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15622747-DS-12 | 20,533,412 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for low blood levels (anemia) and shortness
of breath.
What was done for me in the hospital?
- You received blood transfusions.
- You had a colonoscopy, which showed some small polyps. These
will need to be evaluated with another colonoscopy in the
future.
- You had an endoscopy, which showed mild "Gastric Antral
Vascular Ectopy (GAVE)" This means the lining of your stomach is
a little eroded in places and may have bled, which could have
been the reason why you had dark stools. You will follow up with
the GI doctor in ___ months.
- You had a "capsule study" in which you swallowed a pill with a
tiny camera on it. This will take pictures along your intestinal
tract and may help uncover the source of any bleeding.
What should I do when I leave the hospital?
- Please follow up with your primary care doctor.
- Please take all your medicines as prescribed.
- Please continue checking your INRs. Restart your Coumadin on
___ at your usual dose.
We wish you the ___ of luck in your health!
Sincerely,
Your ___ Treatment Team | PATIENT SUMMARY
=================
Mr. ___ is an ___ man with a PMH of CAD, DM2, HTN, afib on
Coumadin, and spinal cord thrombosis ___ years ago, on warfarin)
who presented with progressive dyspnea on exertion for 1 month,
found to be anemic with guaiac positive stool, s/p colonoscopy
and EGD with evidence of non-bleeding polyps and mild GAVE, s/p
2 blood transfusions, now with improvement of dyspnea. | 204 | 66 |
17857941-DS-21 | 25,385,067 | Brain Tumor
Activity
* We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until you are cleared by your
primary care provider.
* You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
* No driving while taking any narcotic or sedating medication.
* If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
* No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
* You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
* You are being discharged on dexamethasone. Your blood sugar
was monitored while on this medication, and you did not require
insulin treatment. You should have regular blood testing done
with your PCP for ongoing monitoring.
What You ___ Experience:
* You may experience headaches.
* Feeling more tired or restlessness is also common.
* Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
* Nausea and/or vomiting
* Extreme sleepiness and not being able to stay awake
* Severe headaches not relieved by pain relievers
* Seizures
* Any new problems with your vision or ability to speak
* Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
* Sudden numbness or weakness in the face, arm, or leg
* Sudden confusion or trouble speaking or understanding
* Sudden trouble walking, dizziness, or loss of balance or
coordination
* Sudden severe headaches with no known reason | Mr. ___ was admitted to the neurosurgery with new brain lesion
and intramedullary C7 lesion.
#Brain lesion with cerebral compression
MRI brain w/wo contrast was performed which showed multiple
dural based lesions, including 5.1x4.3 L frontal (concerning for
metastases, less likely atypical meningioma), 3 x 1.1 L middle
cranial fossa lesion, and 1.5x1.2 R cerebellopontine angle mass
(concerning for metastasis, less likely vestibular schwannoma).
He was started on Decadron for cerebral edema and keppra for
seizure prophylaxis. Neuro Oncology was consulted and
recommended resection of the largest left frontal mass and SRS
for the remaining lesions. A family meeting occurred on ___
with oncology and neurosurgery to discuss treatment options and
goals of care. After discussion, the patient and his family
decided that surgery was not the best option, and that they
would prefer to pursue palliative care for symptomatic
treatment. He was evaluated by physical therapy and occupational
therapy and was cleared for discharge home. He is being
discharged home to an assistive living set up by his daughter.
All appropriate intake paperwork was relayed to facility.
#Spinal lesion
MRI without contrast was obtained and showed intramedullary mass
at C7 with extensive cord signal edema spanning to C4-T2. MRI
with/without contrast was obtained for further evaluation which
did not reveal additional spinal lesions.
Neuro-oncology was consulted and felt that the spine lesions
could be treated with radiation.
#Lung lesion
MRI of cervical spine incompletely visualized a left upper lobe
lung lesion. CT Torso was obtained which revealed a large left
upper lobe/perihilar mass encasing left main pulmonary artery
and left mainstem bronchus. Thoracic surgery was consulted, who
did not recommend resection.
#Malignancy
CT Torso was obtained which revealed large left upper
lobe/perihilar mass encasing left main pulmonary artery and left
mainstem bronchus, mediastinal adenopathy, pleural plaques
consistent with asbestosis, colonic wall thickening and a right
femoral head lesion in addition to brain and spine lesions
described above. Oncology was consulted for further management
recommendations, and they recommended outpatient
medical/radiation oncology follow up.
#Geriatric Psychology
The patient seemed to have difficulty understanding and
remembering the diagnosis, therefore Gerontology-Psychiatry was
consulted for evaluation for baseline cognition. Per their
report, the patient does have early mild cognitive impairment
however there were confounding aspects to this as a diagnosis
(steroids, keppra, brain mass). Also, of note, on their
evaluation the patient has a good insight to his diagnosis, and
expressed preference of maximizing his ADL function and quality
of life and would prefer not to pursue invasive measures such as
surgery.
#UTI
He had a positive urine culture on presentation for Klebsiella
pneumoniae. He was completed a 5 days course of Ceftriaxone
(___). | 292 | 431 |
10149722-DS-20 | 23,451,705 | Dear Ms. ___,
You presented to ___ on ___ after suffering a fall. You
sustained left rib fractures and were admitted to the
Trauma/Acute Care Surgery team for further medical care.
You have been scheduled to have Physical Therapy visit you at
home. You are now medically cleared to be discharged to home.
Please note the following discharge instructions:
* Your injury caused left ___ rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | Mrs. ___ was admitted to the hospital on ___ after
sustaining a fall with injury to the ___ ribs on the left
side. Her pain was treated accordingly, and her respiratory
function was observed overnight. She was dischrged home in
stable condition with at-home physical therapy. | 301 | 46 |
12008485-DS-17 | 21,600,587 | You were admitted to the hospital with mid-epigastric to right
lower quadrant pain. There was concern for appendicitis. You
underwent an ultrasound of the abdomen which showed a normal
appearance. You are now preparing for discharge home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you. | The patient was admitted to the hospital with 2 days of mid
abdominal pain that then migrated to the right lower quadrant
with decreased appetite and nausea. His white blood cell count
remained within normal limits. Upon admission, the patient was
made NPO, given intravenous fluids, and underwent imaging. An
ultrasound of the appendix was done which showed a mildly
dilated, partially compressible appendix, measuring 4-6 mm with
slight wall thickening and minimal free fluid in the right lower
quadrant. These findings did not meet all criteria for acute
appendicitis. The patient remained NPO and underwent serial
abdominal examinations. The patient then underwent a cat scan
of the abdomen in which the appendix was poorly visualized. The
radiologist recommended a repeat ultrasound of the abdomen in an
attempt to identify the appendix. The ultrasound showed a
normal appendix measuring 5 mm in diameter with a
normal-appearing wall without evidence of hyper-vascularity.
The patient resumed a regular diet and reported no recurrence of
abdominal pain. His vital signs remained stable and he was
afebrile. The patient was discharged home on HD #1 in stable
condition. He was encouraged to return to the emergency room if
he had a recurrence of abdominal pain, nausea, vomiting, and
fever. The patient was encouraged to follow-up with his primary
care provider. | 171 | 227 |
15229138-DS-10 | 20,079,836 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for vomiting, abdominal pain, and being
unable to eat.
WHAT HAPPENED IN THE HOSPITAL?
-You were given IV antibiotics, your electrolytes and liver
enzymes were monitored.
-Your IV antibiotics were switched to an oral antibiotic, which
you will continue taking at home.
WHAT SHOULD YOU DO AT HOME?
-You should STOP drinking alcohol. This is the most important
thing you can do for your health, and to prevent further
hospitalizations with complications of your alcoholic liver
damage.
-You should continue taking your medicines as prescribed.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | PATIENT: ___ with a PMH of alcohol use disorder, alcoholic
hepatitis, HTN, and neuropathic pain who p/w acute alcoholic
hepatitis, on empiric antibiotic course (Unasyn -> Augmentin)
for cholangitis, now clinically well-appearing, with resolving
hyperbilirubinemia, in the contemplation stage of quitting her
alcohol use. | 114 | 42 |
11086705-DS-19 | 24,699,903 | Dear Mr. ___,
You were admitted to ___ with weakness, abdominal pain, and
worsening of your kidney function. We gave you fluids and
antibiotics in case you had an infection in your abdomen. We
also had the ___ doctors perform the ___ node biopsy that was
scheduled for ___ before you had come into the hospital. This
showed that the lymph nodes were liver cancer as opposed to a
new cancer or infection.
While you were here, you continued to feel worse and we sat down
to discuss that there were no more treatments that would be able
to keep your cancer under control. Instead, we talked about
focusing on treating your symptoms. You were too weak to be able
to go home on your own so we set you up to go to a facility that
can help manage your symptoms and keep you comfortable.
It was a pleasure caring for you.
Sincerely,
Your ___ Oncology Team | Mr. ___ is a ___ year-old ___ man with HCV
Cirrhosis, HCC metastatic to perihepatic and peripancreatic LN
s/p wedge resection, unsuccessful TACE, RFA x2, most recently on
Lenvatinib (on hold since ___, as well as recent
Cholecystectomy ___ for perforated cholecystitis, who
presented
with dyspnea, myalgias and RUQ pain, found to have ___, ascites.
#Pain management
Patient reported that his biggest concern was his lower back
pain. Had been receiving oxycodone Q4H PRN with good initial
relief but continued to have pain between doses. Pain medication
increased to Oxycontin 10mg QAM and 10mg QPM with oxycodone
___ Q4H PRN. Benefitted also from lidocaine path and Tylenol.
Patient certainly somewhat sleepier after starting on more pain
medication, but pt and family in agreement that priority should
be on pain control even at expense of some confusion.
# Hyponatremia
Na on admission 130 and initially stable. After paracentesis and
diuresis, Na rapidly falling. Renal consulted and recommended
free water restriction. Urine electrolytes show sodium-avid
state
c/w hypovolemia or effective hypovolemic state (change from
prior). Has stabilized in mid ___ and ultimately the decision
was made to discontinue monitoring of kidney function an
electrolytes given patient's and family's decision to pursue
hospice.
# ___
Baseline Cr 1.1, although recently ___ w/ Cr 1.7-1.8 at end of
___. Cr elevated to 3.4 on admission. Given hyponatremia,
significant casts, elevated BUN, and overall malaise, most
likely
hypovolemic prerenal. No evidence of hydronephrosis on CT A/P.
Cr
improved with albumin and fluids but ultimately began rising
again with decreased UOP. Repeat urine lytes w/ sodium-avid
state as above.
Per nephrology consult most likely ___ hypotension. Octreotide
started but ultimately discontinued after no effect. Midodrine
started and titrated up to 10mg TID without significant increase
in BP or urine output. Albumin given again on ___ without
response. Ultimately the decision was made to discontinue
monitoring of kidney function an electrolytes given patient's
and family's decision to pursue hospice.
# Dyspnea
# HFrEF
# CAD
HFrEF with EF 40%. Recent MIBI with reversible defect in LAD but
has not had a cath; on medical management. At most recent
appointment in ___ was thought to be euvolemic and down 5
pounds. CXR without clear infiltration, vascular markings or
edema/effusion. Has noted significant dyspnea since stopping
Lenvatinib in ___. He developed worsening dyspnea w/
crackles, +JVD during his admission. Showed minimal response to
diuresis and ___ as above. A repeat CXR showed no significant
vascular congestion or pulmonary edema. Attempts at diuresis
were unsuccessful and without significant urine output.
Diuretics were ultimately discontinued as they were without
benefit. On admission his metoprolol was initially held. He
developed intermittent chest pain and he was restarted on
metoprolol 12.5mg Q6H. He was ultimately restarted on metoprolol
XL but at 50mg daily.
# Abdominal Pain, Distension
On admission his lactate was initially elevated to 4.5 but
improved rapidly with a 500cc bolus. He complained of diffuse
abdominal pain. Given known ascites and elevated lactate was
started on CTX for SBP prophylaxis. A CT A/P was without acute
change to explain symptoms. Throughout his admission he
continued to experience abdominal bloating and discomfort. A
repeat CT A/P on ___ revealed
increasing ascites and he underwent a therapeutic paracentesis
on ___ with 2.25L drained. Analysis of peritoneal fluid did not
reveal evidence of infection. His CTX was switched to cipro and
he completed a 7 day course. He experienced temporary relief of
his abdominal distension/discomfort after the paracentesis but
the distension returned a few days later.
CHRONIC ISSUES
==============
# HCC
Most recently on Lenvatinib, on hold since ___ due to plan
for LN Bx. AFP elevated to 1721 (highest on file here at any
point in clinical course). Recent expansion of lymphadenopathy
and lymph node biopsy while inpatient demonstrated metastatic
HCC. A family meeting was held with the patient, his sister,
brother and outpatient oncologist Dr. ___/ decision made for
DNR/DNI and hospice. Patient expressed that he would very much
like to go home if possible but understands that this is not
likely to
be possible. Ultimately discharged to ___ w/ hospice.
# HBV/HCV Cirrhosis
No evidence of synthetic dysfunction, hepatic encephalopathy, GI
bleed, acute transaminase elevation. RUQUS with patent portal
vein. Continued entecavir.
# Portal Vein Thrombosis
At home on Lovenox ___ daily. Initially managed on heparin
drip due to rising creatinine but decision made to discontinue
anticoagulation given move towards hospice.
# Anemia
Microcytic, stable.
======================================================== | 154 | 690 |
13104901-DS-11 | 20,403,052 | Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
It is very important to take the medication your doctor ___
prescribe for you to keep your blood thin and slippery. This
will prevent clots from developing and sticking to the stent.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
The medication may make you bleed or bruise easily.
Fatigue is very normal.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ is a ___ year old female with known carotid stenosis
concerning for ___ disease who presents with complaints of
headache and blurry vision.
#Carotid stenosis
She was admitted for further workup with diagnostic angiogram.
On ___, she underwent diagnostic angiogram, which showed
completed occlusion of the right ICA above the PCOMM. The
procedure was well tolerated. Stroke neurology was consulted and
recommended labs and starting Aggrenox. She was deemed safe and
ready for discharge home with appropriate follow-up. | 309 | 78 |
13370303-DS-11 | 29,710,977 | Activity:You should not lift anything greater than 10 lbs for 2
weeks.You will be more comfortable if you do not sit or stand
more than~45 minutes without getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care:Mepilex Ag dressing placed on ___.
Keep this dressing in place for 7 days. You may shower with this
dressing as it is waterproof. If this dressing comes off you may
place a dry gauze dressing daily on until your follow up
appointment. Do not soak the incision in a bath or pool.If the
incision starts draining at anytime after surgery, do not get
the incision wet.Cover it with a sterile dressing.Call the
office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Mepilex Ag dressing placed on ___. Keep this dressing in place
for 7 days. Do not soak the incision in a bath or pool.If the
incision starts draining at anytime after surgery, do not get
the incision wet.Cover it with a sterile dressing.Call the
office. | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Post op course is complicated by poor mobility related to pain
control from "coccyx" pain, constipation, and post surgical soft
tissue swelling. He does
have some soft tissue swelling surrounding his incision but does
not appear to be consistent with csf. He has no drainage and
denies headaches. He mobilized with nursing and ___ without
issues. He was able to have a BM and mobilize with good pain
control before discharge.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. | 567 | 186 |
18522436-DS-17 | 23,513,709 | Mr. ___,
You were admitted to ___ for seizures and
alcohol withdrawl. We watched you overnight and gave you valium
as needed for withdrawl symptoms. We also kept you in a
cervical collar given you had pain along your spine. We were
able to remove this collar before you left.
Please take folate, thiamine, and a multivitamin daily | ___ y/o M with PMHx of alcohol abuse admitted for seizures likely
related to alcohol withdrawl.
.
# Seizures/EtOH withdrawl/Neck trauma- Pt was admitted for EtOH
withdrawl seizure and monitoring for further neurological
events. He was put on CIWA and monitored overnight without
scoring over 10. He did not have further seizures. His C-Spine
was cleared radiologically, although initially he had tenderness
on first exam after not intoxicated. The following day his
tenderness significantly improved and was taken off the
C-collar. Patient was discharged with a multivitamin, folate,
and thiamine.
.
SW was consulted for this patient, and stated that given he is
not withdrawing, he does not meet criteria for inpatient detox.
SW provided a number of resources to patient for both inpatient
and outpatient treatment.
.
>> Transitional Issues
-Pt is to follow up with an NP at ___ who is associated with his
primary care physician
-___ will need continued follow up as an outpatient regarding his
alcohol abuse. | 59 | 162 |
16442612-DS-15 | 21,837,686 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for dizziness and low blood
pressures. You were transfused 2 units of blood as your blood
levels were low. The gastroenterology doctors were ___ and
___ under went an upper endoscopy which showed inflammation of
your duodenum and ulcers that showed evidence of recent
bleeding. You were started on a medication to help these ulcers.
