA.
.
# Bradycardia: The patient was noted to have bradycardia into
the ___ at his NH in the days preceding presentation. This is
likley due to the lingering effects of his atenolol in the
setting on worsening renal function. His atenolol was held while
in patient. The patient had one episode of bradycardia again
during the hospitalization while he was sleeping, but remained
asymptomatic with other vital signs stable. Upon discharge, the
patient's atenolol was discontinued. He was not started on any
other rate control agent.
.
# DM: The patient was continued on his home lantus regimen and
placed on an insulin sliding scale while in patient.
.
# HTN: While in patient, the patient's losartan, atenolol, and
chlorthalidone were all held given his acute renal failure. He
was continued on his nifedipine. Upon discharge, his losartan
was restarted, as per renal recommendations. However, his
atenolol and chlorthalidone were both held.
.
# schizophrenia: The patient was continued on his home depakote
and haldol.
.
# H/O CVA: The patient was continued on Plavix.
.. | 229 | 703 |
13275667-DS-20 | 27,394,143 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weightbearing as tolerated right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: To be changed DAILY by ___ starting POD ___. RN - please
overwrap any dressing bleedthrough with ABDs and ACE
Site: right hip
Description: DSG x3
Care: CDI change PRN | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right subtrochanteric femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity
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. | 346 | 255 |
18706216-DS-6 | 27,575,086 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were transferred
here after having severe abdominal pain at home, and we were
concerned for a flare of your underlying inflammatory bowel
disease (IBD). While here, you underwent a procedure called a
flex sigmoidoscopy to look at the tissue in your lower colon,
and this showed inflammation. While here, we also started a new
medication called adalimumab (Humira) for your IBD, and we hope
that this works better than your previous medication infliximab.
While here, you were given pain medicine to help control your
pain, and you started to tolerate eating well. While here, you
also underwent an ultrasound to look at your liver, gall
bladder, and pancreas which all were normal.
The following changes were made to your home medication regimen:
1. START Adalimumab per schedule: 2 injections on ___.
2. CHANGE Prednisone 40 mg daily
3. START Oxycodone 5 mg every ___ hours as needed for pain.
If you develop worsening pain, fevers, chills, bloody bowel
movements or other concerning symptoms contact your primary care
doctor or go to the nearest Emergency Room. Please continue to
take your other home medications as prescribed. Please follow-up
with your primary care doctor and your gastroenterologist upon
discharge from the hospital.
Take Care,
Your ___ Team. | Ms. ___ is a ___ year old female, with past history of mixed
IBD type disease, previously treated with prednisone and
infliximab, recurrent C. diff infection, and history of
pancreatitis, transferred from ___ for abdominal
pain, vomiting, and BRBPR/diarrhea, concerning for colitis.
.
>> ACTIVE ISSUES:
# Colitis/Enteritis: Patient has had a long-standing history of
inflammatory bowel disease, with multiple areas affected leading
to a more mixed type picture of disease. She is currently being
followed by Dr. ___ at ___. Patient has previously been
taking infliximab, however it has been noted that she has
developed detectable antibody titers and waning infliximab
levels, and therefore other treatment options were currently
under discussion. Patient initially presented to OSH, at which
point found to have several episodes of diarrhea, bloody bowel
movements and crampy abdominal pain reminiscent of prior flares
of IBD. Patient underwent CT scan consistent with thickening of
the colon, mural thickening of the ilium consistent with both
colitis and enteritis, c/f Crohn's disease. Given patients
clinical condition, patient was transferred to ___ for further
care. Patient also found to have a severely elevated
leukocytosis with a left shift. Other etiologies for colitis
could include infectious colitis, and stool cultures and C. diff
were sent which were negative. To further determine etiology,
patient underwent flex sigmoidoscopy which showed chronic active
colitis. CMV negative on biopsy. Discussion regarding next agent
to use for IBD treatment, and decided to use monotherapy with
adalilumumab (Humira). It was discussed that patient may benefit
from ___ combination therapy with medication, however
ultimately deferred and chosen to start monotherapy. Patient
started loading dose with 4 injections on ___, with plan for 2
injections in 2 weeks, and 1 injection 1 week after previous.
Patient tolerated injection well without side effects. Patient
was also continued on outpatient prednisone 40 mg daily, and had
resolution of many of her symptoms with hydration and pain
control. Patient to follow up with outpatient GI upon discharge.
.
# Pancreatitis: Patient found on initial presentation to have
lipase of 1600 at OSH, and with epigastric pain radiating to
back. Patient was started on IVF, and per patient's history has
had multiple episodes of pancreatitis with her IBD. Patient had
a repeat lipase drawn in the ED, which was 123, and continued to
downtrend during hospital stay. Etiologies for her pancreatitis
were considered, as patient has IBD flares that have
intermittently affected the duodenum, however unclear if it is
primarily related to IBD or secondarily related to inflammation
accompanied with IBD or prior medications. Patient underwent a
RUQ ultrasound during inpatient stay, which was unremarkable for
gall stones, liver/biliary pathology, and showed a relatively
normal pancreas for part visualized. Patient was transitioned to
normal diet, tolerated well. It was considered that patient may
benefit from outpatient cholecystectomy, however will be
discussed further in outpatient setting.
.
# Recurrent C. diff: Patient was found to have multiple episodes
of C. diff earlier in ___, associated with her IBD flares.
Patient was at one point considered for fecal transplantation
with Dr. ___ unclear whether able to complete
secondary to multiple hospitalizations and infections. Patient
is currently on a PO vancomycin taper. It was considered that
current presentation may be releated, however C. diff tested was
negative during inpatient stay. Patient to continue PO
vancomycin taper as outpatient.
.
# Leukocytosis: Patient found to have severe elevated
leukocytosis of 20.6 with left shift, however during hospital
stay continually downtrended. This was thought to be ___ to not
only her steroid use but also infectious etiologies and
inflammation.
.
# Sleep Disturbances: Patient reports that since initiation of
prednisone, has had difficulty with sleep patterns, and requires
variety of PRN sleep aids including melatonin, zolpidem and
others for sleep.
.
>> TRANSITIONAL ISSUES:
# Steroid: Patient has been on steroids chronically, and will be
continuing prednisone 40 mg daily. Would consider DEXA scan
given prolonged course for bone mineral density measurments.
# Vaccinations: Given immunosuppression ___ ___,
___ require prevnar 12 months s/p PSV23 (___). -> ___
# Combination therapy: Raised by GI consult during inpatient
stay ? regarding combination therapy with ___. Further
discussion as outpt GI.
# C. diff Taper: Patient to complete taper PO Vancomycin for C.
diff
# Adalimumuab: Patient to have repeat 2 injections in ___, and
then 1 injection 1 week after per GI. | 219 | 722 |
15287289-DS-18 | 28,264,457 | Dear Ms. ___,
You were admitted with back pain due to spine involvement of
your cancer. We treated you with radiation and very low dose of
dilaudid pills for this, and your pain improved. You also had
significant pain in your left hip from your cancer. Because the
lesion was at high risk for fracture, our orthopedists
surgically fixed your femur with a nail to prevent fracture. You
worked with our physical therapists, and are ready to go to a
rehab facility to continue recovering from the procedure.
Your course was also complicated by mucositis of your mouth and
lips. We think this was due to a yeast infection, and have you
on medication for this. Please continue this medication and good
mouthcare to help the lesions continue to heal. You also had
some diarrhea which may have been due to radiation or your bowel
medications. There was no indication of significant infection.
It has been a pleasure taking care of you. | PRINCIPLE REASON FOR ADMISSION:
___ w/ CVA, HTN, DL, MD, fibromyalgia, and ocular melanoma c/b
multiple hepatic metastases s/p TACE in ___ and CK in
___, who has progressed through several regimens, now p/w
worsening back pain and lower extremity weakness found to have
metastatic melanoma to the spine s/p XRT to LSpine and fixation
of left femoral neck on ___. | 161 | 60 |
18396526-DS-42 | 24,986,459 | Dear Mr. ___,
You were admitted to the hospital with shortness of breath and
weight gain from your congestive heart failure. We gave you
medicine to remove fluid and your symptoms improved. It is very
important you take all of your medications and avoid foods high
in salt, including cheese. You may also be a good candidate to
have regular IV infusions of lasix as an outpatient. ___
from the heart failure clinic will contact you about this.
Medication Changes:
STOP enalapril
You should continue to take all of your other medications as
prescribed, including torsemide.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | HOSPITAL COURSE BY PROBLEM:
#) CHF exacerbation: Patient with systolic heart failure, EF on
___ 45%. He has had multiple admissions for CHF
exacerbation, most recently late ___. 13kg weight gain since
that time. Question if he is completely absorbing oral
diuretics given colectomy vs dietary indiscretions with cheese.
Managed initially on medicine floor with IV lasix 80mg BID with
good diuresis ___ negative per day), toprol XL 50 daily. ACEI
held secondary to ___ on admission Cr 3.0 (baseline 1.6), not
restarted at discharge as BPs were borderline and Cr still above
baseline. Transferred to Farr3 for lasix drip and diuresed
effectively on lasix gtt at 20mg/hr, then transitioned to
torsemide 80mg daily at discharge. He will follow up with outpt.
___ clinic for lasix infusions. Discharge weight 112kg. ___ need
ACEI restarted in future.
#) AonCKD: Baseline Cr 1.6, Cr 3.0 on admission, trended back to
baseline then bumped again to peak 2.6, then trended down to 2.3
at d/c. Likely ___ ___ CHF exacerbation and poor effective blood
flow to kidneys. UA negative. He has history of BPH, however
patient had no problems urinating on this admission. Lisinopril
stopped. Should have repeat Cr at next visit.
#) INR: Was elevated on admission to 6.3. No clear reason as
patient reported compliance with coumadin regimen. Coumadin
restarted when INR around 3.5. Goal 2.5-3.5 given AVR/MVR. Home
dosing not changed at discharge.
#) ANEMIA: Hct approx same as last admisstion (around 25). Work
up previously showed anemia of chronic inflammation, but also
low haptoglobin and mildly elevated LDH to suggest potential
mechanical shearing from valves. Guaiac negative.
# AFIB s/p AV node ablation, BV pacer (___): Coumadin as above.
Continued metoprolol 50mg PO Daily with good rate control.
# COPD/Asthma: Continued fluticasone Propionate NASAL ___ SPRY
NU DAILY, Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID,
Ipratropium Bromide MDI 2 PUFF IH QID, Ipratropium Bromide Neb 1
NEB IH Q6H:PRN SOB
# Hypothyroidism ___ amiodarone: continued levothyroxine Sodium
100 mcg PO DAILY
# HLD: diet controlled per patient. LDL 71 in ___ | 105 | 343 |
18050591-DS-18 | 25,590,716 | You were admitted with fever and found to have an infection or
MRSA in your bloodstream. Ultrasound of the heart was negative
for infection there. You improved with antibiotics and will be
discharged to complete a course of Daptomycin. Please take all
medications as prescribed. You will be called with an
appointment in ___ infectious disease clinic. | Mr. ___ is a ___ year old man with h/o fistulizing ___
disease on humira weekly, stable, s/p recent ___ placement,
who presents with persistent fevers now found to have high grade
MRSA bloodstream infection. TTE and TEE negative for
endocarditis. | 61 | 42 |
10745462-DS-9 | 25,327,624 | Dear Mr. ___,
It was a pleasure to participate in your care at ___
___! You were admitted with upper
abdominal pain, which was thought to be gastrointestinal in
etiology. You had no evidence of damage to your heart.
Additionally, labs and imaging showed no problems with your
pancreas or gallbladder. This is all very reassuring. You
improved with intravenous fluids and anti-nausea medications.
We hope that you will follow up with Dr. ___
further investigation and management of your symptoms. Please
see below for a list of your follow-up appointments.
As you also mentioned some exertional chest pain, we have
ordered an outpatient nuclear stress test for you. You can
schedule this by calling ___. We recommend that you
have this done within the next month. Dr. ___ will follow-up
with you in Cardiology clinic.
We did not change any of your medications.
Wishing you all the best! | Mr. ___ is a ___ year-old gentleman with a PMH of CAD
(cath at ___ with chronic occlusion of the right coronary
artery and a moderate 50% stenosis in the LAD), GERD, IBS,
admitted with epigastric pain, most likely GI in etiology. | 153 | 42 |
18280780-DS-3 | 28,111,214 | 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, do not
resume these until cleared by your surgeon.
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Patient was trasnferred from an OSH for neurosurgical
evaluation. In the ER he was seen and examined and found to have
bilateral upper extremity tremors consistent with alcohol
withdrawl. Given his CT head findings he was admited to the ICU
for further monitoring and care. He was placed on a CIWA scale,
Dilantin, and a repeat Head CT was ordered for ___ am.
Electrolytes were reviewed and he was noted to have a sodium of
116. He was started on 3% saline at 30cc/hr and NS at 75ml/hr.
He remained stable overnight and neurological exam was improving
in the AM ___. Sodium level was 125 so he was continued on the
same regimen. A repeat Head CT was performed which was stable.
He was started on SQH. Later in the evening the 3% saline was
d/c'd.
On ___ C-spine was cleared and sodium was up to 129. He
remained in the ICU for close neurological observation and
sodium management.
On ___ He was cleared for transfer to the floor. He remained
neurologically and hematologically stable. ___ was consulted for
assistance with discharge planning and recommended discharge to
rehab.
On ___ sodium was stable at 130. He was cleared for rehab and
he was in agreement with this plan. | 192 | 206 |
10113857-DS-13 | 27,005,154 | It was a pleasure taking care of you at the ___
___ for your right foot pain. Due to your
history ov vascular disease you were placed on a heparin drip.
Your angiogram of your right lower extrmity was diagnostic only.
You did not have any intervention performed. Your heparin drip
was discontinued. There are no urgent or emergent vasuclar
needs at this time. You are being discharged ot home with
visiting nurse services | The patient was admitted to the vascular surgery service on
___. He was anticoagulated on heparin and was brought to
the operating room ___ for Right Lower Extremity
diagnostic angiogram, which revealed
R Prof, SFA and Pop patent. 2 vessel run-off through
good AT and mildly diseased ___ (PR occluded)
He was normalized that evening on his home medications and a
regular diet, and was discharged POD1, ___. | 79 | 67 |
11437519-DS-21 | 24,290,910 | Please call the transplant clinic at ___ for fever of
101 or higher, chills, nausea, vomiting, diarrhea, constipation,
inability to tolerate food, fluids or medications, yellowing of
skin or eyes, increased abdominal pain, incision redness,
drainage or bleeding, dizziness or weakness, decreased urine
output or dark, cloudy urine, swelling of abdomen or ankles, or
any other concerning symptoms.
Bring your list of current medications to every clinic visit.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotion or powder near the incision.