Please continue to take these medications. Please follow up with
the GI team for a repeat endoscopy in 6- 8 weeks. Please follow
up with your PCP about your ___ tests. Please avoid NSAIDS
and aspirin as they increase the chance of ulcers and bleeding.
Sincerely,
Your ___ Team | ___ female patient with history of hypertension,
hyperlipidemia, COPD (still smoking) who presents with
left-sided headache, dizziness, shortness of breath with hx of
duodenal ulcer, melena, guaic positive stool and NSAID use
concerning for upper GI bleed. | 119 | 37 |
12019930-DS-14 | 29,681,521 | You were admitted to ___ because you had leg edema (extra
fluid in your legs). An echocardiogram of the heart showed that
you have normal heart pump function, so the edema is not due to
heart failure. The fluid is probably related to fluid you
required during your recent gallbladder surgery. You were given
medication to remove the fluid and this worked well, so you are
being discharged home.
Note that while you were here you were found to have a small
amount of fluid outside of your lungs (pleural effusions) which
is likely from the same cause. You should have a repeat chest
x-ray in 1 month to ensure that this has resolved (please
discuss this with your PCP). In addition, you should have
routine mammogram screening because you might have a breast
nodule that was felt on exam.
We made no changes to your medication list. | Ms. ___ is a ___ lady with a history of severe
COPD/bronchiectasis on chronic antibiotic suppression and
supplemental oxygen, who was recently discharged from ___ s/p
cholecystectomy who presented with bilateral lower extremity
edema that was likely related to IV fluids she required during
her surgery. She was diuresed with IV Lasix and her symptoms
resolved. She was evaluated by ___, who recommended rehab so she
was discharged to the ___ Living in
___.
#. Leg swelling: edema from recent IV fluids.
Elevated BNP. This most likely represented right heart failure
in the setting of receiving IV fluids for her surgery. TTE
confirmed that she has normal pump function overall. She was
diuresed with IV Lasix for a few days with good effect, and then
she required no more diuresis. At the time of discharge, she is
off diuretics. She should keep her legs elevated. She was
evaluated by ___ who recommended rehab so she was discharged
there.
#. Pleural effusion: also likely to be from recent IV fluids,
needs follow-up.
Though exudative effusion was possible, the effusions were in
the setting of mild heart failure, and were very new in onset
(not visualized on ___, but were present on ___. Per
discussion with Interventional Pulmonology, the effusions are
not large. The decision was made to NOT perform thoracentesis
this admission. She should have a follow-up CXR in 1 month to
ensure resolution. If still present at that time, diagnostic
thoracentesis by I.P. should be considered.
#. Foot pain: unclear etiology, resolved.
On the day before discharge, she developed left foot pain, on
the top of her foot and ankle. Mild erythema and tenderness on
palpation along ankle, but no swelling, reduced ROM, or
weakness. X-ray negative for fracture, and ___ negative for
DVT. The pain resolved with Tylenol overnight and was not
present on the day of transfer. No suspicion for pathology
including cellulitis, but her left foot/ankle should be
monitored to ensure no cellulitis.
#. ?Breast lump: needs follow-up.
On exam one morning she was felt to possibly have small left
breast lump (exam was done in the setting of effusions). No
lympahenopathy. She had a mammogram in ___.
___ WILL NEED A MAMMOGRAM AND/OR OTHER BREAST IMAGING FOR FURTHER
EVALUATION.
.
#. s/p lap chole ___: stable.
No pain, no signs of infection at surgical site. ACS came to
visit patient and agreed that her exam and surgical site are
stable. She will follow up with ACS after discharge.
#. COPD/bronchiectasis: chronic, stable.
She uses 3L NC at home and should continue to use this. She was
continued on her nebs and should continue her prophylactic
monthly Levaquin. She should follow up with Pulmonology after
discharge.
#. Osteoporosis: chronic.
Note that she is not on meds for osteoporosis including Calcium.
This should be considered as an outpatient.
#. Transitional Issues:
-needs follow-up CXR in 1 month to ensure resolution of
pulmonary effusions
-small left breast lump; she had a mammogram in ___ but
should have a mammogram soon after discharge
-no suspicion for pathology including cellulitis, but her left
foot/ankle should be monitored to ensure no evolving cellulitis
-follow up with outpatient Pulmonologist, ACS | 152 | 530 |
13225586-DS-18 | 28,938,147 | Dear Mr. ___,
You were hospitalized at ___ following a fall with likely
loss of consciousness. Talking with you and your family, this
event was likely a vasovagal syncopal episode. It was most
likely due to dehydration (you have been limiting your fluid
intake due to problems with incontinence). Suspicion for other
causes (such as seizures) is very low. You had an EEG test that
measures brain activity which was not concerning for any seizure
activity.
While in the hospital you had an increased white blood cell
count that was concerning for the possibility of infection. A
lumbar puncture ("spinal tap") was attempted however it was
difficult to obtain your spinal fluid. We did not attempt this
test again as the probability of you having a Central nervous
system infection was very low given your clinical picture. While
in the hospital you had an episode of markedly elevated heart
rate and were found to have an irregular heart rhythm(atrial
fibrillation). We started you on a new medication (metoprolol)
to control your heart rate. We've prescribed you 100 mg daily of
extended release metoprolol succinate which you should continue
to take at home. You should follow up with your PCP to titrate
the dose as needed. Atrial fibrillation can increase your risk
of stroke, so please continue to take 81 mg of aspirin daily to
lower your risk. As you were found to have this new heart
condition, you had an ultrasound of the heart. You had an MRI
of the brain which did show some small leaky blood vessels and
small hemorrhage consistent with a condition that can cause
memory decline (amyloid angiopathy). With this condition, you
are prone to having bleeds in the brain so we decided to not put
you on a stronger blood thinner and will keep you on aspirin.
Lastly, because of your urinary incontinence you were given
Flomax but you did not tolerate this medication well and it was
quickly discontinued. In addition, you were found to have a
urinary tract infection and this was treated with antibiotics.
This will continue for 7 days. When you developed this urinary
tract infection, your liver enzymes were also checked and were
found to be only minimally elevated. This can happen for anumber
of reasons. You underwent an abdominal ultrasound which showed a
small gall stone. This can cause an elevation in your liver
enzymes. Please keep an eye if you are to develop abdominal
pain, especially after eating. Your PCP ___ follow up these lab
values when they see you next.
Please do not hesitate to call us with any further questions
here at ___ Neurology. Please follow up with your primary care
physician ___ ___ weeks. | This is a ___ y/o man with medical history of multifactorial gait
disorder, chronic small vessel disease, and remote prostate
carcinoma s/p brachytherapy presenting to the ED following an
episode of convulsive syncope. Family also endorses ___ month
history of personality and behavioral changes and intentional
decrease in fluid intake due to urinary incontinence. Upon
presentation in ED, neurological exam was notable for
drowsiness, waxy posturing, and lack of localizing deficits. CT
c-spine was unremarkable and non contrast head CT showed
atrophy, evidence of small vessel ischemic changes and
atherosclerotic disease but not acute processes. Mr. ___ was
admitted to general neurology service out of concern that his
fall was due to seizure activity. EEG monitoring was performed
which showed no activity concerning for seizure activity. After
admission, Mr. ___ developed a leukocytosis and LP was
attempted in order to rule out an infectious process. An LP was
unsuccessful due to Mr. ___ agitation, however, his
leukocytosis improved the following day and a repeat attempt was
deemed unnecessary.
Mr. ___ confusion continued to improve. An MRI was
performed which showed evidence of chronic micro vascular
disease and microhemorrhages consistent with cerebral amyloid
angiopathy, but no acute intracranial processes or acute
hemorrhage. These changes likely explain the personality and
behavioral changes his family has noticed over the last ___
months. On hospital day 5 Mr. ___ developed tachycardia to
150s and atrial fibrillation. He was started on 25 mg metoprolol
in addition to IV pushes of diltiazem. His heart rate returned
to stable levels and sinus rhythm and he remained
hemodynamically stable throughout the episode. Mr. ___ is
being discharged on metoprolol and daily aspirin to manage new
onset atrial fibrillation . Echocardiogram was of limited
quality but no large cardiac clots were seen on ultrasound. No
further anticoagulation was prescribed due to risk of brain
bleeding given MRI finding of microhemorrahges. He is getting
discharged to rehab per ___ recommendation.
Transitions of Care issues
1. In addition to his home medications, Mr. ___ is
discharged with prescriptions for 100 mg of metoprolol succinate
extended release to be taken daily. Please titrate dose as
needed to control HR.
2. Mr. ___ is encouraged to continue taking 81mg of aspirin
daily in order to reduce his risk of stroke given his atrial
fibrillation.
3. Please continue ceftriaxone 1g for 7 days until ___
4. Patient to follow up with PCP: ___ evaluate for GCA should
he develop pain, visual loss etc. We do not think he had this
during hospitalization. Patient had mildly elevated AST/ALT,
liver ultrasound showed cholelithiasis. | 456 | 426 |
16630240-DS-8 | 24,620,580 | Dear Ms ___,
You presented to ___ because your blood sugar
was very high and you were having another episode of diabetic
ketoacidosis.
While in the hospital, you were treated with an insulin drip in
the ICU and your labs were monitored very closely. You were seen
by our podiatry team because of the wounds on your feet. You
were also seen by our kidney team and our diabetes specialists.
Your blood sugars improved and you were able to leave the ICU.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Please be sure not to walk until told by Podiatry, as it can
affect the healing of your foot wound.
Good luck! | ___ year old type 1 diabetic with non-healing foot ulcers
complicated by osteomyelitis of left fifth toe s/p partial
amputation in ___ and right hallux partial amputation and
heel debridement on ___ found to have MSSA bacteremia and
started on cefazolin for total 6 week course presented after
routine labs revealed rising BUN and creatinine and elevated
blood glucose concerning for DKA. | 122 | 62 |
19136566-DS-11 | 21,120,631 | Dear Ms. ___,
It was a pleasure caring form you during your hospitalization at
the ___. As your know, you came
in with chest pain. We did tests which showed that your heart
had some injury from working too hard from a fast heart rate.
When you came into the hospital, your heart was in atrial
fibrillation with fast heart rates. You treated you with
medications, including a new medication called Amiodarone. Your
heart rate continued to be too fast and we had to shock your
heart (called cardioversion) back into normal rhythm. You did
well with this procedure. You will need to continue to take the
new medication called Amiodarone when you are discharged from
the hospital. At discharge, your chest pain resolved. Please
take your medications as instructed. Please followup with your
primary care doctor and cardiologist. If your develop any
worsening chest pain, fast heart rates, lightheadedness, nausea,
or vomiting, please seek medical attention urgently.
Sincerely,
Your ___ Care Team | ___ y.o. woman with HTN, DM, CAD with positive ETT in ___,
and Afib on Apixaban presenting with exertional chest pain.
# Chest Pain/Coronary Artery Disease: Patient with known CAD
(positive ETT in ___. Patient presented with exertional angina
consistent with her known stable angina. CXR unremarkable. EKG
notable for ST depression in V3 and TWI in V4-V6. Trop 0.01->
0.02->0.03. Likely from known CAD/stable angina. Trop 0.01->
0.02->0.03, likely from demand ischemia in the setting of Afib
with RVR as detailed below. The patient was continued on her
home Aspirin, Atorvastatin, Imdur, and SL Nitro. At the time of
discharge, the patient's chest pain had resolved.
# Atrial Fibrillation: CHADS score of 3. On admission, vitals
were T 98.0 HR 120 BP 99/58 RR 18 SpO2 98% RA. EKG initially
notable for Afib with ST depression in V3 and TWI in V4-V6. Trop
initially neg, BNP 906, TSH 1.1. CBC and Chem 7 were all within
normal limits. During her ED course, the patient experienced
nausea and vomiting and was given IV Zofran. She was found to be
in Afib with RVR. She was initially was given IV Metoprolol with
no relief. She was started on ASA 324 mg, given 1 L NS. Her home
Pindolol was discontinued. She was subsequently loaded with 400
mg PO Amiodarone. Given Afib with RVR and soft SBP ___, the
patient was subsequently electrocardioverted with resulting NSR
HRs ___. On the floor, the patient's was continued on her home
Apixiban. Amiodarone was continued. At the time of discharge,
the patient continued to be in NSR with HR 60-70s. She was
discharged on an Amiodarone taper. | 160 | 271 |
15958024-DS-30 | 22,299,399 | Dear Mr. ___,
It was a pleasure caring for you at ___.
You were admitted for an exacerbation of your heart failure and
your kidney function worsened. You received intravenous lasix
which removed the extra fluid. Your weight at discharge is
86.8kg. It is very important that you take all of your pills
every day and weigh yourself every morning, call Dr. ___
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
You will have metolazone at home that you can take in that
instance too or if you have symptoms of fluid overload such as
weakness and swelling in your lower legs.
Your kidney function is worse than it was before and you are due
for your appt with Dr. ___. Please make an appt to see him in
the next month.
Please do not take metolazone until ___, and only if
you notice an increase in your weight. | Mr ___ is a ___ year old gentleman with history significant
for CAD s/p BMS to pLAD ___, ischemic cardiomyopathy with EF
25%, s/p ICD placement ___, mild aortic valve stenosis (valve
area 1.2-1.9cm2, max gradient 26mmHg) and CKD who presents with
hypotension and lethargy presenting from ___ clinic for
evaluation of hypotension, found to be in heart failure with
AoCKD.
# Acute on Chronic Congestive Heart Failure with Systolic
Dysfunction: Precipitants may include recent URI superimposed on
chronic dietary non-compliance due to living circumstances. Also
has anemia slightly worse than baseline. No report of arrythmia
(based on EP evaluation), no e/o acute MI on EKG, and is
compliant with home medications. Weight on admission 91.7Kg, up
from dry weight of 88.0Kg. Has mild AS per last ECHO in ___.
Repeat ECHO on admission unchanged from previous (EF ___. Pt
was initially placed on dobutamine gtt in the setting of
hypotension and ___. He was diuresed aggressively with lasix IV
and metolazone 5mg prn. Upon further improvement, dobutamine gtt
was weaned off and pt was started on home dose torsemide 120mg
daily with metolazone 5mg prn. Weight on discharge 86.8.
Carvedilol was initially held in the setting of hypotension and
resumed once BP's stable. Lisinopril was held throughout
hospitalization. On day of discharge, creatinine was elevated to
3.0 (baseline 2.0-2.5). Thus, lisinopril was discontinued on
discharge until pt follows up with PCP in ___ few days and it may
be resumed once electrolytes/kidney functions are stable on
outpatient f/u. Pt was discharged on metolazone ___ and
instructed to take it only if weight up and symptomatic.
# URI: pt presented with productive cough with thick sputum x1
month. Pt was treated with levofloxacin 750mg Q48 x5 days, last
dose on ___.
# ? RV Pacer lead malfunction: Pt reports beeping sound and
shown to have increased impedence on interrogation. Concern for
possible fracture of SVC coil on RV pacing/defib lead. Evaluated
by EP and taken for lead fluroscopy and DFT testing. Pt will
follow up with EP in one month.
# AoCKD: Baseline reportedly 1.7-1.8, but over past few months
has been in 2.2-2.5 range. Most likely prerenal in the setting
of poor forward flow due to acute on chronic CHF. Pt was
initially placed on boutamine gtt and aggressive diuresis. On
day of discharge, creatinine was 3.0 (up from 2.6) most likely
from aggressive diuresis with home dose torsemide 120mg and
metolazone 5mg. Pt was instructed to hold metolazone dose for
the next two days and only take it then if an increase in weight
or symptomatic.
- Continue home vitamin D
- Continue home cinacalcet
# Troponemia: thought ___ demand.
# Anemia: Low but stable. No signs of acute bleeding.
- continue iron, B12 and folate supplementation
# CAD s/p BMS ___: no chest pain
- Continue ASA 81mg daily
- restarted carvedilol 6.25 BID
- Continue simvastatin 40mg daily
- Hold lisinopril in setting of elevated Cr today
# BPH:
- restarted tamsulosin. | 156 | 493 |
16073473-DS-16 | 25,494,191 | you were hospitalized for blocked bile duct. tumor is invading
these ducts and causing blockadges treated with biliary stents
via ercp
we discussed imaging findings
you will return for repeat ercp
the ercp doctor ___ talk to your oncologist | ___ year old female with history of metastatic colon cancer and
obstructive jaundice and biliary stent in past 2 months,
transferred from ___ for possible cholangitis
# Cholangitis
# Jaundice: obstructive pattern on labs, no current abdominal
pain. Febrile in OSH ED to ___. She has history of previous
obstruction. Concern for malignant obstruction. Given ercp
fidnings and lack of frank purulence and her severe nausea it
was decided with ercp not to prescribe cipro at time of
discharge.
gi and her oncologist will discuss future ercp and biliary stent
options.
will need to return for repeat ercp in ___ weeks
imaging showed possible lung mets and known hepatic mets
i did not obtain ct chest given that she has oncologist who may
have already been scanning her chest
ercp
A 12cm by ___ biliary stent was placed successfully in the left
main hepatic duct.