Check blood pressure daily if possible. Report consistently
elevated values to the transplant clinic of greater than 160 or
less than 110 systolic. | ___ s/p right hepatectomy ___ for RHD stricture & pain who
now returns with returning with RUQ pain.
.
On Admission, an abdominal CT was obtained, with findings of
status post right hepatic lobectomy with a 4.0 x 3.7 x 5.3 cm
thick-walled fluid collection in the resection bed which may
reflect postoperative seroma or resolving hematoma. She was
also noted to have a moderately-sized right pleural effusion
with compressive right lower lobe atelectasis.
.
On ___ she underwent CT-guided aspiration of the small
collection in the hepatectomy bed. Approximately 15 cc of
green/brown fluid was aspirated and sent for cultures and
bilirubin content assessment. The fluid was not noted to be
purulent. Attempt was made to place a pigtail catheter into the
collection, however, 2 attempts were made but unsuccessful in
coiling a pigtail within the collection. Of note the fluid was
no growth at 48 hours. The bilirubin level was 6.2.
.
Pain was managed and she was able to be discharged the following
day. | 113 | 164 |
14594112-DS-13 | 25,357,870 | Dear Mr. ___,
You were admitted after you had a seizure at home. This was
likely because of your PML. Your EEG (brain wave test) did not
show any seizures. You were started on levetiracetam (Keppra)
1000mg daily. Please follow up with Dr. ___ Dr. ___
as an outpatient.
Please do not drive, swim, or climb (ladders, rock climbing etc)
given your recent seizure as it would be unsafe to do so.
You also had some right hip pain on admission. Your x-ray of
your hip did not show any fractures, but your MRI of your right
hip showed a partial tear of your right iliopsoas muscle.
Physical therapy evaluated you and recommended a rolling walk
with home physical therapy.
It was a pleasure taking care of you while you were in the
hospital, and we wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a pleasant ___ man with biopsy proven
PML admitted ___ after a first time seizure. No history of
recent illness. Prior MRI brain showed multiple small enhancing
foci in the L posterior frontal and parietal white mater and T2
signal abnormalities in bilateral cerebral hemispheric white
matter. Given his history of PML, it would not be unreasonable
that this could be a possible focus for seizure. Extended
routine EEG performed during this admission showed variable
bursts of L temporal delta frequency slowing suggestive of
cortical-subcortical dysfunction. On exam, he was unable to lift
his R leg ___ pain. XRay of the R hip negative for fracture, MRI
hip showed a partially torn right IP tendon. No surgical
indication at this time. Physical therapy saw him and
recommended home ___ and rolling walker.
He was started on keppra 1000mg BID and is to follow up in
neurology clinic. He was counseled on seizure precautions prior
to discharge. | 140 | 160 |
14301172-DS-7 | 29,157,298 | Dear ___,
You were hospitalized at ___
due to symptoms of seizure resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where there is an area of bleeding into the
brain. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors.
Your risk factors are:
- Diabetes
- High blood pressure
We are changing your medications as follows:
- Started a medication called amlodipine to help reduce your
blood pressure
- Switched your atenolol to carvedilol
- Started insulin to help better control your diabetes
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
___ year old man with poorly-controlled DM, HTN, and obesity who
initially presented to ___ after being found unresponsive
by his wife in the setting of recurrent bouts of emesis. There
he was found to have a small left anterior temporal IPH and
possible seizure activity for which he was intubated prior to
transfer to ___.
# Left Temporal IPH
# Seizures
The patient presented to ___ after being found
unresponsive by his wife. In the ___, he had a witnessed seizure
and was intubated for airway protection. He was loaded with
Keppra. CT head showed a small intraparenchymal hemorrhage
within the left temporal lobe measuring 1.4 x 1.2 cm. It was
felt that the small IPH caused the seizure activity rather than
vice versa. Etiology of the IPH, however, was not clear. The
superficial location was felt to be atypical for hypertensive
hemorrhage and there was no evidence of CAA on either imaging or
clinical history. MRI brain was obtained and showed a 1.8 cm
acute left temporal lobe parenchymal hematoma. There was also a
small nodular focus of enhancement versus pulsation artifact for
which follow-up MRI was recommended. The patient underwent
conventional cerebral angiogram to rule out dural AV fistula or
other vascular anomaly. This was negative. Ultimately, it was
felt that cavernoma was the most likely etiology of his IPH. The
patient was treated with a 7 day course of Keppra and had no
further seizure activity while admitted.
# Subacute ischemic infarct in right centrum semiovale
There was also noted to be a subacute ischemic infarct on MRI
which appeared embolic vs. small-vessel in nature. Patient will
need cardiac monitoring on discharge from the hospital to
monitor for occult atrial fibrillation.
# Hyperglycemia
Patient has a history of diabetes. Hemoglobin A1c was 9.2% on
admission to ___. Serum glucose was 380. ___ diabetes
___ was consulted. Long-acting insulin was started at an
initial dose of Lantus 6 U QHS and up-titrated to 24 U at
discharge. He was also started on humalog 5U with meals. Sliding
scale insulin was also initiated. The patient did have trace
ketones in his urine and an anion gap of 24 at ___. His
anion gap closed upon arrival to ___. He did not require an
insulin drip at any point.
# Fevers
Patient was admitted with low grade temperatures and
diaphoresis. WBC upon admission was 17.6. He was started on
broad spectrum antibiotics with vancomycin, ceftriaxone,
ampicillin, and acyclovir at meningitic dosing. Blood cultures
and urine cultures were obtained and were negative. Lumbar
puncture was performed and revealed protein 45, glucose 209, TNC
8 -> 1, and RBC 2747 -> 43. HSV PCR was negative and acyclovir
was therefore discontinue. Antibiotics were switched to
vancomycin and cefepime for broad coverage. Bronchoscopy with
BAL was unrevealing. CT torso with contrast showed no evidence
of infection or malignancy. Patient found to have UTI on ___
and pneumonia on ___.
# Hypoxia
# Pulmonary Emboli
While in the ICU, patient had increasing oxygen requirement.
Initially treated with Lasix due to concern for fluid overload
with some improvement. Initial CT chest on ___ showed bibasilar
consolidation, left greater than right, which was felt to be
atelectasis alone or with concurrent pneumonia. He was treated
with a 7 day course of cefepime. He was also initially on
vancomycin and ampicillin, both of which were discontinued. On
___, due to persistent hypoxia and increased work of breathing,
CTA of chest repeated; this showed pulmonary emboli in at least
the interlobar branch of the left upper lobe pulmonary artery
and segmental branch of left lower lobe pulmonary artery.
Systemic anticoagulation was initially deferred given left
temporal IPH. However, once repeat head CT showed no interval
increase in the size of the hemorrhage, he was started on
heparin gtt with goal PTT 50-70 and switched over to apixaban
prior to discharge.
# Hypotension
The patient was admitted to ___ with distributive shock with
BP as low as 78/42 mmHg. He received aggressive IV fluid
resuscitation and was started on phenylephrine initially and
subsequently transitioned to norepinephrine once central venous
access was established. He was soon weaned off of the
norepinephrine entirely on the evening of ___ into ___.
# Acidemia
# Lactic Acidosis
Patient presented to ___ with pH 7.17 and pCO2 61 on venous
blood gas. Lactate was 10.5 at ___ but 3.5 upon arrival to
___. Lactate corrected rapidly with above-described
interventions and aggressive IV fluid resuscitation. pH also
resolved to 7.34 - 7.36 range. | 303 | 741 |
12547682-DS-30 | 22,474,817 | Dear Ms ___,
You were admitted to ___ for detoxification from alcohol while
hooked to EEG to monitor for seizure activity. At the You did
not have any clinical seizures and your EEG did not show any
active seizure. You were discharged with close follow up with
your outpatient psychiatrist, neurologist and ___
___ clinic. | #Voluntary Alchol Withdrawal Admission w/ EEG monitoring
Ms. ___ is a ___ right-handed woman with
intractable primary generalized epilepsy, recurrent admissions
for altered mental status possibly related to nonepileptic
events versus medication toxicity, significant psychiatric
history including bipolar disorder, severe depression with
suicide attempts in the past, who presented with excessive
alcohol intake and recent seizures.
Given her severe epilepsy, she was at significant risk for
breakthrough seizures with abstinence from alcohol. She also
appeared to have significant worsening of her baseline
depression, with passive suicidal ideation.
She was admitted for detoxification from alcohol and for
management of her psychiatric illnesses. She was monitored with
EEG and weaned off of alcohol with a benzodiazepine taper. She
was evaluated by psychiatry who did not feel she was in
immediate danger to herself or others. She did not have any
clinical or electrographic seizures.
Initially she was managed with CIWA, but its use was limited due
to her subjective symptoms ("hallucinations" that were more
consistent with PTSD nightmares) without objective correlate (ie
tachycardia). Objectively, she did not appear to be in clinical
withdrawal. She tolerated 2 days of hospitalization without any
evidence of withdrawal. After discussion with psychiatry, she
was felt to be safe for discharge. She had care established
with an outpatient partial alcohol detox program prior to
discharge and was discharged with close follow up with her
outpatient psychiatrist.
# UTI
- U/A on admission concerning for UTI. Discharged on Bactrim to
complete 4 day course. | 58 | 249 |
13595620-DS-26 | 25,621,430 | Dear ___ were admitted to the hospital with difficulty breathing. We
treated ___ with nebulizers, steroids and fluid removal and ___
improved. ___ should continue to take the prednisone as directed
for a few more days to continue the taper: Take 30 mg daily on
___ and ___ take 30 mg. Take 20 mg daily on ___ & ___. Take
10 mg daily on ___ & ___. Take 5 mg daily on ___ & ___.
Best wishes for your continued healing.
Take care,
Your ___ Care Team | TRANSITIONAL ISSUES:
=====================
[ ] Imaging concerning for obstructive process. Given extensive
exposure to ___ hand smoke, consider PFTs for COPD work-up.
Consider inhalers as needed. | 84 | 24 |
10824195-DS-12 | 22,532,034 | Dear Mr. ___,
It was a pleasure participating in your care here at ___.
During this hospitalization, you were treated and evaluated for
an elevated heart rate. Your lab tests and imaging did not show
evidence of disease in your heart and lungs or a new infection.
You were given IV fluids and pain medication with return of your
heart to a regular rate and rhythm. Please follow up with your
outpatient provider for management of your anti-coagulation
medication and skin ulcer.
Please take 7.5 mg of Coumadin on ___ and then 10mg on ___ and
___. You will need to get your INR checked on ___ when
you come to Healthcare Associates. This is very important to
make sure you are on the right dose of Coumadin.
You also had a fall after getting a blood draw. Imaging of your
head did not show any bleeding but you did have headache and
some nausea that may be from a concussion. Please continue to
monitor these symptoms.
Thank you for allowing us to participate in your care!
--Your ___ care team | =================================
PRIMARY REASON FOR ADMISSION
=================================
Please see Discharge Summary from ___.
Mr. ___ is ___ year old M with history of ___
Syndrome on warfarin, multiple DVTs and PEs s/p CIV/EIV stent
placement at ___ in ___ and IVC filter placement at ___ in
___, and depression who was discharged from ___ ___ s/p
evaluation for LLQ pain and represented to the ED later that day
with tachycardia.
================================= | 183 | 66 |
15401744-DS-21 | 22,068,543 | 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:
- TDWB RLE with posterior hip precautions
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.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
-TDWB RLE
-posterior hip precautions
Treatments Frequency:
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. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right traumatic hip dislocation and posterior wall
acetabulum fracture and was admitted to the orthopedic surgery
service. Closed reduction under sedation was attempted in the
ED, but the hip was unable to stay reduced. The patient was
taken to the operating room on ___ for right acetabulum ORIF,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with services was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the RLE with posterior hip precautions, 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. | 496 | 279 |
15089811-DS-20 | 24,313,943 | You were admitted with multiple complaints in the setting of
failure to thrive due to many acute and chronic issues. You were
found to have acute right lower extremity DVT and are being
treated with a new medication of Apixaban (anticoagulation,
blood thinner). You were found to have urinary retention, likely
due to BPH and were started on Flomax. You should continue to
monitor with bladder scans at rehab. Other subacute to chronic
issues, including dyspnea on exertion, intermittent chest
discomfort, CAD, dysphagia, joint deformity, dementia with
Parkinsonian features, and DM should be followed by establishing
a new PCP and obtaining outpatient specialist appointments. | ___ ___ male with history of CAD s/p remote
PCI, HTN, T2DM now diet-controlled, recent diagnosis of possible
dementia and ___ disease who presents most significantly
brought in by family from ___ for medical evaluation
given overall failure to thrive and was found to have an acute
DVT in the distal right femoral vein and. Patient was started on
heparin drip pending further workup of likely chronic right
ankle joint hardware malfunction and chronic intermittent
dysphagia.
# Acute RLE DVT
- Lower extremity duplex with right femoral vein DVT. No
evidence of PE on CTA. Risk factors for VTE include limited
mobility and recent travel. Patient treated with empiric
heparin infusion and was transitioned to oral anticoagulation
with apixaban.
[ ] Outpatient provider ___ need to review cancer screening and
update necessary testing.
# Dyspnea on exertion and Intermittent chest tightness with
exertion that resolves with rest. Differential includes stable
angina versus chronic bronchitis versus deconditioning (or
combination of all these conditions). CTA chest was negative for
PE, but notable for possible bronchitis. Troponin is negative
and ECG was stable with known LAFB and early R wave transition
without significant change from prior and no ST-T changes.
[ ] Schedule outpatient stress testing unless acute clinical
change or worsening
[ ] Continue ___ treatments at ___
[ ] Consider PRN albuterol
[ ] Obtain repeat chest CT with IV contrast in 6 weeks as
recommended above to assess hilar lymphadenopathy
# Joint malfunction, representing chronic hardware deformity.
There was low suspicion for acute infection based on exam and
imaging, but an may have been temporarily treated with oral
antibiotics prior to arrival. Orthopedic surgery evaluated the
patient and recommend weightbearing as tolerated with outpatient
follow up. A CT foot/ankle did not show evidence of acute
infection.
[ ] Schedule outpatient orthopedic surgery follow up with
___., MD, PHD
# Dysphagia with possible chronic microaspiration. Patient
reported an 8 month history of dysphagia and possibly
odynophagia with unintentional weight loss. CT chest suggestive
of esophageal dysmotility (fluid levels and patulous esophagus).
Patient is maintained on aspiration precautions. Speech therapy
evaluated the patient and recommends a modified diet to soft
solids. Dysphagia is possibly related to ___ disease.
Nutrition recommends supplement with meals.
[ ] Patient requires outpatient GI consultation for EGD versus
other esophageal motility testing.
# Dementia with behavioral disturbance and Parkinsonian features
# FTT
- Plan discharge to ___ with ongoing ___ treatments.
[ ] Establish neurologist
# CAD and HLD
- Continued on home ASA, statin, ACE. Patient is not on
beta-blocker; likely due to sinus bradycardia.
[ ] Outpatient stress test as above
# T2DM is diet controlled. Most recent A1C is 5.4% in ___ (repeated 5.5). Patient should be monitored on consistent
carbohydrate diet and consider corrective insulin sliding scale
if progressive hyperglycemia with improved oral intake.
# Presumed BPH with mild intermittent urinary retention
[ ] Establish follow up with urologist
[ ] Continue with intermittent bladder scans with straight
catheterization as necessary
[ ] Flomax was initiated
[ ] Patient needs PCP referral from rehab
Hospital course, assessments, and discharge plans discussed with
daughter who expressed understanding and agreed with discharge.
Patient had variable understanding of all conditions based on
level of confusion, but had a general awareness and also agreed
with plan. | 104 | 532 |
12257192-DS-28 | 21,179,019 | = You were hospitalized at ___ in the neurology wards
following reports of seizure activity and possible olfactory
hallucinations, which can, in some instances be related to an
aura from a seizure.
- A lumbar puncture analysis of your CSF (cerebrospinal fluid)
showed no signs of infection.
- We obtained an MRI of your brain with and without contrast,
and this did not identify any obvious abnormalities. The final
report from the neuroradiologist is pending at this time, but
there were no abnormal findings to suggest a tumor, bleeding or
infection.
- Several hours of EEG recording did not identify any
"interictal epileptiform discharges" - markers of electrical
excitability that can occur in patients with epilepsy (a
disorder marked by recurrent seizures).
It is important that you continue to follow up with your
psychiatrist. We will make the necessary arrangements to see you
in our neurology clinics, so that we can continue to follow you.
MEDICATION CHANGES:
- We changed GABAPENTIN to 900mg THRICE DAILY
- We provided you with a few pills of tramadol to help with
headache | Mr. ___ was admitted to the general neurology service. He
presented with a new daily headache associated with bifacial
tingling, together with multiple new olfactory hallucinations of
a smell of "sweet bacon/syrup", as well as reports from him of
generalized convulsions that his sister reported to him. The
precise semiology of the seizures themselves is difficult to
know for sure - he described an abrupt loss of consciousness
with eye fluttering and "eyes rolled back", together with
bilateral arm and leg tonic stiffening. There was no urinary
incontinence, tongue biting or post ictal somnolence.
An LP in the ED found 8 WBCs on tube 1, but only 1 WBC on tube
2. Protein, glucose and RBCs were not abnormal, perhaps slightly
elevated RBCs due to a traumatic LP. The patient was empirically
initiated on acyclovir therapy, and on his first examination on
the following day, he was demonstrating significant neck
stiffness and light sensitivity. He was not encephalopathic and
did not have any other focal findings on examination. His
headache was difficult to treat, and while on suboxone therapy,
morphine provided no relief. Since he was unhappy with our
management of his headache pain, he left against medical advice.
Psychiatry was involved, as earlier in the night, he had made
some suicidal ideations and required a sitter. By the time he
left AMA, he was judged to have capacity (see notes from
psychiatry).
He actually returned to the hospital wards about 1 hour later.
He reported that when he walked to the train station, he once
again smelt an aura and was "scared". He agreed to staying on
our terms, and was very apologetic and remorseful. We obtained >
20h of EEG (approximately) which identified no interictal
epileptiform discharges. He did have two generalized convulsions
while in house, and only witnessed by the sitter, but neither
was while he was on EEG.
We also obtained an MRI of his brain with and without contrast.
While this was motion degraded, it did not identify any
significant abnormalities. Ultimately, it is not clear whether
these events were seizures or not. He was deemed to not have any
type of meningitic process, and the 8 WBCs in the first tube was
likely a consequence of a traumatic tap. In his particular case,
risk factors for pseudoseizures are numerous, as are risk
factors for epileptic seizures.
We decided to increase his gabapentin to 900mg TID, as it may
provide better relief of his mood symptoms, and also bring up
this medication to more antiepileptic medication doses. At this
time, we are in the midst of organizing neurology follow up for
him. He will have to follow up with his own psychiatrist. He was
discharged with a prescription for a higher dose of gabapentin,
together with tramadol and his home medication of ativan. | 178 | 469 |
13262414-DS-10 | 22,776,081 | Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic cat scan revealed uncomplicated
appendicitis. WBC was elevated at 15. The patient underwent
laparoscopic appendectomy, which went well without complication
(reader referred to the Operative Note for details). After a
brief, uneventful stay in the recovery room, the patient arrived
on the floor tolerating regular diet, on IV fluids, and
initravenous pain medication. The patient was hemodynamically
stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirrometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. She has been instructed to complete a 1 day course
of antibiotics for finding of gangrenous appendix. The patient
was discharged home without services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 313 | 225 |
12062149-DS-25 | 26,391,520 | Dear Ms. ___,
You were admitted to the hospital because the right half of your
body suddenly became numb, and this change in sensation
persisted. You told us this was very similar to previous MS
flares you have had in the past, which responded well to
steroids. We treated you with IV steroids for 3 days. You
responded immediately to steroids, with total return of all your
sensation. We also repeated your brain MRI, which did not show
any new active MS lesions.
We continued all your home medications. We discussed with you
that we think you are taking Imitrex too often, as you should
not take it more than 2 times per week because it can cause
rebound headaches. You understood this, but want to continue to
take it daily.
We suggest following up with your primary care doctor ___ Dr.
___ as below.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ Neurology Team | ___ is a ___ year old right handed woman
with a past medical history of relapsing remitting multiple
sclerosis who presented for right sided numbness/sensory change.
#Right sided numbness, concern for MS flare
On presentation, patient had decreased sensation on the right
side of the body, which she said felt like 50% on the right
compared to the left. On admission, the decision was made to
start steroids as she has had similar presentations in the past
(last ___ which have responded well to steroids. We started
methylprednisolone 1g Qday on ___, and continued through ___.
She tolerated steroids with no adverse effects. While on
steroids, her fingersticks were monitored and she was put on
insulin sliding scale, and she was given protonix for GI
prophylaxis. Patient reported that the "instant" steroids were
started her sensation returned back to normal. We obtained an
MRI brain which did not demonstrate an acute demyelinating
lesion. While her MRI did not show any active demyelinating
lesions, it is certainly possible that she could have a small
lesion that MRI is not picking up. It is unusual however that
she would have such vast sensory involvement without any lesion
on MRI. However, because of her positive response to steroids,
we decided to complete the 3 days of steroids, followed by
discharge home with follow up with her outpatient neurologist
Dr. ___.
We also continued her home MS medication ___, and she
received her weekly dose on ___. We also continued her vitamin
D, calcium, and vitamin C.
___
-Creatinine elevated to 1.3 on this admission, and this resolved
with fluids.
#Pain, chronic migraines
Patient has chronic migraines which she has struggled with for
years. She reports that at home she takes Imitrex daily. We
discussed with her that this medication should not be taken more
than 2 times per week as it can lead to rebound headaches. She
said she understands this, but she has discussed this medication
with her neurologist in the past and is comfortable with this
risks of taking it daily. We agreed to continue her home regimen
for migraine pain. We continued her home Pregabalin 150 mg PO/NG
TID, Topiramate (Topamax) 100 mg PO/NG BID, Acetaminophen 650 mg
PO/NG Q6H:PRN Headache, Sumatriptan Succinate 50 mg PO DAILY:PRN
migraine, Continue Ondansetron 4 mg PO/NG TID:PRN Nausea,
Continue Cyclobenzaprine 5 mg PO/NG TID:PRN Muscle spasms,
Continue HydrOXYzine 25 mg PO/NG Q6H:PRN Anxiety, Continue
OxyCODONE (Immediate Release) 5 mg PO/NG Q6H:PRN Pain.
#Ophthalmologic
Continued home Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE QID
(patient does not know indication)
#Dermatologic
Continued home Tretinoin 0.05% Cream 1 Appl TP DAILY Acne
#HSV, genital
At home, patient takes valacyclovir. This medication was not
available on formulary, so substituting with equivalent dose per
pharmacy acyclovir. This regimen is unusual for genital HSV
prophylaxis, so we recommended following up with her primary
care doctor.
#Transitional Issues
[ ] Follow up with Dr. ___
[ ] Follow up with primary care doctor regarding HSV prophylaxis
[ ] Discuss Imitrex dose | 162 | 488 |
14789609-DS-20 | 24,011,726 | Dear Mr. ___,
We admitted you to our inpatient neurology stroke service due to
your symptoms of weakness and speech changes, which we think
were most likely due to transient blockage of small blood
vessels deep inside your brain, known as a "TIA." You have
several risk factors for recurrent TIAs and ischemic strokes,
and we need to do better in mitigating these to reduce your
risk. In order to prevent future strokes, as follows:
1. Your blood sugar is too high. You must start taking the
insulin medication (Levemir) that your ___ diabetologist
prescribed
2. Your LDL cholesterol (104) is too high for a diabetic
(should be less than 70). Start taking double the dose of your
statin medication (pravastatin, now take 80 mg increased from
40).
3. Re-start your aspirin (325 mg). This medication reduces the
ability of your platelets to form clots, in turn reducing your
risk for stroke.
Please take your other medications as prescribed, and follow up
with Dr. ___ neurology) and your primary care
physician as listed below. | 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
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 104) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: started on pravastatin 80 mg as
patient had been on pravastatin previously]
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 (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
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 - (x) N/A
===========================
Mr. ___ was admitted to the hospital for stroke work up
given his symptoms. His CTA showed minor atherosclerotic disease
involving the MCA. Brain MRI did not show any acute stroke,
though there was evidence of some chronic hypertensive disease
as well as a FLAIR abnormality in pons. This episode was thought
to be a transient ischemic attack.
His stroke risk work up showed poorly controlled diabetes
(fingersticks in 200s while in house), hypertension and
hyperlipidemia (LDL of 104 on pravastatin 40 mg daily).
He was instructed to start on Levemir as discussed with his
___ physician previously, in addition to his PO diabetes
medications. His pravastatin was increased to 80 mg daily and he
was also started on full dose aspirin, as he had stopped his
aspirin previously on his own. He was instructed to take all of
his medications as prescribed and to follow up with his PCP,
___ and neurology. | 175 | 387 |
19026613-DS-11 | 21,839,111 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were brought into the hospital due to concerns for a blood
clot in your lungs.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have a pulmonary embolism. We started you on
a blood thinner to help treat your blood clot.
- Our neurologists evaluated you given your reports of weakness.
CT scans and MRI of your ___ and neck did not show any
dangerous causes of your symptoms.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please take 5mg of Warfarin tomorrow (___). The
___ clinic will let you know about your subsequent
doses.
We wish you the best!
Sincerely,
Your ___ Team | ___ year old female with recent delivery of single intrauterine
pregnancy at 33 weeks and 0 days gestational age via cesarean
section (___) with severe preeclampsia (by headache and
chronic hypertension), history of NAIT on IVIG, HAs,
hypothyroidism, PCOS, obesity who presented with PE and
ecchymosis to right ring finger.
ACUTE ISSUES:
=============
# Segmental Pulmonary Embolism
Presented with chest tightness and shortness of breath and
underwent CTA chest notable for segmental pulmonary embolism,
without evidence of RV strain (hemodynamically stable, trop <
0.01, BNP 55, TTE mildly dilated RV w/ normal RV free wall
motion). She has multiple risk factors for PE including
immobilization during recent hospitalization, surgical procedure
(C-section with BSO), and pregnancy itself which is a
thrombogenic state. Coags otherwise within normal limits on
admission, and extensive coagulopathy workup has been relatively
unremarkable (see heme note ___. Originally on IV heparin,
transitioned to lovenox, with plan for bridge to Warfarin (given
DOACs not well studied in setting of breast feeding).
[] Patient is being discharged with lovenox, with a plan to
transition to warfarin for a total of ___ months of treatment.
She will follow-up with her hematologist to determine the
ultimate length of therapy.
[] Patient will have her INR monitored by the ___
clinic here at ___. She was instructed to
take 5mg again on ___, and have an INR checked that morning.
# R-sided weakness
Per patient, weakness in R leg started in the ambulance ride
down from ___. The following morning, patient continuing to
complain of R leg weakness and now with R arm weakness in both
flexors, extensors, and IO muscles. Hyperreflexia in RUE as well
which could indicate a cervical radiculopathy. Positive Hoover
sign in R leg and suspect R leg weakness may be functional. Per
neuro, recommended MRI ___ and ___ to r/o stroke or
radiculopathy, both of which were unremarkable. Given her neuro
exam was not concerning for an upper motor neuron dysfunction,
she was cleared for neuro to follow-up with her outpatient
provider.
[] Patient should continue to follow-up with her neurologist to
evaluate her symptoms of weakness further.
# Finger ecchymoses
No history of injury to her hand, now reporting pain and
bruising over her R ___ digit at her finger pad over her middle
phalanx. Has full ROM and sensation. Normal radial and ulnar
pulses. Unclear etiology, likely venous hemorrhage per vascular.
RUE Doppler was negative for DVT. Atypical presentation for
vasculitis but consulted rheum given puzzling presentation and
history, who did not feel her presentation represented a
rheumatologic disease. Resolved by time of discharge.
[] ___ and ___ were still pending at time of discharge. There
is low suspicion these will result positive, but we will
continue to monitor/follow-up.
# Headache/Vision Changes
History of migraine headaches with some blurry vision with "dark
spots". Has been seen by neurology in the past and ddx with
likely IVIG related aseptic meningitis vs. severe complex
HAs/migraines. In ___ MRI/MRA of ___ revealed no e/o dural
venous sinus thrombosis and was otherwise wnl. CT ___, CTA, and
CTV here are all reassuringly negative. Most likely developed
headache in the setting of orthostasis/hypotension vs. migraine.
Per neuro, exam is inconsistent with a central vision process.
Resolved by time of discharged.
CHRONIC ISSUES
===============
# Hypothyroidism
- Continued home levothyroxine
# GERD
- Continued home omeprazole
TRANSITIONAL ISSUES
===================
[] Patient is being discharged with lovenox, with a plan to
transition to warfarin for a total of ___ months of treatment.
She will follow-up with her hematologist to determine the
ultimate length of therapy.
[] Patient will have her INR monitored by the ___
clinic here at ___. She was instructed to
take 5mg again on ___, and have an INR checked that morning.
[] Patient should continue to follow-up with her neurologist to
evaluate her symptoms of weakness further.