A 12cm by ___ biliary stent was placed successfully in the right
main hepatic duct.
Impression: Scout film revealed previously placed straight
plastic stents in right anterior and right posterior hepatic
branches.
These stents were also seen endoscopically; they were removed
via snare.
Evidence of a previous sphincterotomy was noted in the major
papilla.
A cholangiogram was performed:
The CBD was normal in diameter without filling defects noted.
A malignant appearing stricture was seen at the bifurcation of
the main biliary duct.
There was no filling of the intrahepatics noted.
A wire was advanced into the left sided hepatic branch
successfully.
Using dual wire technique, a second wire was advanced into the
right sided hepatic branch successfully.
A 12cm by ___ biliary stent was placed successfully in the left
main hepatic duct.
A 12cm by ___ biliary stent was placed successfully in the right
main hepatic duct.
# Colon cancer: metastatic to liver. Not currently undergoing
chemotherapy. | 37 | 304 |
18572266-DS-8 | 21,414,781 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
Right lower extremity: Non-weight bearing
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-discharge.
******FOLLOW-UP**********
You will be readmitted to ___ on ___ with plans for
scheduled surgery on ___.
Physical Therapy:
Right lower extremity: Non-weight bearing
Treatment Frequency:
None | The patient was admitted to the Orthopaedic Trauma Service for
evaluation of right hip pain with work up for a septic joint and
pain control in setting of three week history of progressively
worsening pain. The work up for infection, which included right
hip ___ guided aspiration, as well as basic labs and inflammatory
marker assessment, was negative for infection. The patient's
pain has been well controlled with po pain meds. X-rays of her
right hip revealed migration of the acetabular component and a
fracture in the acetabulum, both of which will require surgical
repair. She will be discharged to rehab today and be directly
readmitted on ___ for scheduled revision surgery on
___. She may present to ___ anytime prior to 7:00
pm.
Weight bearing status: Right lower extremity non-weight bearing.
The patient received Lovenox for DVT prophylaxis. The incision
from her surgery on ___ was clean, dry, and intact without
evidence of erythema or drainage; and the extremity was NVI
distally throughout. The patient was discharged in stable
condition with written instructions concerning precautionary
instructions and the plans for readmission. The patient will be
continued on chemical DVT prophylaxis for 4 weeks
post-operatively. All questions were answered prior to
discharge and the patient expressed readiness for discharge. | 199 | 215 |
17815790-DS-13 | 24,645,477 | Dear Ms. ___,
It has been a pleasure taking care of you at ___. You were
admitted because of worsening nausea, vomiting, and abdominal
pain. There was also concern about GI bleeding. An endoscopy was
performed on admission, which did not show active upper GI
bleed. You were found to have CDiff colitis, and were started on
oral vancomycin. We also started you on antibiotics for a
possible pneumonia, as well. Your nausea and vomiting persisted,
so we started you on a scopolamine patch, and also performed a
therapeutic paracentesis. You also received your scheduled dose
of chemotherapy, and we did the staging CT you were scheduled to
have as an outpatient. Your symptoms improved and you are ready
to go home. You will need to finish 14 days of oral vancomycin
following your last dose of levofloxacin. Please follow up with
Dr. ___ as scheduled. It has been a pleasure taking care
of you,
Your ___ care team. | PRINCIPLE REASON FOR ADMISSION:
___ with Adenocarcinoma of the gastroesophageal junction, stage
IV (Her2-), on palliative Paclitaxel/Ramucirumab presenting with
concern for melena/hematemesis with no obvious source of
bleeding on endoscopy, now found to have CDiff colitis and PNA.
Course complicated by nausea and vomiting, improved s/p
paracentesis..
# CDiff colitis: First known recurrence of CDiff. Recently
finished course of po vancomycin on ___. Started po
vancomycin on ___ and diarrhea improved.
Plan to complete 14 days following completion of abx for PNA
(through ___.
# Abdominal pain:
# Nausea/vomiting: Intractable, and acute on chronic. Likely
exacerbated by CDiff colitis. Endoscopy was unremarkable.
Scopaliamine and reglan was started with some relief. CT scan on
___ showed moderate ascites, and she underwent therapeutic
paracentesis on ___ with good relief. Otherwise continued her
antacid regimen including PPI/H2 blocker/Viscous
lidocaine/Sucralfate along with her opioids and antiemetics
including Zofran and dexamethasone. Home TPN was continued.
# Transamintis: Unclear etiology. CT a/p on ___ was generally
unremarkable. Hepatitis serologies were negative, and were
transaminases were downtredning on day of discharge.
#? Melena - Concerning given recent Ramucurumab (VEGF inhibitor,
most recent dose on ___. Endoscopy did not show active
bleeding. ___ be due to CDiff. Does have down trending HCT,
although likely due to chemo effect. PPI was continued.
#GE adenocarcinoma - Currently on palliative
Paclitaxel/Ramucirumab. ___ and she received D8 Paclitaxel
on ___. Will follow up next with with primary oncologist for
further treatment.
# Leukocytosis
# Fever:
# Pneumona: Leukocytosis likely from CDiff colitis, and was
downtrending with treatment. Patient also with new productive
cough and ? PNA on CXR and CT. Started levofloxacin with plan to
finish 5 day course on ___.
# Dysphagia/odynophagia. Persistent. Due to malignant distal
esophageal obstruction. S/p distal esophageal stent placement
___ by Dr. ___. Continued with opiates, maximal
anti-acid therapies, topical anesthetics. TPN continued.
# GERD. Due to esophageal stenting. Persistent. Continued
high-dose anti-acid therapy with Pantoprazole BID, Ranitidine
BID, and Sucralfate.
# Peritoneal carcinomatosis:
# Malignant ascites. Most recent paracentesis ___. Repeat
CT scan showed reaccumulation of moderate ascites. Underwent
therapeutic paracentesis on ___. Torsemide and spironolactone
were initially held given N/V/D. Restarted prior to discharge.
# Nutrition. Continued TPN as per the home care team.
# Bilateral malignant pleural effusions: S/p
bilateral pleural catheter placement by ___ in ___. She
received weekly drainage at home via her ___. Drained in house
on day of discharge.
# RLE DVT, LUE DVT. On Lovenox 1mg/kg SC BID indefinitely.
Initially held on admission, restarted on ___.
# Anemia. Due to anemia of chronic inflammation/cancer. No
bleeding noted on endoscopy.
ACCESS: A L-sided port was placed ___. A RUE PICC was
placed for TPN on ___.
CODE STATUS:
- Full
DISPOSITION: Home with services. | 157 | 447 |
10414622-DS-10 | 29,875,260 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
for an exacerbation of your asthma. You were treated with
inhalers and steroids. It is very important for you to continue
taking your medications as prescribed. It is also very
important for you to stop smoking.
Please see below for your upcoming appointments.
Sincerely,
Your ___ team | Ms. ___ is a ___ year old woman with mild intermittent asthma
who was admitted with dyspnea and cough, and found to have an
asthma exacerbation.
#Asthma Exacerbation:
Pt presented with an asthma exacerbation likely precipitated by
recent upper respiratory infection. On admission, pt noted to
have a peak flow of 150 (33% predicted) that improved to 200
(44% predicted) after nebulizers. No evidence of infiltrates on
CXR, and negative flu swab. Pt was managed with nebulizers and
prednisone with significant improvement. On discharge, peak flow
350 (76% predicted). Pt discharged with albuterol inhaler and a
plan to complete a 5-day course of prednisone (last day
___.
# Chest discomfort:
On admission, pt reported intermittent chest discomfort that was
non-exertional and not relieved by rest. Initial EKG with
inferior submm STD that resolved on repeat EKG with normal
rates. Troponin negative. Likely secondary to asthma
exacerbation with low suspicion for ACS.
# Anxiety:
Continued home citalopram
# Sleep apnea:
Continued home CPAP
TRANSITIONAL ISSUES
==================================
1. Consider outpatient PFTs
2. Consider outpatient stress test.
3. Pt should have ongoing smoking cessation counseling. Pt
discharged with nicotine patches but would like to discuss
Chantix and Bupropion with her PCP.
4. Pt should complete a 5-day course of prednisone (last day
___
# CONTACT: Boyfriend, ___ ___
# CODE STATUS: full code, confirmed with patient | 62 | 215 |
15689544-DS-19 | 20,594,750 | You were admitted with worsening shortness of breath. You had a
COPD exacerbation and were treated with steroids, antibiotics
and inhalers. Your breathing slowly improved and you were able
to continue to treat the exacerbation at home.
You were found to have a lung mass on CT scan of your chest.
Interventional pulmonology did a bronchoscopy with biospy of
lymph nodes although this was non-diagnostic. You will need to
follow up on ___ for a PET scan.
You also had abdominal distension. This has been a problem for
your recently and we did not determine a cause. You do have some
atypical findings on your CT that will need to be followed
closely. I recommend you follow up with Dr. ___
___ further evaluation and management of this problem. | ___ y/o female with a hx of asthma, severe COPD and squamous cell
lung CA ___ s/p resection who is admitted with 2 weeks of SOB
and found to have COPD exacerbation and lung mass.
# Acute COPD exacerbation: She was treated with prednisone 40mg,
inhalers/nebulizers and antibiotics (CTX and doxy, which was
later switched to cefepime based on micro data). Her breathing
improved, however, it wasn't at baseline. She was discharged
with a plan to taper her streoids. In addition her bronch grew
three species of pan-sensitive pseudomonas. In the setting of an
acute exacerbation, the decision was made to treat for a total
of 14 days. She has follow up in place with Dr. ___ on
___.
# Lung mass: The differential includes a new primary lung mass
versus recurrence of NSCLC. IP was consulted and biopsy were
taken although non-diagnostic. Thoracics was consulted that
deferred a VATS and recommended an outpatient PET. She it to
follow on ___ with interventional pulmonology for a
PET scan and potential bronch.
# Abdominal fullness/early satiety: The etiology is unclear. She
was set to undergo EGD, however, this had to be cancelled as she
was an inpatient. She still needs further evaluation of her
abdominal fullness as this remained a problem throughout her
admission. CTAP did not show a clear etiology.
# Adrenal adenoma, kidney lesion: The patient will need follow
up of the adrenal adenoma and kidney lesion. The results of the
CTAP and MRI were discussed with her PCP who will complete the
further evaluation.
Full Code | 127 | 254 |
15437028-DS-9 | 26,337,868 | Dear ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You were having increased secretions from your tracheostomy
and blood in your urine
What was done while I was in the hospital?
- We obtained cultures that showed you had a urinary tract
infection, a pneumonia, as well as a bloodstream infection
- Your heart began to beat in an abnormally fast rhythm; you
were started on a beta blocker, which improved this
- You had a procedure with the interventional pulmonologists to
exchange your tracheostomy tube to a smaller size
What should I do when I get home from the hospital?
- You will continue to get your IV antibiotic (nafcillin) until
___
- You will need labs every week while on antibiotics, which will
be drawn at ___
- Continue to take all of your other medications as prescribed
- You will be contacted by the infectious disease doctors for ___
follow-up appointment at some point over the next few days
- If you have fevers, chills, worsening problems breathing,
increased phlegm production, or generally feel unwell, please
call your doctor or go to the emergency room
Sincerely,
Your ___ Treatment Team | SUMMARY STATEMENT
Ms. ___ is a ___ year-old woman with history of recent
traumatic spinal cord injury with resultant paraplegia s/p trach
and PEG and chronic Foley, atrial fibrillation on warfarin,
asthma, diabetes, HTN, and OSA, who presented with hematuria and
increased secretions from her tracheostomy, ultimately diagnosed
with MSSA pneumonia and bacteremia. Hospital course complicated
by a fib with RVR requiring brief period in MICU. | 190 | 65 |
19383073-DS-13 | 21,183,249 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
You were admitted to the hospital because you had a significant
amount of food in your esophagus. You also aspirated food into
your lungs, which caused you to develop pneumonia.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
In the hospital, you had a breathing tube placed (INTUBATION) to
assist with your breathing, and you were admitted to the ICU.
After you improved, you were discharged from the ICU onto the
general medicine floor. You had a chest x-ray that showed a
possible pneumonia, and you were started on two antibiotics,
CEFEPIME and VANCOMYCIN. You were later switched to an
antibiotic called CEFTRIAXONE, which you took for 7 days.
You were kept upright and did not receive any fluids, food, or
medications by mouth for several days. You then had a CT scan of
your esophagus that did not show significant improvement in the
amount of food left, so you had a procedure (EGD, or
EsophagoGastroDuodenoscopy) done to remove the food from your
esophagus. During the procedure, the surgeons removed the
remaining food from your esophagus, examined your esophagus and
stomach for abnormalities, and placed a feeding tube (PEG tube,
or Percutaneous Endoscopic Gastrostomy tube). They did not see
any abnormalities in your esophagus or stomach.
After your procedure, you started using your feeding tube for
nutrition and medications.
WHAT HAPPENS AFTER I LEAVE THE HOSPITAL?
========================================
-Please follow the instructions on how to use your feeding tube.
As we discussed, we recommend that you do not eat anything by
mouth except clear liquids and use only your feeding tube for
nutrition. If you choose to eat anything by mouth, please note
that this does put you at risk for getting food stuck in your
esophagus again and possibly having to come back to the
hospital. If you do choose to take this risk, please limit your
intake to liquids and soft foods only, and limit your meals to
small snacks, with at most one meal/day.
-Please take WARFARIN 5mg daily and follow up with your
outpatient provider at your appointment on ___ (details
below) to make sure your INR returns to the correct range.
-Please take a half tablet of SPIRONOLACTONE daily for your leg
swelling. Please check your weight daily, and if your weight
increases more than ___ lbs over the next few days, or if you
develop difficulty breathing, please call your cardiologist to
make an appointment.
-We switched two of your medications so that we can deliver them
through the PEG tube: your METOPROLOL SUCCINATE XL was changed
to METORPOLOL TARTARATE, and your OMEPRAZOLE was changed to
PANTOPRAZOLE. These new medications will work in the same way as
your old medications.
-Please call the GI office in ___ at ___ to
schedule a three month follow up appointment for your procedure
(end of ___. You may also contact GI if you have any questions
about your diet.
- Please weigh yourself daily and call your cardiologist if your
weight increases by ___ pounds (for management of your heart
failure).
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY:
================
Mr. ___ is an ___ M w/ hx of severe achalasia (diagnosed
40+ years ago) and recurrent esophageal obstructions s/p ___
myotomy, GERD, CAD s/p CABG x 2, HFrEF with EF 36% s/p AICD
placement, and pAFib c/b CVA ___ on warfarin s/p PPM placement,
presenting with food in esophagus secondary to achalasia c/b
aspiration PNA requiring intubation now s/p extubation and ___lso s/p EGD ___ with PEG placement. | 521 | 70 |
12415393-DS-13 | 26,671,830 | Dear Ms ___,
Why was I admitted to the hospital?
- You were admitted to the hospital because you had been feeling
short of breath and were having palpitations, and you were found
to have fluid on your lungs. This was felt to be due to your
heart failure.
What happened while I was admitted?
- You were given a diuretic medication through the IV to help
get the fluid out.
- You were weighed and your weight came down with the diuretic
medication we gave you.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please call your primary care doctor, ___,
___, on ___ morning to ask for an INR check
and a follow up appointment within one week.
- Please keep a low salt diet (goal of less than 2 grams of
sodium per day)
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs in 1 week.
- 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.
It was a pleasure participating in your care. We wish you the
___.
-Your ___ Cardiology Team | ___ old woman with a history of endometrial CA and HFpEF
(>55%) who presents with dyspnea and palpitations, found to have
volume overload concerning for heart failure exacerbation likely
secondary to dietary noncompliance. She was diuresed with IV
lasix then transitioned to back to her home regimen Lasix 40 mg
daily. Her discharge weight was 72.8 kg.
# CORONARIES: Unknown
# PUMP: EF >55%
# RHYTHM: Atrial fibrillation
ACTIVE ISSUES:
====================================
#HFpEF: Ms. ___ was noted to have a 2 pound weight gain above
her dry weight in the setting of noncompliance with a low sodium
diet for the past week. Her reported dry weight was 164 lbs.
Work up for infection or ischemic event was unremarkable. She
was noted to be grossly volume overloaded on exam, with crackles
in her lungs, pitting edema, and an elevated JVP. She was
diuresed with lasix IV 40-80 mg ___ times each day until she had
significant symptomatic improvement. Her discharge weight was
72.8 kg.