[] ___ and ___ were still pending at time of discharge and
returned negative. | 160 | 643 |
10877695-DS-27 | 21,386,767 | Dear Ms. ___,
It was a pleasure to care for you at ___
___. Please find detailed discharge instructions
below:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you had acutely worsened nausea,
vomiting and abdominal pain.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- You were treated supportively, with IV fluids, pain
management, and anti-nausea medications. Your symptoms gradually
improved.
- You were able to slowly tolerate a diet, advancing to a
regular diet by discharge.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please make a follow up appointment with you primary care
provider (Dr. ___: ___ ), scheduled for
within 1 week from discharge.
- Please make a follow up with your gastroenterologist (Dr.
___: ___, scheduled for 1 month from
discharge.
- Please follow up for esophageal manometry (testing for
motility function of your esophagus), as scheduled.
- Please start and complete antibiotic treatment for h pylori,
the bacterial infection in your stomach. You will take
clarithromycin and metronidazole for a total of 14 days.
We wish you the best!
- Your ___ treatment team | ==================
BRIEF SUMMARY
==================
___ year old female with history of achalasia, hiatal hernia s/p
repair & fundoplication ___, recent EGD with H pylori (not
on treatment), GERD, depression, and asthma, who is presenting
with acute on chronic nausea, vomiting, and abdominal pain, with
inability to take PO. She was treated supportively and her diet
was advanced as tolerated. Barium swallow inpatient was
unremarkable. By discharge, she was able to tolerate a regular
diet with improvement in her symptoms. She was instructed to
start on triple therapy for h pylori treatment upon discharge.
========================
PROBLEM-BASED SUMMARY
======================== | 185 | 93 |
15981258-DS-21 | 29,448,208 | Eat only full liquid diet until you follow up with OMFS in
clinic. Take tylenol and motrin for pain control. If this does
not work, take the narcotic pain medications you were
prescribed. Please do not drive, operate heavy machinery or make
decisions while taking narcotic pain medication. Please take a
stool softener twice a day while taking pain medication. Get out
of bed to ambulate as much as possible.
Please call the ___ clinic if you experience any of
the following: Fever greater than 101
Redness that is spreading
Pain not adequately relieved with medication
Drainage from wound
Opening of incision
Nausea and vomiting
Shortness of breath
Pain with breathing
Coughing up blood
Wheezing | The patient presented to the ED after being punched in the face.
His trauma was performed in the standard fashion. Based on his
mechanism of injury and appropriate imaging, he was found to
have bilateral mandibular fractures. OMFS was consulted and he
was taken to the OR on ___ for ORIF of bilateral
mandibles. The procedure occured without complication. For more
information about the procedure, please refer to the operative
report. Tertiary survey was performed and revealed no additional
injuries. His diet was advanced to a full liquid diet per OMFS
recommendations. He was discharged home on HD 3. At the time of
dischage, he was out of bed to ambulate, urinating and stooling
normally, and pain was controlled with oral pain mediciation. he
was discharged with plan to follow up with OMFS in clinic in 2
weeks. | 106 | 139 |
12604466-DS-2 | 28,165,275 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
in the hospital because you abdominal pain. We preformed blood
tests, a CT scan of you abdomen and an ultrasound to look for
causes of this and think that the most like cause of your pain
was mild pancreatitis. You were initially treated with not
eating and iv fluids and medications to treat your pain. You
were able to eat and your pain improved so you were discharged
home.
Please follow up with your primary care doctor as below:
Please continue taking all of your home medications including
your metformin and glyburide. | ___ with diabetes, HCV who presents with abdominal pain and poor
PO intake and found to have elevated lipase, concerning for
pancreatitis.
.
# Abdominal Pain: Consistant with pancreatitis given radiation,
association with food, elevated lipase. BISAP score = 0. EKG
without signs of ischemia. CT abd/pelvis wnl. RUQ us without
evidance of gallstones. He denies alcahol abuse. His pain
resolved well with bowel rest and IVF. His diet was advanced on
HD2 without associated nausea, vomiting or abdominal pain. He
had BM2x which were liquidy after receiving senna and colase for
his constipation. He was written for tylenol and oxycodone for
pain control but did not require this. He was discharged home to
pcp ___.
.
# Diabetes: Poor compliance with home medications. A1c
uncontrolled. His home medications were held and he was place on
a humalog sliding scale. BS in house in 100s and low 200s. He
was given prescriptions for his home antihyperglycemics since he
ran out of these a few weeks before admission. He will contiue
to work on his diabetes regimen with his outpatient provider.
.
# Depression: stable. He was continued on his home sertraline. | 105 | 189 |
13658136-DS-8 | 26,092,388 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
vomiting and diarrhea.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were found to have damage to your liver which was likely
due to drinking too much alcohol
- Your liver damage caused damage to your kidneys. Your kidney
function got better with medications.
- You were treated for pneumonia.
- You were very malnourished.
- You improved and will continue with physical rehab.
- Your liver is very sick, and the damage is not reversible.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds
- Seek medical attention if you have new or concerning
symptoms.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
___ with history of alcohol use disorder, complicated by
alcoholic hepatitis and neuropathy, and recurrent
pyelonephritis, who initially presented to ___ with
nausea/vomiting/diarrhea and lethargy, transferred to ___ for
further evaluation/management of acute liver injury thought to
represent alcoholic hepatitis.
ACUTE ISSUES
============
# Acute Liver Injury
# Alcoholic Hepatitis
# Cirrhosis
Patient presented with n/v/d x 2 weeks, hyperbilirubinemia
concerning for alcoholic hepatitis. ___ score 157.4 on
admission, MELD-Na 46. AST/ALT ratio was >2:1 and MCV of 111
consistent with ongoing alcohol use, although it was unclear if
patient had cirrhosis. Viral serologies were negative.
Autoimmune serologies remarkable for ___ positive with low
titer, although nonspecific and not concerning for autoimmune
hepatitis given low IgG/IgM titers. Steroids initially held in
the setting of a possible GI bleed. Initiated for short trial
but then dc'd in the setting of HRS and infection. MELD improved
to 22, bilirubin improved from 24 on admission to 10 upon
discharge. clinically diagnosed with cirrhosis.
# Type 1 Hepatorenal syndrome, resolving
# Pre-renal azotemia
Admission Cr 4.8 from baseline 0.6, with improvement after IVF.
Initially thought likely pre-renal given volume loss from v/d,
poor PO intake and response to IVF. However, Cr again increased
to peak 1.9, this time thought to be due to HRS. Improved to Cr
0.9 on midodrine and octreotide.
# Hypoxemia
# Pleural effusion
# Hepatopulmonary syndrome
# LUL Pneumonia
Oxygen saturation 88-92% on admission, CXR with pulmonary edema,
requiring prn 40 IV Lasix boluses in ICU. Respiratory status
worsened later in hospital course with patient endorsing
platypnea and chest CT notable for PNA and large pleural
effusion. Echo with bubble study was performed which was
consistent with HPS. IP was consulted for paracentesis but
patient declined procedure. She was initially treated with
Ceftazidime (___), became febrile again with
worsening respiratory distress after narrowing to ceftriaxone. A
new 7 day course of ceftaz was started on ___ with clinical
improvement, due to end ___. She was started on furosemide 20
daily and spironolactone 50 daily prior to discharge.
# Malnutrition
# Hypophosphatemia
# Hypomangesemia
# Hypokalemia
Dobhoff was placed and tube feeds were started for nutrition
with a goal for 3000kcal/day, became dislodged x2. Given
___ initial hesitancy and likely inability to receive tube
feeds at SNF, feeding tube was not replaced and she was
discharged off tube feeds. Required aggressive electrolyte
repletion an discharged on standing 400 Mg oxide daily, 40 PO
KCl daily, 1 packet neutraphos daily. Will require checking
lytes and adjusting at rehab.
# Hypotension, resolved
Initially required levophed for hypotension despite adequate
fluid resuscitation. Likely vasodilation in setting of alcoholic
hepatitis. Initial concern for GI bleed but no evidence of
variceal bleed on EGD. TTE w hyperdynamic circulation and mild
to mod TR, but no clear cardiogenic etiology of hypotension.
Midodrine started for HRS as above, increased to 15 TID upon
discharge.
# Anemia
# Concern for GI bleed
Hgb 9.4 on admission from 11.1, and remained stable s/p FFP x2
in ___. The patient reported episodes of dark stool prior to
admission; however, no evidence of overt bleeding during
admission and no clear source on EGD. She required 2U PRBC on
day of admission, none further. H pylori antigen ordered given
concern for gastritis and was negative. Further downtrend in Hgb
thought to be due to phlebotomy and infection; Hgb 7.6 upon
discharge with no clinical signs of significant bleeding.
# Alcohol use disorder
Long history of alcohol abuse, complicated by alcoholic
hepatitis. Denied history of withdrawal seizures. Last drink
evening of ___, at that time drinking about one bottle of wine
per night. Started on CIWA protocol with diazepam. Given PO
thiamine, folate as well as IV vit K x3 days given elevated INR.
SW, ___, nutrition were consulted. Reports desire to remain
sober.
#Depression:
withdrawn at times during hospitalization. started on
mirtazapine ___ (evening).
TRANSITIONAL ISSUES
===================
Discharge weight: 64.3 kg
Discharge Cr: 0.9
Discharge MELD: 22
[] Continue to evaluate goals of care. Patient expressed desire
to work in rehab to improve her quality of life at home.
ultimately her goal is to spend time with family/grandchildren,
be home, and have some independence. She will need a caretaker
for most if not all of the day. She and her family will continue
to evaluate her goals of care in the setting of her overall poor
prognosis, which was discussed this admission.
[] please recheck complete metabolic panel every other day.
Replete electrolytes (especially K, Mg, P) as needed. Adjust
standing KCl, MgO, neutra-phos as needed.
[] please check CBC and LFTs twice weekly. goal Hgb >7. If LFTs
worsening would recommend transfer back to ___ ___
[] on 7 day course of IV Ceftazidime for HAP due to finish ___
[] if short of breath consider lying flat (has hepatopulmonary
syndrome), 40 IV Lasix, or nebulizers
[] clinically diagnosed with cirrhosis this admission. should
follow up in ___ Liver Clinic within 2 weeks
[] currently not transplant candidate due to active alcohol use
prior to admission. patient has expressed desire to remain sober
[] Social work service discussed and provided pt/family with
resources for relapse prevention
[] started on midodrine for hepatorenal syndrome. please monitor
blood pressure closely
[] please actively encourage nutritional supplements (Ensure
TID). Consider feeding tube if losing weight.
[] started on mirtazapine for lack of appetite and suspected
depression
[] please check QTc on ___. If >500 please check again on
___. Please limit QTc prolonging medications such as
anti-emetics. If worsening consider dc'ing mirtazapine, though
believe this is unlikely to have significant effect on QTc in
moderate doses
Code status: DNR/DNI
HCP: niece ___ ___. alternate: son ___
___ ___ | 197 | 905 |
12736635-DS-22 | 20,750,159 | Dear ___,
___ was a pleasure taking care of you durign your recent
admission to ___. You were admited
for confusion, and the level of calcium in your blood was found
to be high. We treated you with fluids and medications to
reduce your calcium levels and your confusion improved. We also
performed tests to look at the lymph nodes and glands in your
neck. You do have a small nodule in your thyroid which you can
have your primary care doctor. | Patient is an ___ female with history of diabetes type
2, dementia, depression and s/p CVA with residual right leg
weakness, who comes to ED after referral from her PCP for
increased weakness, dehydration, gait instability and confusion,
found to be hypercalcemic.
# Hypercalcemia: likely the cause of her worsening of her mental
status in the setting of baseline dementia. Other symptoms
reported by family were consistent with hypercalcemia including:
constipation, decreased appetite, weight loss, dehydration, and
weakness. Hydration was begun in the ED to a total of 3L IVF,
and aggressive hydration was continued on the floor with good
resolution of patient's hypercalcemia and return of mental
status to baseline per family. Electrolytes including Phos,
Mag, K were repleted as needed. Mag and Phos were quite low on
admission as was PTH suggesting a primary hypercalcemia.
Endocrine consult was placed and it was felt that most likely
cause of patient's hypercalcemia was malignancy vs.
sarcoid/granulomatous disease. Patient went for CT Torso with
contrast on ___ showing multiple nodules in the thyroid,
with a large dominant nodule in the left lobe of the thyroid
measuring over 4 cm with internal calcification. From prior
records it was found that the she had a biopsy of a throid
nodule in the past a ___ that was diagnosed as multi
nodulular goiter. On physical exam the patient has left
posterior cervical lymphadenopathy that was not appreciated on
US or CT scan, and was thus not amenable to biopsy. Of note,
the cause of her hypercalcemia remains unclear; calcium levels
should be monitored weekly as an outpatient. HCTZ was d/c'ed.
PTHrp pending at discharge and well need to be followed up.
# ___: patient's creatinine on presentation 1.3, which is
elevated from baseline of ___, which is likely related to
hypercalcemia causing polyuria, dehydration. HCTZ and Metformin
were held. With fluids patient's creatinine returned to
baseline (0.9)).
# Weakness: also likely related hypercalcemia and some
deconditioning. ___ saw and evaluated patient, who would likely
benefit from some rehabilitation post discharge.
# Dementia: patient has baseline dementia (Alzheimer's type)
but per family report has increasing decline in function over
last couple of months. CT on admission showed no acute changes,
encephalomalacia in the left frontoparietal region, likely
chronic. Namenda was continued while patient was hospitalized.
Per family, with resolution of hypercalcemia, patient's mental
status returned to baseline.
Chronic Issues:
# DM: Last HbA1c 6.4 on ___, Metformin was held while
inpatient and patient was well controlled on SSI. On discharge
she was restarted on her home dose of metformin.
# HTN: Continued Verapamil 240mg daily and restarted Losartan
100mg daily once patient was rehydrated. Home HCTZ was
discontinued, as this could contribute to hypercalcemia. Her
pressures remained stable on losartan and verapamil alone.
# HLD: continued home atorvastatin | 86 | 478 |
18614713-DS-10 | 27,479,154 | Dear ___,
___ were admitted to the Neurology Service with a prolonged
seizure event consistent of right-sided twitching. When ___
arrived to the Emergency Room ___ were given medications to
prevent the seizure (Ativan and Dilantin). Your labs and head
CT showed no acute pathology. We reviewed your records and
believe that the seizure may have been triggered by underdosing
of KEPPRA. We treated ___ with 2000mg TWICE DAILY while
hospitalized and ___ tolerated this well.
Although ___ were quite sleepy and confused after the seizure,
your mental status improved over 2 days, essentially at baseline
upon discharge. ___ should remain on KEPPRA ___ mg twice daily
and LACOSAMIDE 200mg twice daily for seizure control.
Please follow up with Dr. ___ in Neurology
___ | Ms. ___ is a ___ yo woman with h/o left temporal IPH related
to cocaine use, with resultant seizure disorder, who presented
to the ED with focal motor status involving the right arm and
abdomen, which is consistent with her past seizures. No obvious
trigger, although she may not have been taking her levetiracetam
at home at the prescribed dosage correctly (2000mg BID). Seizure
activity here was aborted with lorazepam 4 mg total and
fosphenytoin load. She had post-ictal lethargy in the immediate
aftermath of the seizure, but mental status improved and she had
no further seizures. She was discharged to home at her
pre-admission baseline on ___.
Outpatient: Continue home Vimpat 200mg BID amd prescribed Keppra
dose of ___ mg bid
CT Head
There is no intra-axial or extra-axial hemorrhage, edema, shift
of normally midline structures, or evidence of acute major
vascular territorial infarction. Encephalomalacia within the
left temporal lobe likely is from a prior left middle cerebral
artery territory infarct. There is associated ex vacuo
dilatation of the temporal horn of the left lateral ventricle.
Subcentimeter hypodensities in the bilateral basal ganglia may
represent either chronic lacunes or ___ spaces. There
is a mucous retention cyst in the right maxillary sinus.
Deformity of the left lamina papyracea likely reflects prior
trauma. Mastoid air cells and middle ear cavities are well
aerated. Prior craniotomy site is seen in the left calvarium.
IMPRESSION:
No acute intracranial process. Encephalomalacia in the left
temporal lobe, likely from remote infarction. | 127 | 240 |
19005698-DS-9 | 27,491,245 | Dear ___,
You were hospitalized due to symptoms of left face and arm
weakness resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High blood pressure
- High cholesterol
We are changing your medications as follows:
- Starting atorvastatin
- Starting aspirin
- Starting low dose oxycodone for bad back pain
- Quetiapine 25 mg QHS
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
___ is an ___ year old woman with a past medical history
of peripheral neuropathy, known gait instability, severe hearing
loss, status post cochlear surgery for Ménière's disease with
resulting disequilibrium who presented with acute left face and
arm weakness with a last known well ___.
Her exam is notable for a subtle left facial droop, dysarthria,
left arm weakness and extensor plantar response on the right.
CTA with stenotic R M1, but no LVO and unchanged from prior. No
tPA as she was out of the window, no thrombectomy indicated
given no LVO.
Unable to get MRI due to cochlear implants. Repeat CTH showed
evolving right basal ganglia infarct. Somewhat too large for a
lacune. TTE was unremarkable. Most likely etiology is small
vessel disease but cannot rule out cardioembolism. Therefore,
patient discharged with Ziopatch to monitor for occult atrial
fibrillation. | 299 | 142 |
11710824-DS-10 | 20,815,170 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and found to have an infection in your
gallbladder. You were taken to the operating room and had your
gallbladder removed laparoscopically.
You are now doing better, tolerating a regular diet, pain is
better controlled on oral medications, and you are ready to be
discharged home to continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water. | ___ is a ___ who was admitted on ___ under the
acute care surgery service for management of her acute
cholecystitis. She was taken to the operating room and underwent
a laparoscopic cholecystectomy. Please see operative report for
details of this procedure. She tolerated the procedure well and
was extubated upon completion. She was subsequently taken to the
PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ (POD1) to regular, which she tolerated without abdominal
pain, nausea, or vomiting. She was voiding adequate amounts of
urine without difficulty. She was encouraged to mobilize out of
bed and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.On POD1,
she was discharged home with scheduled follow up in ___ clinic. | 839 | 176 |
15080981-DS-35 | 24,418,183 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
=======================================
- You were not feeling well, and you were found to have a
urinary tract infection and bacteria in your blood at your
facility.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
=======================================
- You were started on IV daptomycin and IV meropenem.
- The cultures showed proteus and klebsiella which are sensitive
to ertapenem
- A CT scan showed stable stones in your kidneys
- Infectious disease was called, and said -
WHAT SHOULD I DO WHEN I LEAVE IN THE HOSPITAL?
================================================
- complete your course of antibiotics
- follow-up with urology as an outpatient
- continue to receive treatment for your pressure ulcers
WHAT ARE REASONS TO RETURN TO THE HOSPITAL?
================================================
- fevers, low blood pressure, tachycardia or lethargy could
signal a new infection
We wish you the best.
Warmly,
Your ___ Team | Mr. ___ is a ___ year old man with debilitating seronegative
arthritis (bedbound), chronic PVT/PE, prior C diff infection,
and multiple UTIs in the setting of nephrolithiasis, and
bacteremias with multiple organisms, who presents from his
facility with urinary tract infection completing course of
ertapenem on ___.
ACTIVE ISSUES
#Proteus/Klebsiella UTI: Per facility proteus UTI. Sensitive to
cefepime, but pharmacy recommended meropenem given prior
sensitivities and risk of resistance. Now UCx from ___ does
have klebsiella which would be susceptible to meropenem or
ertapenem. CT with stable stone burden will pursue outpatient
urology follow-up. Infectious Disease team was consulted and
agreed with above. Meropenem day 1 of ___ = ___ to complete
ertapenem ___.
CHRONIC ISSUES
#History of afib: Patient has a documented history of afib, but
currently sinus and
EKG ___ in sinus. History of this per chart review at least
was ___ when infected. CHADVASC2 ___. Held home
metoprolol 12.5mg BID, would consider restarting as outpatient.
Patient not currently on anticoagulation.
#History of DVT: Patient has a history LUE DVT ___ (unclear
if line
associated), ___ line associated LUE DVT, RLE DVT ___, and
he previously was on lovenox. Per his facility, this was
recently discontinued and he is only on aspirin. However, left
arm does appear to be greater than right but no DVT on US ___.
Would continue SC heparin as outpatient.
#Pressure ulcer: pre-existing multiple open partial thickness
ulcers with one larger full thickness ulcer distally ( approx. 4
x 2 cm ) total area approx. 12 x 12 cm. Patient has declined
full exam. Patient will follow up with outpatient wound clinic
after discharge back to ___.
#Seronegative arthritis: continued home prednisone 20 mg daily,
with Bactrim for PCP ___. Pain control with home gabapentin,
Dilaudid, methadone, prednisone.
#Major depression disorder
#Anxiety: continued home quetiapine and clonazepam
#Normocytic anemia: Hb at baseline of ___, suspect from chronic
disease and iron deficiency (transferrin sat <20%), continue
home iron.
# coagulase negative bacteremia: initially started on daptomycin
however after consultation with Infectious Disease team believed
to be contaminant especially given two different strains.
# right ear hearing loss: continue ___ drops, underwent
bedside irrigation ___.
TRANSITIONAL ISSUES
L picc 55 cm
- ertapenem day 1 of ten = ___ to end ___ for complicated
UTI
- continue outpatient urology follow-up for stable stone burden
- underwent right ear bedside irrigation and ___ need
repeat as outpatient
- would re-evaluate need for outpatient beta-blockade for
history of provoked atrial fibrillation
- would continue wound care for pressure ulcers
- Would continue SC heparin or lovenox 40 daily as outpatient
#CODE: Full (confirmed)
#CONTACT: Patient's pastor, Father ___ (___) | 141 | 436 |
11967769-DS-13 | 29,064,888 | Dear Mr. ___,
You were admitted to ___ and
underwent right-sided carotid endarterectomy. You have now
recovered from surgery and are ready to be discharged. Please
follow the instructions below to continue your recovery:
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite
will return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over 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
over the area
CALL THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions | Patient was admitted as a transfer to ___
___ as a transfer for code stroke. With left hand
and arm weakness, he was admitted to the neurology service and
started on heparin drip vascular surgery was consulted for
possible carotid endarterectomy. He underwent a CTA that
demonstrated 50% stenosis of the right internal carotid artery.
He is brought to the operating room and underwent a right
carotid endarterectomy. For details of the procedure please see
the surgeon's operative note. Postoperatively the patient was
unable to move his left upper extremity and had a left facial
droop he was sent for a stat CT angiogram which showed a
dissection of the right carotid artery.
The following morning the patient had persistent weakness of his
left upper extremity, neurology was consulted for new onset
weakness of left upper extremity in the setting of post
operative dissection. He was started on a heparin drip and an
MRI brain was performed which showed which progressed in size
and number compared to the prior exam stable punctate infarcts
in the right cerebral hemisphere, there were also new small
acute infarcts in the left parietal lobe. There is a small area
of hemorrhagic conversion in the right frontal lobe near the
vertex.
The patient had persistent neck pain at his occipital skull base
which was likely secondary to his right carotid dissection he
was started on gabapentin which relieved his pain. He was
titrated up to gabapentin 300 3 times daily prior to discharge
which was a satisfactory regimen for him.
The patient's heparin drip was discontinued and he was
transitioned back to aspirin for antiplatelet.
The patient worked with physical therapy who recommended
discharge to acute rehab. Throughout his hospitalization he
began to steadily increase his mobility in his left upper
extremity and his facial droop had resolved.
Prior to discharge the patient was tolerating a regular diet, he
was voiding without difficulty. He was ambulating
independently, his pain was well-controlled on oral pain
medications. He was discharged in stable condition to ___
___ facility so he can continue to work on his postoperative
recovery following his stroke. He will follow-up with Dr.
___ in clinic in 1 month's time. | 454 | 371 |
16658682-DS-8 | 26,931,759 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because of your abdominal
pain, nausea and vomiting. We think these symptoms are from a
flare of your Crohn's disease. Your symptoms improved after
giving you fluids, medications to treat your nausea, bowel rest
and IV steroids. You were given an infusion of remicade,
however, you developed an infusion reaction so we had to stop
the infusion. You required a different medication to treat your
Chron's disease since you had a reaction to remicade.
Therefore, you were started on humira. You will need to
continue your oral steroid as prescribed. You will follow-up
with Dr. ___ to discuss titrating down your steroid dose. You
were started on vitamin D and calcium to protect your bones
while you are on prednisone. You were also started on bactrim
to prevent infections while you are on steroids. You were
started on TPN for your nutrition.
Also of note, you have iron deficiency anemia. You may need to
be started on iron in the future after your abdominal pain has
improved.
Sincerely,
Your ___ team | Mr. ___ is a ___ year old man with Crohn's (diagnosed in
___, presented with disease of the acending colon, terminal
ileum and perianal fistula), on Remicade, admitted with Crohn's
flare.
## CROHN DISEASE FLARE:
The patient received his last dose of remicade of 5mg/kg 3 weeks
prior to admission (received on ___. He had a good initial
response for two weeks following the remicade infusion, but
symptoms worsened over the week preceding his current admission.
On admission, AXR was not convincing for obstruction. His CRP
was elevated to 52 (from 25 on ___ and ESR was 25, but he
was not toxic in appearance. The patient was initially managed
with bowel rest, and IVF. He was not started on steroids since
he clinically looked well. Stool studies, including cdif, were
all negative. The patient received a remicade infusion during
hospitalization but developed an infusion reaction at the
beginning of a 10mg/kg infusion despite being pre-medicated
(received 100mg IV, 1g tylenol, and fexofenadine 180mg po). He
developed heavy chest tightness and palpitations, so the
infusion was stopped. EKG was normal, and he was given benadryl
50mg IV with symptom resolution. He was started on prednisone
40mg (___), then switched to IV solumedrol 20mg Q8H (___).
MRE (on ___ showed involvement of 25cm TI through ascending
and transverse colon. Patient continued to not tolerate
advancement of diet, so he was started on ciprofloxacin/flagyl
and Humira (___). CT scan (___) showed Crohn's involvement
of the terminal ileum extending to the ascending colon with no
evidence of perforation, abscess or fistula. He developed
worsening symptoms, so colonoscopy was performed, which showed
active disease and ulceration from 50cm to cecum and into TI.
Steroids were discontinued (___). Surgical intervention
was recommended given the patient was not responding to medical
management with fluctuating symptoms and severe endoscopy
disease and rising CRP. Colorectal surgery was consulted and
surgical intervention was pursued (___).
## MALNUTRITION:
Patient continued to not tolerated advancement of diet during
entire hospital stay. Nutrition consulted. On ___ was started
on oral elemental diet, but could not tolerate taste. Dobhoff
placed and tube feeding of elemental diet started on ___.
However, patient developed worsening abdominal pain and bloody
bowel movements so tube feeding discontinued. Started TPN
(___).
# Dysphagia:
Patient with throat discomfort and findings on CT scan
concerning for esophagitis. No evidence of thrush on exam. PPI
dosing increased to BID. Started on
Maalox/diphenhydramine/lidocaine 30 mL PO QID PRN throat pain
Throat pain has been improving.
## ANEMIA:
Near previous baseline. Iron studies suggestive anemia of
chronic inflammation with superimposed iron deficiency anemia.
Iron repletion held in setting of GI symptoms. Would recommend
consideration of starting iron oral repletion in the future.
TRANSITIONAL ISSUES
=======================================================
#Will need close outpatient follow-up with gastroenterologist,
Dr. ___
#Needs repeat humira injection 2 weeks after first dose
#Consider iron repletion for iron deficiency anemia once GI
symptoms resolve | 196 | 492 |
14249583-DS-22 | 27,838,676 | Dear Mr. ___,
You were admitted to ___ on ___ with a fever, abdominal
pain, nausea, and vomiting. You had a CT scan at an outside
hospital that was concerning for a small bowel obstruction. You
had a nasogastric tube placed to help decompress your stomach.
You are now tolerating a regular diet, having bowel movements,
and your markers of infection are decreased.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain, fevers,
and vomiting. Admission abdominal/pelvic CT from OSH was not
concerning for a small bowel obstruction but WBC was elevated at
12.5. Given his history of recurrent bowel obstructions and
recent surgery, a nasogastric tube was placed for bowel
decompression. The patient was hemodynamically stable. He was
kept nothing by mouth with IV fluids and was monitored closely
with serial abdominal exams, with the working diagnosis of
gastroenteritis. By HD1, the patient had return of bowel
function and his abdominal pain had resolved. The WBC had
normalized. Diet was progressively advanced as tolerated to a
regular diet with good tolerability. The patient voided without
problem. During this hospitalization, the patient ambulated
early and frequently, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and denied pain.
The patient was discharged home without services. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 246 | 215 |
16126402-DS-23 | 28,245,472 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
========================================
- You were admitted because you had cough, shortness of breath
and increased sputum production.
What happened while I was ___ the hospital?
==============================================
You were started on antibiotics to treat a pneumonia and
started on steroids to treat a COPD exacerbation.
- When your shortness of breath was not improving as expected, a
CT scan of your chest was obtained which showed that you had a
blood clot ___ your lungs (pulmonary embolism).
You were started on a blood thinner (anticoagulant) called
apixaban (Eliquis) to treat your pulmonary embolism.