#Type 2 NSTEMI: Mild trop elevation to 0.03 and stabilized.
Likely attributed to her heart failure exacerbation as above.
CHRONIC/STABLE ISSUES:
====================================
# Atrial fibrillation: CHADSVASC 4. Rate controlled so far and
anti-coagulated, though some concern for increased tachycardia
given subjective palpitations. Patient remained in atrial
fibrillation. She should continue her metoprolol succinate XL
125 mg daily. She may consider a NOAC as outpatient after
discussion with PCP given labile INRs. Her INR at discharge was
3.7. She was instructed to hold her warfarin dose the night of
discharge (and resume it the following night) and call her PCP
___ ___ for an INR check and follow up.
# CKD: Cr 1.2 from 1.4 in ___. Her creatinine remained
stable at 1.2.
#HLD: Continued home atorvastatin | 219 | 279 |
18230892-DS-7 | 20,187,726 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted with shortness of breath and were
found to have extra fluid in your body. You were given strong
doses of lasix to help remove this extra fluid. However, you
then became confused, had fevers, and had low blood pressures.
You were transferred to the ICU for closer monitoring, where you
were found to have a urinary tract infection. You were started
on antibiotics, and you eventually improved.
It will be important for you to continue taking these
antibiotics for a total of 14 days. Therefore, your last day of
antibiotics will be ___. | ___ with PMH significant for diastolic dysfunction with EF >55%,
moderate pulmonary HTN who presented with worsening exertional
dyspnea since falling out of a wheelchair 3-days prior to
admission.
# UTI - Pt was admitted to MICU for altered mental status and
hypotension in the setting of urine culture positive for GNR
with concerns for urosepsis. She was initially treated with
broad spectrum antibiotics which were narrowed to ciprofloxacin
on ___, once sensitivities returned on the E.Coli growing in
the urine. Her leukocytosis, blood pressure, and mental status
improved with continued treatment. However, it was thought her
blood pressure may have been secondary to overdiuresis v.
infection. She developed this infection in the setting of a
urinary catheter, and so should take ciprofloxacin until ___ to
complete a full, 14-day course.
# Acute encephalopathy - Likely delirium attributed to UTI,
though she also had evidence of metabolic alkalosis with
compensated hypercarbia - but her CO2 appeared inappropriately
elevated and a secondary process to explain her hypercarbia may
have been responsible, such as impending pneumonia vs.
aspiration. Due to her altered mental status and concern for
aspiration, an NG tube was placed in the MICU and tube feeds
were initiated. As her mental status improved with treatment of
her UTI, she was evaluated by speech/swallow, who recommended a
regular diet. The NG tube was removed and the tube feeds
discontinued. Her home trazodone and oxycodone were held in this
setting - though these can be considered for re-initiation as
her mental status improves, if clinically indicated.
# Acute on chronic diastolic congestive heart failure - She
initially presented with significant volume overload on exam
with pulmonary edema, sacral edema and JVP elevation with
hypoxemia. Her proBNP was > 32,000. The trigger for her
exacerbation remained unclear. She responded to initiation of
continuous lasix infusion with adequate improvement in
oxygenation and volume status. However, diuresis was limited by
subsequent hypotension. Upon transfer to the MICU, her diuresis
was held. She was re-started on her home torsemide on ___, her
home spironolactone and isosorbide mononitrate on ___. Her
weight upon discharge was 43.9kg, she was 89-92% RA, but 97% on
1L NC.
# Fall - There were reports on admission that she fell from out
of bed a few days prior to admission, though she did not hit her
head or lose consciousness. She had her T-spine and lumbosacral
spine imaged upon admission, that only demonstrated a stable
compression of the T12 vertebral body and mild anterolisthesis
of L4
over L5 as seen on the lumbar spine radiographs.
# Wounds on her coccyx - Per wound care, there is an unstageable
pressure ulcer, present on admission, that measures approx 2 x 2
x 1 cm with undermining
from ___ o'clock, 1 cm deep on the left aspect of her coccyx.
There is an unstageable pressure ulcer, present on admission
that measures approx. 0.3 x 0.3 x 2 cm depth with undermining 2
cm along the periphery at the right aspect of the coccyx. There
was also a skin tear (maybe related to tape injury) that is
partial thickness, approx 1.5 x 1 cm, 100% red wound bed with
irreg wound edges, no periwound s/s of infection at the midline
of the coccyx. Surgery was consulted to evaluate these lesions
as well, but it was determined that she did not need surgical
intervention. ___ care RN left recommendations, which are
documented in the page 1 referral form.
# Acute kidney injury - Baseline 1.1 as recent as ___.
Elevated on admission to 1.7. Her creatinine continued to rise
in the setting of diuresis, reaching a peak of 2.0, though
trended down to 1.1 on discharge.
# Moderate pulmonary hypertension - Does not require any oxygen
at baseline and is not currently managed medically. She was on
nasal cannula oxygen supplementation during this
hospitalization.
# Coronary artery disease - Her home beta-blocker was initially
held, though re-started at a lower dose than her admission
dosage given labile blood pressures while in the MICU. This can
be uptitrated as tolerated if clinically indicated. Her
isosorbide mononitrate was re-started on ___. She has a
reported allergy to aspirin, though the reaction is unknown.
# Hypertension - Beta blocker initially held in setting of acute
CHF exacerbation, though was continued at a lower dose prior to
discharge.
# Hyperlipidemia - Continued simvastatin
# Sciatica - Held neurontin 100 mg PO TID given encephalopathy,
though was re-started on ___. She was also provided a
lidocaine patch for pain relief.
# Chronic lymphedema of LLE - Secondary to history of sarcoma
with radiation therapy. Noted throughout her medical record. | 112 | 762 |
14448178-DS-19 | 23,411,154 | Dear Ms. ___,
You were admitted to the hospital with fevers and weakness. You
were found to have the flu. We started you on a medication to
help decrease the severity of the symptoms. We gave you IV
fluids and medication for your fevers. At this time we feel that
you are safe to go home. However, it is important for you to
wear a mask for the next 4 days when you are around other people
in order to prevent the spread of the virus. It is also VERY
important for you to drink fluids, eat chicken soup and stay
hydrated.
We hope you feel better soon. It was a pleasure to be a part of
your care,
Your ___ treatment team. | Ms. ___ is an ___ year old woman with a history of
hypertension, peripheral vascular disease, microcytic anemia who
presents with a 2 day history of fever, myalgia, and fatigue
found to be influenza positive.
# Influenza A: Ms. ___ received her first dose of
oseltamivir in the ED and is discharged with a plan to complete
a five day course. She received IV fluids in the hospital and
was able to tolerate PO intake. She was continued on standing
Tylenol in-house. There was no evidence for bacterial
superinfection or respiratory decompensation. She is discharged
home with ___ services. She and her family were extensively
counseled on hydration including soups and broths to ensure that
she does not become dehydrated or hyponatremic. Both the patient
and the family expressed understanding.
# Microcytic anemia: Last colonoscopy in ___ revealed several
polyps for which she underwent polypectomy. She was advised to
undergo repeat colonoscopy in ___ years, though has not done so
yet. She will need ongoing GI follow up for repeat colonoscopy.
# Pancytopenia: New since admission and likely secondary to
myeolsuppression in the setting of acute illness. | 120 | 186 |
13124363-DS-6 | 21,588,098 | It was a pleasure to care for you Ms ___. You were found to
have a large kidney tumor which was invading the liver. You had
a fever and there was a concern for infection either from the
liver or that the kidney tumor itself was infected. Please
complete a total of 10 days of antibiotics including the
antibiotics you took in the hospital. | Ms. ___ is a ___ year old female, with past history of
Hypertension, Urinary Incontinence, Dementia, presenting with
fall, with workup c/f abdominal mass with renal primary.
.
>> ACTIVE ISSUES:
# Abdominal Mass: Druing workup for fall, patient found to have
an abdominal mass during workup. Patient had an ultrasound and
abdominal CT scan concerning for a large renal mass invading the
right hepatic lobe. Tumor markers were sent with AFP and ___
given unclear primary origin, however radiographically
concerning for renal cell carcinoma. Goals of care meetings were
held with family regarding further workup. Heme onc was
involved. She underwent a limited MRI since she was not able to
obey commands. Radiology and Oncology agreed that the tumor was
most likely of renal origin and given her functional status no
treatment options were available. Her life expectancy was
estimated at months to a year with a wide variation. Several
family meetings were held with the patients daughters who did
not want to pursue aggressive w/u nor treatment. She was thus
discharged to the memory care unit with ___ with the plan to
transition to hospice.
.
# Fever: Patient was found to be febrile in the ED, and
concerning for infection vs. underlying malignancy. Imaging with
heterogenieity, and initial concerns for possible superimposed
infection if tumor itself was necrosing vs cholangitis from
biliary obstruction caused by tumor. Vanc and zosyn were
switched to po antibiotics prior to discharge. She remained
stable and thus and she was discharged on po antibiotics to
complete a 10 day course of abx in total.
.
# Metabolic Acidosis: Patient presented witb an anion gap
acidosis, felt likely to be due to elevated lactate. Her urine
was without ketones. Serial lactates were followed, which
improved with volume resucitation.
.
# Fall: Unclear specific trigger, per OMR note no prior falls
prior to ___. Patient may have had abdominal pain, and
vagal episode ___ to underlying malignancy. Patient found to
have poor PO intake (specific gravity elevated, lactate
resolving with IVF), initial trauma workup with CT head/neck
negative.
.
# Transaminitis: Patient found to have acutely increased from
prior, likely reflecting underlying primary renal malignancy
invading into the right hepatic lobe. LFTs were trended during
hospital stay.
.
ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
- She was found to have acute on chronic heart failure in the
setting of fluid resuscitation and holding her home lasix. Her
chest CT demonstrated mild pulmonary edema. Her BNP > 10, 000.
She was digressed with lasix 20 mg IV bid Even with the
elevated BNP she never developed wheezes, rales nor shortness of
breath.
.
CHRONIC ISSUES
# Hypothyroidism: Continued home levothyroxine
# Atrial Fibrillation: Patient continued on home metoprolol.
Aspirin was held initially in the setting of possible
hypovolemia from tumor and concerns for bleeding. ASA was then
continued to be held in case she needed a biopsy. It was
confirmed with her daughters that she had not been considered a
candidate for coumadin.
# Dementia: At baseline. Home namenda was continued.
# Bladder Incontinence: Continued home oxybutinin
# Depression: Continued ___ sertraline.
TRANSITIONAL ISSUES
# Contact: Daughter, ___, health care proxy, ___
# Code: DNR/DNI (confirmed with daughter and HCP. MOLST form
also completed. | 64 | 532 |
13937874-DS-15 | 20,982,322 | Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
admitted for abdominal pain, and tests performed in the hospital
did not show new infection or bleed in your abdomen. This was
most likely residual pain from your pseudoaneurysm, which was
embolized during the last hospitalization. You were treated with
lidoderm patch, tylenol, and tramadol. A paracentesis was
performed, which did not show any evidence of infection. | ___ with history HCV/EtOH cirrhosis c/b hepatic encephalopathy,
portal hypertension, esophageal varices, and ascites, HTN, and
depression with a recent hospitalization for abdominal pain
following paracentesis 3 days prior to admission, and who was
found to have pseudoaneurysm in the left internal oblique muscle
at the site of recent paracentesis status post thrombin
injection presenting with abdominal pain.
# Abdominal pain: This was likely residual muscular /
superficial pain from recurrent taps in the LLQ, with healing
pseudoaneurysm in the internal oblique muscle. Patient s/p
successful obliteration of a LLQ subcutaneous, 1 cm
pseudoaneurysm with approximately 200 units of topical thrombin
without complication on the previous admission. CT abdomen
showed no extravasation into the peritoneum, no abscess, and
stable pseudoaneurysm. ___ paracentesis showed no evidence
of SBP (WBC < 250). He was treated with lidoderm patch, low dose
acetaminophen, and tramadol. At the time of discharge, his
abdominal pain was much improved.
# HCV/EtOH Cirrhosis: c/b portal hypertension, varices, hepatic
encephalopathy, and ascites requiring paracentesis every 2
weeks. He has previously not tolerated higher doses of diuretic
therapy in the past secondary to renal impairment. He was
continued on his home lasix 40mg BID, lactulose / rifaximin,
nadolol, PPI, and ciprofloxacin for SBP prophylaxis.
# HTN: he was continued on his home nadolol and furosemide.
TRANSITIONAL
# Mr. ___ was admitted with left sided abdominal pain, most
likely residual pain from his pseudoaneurysm s/p ablation in the
previous hospitalization. ___ paracentesis did not show
evidence of SBP. CT abdomen showed stable pseudoaneurysm without
acute extravization or intrabdominal process. He was treated
with lidoderm patch, low dose acetaminophen, and tramadol prn.
Please follow up to ensure that his abdominal pain is stable.
# Full code | 73 | 285 |
17779248-DS-12 | 23,619,822 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
You came to the hospital because you were feeling shortness of
breath and became unresponsive. You required a breathing tube to
help you breathe. This was because you had a COPD exacerbation
and we treated you with steroids, antibiotics, and breathing
treatments. We also gave you a IV diuretic, which is a
medication that helps you urinate to get rid of fluid in your
lungs. Lastly, we did an ultrasound of your heart
(echocardiogram) which showed that your heart was stiff. We
recommend that you discuss with your primary care physician
regarding possible need for a diuretic medication (furosemide)
at home.
Please weigh yourself daily. Your dry weight is 163.6 pounds, or
74.21 kg. If your weight increases by 3 pounds, please call your
doctor to discuss whether you need to be started on a low dose
diuretic medication.
When you leave the hospital, you should continue to use your
trilogy machine and use all your inhalers. You need to follow up
with your doctors as listed below.
We wish you the best,
Your care team at ___ | Ms. ___ is a ___ year old woman with a history of
COPD on 2L, OSA on trilogy, HTN, HLD, lung CA s/p recent wedge
resection, polycythemia presenting from ___ after
becoming acutely altered mental status from hypercarbic
respiratory failure from COPD exacerbation with component from
diastolic heart failure.
#COPD exacerbation on home O2
#OSA
#Hypercarbic hypoxic respiratory failure s/p extubation ___:
Likely from COPD exacerbation. Patient required intubation but
quickly extubated. Patient improved with prednisone burst of 40
mg daily and azithromycin x 5 days (day 1: ___, standing
duonebs, and albuterol.
# Acute diastolic heart failure: Patient was volume overloaded.
She was diuresed with IV Lasix 20 mg boluses. TTE showed grade I
diastolic dysfunction. She was transitioned to 20 mg PO Lasix
but had mild increase in bicarbonate as well as BUN/Cr so
decision was made to hold off on standing diuretics at time of
discharge.
# Toxic Metabolic Encephalopathy: Patient with acute onset
altered mental status requiring intubation. No evidence of
stroke at OSH imaging and no head bleed or evidence of mets on
MRI here. Initially treated with vanc / cefepime / ampicillin /
acyclovir for concern for meningitis, but had subsequent
improvement with respiratory support and treatment of COPD
exacerbation. No abnormalities in tox screen, TSH / B12 / RPR
all WNL. EEG without seizure activity. No PE on CTA chest.
Etiology likely hypercarbic hypoxic respiratory failure in the
setting of COPD exacerbation.
# Squamous Cell Lung Cancer s/p Right Upper Lobe Resection: MRI
brain without mets.
TRANSITIONAL ISSUES
===================
[] DRY WEIGHT: 163.6 pounds or 74.21 kg
[] Hypertension: Patient's blood pressure was elevated to SBP
150-170. She reports that she is only on metoprolol tartrate for
high blood pressure. She was started on amlodipine 5 mg daily
with improvement in BP with discontinuation of metoprolol
tartrate. Please titrate BP medications as necessary.
[] Mild diastolic dysfunction: Patient was grossly volume during
hospitalization and was diuresed with IV Lasix 20 mg boluses.
Due to concern for overdiuresis on 20 mg PO Lasix, she was
discharged without diuretics. Plan was made with patient to
monitor her home weights and call PCP to discuss possible need
for 10 mg PO Lasix as an outpatient.
[] Please consider checking chemistry panel on ___ at
outpatient follow-up appointment.
[] COPD medications: Patient is on symbicort at home but
adherence is unclear. Consider Spiriva as an outpatient.
[] MRI showed nonspecific subtle linear enhancement along the
course of the left seventh eighth cranial nerve complex from the
cisternal to cannular segment. This is likely venous or
artifactual in nature. Neurology recommended dedicated ___ MRI
to exclude infectious/inflammatory or neoplastic etiology if
there are concerns.
[] ___ saw patient and recommended outpatient pulmonary rehab.
Please help patient set this up.