- An echocardiogram showed that your hypertrophic cardiomyopathy
may be worse. You should follow up with your Cardiologist as an
outpatient (appointment is being made for you).
What should I do after leaving the hospital?
==============================================
- Please take your medications as listed ___ discharge summary
and follow up at the listed appointments.
- Please take doxycycline for 5 more days. You were also started
on apixaban and metoprolol during this admission, please
continue taking these medications at home as directed.
- Please continue to take apixaban 10mg twice a day as listed ___
your dose pack, then reduce dose to 5mg twice a day
- Your lisinopril was stopped given that your blood pressures
were normal.
- Please stop taking NSAIDs (including naproxen) given increased
risk of bleeding while on apixaban.
Thank you for allowing us to be involved ___ your care, we wish
you all the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY
====================
___ yo man with h/o presumed COPD, hypertrophic CMP, h/o
epiglottitis s/p cricothyrotomy s/p decannulation, who presented
with subacute worsening of cough, shortness of breath, and
sputum production and was found to have an atypical pneumonia,
COPD exacerbation, and right middle lobe pulmonary embolism.
TRANSITIONAL ISSUES
====================
[] Bilateral subacute rib fractures: Dexa scan as outpatient
[] Beta glucan pending at time of discharge, unlikely to be
clinically significant
[] F/u resolution of cough and hypoxemia on PNA/COPD
exacerbation and PE treatment
[] Doxycycline 100mg BID for atypical PNA will continue through
___
[] Cardiology follow up of newly severe LVOT gradient, consider
repeat TTE after resolution of PNA and PE
[] Duration of anticoagulation - tentative plan for 6 months
apixaban for provoked PE ___ setting of recent decreased
mobility ___ dyspnea prior to admission). Started loading dose
apixaban on ___, discharged with apixaban 10mg BID to complete
7 day loading course, then 5mg BID.
[] Started Metoprolol succinate 25mg qd given LVOT obstruction
[] Home lisinopril 10mg qd was held given normotension this
admission (SBPs 110s-130s), please continue to assess BPs and
restart as indicated
**Patient was discharged on prednisone taper through ___,
also with bactrim for PJP prophylaxis while on steroids. On team
re-evaluation, the long prednisone taper and bactrim were felt
to be unnecessary. Will contact patient to instruct him not to
take prednisone or bactrim at home. Please confirm this at his
PCP visit on ___. | 255 | 233 |
15211280-DS-25 | 28,345,776 | ___
___ were admitted to the hospital because ___ were vomiting and
___ were very weak. This was because your sugars were too high.
We gave ___ insulin injections and ___ felt back to normal and
were able to eat.
It is VERY important that ___ take insulin every day and check
your sugars. Please call your primary care doctor if ___ are
worried.
Best of luck! | ___ c HTN, HL, DM2, OSA, chronic back pain, pancreatitis, prior
H
pylori a/w worsening fatigue and recurrent vomiting.
W/u relatively unrevealing except mild ___ and ___ TSH and
anemia
of chronic disease.
Presentation attributed to poorly controlled diabetes. With
better management of his diabetes, he felt completely better.
Great energy, good appetite, and no nausea/vomiting/abd pain.
Diabetes managed with help ___ consult service. At
discharge was on Lantus 15 qhs and 3 units with meals. There was
significant concern about comprehension of his insulin and
whether he fully understand how to give insulin. given this we
chose not to d/c him on a sliding scale and just use standing
lantus and Humalog with meals with the thought this could be
added as he becomes more comfortable. Physicians and nurses
spend significant time educating him and we obtained both
lantus/Humalog pens from pharmacy so he could practice with what
he is going home with. d/c his metformin to simplify regimen.
We set up home nursing and a medication check as well as
follow-up on ___ at his primary care practice. ___ offered
to also have diabetes education but they were not available due
to holiday weekend.
# ___: Possibly dehydration/hypovolemia in context of poor PO
intake, NSAID use, glycosuria.
- improved with time
# Abdominal pain
# Nausea
# Chronic pancreatitis:
Pain/vomiting resolved.
# Low TSH level: T4/T3 basically normal, so would have to query
subclinical hyperthyroidism. Symptoms are inconsistent with
hyperthyroidism, though chronic tachycardia for which he was
started on beta blocker is curious, but better today after
hydration.
- outpatient follow-up after clinically stable.
# Microscopic hematuria: He is a lifelong smoker, but abdominal
CT and renal US ___ showed multiple small cysts but no
masses,
and chest CT showed no nodules. Overall, would be surprised if
he
had a urothelial malignancy explaining his symptoms (though he
could certainly have a low grade/early stage lesion and warrants
followup).
- Outpatient followup
# HL: Stable
- hold pravastatin in case could be contributing.
# Tachycardia
- resolved with better diabetes control
# HTN: Holding both metoprolol and losartan, he was
normotensive. Question whether med noncompliance was
contributing.
- stopped metoprolol and losartan at d/c
# Allergic rhinitis: Stable
- Continue Flonase
# Tobacco use:
- Nicotine patch
- Nicotine gum PRN
- encouraged him to quit | 65 | 351 |
11296951-DS-25 | 23,512,517 | Dear Mr. ___,
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital for increased swelling of
your abdomen
- You also were found to have an injury to your kidney
- You were also felt to be somewhat more confused than usual
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- We stuck a needle in your belly and removed some of the excess
fluid
- Your kidney function remained poor, but the kidney doctors
ensured that ___ were not getting worse and that you did not
need dialysis (a machine that takes the place of non-functional
kidneys and filters the blood)
- You were given the medications lactulose and rifaximin to make
sure your liver disease was not making you confused. You were
also given a vitamin called thiamine, in case part of your
confusion was related to chronic alcohol consumption. We got a
CAT scan of your brain, which showed that this may be the case.
WHAT SHOULD I DO UPON LEAVING THE HOSPITAL?
- Take all your medications as prescribed
- Keep all your appointments with your doctors
- Weigh yourself each day, and if you weight 3 or more pounds
more than before, contact your doctor immediately
All our best,
Your ___ Care Team | SUMMARY STATEMENT FOR ADMISSION
==================================
Mr. ___ is a ___ man, with a history of alcoholic
cirrhosis c/b persistent ascites, status post TIPS procedure
with
subsequent revision, as well as bladder cancer s/p TURBT, HTN,
HLD, T2DM, and PAD s/p stent placement, who presented with
increased abdominal distension, weakness, ___, and anion gap
metabolic acidosis. Patient presented with ___ and altered
mental status. AMS improved with lactulose. He was followed by
renal for his ___ and ___ had a Cr at the time of discharge in
the mid-5s but without any acute need for dialysis. He will
follow up with renal as an outpatient.
===================================
ACUTE MEDICAL ISSUES ADDRESSED
===================================
#Acute kidney injury:
Pt's baseline Cr 1.6 as of last hospital discharge, presented
with Cr 5.7 this admission and has unfortunately stayed in
5.4-5.9 range despite trials of both volume repletion (via IV
albumin challenge) & diuresis (started furosemide 80mg BID).
Renal team was consulted. Initially felt to be prerenal I/s/o
recent large fluid shifts from therapeutic paracentesis prior to
admission, given FENa<1%. Then progressed to ATN, as evidenced
by urine sediment with muddy brown casts. Started sevelamer for
hyperphosphatemia. Electrolytes were otherwise stable, no overt
uremia and did not required hemodialysis. His spironolactone was
discontinued given his worsened renal insufficiency, and
furosemide 80mg daily was started and ultimately increased to
BID to maintain euvolemia and adequate urine output (55ml/h at
time of discharge, 0.54ml/kg/h). ___ was placed on admission
to monitor accurate urine output. Still in at time of discharge
to rehab; can perform voiding trial at rehab.
#Anion gap metabolic acidosis: Patient has evidence of acute
anion gap metabolic acidosis on VBG without complete respiratory
compensation. The most likely etiology was that this was related
to his ___ on CKD, as his lactate was normal, sugars are low,
and there is no evidence of ingestion. He was initially started
on a bicarb gtt, which was stopped when his electrolytes
remained stable. He was on oral NaHCO3 for a few days but this
was discontinued given desire to reduce salt load in the setting
of cirrhosis and hypervolemia.
#Toxic/metabolic encephalopathy:
The patient was alert and oriented x 2 on admission (knew self,
place, often would get year and president wrong), and his mental
status stayed basically the same throughout the admission.
Confirmed with patient's wife that this is his baseline at home,
and suspect there may be underlying ___ syndrome ___ heavy
alcohol use history. CT head showing cerebral atrophy consistent
with this diagnosis. Gave PO thiamine supplementation.
Intermittent asterixis was noted on exam during his hospital
stay, so he was treated empirically with lactulose and rifaximin
for possible superimposed HE. Held home haloperidol given
concern for acute on chronic encephalopathy, could assess need
to resume it as an outpatient.
#Ascites: The patient has a positive fluid wave and ascites on
imaging. Diagnostic paracentesis in the ED with large amount of
macrophages, but no evidence of SBP. Patient received
ceftriaxone 2g in the ED. Subsequently transitioned back to home
cipro for prophylaxis. Had abdominal US showing patent TIPS with
lack of wall-to-wall flow and reduced intra-TIPS velocities,
which could have explained his refractory/recurrent ascites.
Could consider TIPS revision in the future, held off in the
hospital given concern for worsened encephalopathy. Had repeat
diagnostic para ___ which was again negative for SBP. Had ___ therapeutic LVP, which he tolerated well. He was started on
furosemide PO 80mg BID, spironolactone discontinued given
worsened renal insufficiency.
#Decompensated EtOH cirrhosis: The patient has had numerous
decompensations of his cirrhosis with hepatic encephalopathy and
SBP. This admission, abdominal US showed intra-TIPS stasis as
above, but no TIPS revision performed given concern for worsened
encephalopathy. Patient was continued on his home omeprazole,
ciprofloxacin, lactulose, rifaximin. Spironolactone was held
given ___, as above.
#T2DM
#Hypoglycemia: Patient with a history of T2DM on 70/30 at home,
but with episodes of hypoglycemia in the ED that responded
somewhat to dextrose. Etiology likely poor PO intake, insulin
and ___. Standing insulin was discontinued during his MICU
course, and he was put on a sliding scale insulin regimen for
the rest of the hospitalization. His blood glucose was in the
200s-300s on sliding scale. He could have his home regimen
gradually reintroduced as an outpatient.
#Leukocytosis: Was 18.2 on admission, downtrended gradually to
14.4 at the time of discharge. Patient without obvious
localizing signs/symptoms of infection. Had negative urine and
blood cultures, CXR without focal consolidations, ascites not
meeting SBP criteria (see above). Aside from CTX dose in ED, was
not treated with further abx, therefore.
===================================
CHRONIC ISSUES PERTINENT TO ADMISSION
==================================
#Anemia: Hb between 7 and 8 over the past month, has been stable
this admission but decided to transfuse 1 unit PRBCs ___ given
Hb 7.3 and decompensated cirrhosis. Improved to Hb 8.6 at time
of discharge.
#Coagulopathy: INR 1.5-1.7, remained stable, likely ___
cirrhosis, did not intervene.
====================== | 201 | 808 |
15990067-DS-20 | 22,349,089 | You were admitted for chest and abdominal pain, and burning
while eating. ECG, CT-chest, and CT-abdomen, did not reveal an
etiology to your pain. You had an EGD that showed esophagitis,
biopsies were taken and are pending. We recommend that you take
omeprazole twice a day, sucralfate three times a day, and
viscous lidocaine as needed for pain.
You have decided to leave against medical advice because you
would not receive more narcotics. Please follow up with GI as an
outpatient. Their telephone number is ___. | # Chest pain- history most suggestive of esophagitis, possibly
PUD/gastritis, less likely cardiac in etiology, no ECG changes,
initial troponin negative. Regarding etiology of presumed
esophagitis, chemical most likely, less likely infectious, as
patient is not immunocompromised. History does not support pill
esophagitis, and normal amount of eosinophils on differential.
Repeat troponin also negative. Started on high dose H2 blocker
and PPI IV, NPO, IVF, and viscous lidocaine PRN comfort for
presumed esophagitis. EGD performed, results above, with distal
esphagitis/GE junction esophagitis. Transitioned to PO antiacid
therapy, tolerating full diet without worsening symptoms.
Biopsies pending, HIV negative. Patient left against medical
advice on ___. He tolerated a full diet, and his abdominal
exam was benign. Distal esophagitis/GE junction inflammation
appears to be the cause of the patient's symptoms, less likely
esophageal spasm. If symptoms persist, consideration could be
given to upper GI series with barium as an outpatient to assess
for spasm/dysmotility.
# Leukocytosis- presumably due to esophagitis, u/a only with
microscopic hematuria, no pneumonia on imaging, abdominal exam
benign. Leukocytosis improved the day following
# Microscopic hematuria- will need to repeated as outpatient, if
persists, will need cystoscopy.
# Chronic kidney disease- creatinine at baseline, renally dosed
meds
# Hypertension- continued lisinopril
# s/p CCY, umbilical hernia repair (at ___
___- dressing changes, monitor incisions, patient will
restart home Vicodin prescribed by his surgeons
# h/o hyperlipidemia- per pt, diet controlled, not on any meds
# Gout- allopurinol
# FEN- IVF, replete lytes, NPO for now
# PPx- heparin SC
# Code- full
# Contact- patient, girlfriend | 86 | 259 |
14018231-DS-34 | 27,051,854 | The patient is being discharged to a Skilled Nursing Facility in
an effort to transition to hospice care. His primary malignancy
is NSCLC with a metastatic lesion to the brain that has enlarged
despite attempts at treatment. The medications he is currently
being maintained on at this time includes systemic
corticosteroid to alleviate pressure and vasogenic edema
associated with the metastatic lesion on the brain as well as
anti-rejection medications for his transplant history. These
medications may be discontinued by hospice care at their
discretion. | ___ w/ initially stage II NSCLC s/p VATS w/ LL lobectomy ___ w/
brain met dx same here s/p XRT, now on bevacizumab (C23
___, who also has HIV, HCV cirrhosis s/p orthotopic
liver transplant ___, COPD, OSA on BiPAP, HTN, DL, CKD
III-IV,
T2DM, and chronic unsteady gait who p/w LUE weakness/drift and
confusion.
# Metabolic Encephalopathy associated with worsening metastatic
brain lesion with primary NSCLC
- Case discussed with his primary oncologist as well as the
patient, his fiancée, and primary care; family meeting held with
primary HMED team, CM, SW, ___, RN, the patient and his
fiancée. Clinical updates and impressions regarding his current
condition with the overall context of his oncologic history.