[] New Medications:
-Amlodipine 5 mg | 187 | 457 |
18049978-DS-21 | 28,569,585 | Dear Mr. ___,
You were admitted for concern for gastrointestinal hemorrhage as
well as a malfunctioning J-tube. Your J-tube was replaced and is
now functioning normally. Your blood counts and your
hemodynamics (blood pressure/heart rate) remained stable
suggesting that you did not have active bleeding. You should
follow-up with your PCP regarding further workup of GI bleeding.
Thank you for allowing us to participate in your care,
Your ___ team | ___ M h/o schizophrenia, HTN, and recent prolonged admission
(___) for resp failure secondary to pneumonia s/p trach/PEG
(trach has since been decannulated),
multiple UTIs with MDR organisms, and persistent encephalopathy
presents from ___ for coffee-ground emesis and J-tube
malfunction.
# Coffee ground emesis - Presented with reported coffee-ground
emesis with no recurrence during admission at ___. Had
similar presentation last month - admission at ___. His
stool was guaiac positive in ED this admission. GI was consulted
in ED but did not recommend endoscopic evaluation given stable
Hgb. He was maintained on PPI BID and transitioned back to his
home PPI regimen on discharge.
# Clogged J-tube - ___ was consulted and J-tube replaced on ___.
Restarted TFs without issue
# Leukocytosis (resolved): WBC elevated on admission. No fever,
focal symptoms. CXR neg from ___ and UA here not c/w
infection. WBC improved without ___, ___ have been reactive
vs. from hemo-concentration
# Schizophrenia: Seen by psychiatry in prior hospitalization -
and was taken off
Lithium and clozapine.
- Continued Haldol 10 daily and 5 TID PRN agitation.
# h/o hypoxic respiratory failure:
# Recurrent aspiration: NO respiratory issues this admission.
- NPO for risk of aspiration
# Hypertension: Continued home amlodipine
# HLD: continued home atorvastatin
# Hypothyroidism: continued home levothyroxine
# BPH: continued home tamsulosin | 70 | 218 |
14878442-DS-13 | 28,460,088 | Mr. ___,
You were seen at ___ for blood
in your urine and for a fast heart rate. You were seen by our
urology team to evaluate your foley, who did not think there was
anything to do, since it was draining well. Most likely this was
due to prior trauma that occurred when the catheter was
exchanged, or it may have to do with your blood thinning
medication, even though they were at normal levels.
While you were here, you were initially treated for a pneumonia,
but it appears your lungs had fluid on them from your heart not
pumping efficiently. We gave you a medication called lasix that
you have been on in the past to get some of this fluid off. We
also checked an ultrasound of your heart called an
echocardiogram. This showed some decreased movement of your
heart when it pumps. It is not pumping blood out as well as it
should. We call this heart failure. You were seen by our
cardiologists who recommended follow up for a stress test in the
outpatient setting.
In addition, while you were here you were kept on your
antibiotics for your urinary tract infection. You also kept your
gallbladder drain in place.
Please follow up with the appointments we have previously
arranged for you. Please take all medications as prescribed. It
was a pleasure taking care of you at ___.
Your ___ care team | Mr. ___ is a ___ yo gentleman with a history of
neurodegenerative disease with Parkinsonian features, neurogenic
bladder with indwelling foley and MDR UTIs, MVR w/ prosthetic
valve on coumadin, with recent admission for sepsis during which
he was found to have MDR Morganella and E. coli UTI and was
started on meropenem. He re-presents with hematuria and
tachycardia.
#hematuria: Urology was consulted given hematuria, which was
manifested as dark brown urine with clots. Per urology, no
intervention indicated, as foley was flushing normally and
patient had adequate urine output. His hematuria improved during
admission. He was kept on meropenem for UTI for planned course
of meropenem 500 mg IV q6h ___.
#CHF: On initial presentation, his CXR showed R > L infiltrate
concerning for pulmonary edema vs infection. He was treated
initially with vancomycin to add on coverage for HCAP.
Vancomycin was discontinued after a course from ___ as
this was felt to be more due to pulmonary edema and volume
overload. As such, he was diuresed with lasix 20 mg IV x1, but
his blood pressures, which were generally around systolics of 95
during this admission, made further diuresis tenuous. During
this admission, he had a TTE done that showed LVEF 40% and
markedly hypokinetic inferior wall. Cardiology was consulted. It
was felt that he should follow up with cardiology as an
outpatient for possible stress test at that time but this was
not warranted in the hospital.
#NSTEMI: EKG showed sinus tachycardia that was consistent with
prior EKGs. He did have elevated troponins concerning for NSTEMI
. These peaked from 0.02 to 0.23 but downtrended to 0.18. He was
changed to a high intensity statin with rosuvastatin 20 mg
daily. He is on aspirin, and was placed on metoprolol 6.25 BID
by the time of discharge.
#tachycardia: Due to sepsis vs anemia vs heart failure. He had
repeat blood and urine cultures as well as CXR to rule out other
sources of sepsis beyond his UTI. Urine cultures were negative,
and blood cultures showed no growth to date by time of
discharge. See #CHF and #anemia for other management.
#anemia: iron studies during previous admissions were consistent
with ACD. However, a slight downward trend and his persistent
tachycardia prompted transfusion of pRBCs x2 during this
admission. His hemoglobin during this admission was similar to
prior in ___ when he previously received pRBCs. CT abd/pelvis
did not show a retroperitoneal bleed.
#Stercolitis with Left hydroureteronephrosis (without ___:
previous admissions have been complicated by large stool burden
and ___ syndrome. CT findings consistent with stercolitis
and so treated with extensive bowel regimen, including colace,
bisacodul Treated with extensive bowel regimen this admission,
including bisacodyl po and pr, colace, psyllium, lactulose,
manual disimpaction, and moviprep. Patient having BM by the time
of discharge.
# Mitral valve replacement: mechanical MV prosthesis. Patient
was initially placed on heparin drip due to subtherapeutic INR.
His coumadin remained at 4 mg daily with a goal 2.5-3.5
# Cholecystitis s/p percutaneous cholecystostomy: drain was
capped during prior admission (see discharge summary for
details). Will follow up in surgery clinic per scheduled visit
for removal.
# Dysphagia: Pureed solids and thins with aspiration
precautions per speech and swallow recommendations on previous
admissions
# Depression: continued home fluoxetine
# HLD: now on rosuvastatin, see above | 234 | 551 |
13254811-DS-4 | 25,846,843 | You were admitted to the Internal Medicine service at ___
___ on ___ 7 regarding management
of your fever, headache and photophobia, which was initially
concerning for meningitis. We did a lumbar puncture which did
not show any evidence for meningitis. These symptoms were likely
due to a pneumonia we saw on a CT scan. You were initially
treated with vancomycin and ceftriaxone, together with percocet
and oxycodone for your headache. You will be discharged on
levofloxacin, as well as a few extra oxycodone for your
headache.
It is important to take all of your medications as prescribed.
In addition, please make every attempt to attend your follow-up
appointments, as scheduled.
Please call your doctor or go to the emergency department if:
* You experience new chest ___, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* Your ___ is not improving within 12 hours or is not under
control within 24 hours.
* Your ___ worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms. | ___ with chronic lower back ___ s/p spinal stimulator and h/o
meningitis who p/w fever, headache, neck stiffness, and acute on
chronic back ___. She was admitted for fluoroscopic-guided LP.
# Fever/HA/Neck stiffness: The clinical picture of acute
headache, neck stiffness, photophobia, fevers, in the setting of
having hardware raises concerns for meningitis. However, CT head
was negative for acute process. Furthermore, unable to perform
LP in the emergency department due to spinal hardware. Other
considerations were tension headache or migraine. However, these
were less likely given that fevers and neck stiffness are
typically not associated with tension or migraine headaches. It
is also possible that her presentation was due to a pneumonia
since she has the hazy opacities on CT scan. The headache could
have been secondary to her pneumonia. Pneumonia was less likely
since her respiratory symptoms are very mild. Therefore she was
initially empirically given meningitis treatment with
Vancomycin/Ceftriaxone, with acyclovir. Fluroscopy-guided lumbar
puncture was performed. CSF was normal. Given these results she
was transitioned to levoquin for treatment of likely community
acquired pneumonia.
# ___: She was maintained on her home dose of percocet and
oxycodone was added for breathrough ___. The ___ service was
consulted about whether the spinal stimulator should be removed,
but they advised against it on this admission. The patient is
followed closely by ___.
For her chronic medical conditions she was maintained on her
home medications. | 255 | 235 |
13717902-DS-22 | 28,850,306 | Dear ___,
___ were admitted to ___ due to fatigue, urinary tract
infection, and difficulty breathing. ___ received antibiotics to
treat your infection. While ___ were here ___ were noted to have
a high white blood cell count and concern for a mass in your
left lung that could be cancer. ___ were seen by the
Interventional Pulmonology doctors; ___ and your family have
decided to think about how to proceed from here and can let your
primary care doctor know. Arrangements will be made based on
your decision.
In addition, your stay was complicated by acute angle closure
glaucoma which caused increased pressure and pain in your left
eye. ___ were seen by the Ophthalmology doctors and ___
iridotomy procedure to relieve the pressure in your eye. ___
will need to continue to use Pred-Forte eye drops; please place
one drop in your left eye four times daily. ___ should also
continue Iopidine drops; please place one drop in your left eye
twice daily along with dorzolamide/timolol drops; please place
one drop in your left eye twice daily. ___ will need to follow
up with the Ophthalmology doctors ___ x1 week.
Thank ___ for letting us be a part of your care!
Your ___ Team | ___ PMHx CHF (NOS), HTN T2DM (c/b neuropathy), CKD (b/l cr
1.6-1.7), h/o recurrent UTIs, nephrolithiasis with recent
pan-sensitivity Klebsiella UTI admitted with persistent
leukocytosis despite broad spectrum antibiotics, and found to
have lung mass concerning for malignancy (awaiting
thoracentesis), hypercarbia and AMS (likely ___ sedating meds)
w/ course c/b acute angle closure glaucoma (s/p iridotomy
___.
ACTIVE ISSUES
=============
# LLL spiculated mass:
Pt noted to have LLL spiculated mass highly concerning for
malignancy along with a small to moderate pleural effusion.
Would possibly explain the leukocytosis, altered mental status,
hypercarbia. Interventional Pulmonology was consulted, who felt
that, given patient's stability and the high risk of biopsy,
recommended obtaining PET-CT, MRI and deferring bronchoscopy
until patient was an outpatient. However, following a family
discussion including the patient, the decision was made to defer
further work-up of the lung mass given desire for stable quality
of life for the patient. Patient will follow up with her primary
care provider to determine need for further evaluation.
# Acute closed angle glaucoma:
Pt reported worsening left eye pain and was seen by
ophthalmology and found to have acute closed angle glaucoma, for
which she underwent iridotomy on ___. She was continued on
home Timolol and Latanoprost eye drops. She received Iopidine
drops after the iridotomy. She was started on Pred Forte, but
on ___ developed worsening left eye pain. Ophtho assessed and
found elevated left eye pressures likely secondary to
inflammation post-procedure. She was given Diamox 500mg IV x 1,
cosopt, brimonidine and pred forte with improvement in pressure
in symptoms. She was continued on cosopt, brimonidine and pred
forte on discharge with plan to follow up with Ophthalmology in
x1 week following discharge. She was continued on her home
latanoprost only in her right eye.
# Leukocytosis:
Pt presented with leukocytosis but remained afebrile during
admission. She was initially treated with antibiotics, which
were discontinued in setting of low suspicion for infection.
Leukocytosis thought to be likely secondary to suspected lung
malignancy. Blood and urine cultures were negative.
# Respiratory depression:
Pt noted to have CO2 retention with VBG showing pH 7.32 and pCO2
68, likely chronic but exacerbated by recent oxycodone causing
respiratory depression. Improved with narcan. CT head without
any acute abnormalities. Sedating medications, including patient
home oxycodone, trazodone, and tramadol were held. She should
follow up with her primary care doctor to restart safely.
# ___ on CKD: baseline Cr 1.8; creatinine was elevated on
admission. Concern for pre-renal azotemia in the setting of poor
po intake. Patient received fluid resuscitation and po intake
was encouraged, resulting in improvement in creatinine.
#Hypercalcemia: 11.7 corrected for hypoalbuminemia. Unclear if
related to underlying malignancy. PTH inappropriately high at
445, suggesting potential underlying primary hypoparathryodism.
PTHrP was pending on discharge.
CHRONIC ISSUES
==============
# HYPERTENSION. Continued home amlodipine.
# DEPRESSION. Continued home duloxetine.
# DIASTOLIC HEART FAILURE. Diuretics discontinued at rehab.
# OSTEOARTHRITIS. Decreased home gabapentin in setting of AMS.
TRANSITIONAL ISSUES
===========================================
[] Will need ophtho follow-up in x1 week from discharge.
[] Eye drop regimen: continue pred-forte QID, brimonidine and
cosopt BID until her follow-up appointment in one week.
[] Noted to have hypercalcemia with inappropriately elevated
PTH. Consider further w/u in the outpatient setting as
indicated. PTHrP pending on discharge.
[] please readdress need for ongoing treatment with trazadone,
tramadol, Norco - discontinued on discharge given increased
sedation
# CODE: * DNR, OK TO INTUBATE * MOLST IN CHART *
# CONTACT: Daughter: ___ cell phone ___ ___,
husband, ___ | 204 | 580 |
19990072-DS-16 | 22,632,312 | You were admitted with fever, headache, and neck pain and found
to have a condition known as asceptic meningitis, which is
usually caused by a virus. The cause of your condition remains
unknown at this time, however, as we discussed. You underwent an
extensive work up and were evaluated by the infectious disease
team. Your symptoms improved, and as of the time of discharge,
we have multiple test results still pending, and will alert you
to the final results if they are positive.
You should NOT: take any ibuprofen or other NSAID as this may
worsen your headache (as can cause rebound headaches and also
asceptic meningitis), NOT take more than ___ mg of tylenol
(acetaminophen) in any one 24 hour period, NOT drink any
alcohol.
You SHOULD: Call Dr. ___ to arrange to be seen by her later
this week to be re-evaluated and to have your liver function
tests repeated, and to follow up on the results of the tests
that are pending. When you see Dr. ___ following should
be checked (blood tests): Complete blood count, ALT, AST, Alk
Phos, Total Bilirubin, and a 'Chemistry-7' | Assessment/Plan:
___ y.o woman with no PMH who presents with headache and fever
found to have aseptic meningitis.
.
#aseptic meningitis
#headache (likely combination of post LP and meningitis) ?NSAID
related
#fever
Pt was treated for a presumed viral meningitis. CSF gram stain
and cx negative. She was given CTx and vancomycin in the ED
which were discontinued on the floor given negative CSF. She was
treated with acyclovir until HSV and VZV were negative. GIven
that she continued to spike fevers despite supportive care,
consulted ID who recommended a more intensive work up that was
unrevealing by the time of discharge. She did develop some
abdominal pain mostly in the ruq. LFTs were slightly elevated,
and multiple additional serologies were sent and were
unrevealing at the time of discharge. Transvaginal, abdominal,
and ruq ultrasounds were negative for pathology. Pt's continued
headache could have also been due to post LP headache and/or
NSAId induced. Symptoms improved. On the day of discharge pt.
had been afebrile for over 24 hours, and was strongly desirous
of going home. Her pain was controlled, she was tolerating po
intake, ambulatory, and voiding on her own. Her LFTs were
stable, with ALT of approx 100, without any elevation in
bilirubin. This was felt to be part of a likely viral syndrome.
Doxycycline was started emperically at ID's recommendation over
concern for possible anaplasmosis (test pending at discharge),
and this was well tolerated. The plan is for her to return home
and we will follow up on the results of multiple pending
serologies. She should see Dr. ___ this week for repeat
evaluation including a repeat test of LFTs, CBC, and Chemistry 7
(see below, and this was explained to patient).
.
#hyponatremia-likely hypovolemic in etiology. Improved with IVF.
.
#elevated lactate-improved with IVF | 190 | 301 |
14699452-DS-8 | 22,995,030 | You came to the hospital because you fell and had back pain. You
had x-rays and a CT scan which did not show any evidence of a
fracture in your pelvis. You were given pain medication and were
seen by physical therapy who thought it would be safe for you to
go home. Please follow up with your primary care doctor in one
week.
The following changes were made to your medication:
ibuprofen 400 mg 2 Tablet every 8 hours as needed for pain
acetaminophen 325 mg Tablet 2 Tablet 3 times a day
docusate sodium 100 mg Capsule 1 Capsule 2 times a day for
constipation
tramadol 50 mg Tablet 1 Tablet every 6 hours as needed for pain
STOPPED fluoxetine temporarily while on tramadol (these can
interact) | ___ year old with history of CLL, depression, mitral valve
prolapse, status post cataract surgery, and osteoarthritis with
osteoporosis with new hip pain s/p recent fall with no evidence
of radiologic abnormalities, admitted for rehabilitation.