- Transitioning to Hospice Care with plan to d/c to SNF with
hospice capability
- For now will continue with the following therapeutics:
systemic corticosteroid, insulin as needed for glycemic control,
analgesic therapy, anti-epileptic agents, and his
immunosuppressant therapy for anti-rejection
Chronic Issues
# T2DM: Continue SSI coverage; de-escalate and discontinue at
the discretion of hospice
# HIV: Continue with efavirenz, lamivudine; de-escalate and
discontinue at the discretion of hospice
# S/P Liver transplant: Continue with cyclosporin; de-escalate
and discontinue at the discretion of hospice
# OSA: cont bipap machine he uses at night
# CKD III-IV: Cr 2.2 at baseline, avoided nephrotoxic agents
- Planning to de-escalate medications/therapeutics as part of
his continued management transition to hospice care.
Discontinued medications that are not included above.
# HTN: d/c antihypertensives
# COPD: d/c COPD-related medications | 85 | 241 |
12835259-DS-8 | 27,263,071 | You were admitted to the ___ service for your injuries.
Diet: Tube feeds through the PEG tube.
Activity: Bedrest, assistance to get out of bed to chair. You
should continue to wear your ___ J collar when out of bed.
Pain control: tylenol, narcotics as needed for pain
Medications: You should resume home medications unless
specifically told to stop. You may take tylenol or oxycodone for
pain. | Ms. ___ was tranferred to the ICU for close hemodynamic
monitoring. She was kept in a c-collar due to her c-spine
injuries. She was mentating well and responsive. She was
initially breathing well on room air. She was kept NPO and
placed on IV fluids. Her urine output was monitored with a
foley. She did not have any sensation or movements in her lower
extremities. Her ICU course by systems:
Neuro: she was kept on spine logroll precautions as well as
CTLSO brace. She had a c-collar in place. She went to the OR for
fixation of her spine on ___. Afterwards, she was taken off
logroll precautions, although she continued to wear her brace.
She was alert and responsive. Her pain was controlled with
dilaudid but narcotics were minimzed during her hospital course.
CV: She was placed on pressors initially in the ICU. Her
pressors were weaned. She had a brief period of atrial
fibrillation early in her ICU course but this resolved. After
her orthopedic surgery on ___ she again went into atrial
fibrillation; she was given 2u pRBC for a Hct of 20 and
converted to sinus rhythm with a diltiazem drip. The dilt was
weaned and she remained in sinus.
Pulm: She was trached and her vent was weaned. She was
tolerating CPAP. She had difficulty weaning to trach mask
secondary to tachypnea and tachycardia.
GI: She was kept NPO. An NGT was attempted on ___ however due
to copious secretions in the back of the throat this was not
possible. She was taken to the OR for a PEG placement on ___.
Tube feeds were started ___ and advanced to goal.
GU: Her UOP was monitored.
ID: Her WBC was elevated on ___ and an infectious workup was
done, including blood culture, urine culture, and cdiff. She had
a UTI and was put on Cipro, for a planned 3 day course. She was
also c.diff + and was treated with flagyl and PO vancomycin.
Prophy: She had an IVC filter and SQH was given. | 66 | 338 |
10921358-DS-21 | 25,025,457 | Dear Mr. ___,
Dear,
You were admitted to the hospital because of malnutrition.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- A feeding tube was placed and you tolerated the tube feeds
at your goal rate.
- You had an episode of severe confusion, anger, and
aggression. We had our psychiatrists see you and they determined
that you were not a risk to yourself or others.
- We completed multiple studies for your liver transplant
evaluation
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | ___ with past medical history alcoholic cirrhosis, COPD, recent
c-diff colitis (currently on po vanc Q OD), HTN, HLD, GERD,
Depression, Anxiety, presenting from his outpatient provider for
feeding tube placement, coronary angiogram, and to finish liver
transplant work up. | 213 | 36 |
11826927-DS-15 | 22,736,328 | Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you were
having shortness of breath, then later developed low blood
pressures during dialysis. You were initially admitted to the
intensive care unit where your blood pressures were stabilized.
On transfer out of the ICU, your shortness of breath had also
resolved. You had blood tests and an ultrasound to look for
complications of your HIV including lymphoma, which were
generally unrevealing; you had elevated levels of
immunoglobulins in your blood, which is a non-specific finding.
We changed the following medications:
Please increase SEVELAMER to 4000 mg three times daily, with
meals
Please follow up with Dr. ___. See below for appointment
details. | ___ w/ HIV (off and on HAART, currently off, last CD4 ___,000 copies/ml on ___ also with ESRD on HD, and presenting
w/ ___ days of gradual onset SOB of unclear etiology and
hypotension that seems to be ___ fluid taken off by extra HD
session.
# Hypotension: It was likely that the patient's hypotension
occurred in the setting of taking off too much volume at HD.
The patient was in the low ___ on arrival to ED, initially
admitted to the MICU and was briefly on pressors with lactate
initially of 4.2. She improved quickly with a small fluid bolus
and soon titrated off pressors. The patient received one dose
of vanc/zosyn in the ED out of concern for infectious etiology,
but infectious work up in the MICU was all negative. On
transfer from the MICU to the ward, the patient continued to
remain normotensive. She was continued on her home dialysis
schedule.
# shortness of breath: The etiology of the patient's shortness
of breath is unclear. She was ruled out for PE with CTA, and
there were no signs or symptoms of heart failure. The patient
had elevated LDH in the setting of low CD4 count; however, she
reports taking her Bactrim ppx and was never hypoxic, making PCP
very unlikely. An ECHO was done to evaluate for any underlying
pulmonary hypertension which was remarkable for ASD and mild MR.
___ that the patient's shortness of breath was in the
setting of being volume overloaded and did resolve after her
initial HD session, but then led to resultant hypotension after
taking off too much fluid. Upon discharge, the patient was not
having any shortness of breath.
# Elevated LDH: The patient was noted to have elevated LDH and
in the setting of having a borderline calcium, elevated
eosinophils, and relatively new thrombocytopenia, the work up
for lymphoma/malignancy was started while the patient was in the
intensive care unit. An u/s was done showing a borderline
increased spleen compared to a study from ___. The
patient was also found to have elevated B2 microglobulin, IgG
and IgM, and PEP was c/w polyclonal hypergammaglobulinemia.
# Thrombocytopenia: The patient has new thrombocytopenia since
___. Her platelets were trended during this admission.
Uncler etiolgy, but could be secondary to bone marrow
suppression in the setting of her active HIV disease.
# ESRD on HD: The patient was continued on her home MWF HD
schedule while in patinet. She was continued on her home
cinacalcet and sevelamer, which was increased at discharge.
# HIV: The patient is not taking her HAART medications, with
last CD4 of ___,000 copies/ml on ___. The patient
was not started on HAART while in patient, as she has not been
taking the medications at home. She was continued on her
Bactrim and Azithro ppx, which she reports taking at home. The
patient has follow up with her ID doctor, ___. | 127 | 510 |
14310882-DS-25 | 24,572,395 | Mr. ___:
It was a pleasure taking care of you at ___. You were
admitted with diarrhea. You tested positive for an infection
called Cdiff that causes diarrhea. You were treated with an
antibiotic and improved, but will need to continue this for an
additional 8 days. You had many electrolyte abnormalities,
which improved as your diarrhea resolved. You are now ready for
discharge back to assisted living | This is a ___ year old male with past medical history of myotonic
dystrophy type 1 resulting in dysphagia requiring Gtube, recent
___ admission for influenza and bacterial pnuemonia, admitted
here ___ w diarrhea x 1 week, found to have cdiff colitis,
started on PO vancomycin, with improvement in stool ouput and
electrolyte abnormalities. Given his insurance issues, he was
switched to oral metronidazole TID for an additional 8 days on
discharge (he did not have severe c difficile disease).
# Cdiff Colitis / Diarrhea - patient reported 10BM per day on
presentation in setting of recent hospitalization and antibiotic
exposure; cdiff returned positive; patient treated with PO
vancomycin with clinical improvement, bowel movements decreasing
to 1 per day. Discharged to complete 8 day metronidazole
course.
# Severe Protein Calorie Malnutrition - patient with BMI 14 in
setting of chronic myotonic dystrophy and acute illness above;
patient advanced to home 4.5 cans tube feeds (Jevity), but
unable to advance further than that given residuals; started
banana flakes to help with diarrhea.
# Hypophosphatemia / Hypokalemia / Hypernatremia - patient with
significant metabolic abnormalities requiring IV correction in
setting of large diarrhea; resolved as diarrhea improved
# Microcytic Anemia - defer workup to outpatient setting
# Incidental findings - Aneurysm of the infrarenal aorta is seen
up to 2.1 cm; defer to PCP regarding monitoring / management.
# HLD - continued home ASA, statin
# Hypothyroidism - continued home levothyroxine
# Depression - continued home mirtazapine, quetiapine | 72 | 246 |
14507136-DS-9 | 29,462,350 | You were admitted to ___ after being struck by a falling tree.
You suffered multiple injuries including head trauma, a lip
laceration which was repaired by Plastics, multiple bilateral
rib fractures, a pelvic fracture, and left ankle fracture. You
were seen by Neurosurgery for the head trauma. Your repeat head
CT scan was stable and did not show any increase in intracranial
bleeding. Orthopedic surgery took you to the operating room for
repair of your pelvic and ankle fracture. You tolerated these
procedures well. You have worked with Physical therapy and you
are now medically stable to be discharged to rehab to continue
your recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | ___ with HTN, prostate CA s/p prostatectomy, medflighted to
___ after being
struck by tree with + LOC. Imaging revealed LLE ankle fracture
w/ exposed bone,
pelvic fracture, multiple rib fractures, small SAH/SDH. The
patient was admitted to the TICU for close monitoring and
resuscitation. Plastics repaired the lip avulsion at the
bedside. Neurosurgery was consulted and recommended a repeat
head CT which was unchanged, q1h neuro exams, and tight blood
pressure control. The patient received multiple fluid boluses
due to rising creatinine and low urine output. Renal US was
normal. On ___, Orthopedic surgery took the patient to the OR
for ex-fix of the ankle and ORIF of the pelvic fracture. The
patient remained intubated post-op due to poor oxygenation. The
patient was successfully extubated on POD1.
Nephrology was consulted due to ___. Creatinine peaked at 5.2 on
HD5. They felt the ___ was likely due to contrast, hypotension,
rhabdo, third spacing from trauma in setting of hypovolemia
during trauma in addition to patient being on hctz and ACE
inhibitors. Urine output was improving and the creatinine
plateaued and eventually downtrended. They recommended
continuing to hold antihypertensives.
On POD2 the patient was hemodynamically stable and transferred
out of the TICU to the general surgical floor. Pain was well
controlled. Diet was progressively advanced as tolerated to a
regular diet with good tolerability. POD3 the foley catheter was
removed and the patient voided without difficulty. During this
hospitalization, the patient was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. He worked with ___ and was able to pivot OOB to
chair with assist. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, OOB with assist, voiding without assistance, and pain was
well controlled. The patient was discharged to rehab. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 328 | 337 |
17959236-DS-17 | 26,754,348 | You were admitted to the hospital after you had headache for 24
hours and hyperasthesias in forearms, midback and lower
ankles/feet bilaterally. There wasd concern for an inflammatory
process as you were recently diagnosed with ___ disease at
Mass Eye and Ear based on scleritis and ulcers. You had a lumbar
puncture performed which showed no pleocytosis and no elevation
in protein. You had an MRI, MR angiography and MR venography
which were normal.
You will follow-up in neurology clinic with Dr. ___ Dr.
___. You will be called with an appointment. Please contact
us if you have not heard about an appointment.
You should contact rheumatology at ___ to confirm the
diagnosis of ___ disease. Their number is ___. | Sensory changes
Dr. ___ was admitted to the hospital for sensory changes in
his arms and legs. He was recently diagnosed with ___
disease for scleritis and recurrent ulcers. There was some
concern that he may have an aseptic meningitis, or inflammatory
lesions causing the sensory changes. MRI/A/V failed to
demonstrate any acute lesions. He had a lumbar puncture
performed which was normal. He did ask whether steroids would be
appropriate, but we opted to not treat given no current signs of
infection or inflammation. We referred him to rheumatology for
additional possible testing and confirmation of ___ and
will have him follow in the neurology clinic. | 118 | 106 |
17049363-DS-20 | 28,132,350 | Dear Mr. ___:
You came to the hospital because you were confused, having
uncontrolled movements of your left arm and were found to have
what initially looked like bleeding in your brain on a prior CT
scan. Initially, you were on the liver floor where the doctors
treated your ___ and you improved and were then
transferred to the neurology service.
On the neurology service, we suspected that the lesion in your
brain was not a bleed so we obtained several more tests. A
lumbar puncture was done to look at your cerebral spinal fluid
and we found that you had lymphoma, or cancer cells, in the
fluid. You were transferred to the oncology service and received
an oral chemotherapy agent to treat the tumor. You will be
followed closely by Dr. ___ tumor doctor) and will
continue chemotherapy. You were also started on diuretics (water
pills such as lasix) for your underlying liver disease and a new
medication to help prevent confusion from your liver disease. | Mr. ___ is a ___ with history of alcoholic cirrhosis
complicated by past variceal bleeding, ascites and spontaneous
bacterial peritonitis, and recent admission ___ for
weakness complicated by spontaneous bacterial peritonitis, acute
kidney injury, Enterococcal urinary tract infection and
healthcare-associated pneumonia, admitted from rehab with
encephalopathy, choreo-athetoid dyskinesia, and subacute right
thalamic bleed. He was found to have a likely B-cell primary CNS
lymphoma. Given his underlying liver disease, he was treated
temozolomide 200 mg PO x 5 days (100 mg/m2 - dose reduced by 2%
to 98 mg/m2).
<< Active Issues:
# Intracranial lesions/CNS lymphoma: Patient was noted to have
what initially resembled a subacute right thalamic bleed on
non-contrast ___ CT, explaining onset of choreo-athetoid
dyskinesia in the days prior to admission. Neurology was
consulted in the ED and advised conservative management with
maintenance of systolic blood pressure between 120 and 160. MRI
demonstrated diffuse vasogenic edema extending into the basal
ganglia and midbrain, with bilateral areas of enhancement, more
significant on the right, concerning for infection versus
malignancy rather than stroke, prompting transfer to the
neurology service. Lumbar puncture was performed, with CSF
cytology positive for malignant cells consistent with B cell
lymphoma. CT torso was negative for lymphadenopathy while
scrotal ultrasound showed no evidence of lymphomatous
involvement. Decadron 10mg IV x1 followed by 4mg PO daily was
initiated along with Humalog insulin sliding scale, with blood
glucose remaining </= 200. On transfer to the oncology service,
bone marrow biopsy was performed, with results pending at the
time of discharge, and he received oral temozolomide x5 days,
with plans for subsequent cycle in the outpatient setting
beginning ___. For his chemotherapy, he should be
pre-medicated with zofran and started on dexamethasone 4 mg PO x
3 days during chemotherapy. He should fast for one hour before
and one hour after taking chemotherapy. He also received
continued Decadron 4mg daily, including 8mg x1 on the day of
discharge for possible chemotherapy-associated maculopapular
rash overlying his back, with transition to 3mg daily at
discharge in anticipation of taper on outpatient follow-up. Of
note, CSF HSV was negative, toxoplasma was negative, and VDRL
was pending at the time of discharge.
# Encephalopathy: Patient presented with encephalopathy,
initially felt to be most consistent with hepatic encephalopathy
in the setting of urinary tract infection versus confusion
secondary to right thalamic hemorrhage. Despite recent history
of enterococcal urinary tract infection and admission urinalysis
with large leukocytes, admission urine culture was found to be
negative, as were blood and peritoneal fluid cultures following
large-volume paracentesis (6L) x2. CXR showed no evidence of
infection. Hepatic encephalopathy was treated with lactulose and
rifaximin, with mental status back to baseline by the time of
discharge.
# Cirrhosis: As noted above, he was found to be encephalopathic
on admission with known cirrhosis, patent vasculature, and
moderate ascites on ultrasound, prompting therapeutic
large-volume paracentesis (6L) x2, both negative for spontaneous
bacterial peritonitis, over the course of admission. INR
remained stably supratherapeutic at 1.4-1.7 throughout
admission, likely due to synthetic dysfunction. Stable
pancytopenia, including Wbc of 1.7-7, Hct of 22.9-28.5, and
platelets of ___, was felt to reflect splenic sequestion
and anemia of chronic disease; despite presence of
paraesophageal varices on CT torso, there was no evidence of
variceal bleed throughout admission. Home octreotide, midodrine,
and omeprazole were continued, and ceftriaxone was initiated for
SBP prophylaxis. Per hepatology recommendations, octreotide and
midodrine were discontinued, Lasix and spironolactone initiated,
and ceftriaxone discontinued in favor of home ciprofloxacin for
spontaneous bacterial peritonitis prophylaxis. Close follow-up
with hepatology is arranged in the outpatient setting.
# Shortness of breath: He reported mild shortness of breath at
rest without hypoxia and not relieved entirely by large-volume
paracenteses in association with left upper lobe ground glass
opacities on staging CT torso. In the absence of fever or cough,
empiric antibiotics were held, and symptoms resolved with
diuresis as above.
<< Inactive Issues:
# Alcohol abuse: Home multivitamin, thiamine, and folic acid
were continued throughout admission. As he was admitted from
rehab, CIWA protocol was not initiated, and there was no
evidence of alcohol withdrawal throughout admission.
#Zinc deficiency: Home zinc sulfate was continued throughout
admission.
<< Transitional Issues:
- Close ___ follow-up is arranged, with plans for
subsequent cycle of temozolomide beginning ___ in the
outpatient setting. Decadron taper also is anticipated in the
outpatient setting. He will likely need to continue humalog SSI
for now given ongoing steroid usage. This could be discontinued
if he is not expected to receive dexamethasone. Please see
medication information above and in the page 1 for
pre-chemotherapy medications such as zofran, fasting
instructions, and dexamethasone burst for 3 days.
- Close hepatology follow-up is arranged, with need for elective
EGD anticipated in the outpatient setting.
- While at rehab, weekly basic metabolic panel
(Na,K,HCO3,Cl,BUN,Cr), complete blood count with differential,
and liver function tests (ALT,AST,Tbili,AlkPhos) should be
obtained every ___ beginning ___ and faxed to Dr. ___
(___) (phone ___, fax (___)
and Dr. ___ hepatology) (phone ___,
fax (___) for review.
- Of note, prophylactic anticoagulation was held in the setting
of supratherapeutic INR with subacute thalamic bleed, and he
declined use of Pneumoboots despite explanation of risks in the
setting of known malignancy and cirrhosis.
- Pending studies: CSF VDRL ___ bone marrow biopsy
___ serum EBV (___).
- Code status: Full. | 168 | 873 |
17114771-DS-21 | 25,905,431 | Dear Ms. ___
It was a pleasure caring for you during your recent admission.
You came to the hospital with swelling in your legs, and
worsening pain from your skin sores. We did an ultrasound of
your legs and did not find any blood clots that would explain
the swelling, which is good news. We gave you a higher dose of
your water pill, and the swelling improved. We also did an
ultrasound of your heart, which is unchanged from your last
ultrasound but does show that your heart is not pumping very
well. At Dr. ___, we did a CT scan of your lungs
because of your smoking history: we did not see any evidence of
a lung tumor, but it is important for your health to stop
smoking. We also had the dermatologists examine your skin, and
they recommend continueing the same dose of clindamycin and
hibicleanse. We rescheduled your outpatient dermatology
appointment to be sooner, as outlined below.
We also had concerns about your risk of falling, and we wanted
to keep you in the hospital to work with the physical
therapists. You made it very clear that you do not want to go to
rehab, or to work with physical therapy in the hospital. You
understand the potential risks of this decision, which include
falling at home, breaking a bone, or even death. You still
decided that you wanted to go home today and will be leaving
against medical advice.
Please take your medications as directed and follow-up with your
doctors as ___ below. Also, because of your heart failure,
please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Sincerely,
Your ___ Care Team | ___ F with a history of mechanical AVR (___), diabetes mellitus,
hidradenitis suppuritiva, who presents to the ED from clinic for
worsening hidradenitis and bilateral lower extremity swelling.
# Hidradenitis suppuritiva: ___ stage III given evidence of
tracking on exam. On exam, no evidence of super-imposed
infection. Has been on clindamycin as an outpatient-- she
declines tetracycline and doxycycline. S/p IV vancomycin and IV
clindamycin on admission, but resumed PO clindamycin the next
morning. Dermatology was consulted, who believe intra-lesional
steroid injections would be beneficial however she declines as
this time. She will follow-up with Dermatology as an outpatient.
# Lower extremity edema: per patient, has greatly improved over
the last several days. Continues to have mild pitting edema in
feet, and non-pitting edema in ___ L > R. Does have protein on
UA, and albumin below baseline, however likely not a major
contributing factor. s/p 40mg IV Lasix on admission, and then
restarted on home diuretic dose. U/S ___ showed no DVT, L-sided
___ cyst which may explain asymetrical edema. ECHO on ___
which was basically unchanged from prior. She declined
compression stockings.
# HEART FAILURE WITH REDUCED EJECTION FRACTION: Hx of
non-ischemic cardiomyopathy. LVEF 20% ___. s/p 40 IV Lasix on
admission, and then restarted on home diuretic dose. ECHO on
___ grossly unchanged from prio. Continued on home metoprolol
and home losartan.
# DIABETES MELLITUS, TYPE 2: Last HbA1c 8.9%. Wounds would heal
better with tighter glucose control. She was continued on home
glargine dose of 25 Units QHS however she does not take this
dose at home. She was encouraged to take home insulin dose on
discharge.
# AORTIC VALVE REPLACEMENT: goal INR should be 2.5 - 3.5 given
AVR with comorbid CHF. INR 5.3 on admission, and coumadin was
held for two days prior to being restarted at 5 mg daily, to be
rechecked by ___ on ___. PCP office will follow INR.
# DYSLIPIDEMIA: continued on home dose statin.
# COPD: lungs CTAB, no wheezing to suggest active flare.
Continued on home ipratropium-albuterol, tiotropium.
# GOUT: continued on home allopurinol
# HYPERTENSION: continued on home losartan, metoprolol. BP in
good range.
TRANSITIONAL ISSUES:
=======================
# ___ edema is most likely secondary to venous stasis: we
recommended she elevate her legs and wrap with ACE bandages as
tolerated
# ECHO showed: unchanged EF ___
# CT chest showed no evidence of lung nodule or mass to suggest
intrathoracic malignancy is a potential cause for weight loss
# Discharged on home dose clindamycin for hidradenitis: per
Dermatology, would likely benefit from intralesional steroid
injections but she remains wary of this procedure
# INR elevated on admission; coumadin held on ___ and ___ and
per pharmacy was restarted at 5 mg on ___, with the plan to
continue 5 mg on ___ and ___ and INR to be checked by ___ on
___.
# CT finding: Incompletely imaged pre-vascular hyperdense soft
tissue density abutting the anterior abdominal aorta, similar to
___t that time, the differential
diagnosis included retroperitoneal fibrosis and thrombosed
abdominal aortic aneurysm with intramural hematoma. If warranted
clinically, this could be more fully evaluated by an MRA study.
# She left AMA on ___ after extensive discussion about the
benefits of staying in the hospital. Specifically, she
understands the risks of leaving without a physical therapy
evaluation: she understands she may fall at home because she is
unsteady on her feet, and this could lead to hemmorhage, broken
bones, or even death. Home safety eval ordered to be done by
___. | 282 | 585 |
18273344-DS-9 | 26,474,756 | Dear Ms. ___,
It was a pleasure taking care of you during your recent hospital
stay at the ___. You were
admitted because you were experiencing nausea, vomiting, and
diarrhea, along with findings indicative of an enlarged spleen
and some abnormalities in your bloodwork. Because you had
recently returned from ___, you were evaluated for a
series of infectious diseases known to be common in returning
travelers from that area. Based on the lab results, it was
discovered that you most likely have an acute viral infection
due to Chikungunya and CMV mononucleosis. Your spleen was
enlarged on the ultrasound. You should avoid doing any contact
sports and will need a repeat ultrasound to monitor improvement
by your primary care doctor.
Please ___ with your primary care physician following your
discharge from the hospital next week.
We wish you the best with your health.
Sincerely,
Your ___ Care Team | This is a ___ year old female with past medical history of NASH,
recent travel to ___, admitted ___ with
constellation of symptoms including cough, malaise,
nausea/vomitting, joint pain, abdominal pain, found to have
splenomegaly and hemolytic anemia, thought to be reactive to an
infectious process, found to have positive chikungunya ___ as
well as positive CMV ___ and viral load, seen by ID consult
service who believe patient likely had both acute chikungunya
and
CMV infections (the second possibly being a reactivation),
started on empiric doxycycline for leptospirosis coverage,
returning to baseline health status, discharged home with close
outpatient ___.
# Chikungunya / Acute CMV Reactivation Infection: Patient
admitted from clinic following sub-acute presentation with
abdominal/epigastric pain, diarrhea, slightly elevated LFTs,
elevated LDH, atypical lymphocytes, and splenomegaly following a
trip to ___. Given her recent travel there was a broad
differential for fever in a traveller in an area where several
bacterial, viral and parasitic infections are endemic. The
patient also had multiple clinic/ED visits with limited work up.
The patient was appropriately admitted for further work up.
Infectious disease was consulted and recommended a broad work
up. Infectious disease evaluation including Dengue, Typhoid,
Leptospirosis, Legionella, Chikengunya, Dengue, EBV, CMV, and
HIV. Patient tested positive for Chikungunya, and CMV ___ and
IgG, suggesting an active/acute infection. She was initiated on
doxycycline empirically throughout her evaluation, given that
her cough and splenomegaly were potentially consistent with
Leptospirosis. She also had endorsed seafood exposure so there
was initially concern for Hepatitis or vibrio parahemolyticus.
During the work up CMV ___ returned positive. Chikungunya ___
positivity suggested concurrent Chikungunya infection, which
possibly led to reactivation of latent CMV (given IgG
positivity). Serologies also suggested past Dengue/Toxoplasma
exposure. Patient was otherwise treated conservatively with
improvement in symptoms to her baseline. She was discharged to
complete empiric leptospirosis coverage and with close PCP and
subspecialist ___.
# Atypical lymphocytosis / Splenomegaly - this was felt to be in
response to her ongoing infection; patient is recommended for
repeat blood work and splenic ultrasound to reassess.
# Acute Hemolytic Anemia: Admitted with elevated LDH, low
haptoglobin and elevated reticulocyte. There were no
schistocytes on peripheral smear, Coombs was negative. Guaiac
negative. Hgb remained stable during admission, thought to be
related to a self resolving hemolysis in the setting of her
above infections. Hgb at discharge was 10.1.
# Psych history: patient has hx of depression and multiple
hospital stays. Has been prescribed several medications which
she states she has not been taking recently. They were held
given she reports she has been off of them for several months.
Patient will need outpatient follow up | 148 | 444 |
18658401-DS-26 | 21,351,301 | You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck! | Ms. ___ presented to the ED with an acute small bowel
obstruction. She was admitted for pain control and IV fluids.
She came to the floor and stated her abdominal pain was much
improved from initial presentation to the ED and she denied any
nausea. Patient was kept NPO overnight. Overnight she required
IV Tylenol and toradol x1, but serial abdominal exams continued
to improve. The following morning she stated her pain was much
improved and she was given a clear liquid diet which she
tolerated well. Her diet was advanced to regular for lunch which
she also tolerated well without pain or nausea. Patient was
then deemed stable for discharge.
Patient had no cardiac, pulmonary or GU issues during this
admission.
Patient did have a significant cough during her admission, but
CXR was normal. WBC count decreased from 18 on initial
presentation in the ED to 4 the following morning.
On discharge, she was passing gas, stool, and urine
spontaneously, tolerating a regular diet, and ambulating
independently. | 289 | 170 |
19441625-DS-17 | 20,711,225 | Dear Ms. ___,
You were admitted to ___ with shortness of breath. You were
found to be positive for influenza and were treated with
Tamiflu. We also started you on antibiotics for pneumonia.
Changes to your home medications include:
- Tamiflu (oseltamivir) 75mg twice a day (last day will be
___
- Levofloxacin 750mg daily (last day will be ___
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward. | ___ with history of DM, COPD, hypogammaglobulinemia receiving
IVIG infusion every 3 weeks who presented with myalgias and
shortness of breath found to have fever and concern for flu.
Active issues
# Influenza: Fever, myalgias and dyspnea concerning for
influenza, so patient placed on Tamiflu at time of admission.
DFA testing later returned positive for Influenza A and patient
was continued on Tamiflu.
.
# Community acquired pneumonia: Admission X-ray showed possible
RLL infiltrate, so given immunosuppression patient was treated
for concurrent community acquired pneumonia with course of
levofloxacin. Patient afebrile with normal white blood cell
count and significantly improved dyspnea by time of discharge.
However, she continued to desat to 84% on room air w/exertion
but 95% with 2L NC. She was discharged home with oxygen.
.
# ___: Creatinine 1.2 at time of admission secondary to
hypovolemia. Improved to 0.6-0.8 with fluids.
.
# Hyponatremia: Sodium 127 at admission due to hypovolemia and
normalized with fluids.
. | 76 | 154 |
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