# Hip/back pain: Likely a contusion alone, given the negative
radiologic studies. This was little concern for anything but a
mechanical fall, but her fracture risk is higher given her
osteoporosis. She did not have any evidence of a syncopal
episode. However, given her pain and difficulty walking, she was
admitted for ___ eval to determine if she is safe to return to
her assisted living facility. Pain controlled with standing
tylenol and tramadol prn. ___ saw pt and determined she is OK to
go back to her home.
# Osteoporosis: continued Evista and vitamin D
# Depression: on discharge, recommended pt stop fluoxetine
temporarily while on tramadol due to risk of serotonin syndrome | 127 | 155 |
14627997-DS-2 | 23,869,032 | You were admitted into the gynecology oncology service for
pre-operative hydration prior to your surgery and you were kept
after your surgery for routine post-operative care
General instructions:
* Take your medications as prescribed.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
Incision care:
* You have a wound vac, which will be changed on ___,
___ and ___
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms ___ was admitted to the gynecology-oncology service for
preoperative management and hydration. Her hospital course is
outlined below.
Pre-op: She received intravenous hydration and antiemetics.
Intraoperative: During her procedure, she had 2L of ascites and
her estimated blood loss was 1200cc. She got transfused 3 units
of blood intra-operatively and 250 of albumin. Please refer to
full operative notes for details.
Post-Operative Course
#1 Routine
She was placed on a dilaudid PCA for pain control and was
transitioned to oral pain medications by post-operative day 3.
During the time frame of her ileus, she was switched back to
intravenous dilaudid for pain control. She was evaluated by
physical therapy given her history of bilateral hip and knee
replacement and they recommended a rehabilitation facility. This
was largely supported by the fact that the patient will require
chemotherapy and she needed to get strong enough for treatment.
#2 Acute Kidney Injury: Her post-operative course was
complicated by acute kidney injury. Her Creatinine rose from 0.6
to a peak of 1.5. She had a fractional excretion of sodium,
which was consistent with a pre-renal etiology. Her urine output
ranged from ___. She was kept on maintenance IV fluids of
200cc/hr and she received 500cc more of albumin. She also had
hyperphosphatemia, which combined with acute kidney injury and
hyperkalemia was concerning for rhabdomyolysis. However, her
creatinine kinase level was in the 200s, much less that what is
expected from rhabdomyolysis. In addition, the hyperphosphatemia
and hyperkalemia resolved by post-operative day 2. By
post-operative day 3, Ms. ___ urine output had normalized
and she was making excellent urine. Her creatinine had also
normalized. Her foley was subsequently discontinued and she
voided without difficulty. She did have her foley replaced once
more later in the course of her hospitalization for a borderline
urine output and for comfort. It was subsequently discontinued
after her urine output improved and after she was able to get
out of bed to get to the bedside comode.
#3 Ileus: Post-operative course was complicated by Ileus, which
developed on post-operative day #4. She was then made NPO and
placed on intravenous fluids. She had multiple episodes of
emesis overnight that first day of her ilues. A KUB was
obtained, which demonstrated paucity of gas in the colon and
multiple air-fluid levels. She was placed on intravenous
antiemetics. Her emesis stopped but her nausea persisted. An NG
tube was therefore placed. She had a CT scan, which was negative
for a small bowel obstruction. Her NG tube initially put out
moderate drainage but by the ___ day after placement, was
putting out minimal drainage. It was therefore pulled and her
diet was advanced very slowly starting on post-op day 10. Her
electrolytes were monitored daily and repleted as needed.
#4 Incision cellulitis/Panniculitis: On post-op day 7, Ms.
___ developed erythema around her incision. She was started
on intravenous cefazolin and completed a 7 day course. She also
had abdominal wall edema, which evolved and became erythematous
concerning for drainage in her incision. Overnight, on
post-operative day ___, she developed drainage from her incision
prompting removal of her staples. She had 1L of drainage from
the incision. There was no evidence of fascial dehiscence. Her
wound was then packed with kerlix. The wound nurse was consulted
and ___ a wound vac. A wound vac was placed on post-op
day 9. Over the weekend after the wound vac was placed, there
was large amount of serous output from the wound vac to a
maximum of >3L, which eventually tapered. Ms. ___ was
clinically stable without severe nausea and vitals signs within
normal limits. She was also already tolerating PO intake. Her
wound vac was therefore left in place until it was replaced on
___. On evaluation of her wound on ___, there was no
evidence of fascial dehiscence. There was an area inferior in
the incision that had some weakening of the fascia but no
evidence of bowel incarceration, which was supported by her lack
of symptoms. The wound vac was replaced. She will continue to
have it changed every ___ and ___
#5 Follow Up
Ms. ___ is scheduled for an appointment with oncology to
discuss treatment options. Her pathology results showed that she
had a teratoid carcinosarcoma with neuroepithelial
differentiation. All 7 periaortic lymph nodes obtained were
positive for malignancy.
Ms. ___ was discharged on post-operative day ___ to a rehab
facility center. She had adequate follow up in place. | 126 | 733 |
15345462-DS-12 | 24,167,738 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to us after you
experienced chest pain. While in the hospital you underwent an
extensive work-up including an echocardiogram of your heart
which was normal. You also had a nuclear heart stress test which
was normal and did not show any signs of decreased blood flow to
your heart. As a result of these normal tests, we feel that your
chest pain is most likely not caused by your heart as all the
tests were normal. You do not need a cardiac catheterization at
this time.
We do strongly urge you to stop smoking. It will be the best
thing that you can do for your health and will help with
shortness of breath and prevent any further damage to your
organs. We are giving you nicotine patches. You can talk with
your new primary care doctor about quitting.
We started amlodipine to help control your blood pressure.
We also found that some of your liver enzymes were elevated
which should be followed up by your primary care doctor. You
were found to have Hepatitis C which can be causing these
abnormalities. You will follow up with your primary care doctor
for further work-up and treatment.
We wish you the best of health,
Your ___ Care Team | ___ CAD (LAD 40% cath in ___ at ___), HTN, anxiety, PTSD,
multiple ED visits in the last year for CP, FH of early cardiac
events presents with exertional chest pain and abdominal pain.
#Chest Pain: Upon work-up patient had an unremarkable ECG
unchanged from prior, with negative troponins x3. He had a pBNP
of 191. Patient complained of CP during hospitalization that was
relieved with nitroglycerin SL again with no ECG changes.
Underwent a TTE which showed normal cardiac function with LVEF >
55%. Had a nuclear cardiac stress test which was normal with no
evidence of ischemia. Most likely reason of chest pain is not
cardiac in nature. However, given that patient's symptoms are
relieved with nitro SL he was discharged with it.
#Hypertension: He was found to be hypertensive on current
regimen and started on amlodipine 5mg.
#Transaminits: Patient had transaminitis with ALT 94 AST 63 with
a positive HCV Ab from ___. An HCV viral load was 19,900,000
IU/mL confirming active HepC. He should follow this up with his
PCP and undergo further work-up and treatment.
#Hyperlipidemia: Statin held due to transaminitis and should be
restarted as outpatient or referred to a ___ clinic as his LDL
is 144.
Patient's symptoms of chest pain and abdominal pain might be due
to from prolonged use of risperidone and should be evaluated as
an outpatient. Consider psychiatry referral for further
management of PTSD/anxiety.
Patient showed an interest with smoking cessation and provided
with nicotine patch.
TRANSITIONAL ISSUES
===================
[] Transaminitis - HepC Ab positive with viral load 19,900,000
IU/mL. Needs monitoring, further work-up and treatment, will
need hepatology referral
[] holding statin given elevated LFTs, HepC. Will need to be
restarted as outpatient or get in with ___ clinic for
different treatment
[] provide assistance with smoking cessation
[] evaluate patient for OSA given body habitus
[] consider psychiatry referral as patient recently moved to
___
[] needs cardiac risk factor modification: BMI 40, active
smoker, | 221 | 321 |
11112875-DS-22 | 26,561,133 | Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted with altered mental status and
difficulty caring for yourself. You were found to have bloody
bowel movements and a gastrointestinal bleed. You underwent an
endoscopy and there was evidence of bleeding blood vessel in one
part of your intestine along with ulcerations. An attempt was
made to stop the vessel from bleeding and you were placed on
medicines to reduce bleeding and help the GI tract heal. You
required multiple units of blood and were ultimately sent to the
ICU for a second endoscopy which was unrevealing.
It is important you take the proton pump inhibitor as an
outpatient as prescribed. Do not take drugs known as NSAIDs such
as ibuprofen. If you have pain or discomfort, contact a doctor.
In addition, you need to follow up with your regular outpatient
doctor and other physicians as scheduled below including
orthopedics for your shoulder.
Best wishes,
Your ___ Care Team | ___ w/ PMH dementia, recent UTI c/b delirium requiring
hospitalization (___), p/w ongoing confusion and concerns
for ADLs at behest of family now with UGIB that is persistent
despite EGD x 1, clears, and PPI drip s/p multiple transfusions.
MICU COURSE ___
EGD
- Previous ulcers seen appear to be healing
- No blood seen in the stomach or duodenum.
- Can transition to oral PPI.
- If rebleeding with consider CTA versus tagged RBC scan
depending on clinical scenario.
- Hct: 23% -> 1U pRBC -> 28.8%
- Hemodynamically stable: Latest vitals HR 65 BP 130/88 SpO2 99%
on RA (14:21)
- Called out to Blumgart A on ___ ___
Patient initially called out to the floor, however had another
large bowel movement, became hypotensive and
lightheaded/symptomatic. Therefore, was transferred back to the
ICU. CTA performed which did not identify any obvious source of
bleeding. Patient under went ___ procedure in attempt to identify
source of bleeding. Performed embolization of gastro-duodenal
ulcer given hx of previous gastric ulcer bleeding 3 days prior
despite no visible extravasation. Patients Hgb stable on recheck
without further transfusion requirement therefore called out to
medicine floor.
FLOOR COURSE
#UGI BLEED: EGD ___ showed actively bleeding duodenal
ulcers, suspicion for NSAID use. Hct 35.1 ___ to 26.1
___ in setting of ___ hematochezia, dark-red
colour. Received 5 units pRBCs through ___. Denied
significant pain and has no major changes in vitals since
admission. Repeat bleed with EGD on ___, then ___
embolization of the GDA on ___. Transferred back to floor
on ___ with melena X 2 on AM of ___. Painless and
hemodynamically stable. Tagged RBC Scan on ___ was negative. Of
note, colonoscopy in ___ w/ moderate sigmoid diverticula
and 10mm sessile polyp s/p polypectomy. ___
sigmoidoscopy unconcerning for pathological progression. The
patient was continued on Pantoprazole 40mg BID and followed by
GI throughout his stay.
#CHRONIC MILD COGNITIVE DEFICITS: Increased confusion compared
to first day at hospital. Likely secondary to UGI bleed. Has
baseline cognitive impairment per OMR w/ established
Neurocognitive consult (___). ___ administration ___
confirms moderate cognitive impairment (Score ___, with
significant recall deficiency. No focal neurological deficits,
reassuring CT elicit no concern for stroke. Delirium has low
suspicion given absent hallucinations, confluent thoughts.
Possible encephalopathy ___ from UTI during previous
admission - pt does not recall this hospitalization. Regarding
the family's concern for delirium, cause unclear. No focal infx
signs given clear UA, afebrile status, stable vitals, CT and CXR
reassuring for no focal processes. No CNS depressants or
anticholinergics. Pt does not present this hospitalization w/
waxing/waning consciousness, hallucinations, or agitation
casting doubt on delirium diagnosis. Reversible causes of
dementia investigated (RPR, HIV), found negative; denies EtOH
abuse, CBC and tox screen reassuring for metabolic insult.
Donepezil was continued throughout his hospitalization.
___: Resolved. Cr 1.6 on admission, 1.1 on recheck ___,
0.8 ___ indicating return to baseline. No clinically
hypovolemic by vitals; unclear daily PO intake. Likely pre-renal
___ from mild hypovolemia while on ACEi. U/A not consistent with
glomerular pathology. Possible medication misuse concern given
ACEi effects on kidney. Resolved, with Cr of 0.8-0.9 on
discharge. ACE inhibitor and metformin were held during
admission.
#RIGHT ROTATOR CUFF TEAR: Patient unable to abduct shoulder; no
profound TTP. Outpatient MRI was ordered. Acetaminophen given
for pain.
#T2DM: Was on glipizide and metformin. Glipizide held while he
was on Bactrim. Held metformin given ___. HISS was used to
manage blood glucose. Restarted oral meds when Cr normalized.
#HTN: H/O hold lisinopril for now
#CATARACT SURGERY OD, H/O. Continued prednisolone and ketorolac
drops, as prescribed.
#EMPTY SELLA on IMAGING: No overt signs of hypopituitarism;
possible subarachnoid cyst. Plan for outpatient evaluation
following discharge.
#TRANSITIONAL ISSUES:
-Right shoulder is essentially nonfunctional due to a severe
rotator cuff tear from his fall. He has been seen by an
orthopedic surgeon who recommends follow-up for an MRI and
non-urgent surgical consultation. His right arm should be
supported in a sling in the meantime.
-Mr. ___ was recommended to continue Pantoprazole 40mg twice
daily for 8 weeks. He then should take Pantoprazole 20mg once
daily for an additional 4 weeks. If he has no further episodes
of bloody stool or melena, PPI therapy can be discontinued at
this point (total 12 week course).
-CT-head on admission showed an expanded and empty sella with an
underlying arachnoid cyst. The radiologist has recommended
"further assessment with nonurgent MRI of the pituatary gland
may be helpful for further assessment."
- F/u dementia and consider need for additional medication.
- Code: Comments: DNR/ok to intubate if temporary, no long term
intubation, no procedures to be done if we think he will not
recover back to his baseline, if there is a reasonable
expectation he will return back to his baseline it is ok to do
certain procedures,(as discussed with HCP ___ 8:30), see
MOLST form in chart/contact HCP
- Contact: ___ (Pt's niece at ___ | 161 | 807 |
18304932-DS-33 | 23,460,003 | Dear. Ms ___,
It was a pleasure meeting you and taking ___ of you during your
recent hospitalization at ___.
You were hospitalized following several days of nausea, itching,
and vomiting that started when you took clindamycin for a facial
MRSA infection, and became much worse when you took doxycycline.
The most likely cause of your symptoms was an adverse reaction
to one or both of these medications.
Fortunately you improved quickly in the hospital, and were
treated with diphenhydramine (Benadryl) and Sarna lotion for
itching. You also underwent dialysis on your normally-scheduled
day, and received vancomycin intravenously, which is another
type of antibiotic used to treat MRSA, which you tolerated well
without further adverse side-effects.
In order to better treat the stomach upset caused by these
medications we recommend stopping the medication ranitidine for
2 weeks and taking omeprazole instead. Once you are finished
with omeprazole, you may resume taking ranitidine. You will also
get more vancomycin at the next two dialysis sessions, and your
last day of vancomycin will be on ___.
You should call to schedule an appointment with your primary
___ doctor in approximately one month, and keep the
appointments that have already been scheduled with plastic
surgery and other specialists as listed below.
We hope you continue to do well!
Regards,
Your ___ Team | ACTIVE ISSUES:
=====================
___ woman with ESRD on dialysis, diabetes, obesity,
hypertension, hypothyroidism, and psoriatic arthritis, who
present with hives, pruritus, nausea and vomiting in the setting
of facial MRSA abscess treated with clindamycin and doxycycline.
Given her recent exposure to clindamycin and doxycycline, and
the timing of onset of her symptoms, the most likely reason for
her presentation was drug reaction. She has no prior known
exposures to doxycycline. She was observed in the hospital
overnight, and her nausea, vomiting, and pruritus improved with
antiemetics, sarna lotion, and diphenhydramine, and after
withdrawal of doxycycline.
# Left cheek MRSA abscess; s/p I&D
Patient unable to take clindamycin, bactrim, or doxycycline due
to drug intolerance. Prior to admission to the hospital, she
underwent hemodialysis and tolerated vancomycin in hemodialysis
___. The facial lesion was healing well without signs of
worsening infection, and her blood pressure and temperature were
within normal limits, suggesting against systemic infection.
Blood cultures were negative. She was scheduled to receive 2
additional doses of vancomycin 1g IV post-HD after leaving the
hospital. | 216 | 174 |
10373824-DS-19 | 28,293,498 | Dear Ms. ___,
You were seen in the hospital for shortness of breath. You
received an evaluation of your symptoms, and we suspect that
there are multiple factors contributing. Your asthma medications
were increased to improve your breathing. You should follow up
with Dr. ___ re-connect with Dr. ___
pulmonologist, to discuss your breathing problems.
Please follow up with your doctors as listed below.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ team | ___ year old female with h/o CHF EF 15%, COPD/asthma, pAF, and
CAD presenting with dyspnea on exertion likely related to viral
URI and underlying COPD/CHF.
# dyspnea: based on symptoms of sneezing and rhinorrhea, likely
a viral URI. Not consistent with COPD exacerbation or PNA.
Although BNP was elevated, it is likely chronically elevated
because of EF <15%, and only an elevation >20,000 would be
consistent with a true CHF exacerbation. Patient was euvolemic
on exam. She was treated with a nebulizer and felt better,
suggesting that this might be more of a respiratory process. She
was arranged to have cardiology follow up for discussion of an
ECHO and pulmonology follow up for her asthma/COPD. Home Advair
was increased.
# anemia: workup initiated for chronic anemia. found to have
evidence of B12 deficiency on anemia labs. Injection offered but
patient deferred. This should be discussed in the ___
setting. Also, started on iron supplement for likely iron
deficiency.
***Transitional issues***:
- patient deferred dose of B12. Should discuss in outpatient
setting.
- Advair increased to 250 mcg formulation. This can be titrated
as needed. Patient should follow up with Dr. ___
(___) and consider having repeat PFTs to evaluate
severity of lung disease.
- patient should be monitoring daily weights. Weight on date of
discharge: 42 kg
- Cr on ___: 1.1
- may benefit from pulmonary rehab
DNR/DNI | 82 | 231 |
19154640-DS-22 | 29,229,062 | Discharge Instructions
Ventriculoperitoneal Shunt
Surgery
You had a revision of your VP shunt, which was placed for
hydrocephalus. Your incisions should be kept dry until your
sutures are removed.
Your shunt is a ___ Strata Valve which is programmable.
This will need to be readjusted after all MRIs or exposure to
large magnets. Your shunt is programmed to 1.0.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Headache or pain along your incision.
Some neck tenderness along the shunt tubing.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | #VP shunt malfunction
___ year old male known to the Neurosurgical service for recent
admission for L cerebellar IPH s/p posterior fossa AVM resection
and R VP shunt placement, returns from rehab from after three
episodes of vomiting earlier in the day. CT of the head reveals
a slight increase in the size of the lateral and third
ventricles as well as an increase in the size of the fluid
collection adjacent to the surgical site. Patient was admitted
to the Neurosurgery Service for further evaluation and
management. He was taken to the OR for R VP shunt revision.
Procedure was well tolerated and patient recovered from
anesthesia in the OR. Patient was transferred to the PACU for
further monitoring. Patient remained stable post-operatively and
was transferred to the floor for further management. Patient's
vomiting resolved after revision of VP shunt and tube feeds were
resumed on ___ with no further complications.
#Tracheostomy
On ___ patient dislodged his tracheostomy tube. Respiratory
attempted to replace it, but was unsuccessful. ACS was paged for
further evaluation. During the time the tracheostomy was out,
patient maintained O2 saturation without any respiratory
struggles. After discussion of ACS, it was determined that since
the patient's VP shunt was now revised, vomiting and aspiration
were no longer a concern. It was decided that the tracheostomy
tube would not need to be replaced at this time if he is able to
tolerate breathing on his own. Patient was placed on NC, and
eventually weaned to room air without complications. He remained
neurologically stable and was discharged to rehab on ___.
#Agitation
Patient's course was complicated by agitation. Patient was kept
in wrist restrains and mitts to keep him from pulling at his
lines and tubes. Patient was medically managed with Seroquel to
minimize the use of restraints.
#Hypernatremia/Hyponatremia
On previous admission the patient had been hyponatremic and was
discharged on salt tabs. When patient was admitted, he had
elevated ___ and was on salt tabs. Salt tabs were discontinued
and ___ normalized on ___. ___ was closely monitored throughout
the remainder of admission. Patient was hyponatremic on ___ and
was restarted on salt tabs with instructions to follow up with
PCP for ___ monitoring and management.
#Pneumonia
Prior to admission patient was being treated for pneumonia with
Bactrim, which was started during his prior admission. Patient
was continued on Bactrim to complete his full course through
___. | 354 | 397 |
16336676-DS-5 | 23,883,213 | You were admitted to the hospital due to pneumonia. Your chest
xray showed that the pneumonia was fairly extensive, which
explains the severity of your symptoms. Your symptoms improved
somewhat while in the hospital, although you continued to have a
severe cough. We are prescribing you an antibiotic course to
complete at home - The antibiotic is levofloxacin (Levaquin) and
should be taken daily for 5 more days. We are also prescribing
two cough medications, codeine-guaifenesin, and benzonotate.
Because codeine is a narcotic it is important to exercise safety
precautions, such as avoiding driving or other dangerous
activities while taking it, and keeping it safely stored. We
will also prescribe an albuterol inhaler, which you may find
helpful for wheezing or shortness of breath.
It will be very important to ___ closely, ideally this
week, with your primary care doctor. Because of the extent of
your pneumonia you will need a repeat xray checked in about a
month. It will also be important to have your primary care
office check your oxygen levels to make sure that they are
improving.
If you have any worsening symptoms, any fevers, chills,
worsening shortness of breath, or other new concerning symptoms,
you should seek medical attention.
We would recommend avoiding smoking as you are healing and
ideally working towards quitting completely in the future. | ___ year old man w/ tobacco dependence who presents with
multifocal pneumonia. No known history of pulmonary disease.
History of GI symptoms and sick contacts raise the question of
legionella, so sent urinare for antigen testing. No history of
prior infections, incarceration, or IVDU, no chronic
constitutional symptoms, although history of unprotected sex
with multiple partners. Sent HIV although suspicion for HIV is
low. Extremely low suspicion for TB based on lack of risk
factors or consistent clinical presentation. Recent binge
drinking may have led to aspiration event w/ GNR PNA.
# CAP:
Septic on presentation to ED w/ tachycardia and leukocytosis.
Both resolved quickly after IVFs and abx. His HRs normalized
prior to discharge despite no IVFs x 24h. His constitutional
symptoms and dyspnea improved somewhat during the admission,
although he continued to have a severe cough and wheezing on
exam. Given the multifocal nature of his PNA, he was admitted
for observation and close monitoring of his respiratory status.
At rest he maintained sats in mid-high ___ on room air. With
ambulation his sats were low-mid ___ on room air. He has a very
small effusion on CXR but felt to be too small to warrant
diagnostic thoracentesis at this time.
Given the impressive radiographic picture and mild hypoxia the
patient was strongly encouraged to seek close ___ with his
primary care physician. Would recheck O2 sats and also plan for
repeat imaging in 4 weeks, or sooner if any worsening.
While inpatient the patient completed 3 days of
ceftriaxone/azithromycin and will complete 5 days of
levofloxacin as an outpatient. He was also prescribed PRN
benzonotate, codeine-guaifenesin, and albuterol. He was also
provided with an incentive spirometer and smoking cessation
recommended.
===================================== | 219 | 282 |
15857820-DS-18 | 29,444,341 | 1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours | Mr. ___ was admitted to the ___ on ___ via transfer
from ___ for further management of his myocardial
infarction. He was worked-up in the usual preoperative fashion.
On ___ he was taken to the operating room where he underwent
coronary artery bypass grafting to three vessels. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for further monitoring. Over the next
several hours, he awoke neurologically intact and was extubated.
He developed AFib and converted to SR w Amiodarone.
Anti-coagulation will not be required due to brevity of episode.
On postoperative day one, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
By the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions. | 127 | 174 |
17225083-DS-19 | 28,708,252 | Mr. ___,
Why were you admitted to the hospital?
- You were admitted to the hospital because you were having
severe back pain.
What was done for you in the hospital?
- You had imaging that showed that your cancer was likely not
causing your acute pain.
- We consulted the palliative care doctors who helped ___ come up
with a medication regimen to help treat your pain.
- The chronic pain doctors did ___ joint injection to help improve
your pain.
What should you do when you go home?
- You should continue taking your medications, as prescribed.
- You should follow up with your oncologist, palliative care
doctors, and chronic pain doctors.
- You should weigh yourself every morning, and call your doctor
if your weight goes up by more than 3 lbs.
It was a pleasure taking care of you, and we wish you well.
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with history of
locally advanced melanoma, BRAF negative s/p multiple cycles of
pembrolizumab currently on hold with metastases to right
inguinal node s/p XRT as well as atrial fibrillation on coumadin
who presents with back pain s/p unchanged CT scan, admitted for
pain control, s/p SI joint injection. | 144 | 55 |
16573705-DS-37 | 29,925,981 | Dear Mr ___,
You were admitted to the ___ because you had a fever at home
and were found to have a urinary tract infection. You were
initially admitted to the ICU since your blood pressure was low,
and moved to the general floor when it stabilized. You responded
well to antibiotics and your white blood cell count improved,
and fever went away. A midline was placed so you could receive
IV antibiotics, please continue the same as prescribed.
Thank you for allowing us to participate in your care. | This is a ___ yo M with quadrapalegia with recurrent UTIs who
presents with fevers, chills, and hypotension concerning for
urosepsis.
# Sepsis from a Urinary Source: Initial picture concerning for
sepsis given hypotension and leukocytosis to ___ while patient
was on fosfomycin. He was admitted to the MICU and started
empirically on vanc and zosyn, urine cultures were sent. He
remained afebrile and white count downtrending, no episodes of
hypotension noted since admission. Urine cultures showed
pseudomonas resistant to cipro and fosfomycin, per ID recs,
vancomycin was discontinued and patient was discharged home on a
2 week course of zosyn.
#.HTN: Antihypertensives initially held given concern for
sepsis. Hypertensive while in ICU on two separate occasions to
SBP 220 and SBP 180, likely a manifestation of autonomic
dysreflexia. First episode responded to small dose of IV hydral,
home metoprolol and triamterene-HCTZ restarted thereafter; BP
remained within acceptable limits.
# Sacral Ulcer: Red skin on sacrum. Wound care was consulted and
recommendations followed.
TRANSITIONAL ISSUES
#.Urine cultures pending at discharge
#.will likely need prophylactic antibiotics once current course
of zosyn complete. | 87 | 178 |
13930807-DS-20 | 26,147,125 | Dear ___,
It was a pleasure taking care of you at ___.
Why were you here?
- You were vomiting and feeling unless.
What was done while I was here?
- You got antibiotics through the IV.
- We changed your medicines to ones by mouth.
What should I do when I get home?
- Take all your medicines as prescribed.
- You will need to take your antibiotics for 8 more days. | ___ w/ PMHx unclear kidney disease (s/p R nephrectomy while
living in ___ and glaucoma who presented with one day history
of n/v, malaise, and cough with urinalysis suggestive of UTI.
# UTI
She was admitted to the medicine service and quickly improved
with IV ceftriaxone. On HD3 (after 3 doses of IV ceftriaxone)
she was transitioned to PO bactrim for planned additional 8
days. Day after discharge, Urine Cx showed E coli sensitive to
Bactrim.
# Macrocytic anemia: Stable from prior admission in ___, MCV
103. B12 normal.
# Glaucoma: continued home timolol, latanoprost, and hypertonic
saline ointment
==================== | 68 | 103 |
13662941-DS-19 | 21,557,697 | Dear Mr. ___,
It was a pleasure to take care of you. You were recently
admitted to the ___ for
abdominal pain. You had abdominal distention and were nauseous.
You had a nasogastric tube placed to help relieve the pressure.
You had a scan of your abdomen, which showed an obstruction in
your bowel. You then began to pass gas and have a bowel
movement. When your abdomen was less distended and the tube was
not putting out much fluid, the tube was removed. You were then
started on a regular diet, which you were able to tolerate. You
also continued to pass gas and have bowel movements. At the time
of discharge, your abdomen was no longer distended, you were
eating a regular diet, and having regular bowel movements. | The patient presented to Emergency Department on ___. Upon
arrival to ED, the patient was noted to have a distended abdomen
with ___ tenderness. A KUB showed air-fluid levels.
Given findings, the patient was made NPO, an NGT was placed, and
he was admitted to the hospital under the acute care surgery
service.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with an IV pain
medication and then transitioned to orals once tolerating a
diet.
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 with a
___ tube in place for decompression. He underwent a CT
scan, which showed an obstruction in his small bowel in the same
place as previously seen during his last admission. On HD2, the
patient was passing flatus and having regular bowel movements.
On HD3, NGT was removed after a well-tolerated clamp trial. He
tolerated the removal of the NGT without nausea or increased
distention, therefore, he was started on a regular diet, which
was well tolerated. Patient's intake and output were closely
monitored. During this admission, patient's surgical staples
were also removed.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and abdomen distention
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 130 | 332 |
14508643-DS-20 | 22,791,099 | Dear Ms. ___,
It was a pleasure taking care of you. You were admitted for
right leg cellulitis and IV antibiotics. Imaging of your leg
showed no evidence of blood clot or fracture causing your
symptoms. You improved with one dose of IV antibiotics and were
then transitioned to an oral antibiotic which you have tolerated
well. You should continue this medication called doxycycline 100
mg twice daily for 10 days (last dose ___. Please notify
your primary care doctor if you have worsening pain or
difficulty walking. We wish you all the best.
Sincerely,
Your ___ team | ___ F with HTN, osteoarthritis and chronic venous stasis
presenting with R lower leg posterior soreness/swollen
concerning for cellulitis.
# Cellulitis: Fortunately, there was no evidence of fracture or
dvt on imaging. Likely began with incidental trauma given
findings of abrasions on anterior shin. Patient was
administered unasyn in the emergency department initially. Given
lack of improvement over 12 hours, she was started on vancomycin
instead and admitted. Patient was transitioned to po doxycycline
the following day with interval improvement in cellulitis.
Patient was evaluated by physical therapy who recommended home
with ___.
# ___: baseline 0.7-1.0, 1.2 on admission: presumably in the
setting of poor po intake while patient with severe pain and
difficulty ambulating over this period. Improved to baseline by
time of discharge with increased po fluid intake. Lasix and
lisinopril were held during admission but restarted at time of
discharge.
TRANSITIONAL ISSUES
- complete 10 day course of doxycycline (last dose ___
- patient was started on standing tylenol to control pain
- patient had mild ___ in the setting of poor po intake which
improved with increased po intake during hospital stay (baseline
creatinine 1.0) - patient's lasix and lisinopril were held for
this reason but restarted on discharge
- consider sending b12 and folate as an outpatient for chronic
macrocytic anemia
# CODE: FULL CODE however pt would not want to be intubated.
Confirmed with daughter.
# CONTACT: ___, daughter ___ | 95 | 238 |
14767018-DS-22 | 22,106,199 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain, nausea and vomiting. You had an ultrasound
and gallbladder scan that showed gallstones. You were taken to
the operating room on ___ for a laparascopic removal of
your gallbladder. You tolerated the procedure well. You are now
tolerating a regular diet, ambulating independently, and pain is
better controlled. You are now ready to be discharged to home to
continue your recovery.
Please note the following discharge instructions.
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ is a ___ yo F admitted to the Acute Care Surgery
Service on ___ with abdominal pain, nausea, and vomitting.
She had a HIDA scan and ultra sound that showed
choledocholithiasis. The MERIT team was consults to assess
per-operative risk given her significant cardiac history. She
was determined to be an appropriote candidate for surgery.
Informed consent was obtained and on ___ she was taken to
the operating room for a laparoscopic cholecystectomy. Please
see operative report for details. 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 POD0 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. | 811 | 210 |
17475607-DS-13 | 21,449,739 | You were admitted with shortness of breath, and your breathing
was worse from your lung disease. You did not have a pneumonia,
or a heart attack, or fluid in your lungs. You improved with
antibitiocs and steroids, and breathing treatments.
You were admitted with shortness of breath. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs. | The patient is a ___ year old female with h/o COPD, CAD, chronic
systolic heart failure with EF = 52% s/p DES to LAD in ___, admitted with shortness of breath, consistent with COPD
exacerbation, improved on steroids and azithromcyin.
.
Shortness of breath/acute copd exacerbation
He was admitted with shortness of breath, with negative CXR and
cardiac enzymes. He was treated with po prednisone, po
azithromycin, and nebulizers. He improved, no longer requiring
oxygen, and ambulating with O2 sat 93-95% on room air. He was
discharged with steroids for 3 more days, and azithromycin for 3
more days. Increased productive cough likely from recent
smoking cessation.
Elevated CK, likely related to recent simvastatin initiation
He was noted to have a new CK of 800, new since ___. It was
noted that he was just initiated on simvastatin. He was advised
to stop simvastatin. He will follow up with Dr. ___ as
scheduled. He had some myalgias possibly attributable. | 63 | 163 |
13111741-DS-27 | 27,116,910 | * You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
* Resume your Coumadin tonight and have an INR drawn on ___
___
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. | The patient was admitted overnight for observation given his
weakness and dizziness on presentation. CXR demonstrated
persistence of the known small hydropneumothorax, with mild
increase of the effusion. The following morning, the patient was
feeling much improved. He was discharged home with his original
scheduled post-op follow-up and chest x-ray in the clinic. | 251 | 54 |
10881788-DS-4 | 29,793,675 | Dear ___,
___ came to us for low blood pressure and were found to be in
septic shock from a bacterial blood stream infection. ___ were
transferred to the ICU to be stabilized. ___ recovered and based
on complaints of hip and back pain we got an MRI of your lower
back which showed spread of cancer, likely an aggressive
recurrence of vulvar cancer. We had a goals of care discussion
and ___ elected to not have imaging of the rest of the spine or
your head. Based on the findings in your spine, the radiation
team here felt a single dose of therapy was not warranted, and
___ should follow-up in ___ for further discussion of
radiation.
For your bloodstrem infection, ___ will take IV ceftriaxone for
4 weeks total. As ___ travel from ___ to ___ should
take amoxicillin until ___ resume IV antibiotics at the infusion
center in ___. The last date of antibiotics will be: ___
It was such a pleasure taking care of ___! We wish ___ all the
best and that Flordia treats ___ oh so well!
Your ___ Oncology Team | BRIEF MICU COURSE
Ms. ___ is a ___ with a PMHx of HTN, metastatic vulvar
cancer, and s/p recent admission ___ for hypercalcemia, who
presents with hypotension.
# Septic Shock, unknown source, though likely from a necrotic
cancerous lesions within the ABD: Pt presented w fever,
hypotension requiring levophed, 7L NS, ___ GPCs bacteremia in
pairs and chains growing. Initial CT abdomen with no abscess,
although contrast deferred due to ___. Empirically started on
vancomycin and cefepime on ___. ID consulted d/t possible
port infection, who recommended TTE, vancomycin troughs, d/c
cefepime. She was called out of the ICU after 24 hours in
stable condition. Later found to be growing Group G Strep,
sensitive to ceftriaxone. TTE negative for valvular involvement.
ID recommended ___ weeks ceftriaxone. Patient to be discharged
to ___ with high dose amoxicillin while traveling and
resumption of IV ceftriaxone for total 4 week course.
___ Weakness and Urinary Incontinence: Pt first noticed bladder
incontinence in ___ and notes that when she stands up, she
loses urine. Also with new weakness in her leg and pain in her
hip since a few days prior to admission. Neurology was consulted
and saw her ___ and felt that her symptoms were consistent
with an UMN pattern, potentially to the frontal lobe given her
difficulty with attention, or anywhere along the spinal cord. It
was recommended to get MRI brain and rest of the the spine;
however, the patient did not wish to know the results of anymore
scans, as it will not change her decision--she is very clear
about no more interventions to extend her life. She is ok with
palliative radiation for pain. She wants quality and states,
"I'd rather have 3 months of good quality than a year of in and
out of hospitals." Rad-onc saw patient and based on lack of cord
involvement, declined one time radiation dose. ___ evaluated
patient and she was able to ambulate well including going up 1
flight of stairs. Discharged with dexamethasone. Patient to
follow-up in ___.
# Pain: Likely ___ widespread disease burden. Seen by palliative
care and started on long-acting morphine and gabapentin with
good results. | 184 | 357 |
18046197-DS-46 | 24,037,974 | Dear Mr. ___,
It was our pleasure taking care of you at ___
___. You were admitted with a skin infection of your
leg (cellulitis). You were treated with antibiotics and
improved, surgery was consulted and said you did not need
surgery. Infectious disease specialists gave us recommendations
for antibiotics. Additionally, you were very volume overloaded
so we gave you medications to take fluid off. Your glucose
levels were initially high but they became better controlled as
we adjusted your u500 insulin dose. You had a fall on your back
which caused a muscle strain and increased back pain. We
increased the amount of your medications and gave you new
medications with the lidocaine patch and tramadol.
- Please continue taking the new antibiotic dicloxacillin
through ___. This is an oral form of the IV antibiotic you
received while in the hospital. | # Cellulitis: Mr. ___ presented with a swollen
left lower extremity. It was erythematous, and painful. He had
no systemic symptoms or elevated white count. He was evaluated
in the ED and he went for CT which showed no gas, deep tissue,
or bone involvement. Surgery was consulted and determined he was
not a surgical candidate. This was a concern as he had a
previous history of nec fasc. He was placed on broad spectrum
antibiotics and began improving. ID was consulted and they
recommended switching to nafcillin as their suspiscion was high
this was MSSA or strep skin infection. This was switched and
initially his leg worsened, but ID decided that this was not
antibiotic failure. He then improved on the nafcillin, he was on
IV antibiotics for 5 days and then switched to oral
dicloxacillin prior to discharge. He originally required a PICC
which was removed prior to discharge. He had a repeat CT when it
appeared his leg was worsening which was consistent with his
first CT scan. He had ___ of his lower left leg which did not
show a clot.
-Antibiotics should be continued through ___ for a total ___ack pain: He had a fall off his bed and landed on his back.
He described this back pain as similar to his past
musculoskeletal strain. He had no tenderness over his spine. His
left shoulder muscles were tender. He often appeared comfortable
and stated his pain was improving, but then stated he had
worsening pain. He was already prescribed a muscle relaxer. He
was discharged with oral dilaudid, tramadol, and lidocaine patch
for back pain. He had an xray which grossly showed no rib
abnormality.
# DM type II: Prior to admission he had been recently started on
U500 which had not yet been titrated. A ___ consult was
placed to assist in titrating his insulin. Originally, he was
very labile but during admission he became under better control.
He did continue to remain labile with occassionally mildly low
glucose in the morning and another day where he was very high.
___ consult was unsure why he remained so labile but
postulated it may be due to the resolving infection with
changing insulin requirements. He was continued on his home dose
of midodrine for his autonomic neuropathy.
# Volume overload: Patient originally admitted grossly volume
overloaded admitting he had gained at least 30 pounds within the
last few months. This was likely a combination of poor dietary
compliance, but as he started steroids within the past few
years, this was probably also contributing. On his last ECHO his
EF 60-65%. He was not thought to be in heart failure. He was
continued on his home diuretics of bumex, spironolactone, hctz.
80mg IV BID of lasix was added. He was repleted daily with
120meq QID of potassium. He diuresed an estimated 10L, but was
still extremely overloaded on discharge. He was changed back to
his home dose of Lasix on discharge. For cardiac issues he was
continued on aspirin, carvedilol, and his statin.
# Glaucoma: He had a complicated eye and glaucoma surgery
history. As an outpatient he had frequent ophthalmology follow
up, so he was seen by ophthalmology who determined that his
pressure was normal and his eye medications needed no adjusting.
He had no new visual impairments.
# Psoriasis: He had a complicated history of psoriasis
complicated by psoriatic arthritis. He was continued on his home
dose of dexamethasone and on atovaquone for prophylaxis.
#Dysuria: He initially presented with vague symptoms of dysuria
but his UA and urine culture were normal. He had no cellulitis
of his testicles. His discomfort resolved without further
intervention. | 141 | 608 |
13488094-DS-13 | 23,172,294 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted after a fainting event, and
were found to have a small head bleed as well as a nasal
fracture. You were initially on the surgery service, and your
bleed appeared stable. You were transferred to the medicine
service and were evaluated by cardiology. They recommended
making several changes to your medications, including stopping
triamterene-hydrochlorothiazide and increasing your lisinopril.
It is important that you stay hydrated and this will be most
important for preventing further fainting episodes. We are
discharging you with a heart monitor as well. Please follow up
with your primary care doctor, to have sutures removed in ___
days. You will also need follow up with the neurosurgeons in 4
weeks.
Nonsurgical Brain Hemorrhage
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen
etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | ___ y/o F with PMH HTN, HL, and UC who presented ___ after a
syncopal episode c/b subdural hematoma, initially on the
neurosurgery service, transferred to medicine for syncopal
evaluation. | 219 | 30 |
15992853-DS-12 | 21,835,694 | Dear Ms. ___,
It was a pleasure taking care of you during your stay. You were
admitted after a fall and was found to have a small brain bleed.
The neurosurgeons evaluated you and did not think you needed
surgery. Your hospital course was complicated by some kidney
injury and confusion, both of which were improving at discharge.
Please wear the cervical collar at all times until you see
Neurosurgery. Please see below for their instructions. We wish
you the best!
Discharge Instructions from Neurosurgery:
Brain Hemorrhage without Surgery
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating,
and remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptom after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches
but avoid taking pain medications on a daily basis unless
prescribed by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | BRIEF HOSPITAL COURSE:
Ms. ___ is an ___ woman with a history of HTN/DM, sick
sinus syndrome s/p pacemaker placement, neuropathy, cervical
stenosis, OA, gout, and left knee replacement, who presented to
OSH s/p fall, found to have small SAH. She was transferred to
the neuro ICU at ___ for further management.
ACUTE ISSUES
# Sub-arachnoid hemorrhage: Subsequent CT scans here at ___
were stable. A small temporal-parietal contusion was noted, not
requiring neurosurgical intervention. Of note, she was initially
found to have blood pressure in the 200s systolic and was placed
on a nicardepine gtt. She subsequently was taken off of the gtt
with blood pressures <160. The cause of the head trauma was
likely due to a mechanical fall, as pt has had multiple previous
falls, however syncope workup was pursued. EEG showed findings
consistent with encephalopathy. Echo without significant
valvular disease. The patient's pacemaker was interrogated, and
did not show any events around the time of the fall. The patient
will follow up with neurosurgery as an outpatient.
# ___ on CKD: Likely pre-renal progressing to ATN, in the
setting of being found down and looking dehydrated on admission.
Initially the patient's lasix was held, but then was restarted
given diastolic HF and concern for volume overload. The
patient's creatinine improved over the course of her medicine
stay, and by discharge it was 2.0 (baseline 1.6-1.9). She was
discharged on her home dose of 40 PO lasix BID.
# AMS: She initially in the ICU the patient had AMS and was
extremely lethargic, not following commands, but spontaneously
moved and withdrew to pain in the SICU. At baseline, she is
alert and interactive, dependent with her ADLs due to severe
arthritis, and walks with a walker. Per prior notes, patient's
daughter reports that patient becomes altered in context of
elevated CR (> 3). DDx also includes hospital induced delirium
on possible baseline dementia, exacerbated by pain and head
trauma. Also with UTI, treated with ceftriaxone. Patient's pain
was managed with home fentanyl patch.
# Hypernatremia: The patient had hypernatremia to 149 during
admission, due to intermittent delirium and C-collar preventing
patient from drinking adequately. Initially required IV D5W,
however by discharge was maintaining sodium levels at 145 or
less with oral intake. Will need sodium level monitored
intermittently at rehab to ensure pt is getting enough free
water.
#UTI: pt had a dirty urinalysis noteable for moderate bactiuria
and pyuria of 181 WBC. Urine culture was finalized as no growth.
Given her course of altered mental status, it was decided to
treat the pt for uncomplicated cystitis with a 3d course of
ceftriaxone. She was transitioned to cefpodoxime 400 mg PO qday
to complete a three day course at rehab, to be finished on
___.
# Gout: Patient has a hx of gout and is on allopurinol and
colchicine at home. In hospital patient did not appear to have
any flares, and her allopurinol was restarted on ___.
# Diastolic heart failure: In house TEE showed no intracardiac
source of syncope, and showed moderate symmetric left
ventricular hypertrophy with preserved biventricular systolic
function. Mildly dilated ascending aorta. Severe pulmonary
artery systolic hypertension. LVEF > 55 %. Patient takes
metolazone and furosemide at home. Her home furosemide dose was
restarted ___.
# Type II DM: Patient on glipizide at home, was put on SSI
here.
# Recurring cellulitis: Patient has cellulitis in setting of
edema at home and is prescribed clindamycin 300 tid for
cellulitis flare. Patient showed no sign of cellulitis. Was not
continued on her cindamycin; should follow up with PCP about
restarting.
# Hip pain: Patient has had significant hip pain, thought to be
from OSA. X-rays and CT abd/pelvis in ___ showed no
fracture or dislocation, but relative osteopenia of the
visualized bony elements. Her home fentanyl patch was continued.
# C-collar: Patient was kept on C-collar in house s/p fall. It
could not be cleared due to persistent neck pain and inability
to get MRI neck ___ pacemaker for SSS. Will need to follow up
with neurosurgery as outpatient to get clearance for C-collar
removal.
# Pacemaker for SSS: Interrogated by cards this hospital stay,
on ___. She had an episode of atrial fibrillation on ___,
but no episodes correlating to the time of her fall. AV paced,
poor conduction.
# Tropinemia: Noted to be 0.012 on admission. ___ be ___
hypoperfusion ___ hypovolemia, CHF or hypoalbuminemia. Given
interrogation, and ECHO, less suscpisious for ischemic ACS.
Troponins subsequently downtrended.
# Nutritional status: Patient was managed to be switched to a
mechanical soft diet (her home diet) before discharge.
# Fungal rash under breasts: Noted during hospital stay. Patient
was given topical nystatin during stay
TRANSITIONAL ISSUES
- Cefpodoxime for 3 days at rehab, finish on ___
- Patient needs to wear C-collar at all times; will follow up
with neurosurgery for clearance as an outpatient
- Check pt's sodium levels every other day until stable.
Encourage PO intake to prevent hypernatremia
- Titration of blood pressure medications as needed
- Chest CT revealed R lung nodules which may be a small focus of
inflammation or aspiration. If patient has high clinical risk of
malignancy, followup CT in ___ year is recommended.
- Abd CT revealed right ovarian cyst which is not well
characterized but probably benign. If clinically indicated,
ultrasound may be useful for further characterization; location
may not be amenable but it could be attempted. | 493 | 915 |
14141441-DS-15 | 27,568,128 | Dear Mr. ___,
You were admitted to the hospital for an overdose on oxycodone.
You were initially treated at ___, then
transferred to ___ for
additional care.
We treated your condition by giving you naloxone, a drug that
reverses the dangerous effects of oxycodone intoxication.
While you were here, you also experienced some episodes of
sweating and tremor. These are consistent with oxycodone
withdrawal. We treated you with another medicine, clonidine, to
help relieve some of these symptoms.
Please make an appointment with the doctor who prescribes you
oxycodone to discuss alternative options for treating your low
back in the future.
Thank you for allowing us to be part of your care.
Your ___ team | ___ with a history of chronic back pain transferred from ___
___ after ingestion of ~700 mg Oxycodone on Narcan drip.
___ ED course: Vitals were: 99.2 95 197/109 14 98% RA.
Continued on the Narcan drip @ 0.4 mg/min. Serum tox negative
for other ingestions, UDS is pending. EKG showed NSR, normal
intervals. Toxicology was consulted in the ED. Per tox note,
"oxycodone peak effects occur within ___ hours, but absorption
may be slowed by opioid effects on GI motility. Normal
elimination half-life of oxycodone is ___ hours." Recommended
trending LFTs, weaning narcan, watching for pulmonary edema or
seizure.
MICU Course notable for:
- improvement on naloxone gtt. No clinical signs of opioid
intoxication (pinpoint pupils, respiratory depression (RR <12),
CNS depression)
- off narcan gtt at 0930 ___
- voided 1200cc after suspected intentional retaining to avoid
urine test
- restarted home ACEI and beta blocker given no evidence of OD
- urine tox screen negative | 111 | 158 |
16554192-DS-20 | 28,177,397 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- <<<>>>
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 <<<<<>>>> 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.
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
Type: Surgical
Dressing: Gauze - dry | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have hip fx and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for orif of hip fx , 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 ot was appropriate. HER
vitamin D was 13 she was cstarted on 50,000 unit q and told to
follow up with her pcp
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 rt lower extremity, and will be discharged on ___
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. | 263 | 276 |
11489099-DS-9 | 24,257,120 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___!
You came into the hospital because you were having worsening
pain in your side. This was probably because you were unable to
obtain your fentaynl patch. Your pain was treated with IV
medications, which were eventually changed to a fentanyl patch
and
medications to take by mouth. You will start chemotherapy today,
which may also help the pain. Please inform your oncologist if
your medications are not adequately treating your pain. | ___ s/p radical cystoprostatectomy w/ ileal loop for bladder
cancer in ___, who presents with acute on chronic flank
pain, persistence of hydroureter, and UTI. Also noted to have
confusion at home.
# Acute on chronic Flank Pain - Likely ___ metastatic bladder CA
with hydroureter and pyelitis. Inadequate pain management at
home due to misunderstanding by family, who was placing tegaderm
patches instead of fentanyl patches. Patient was restarted on
fentanyl patch 100mcg/hr, Gabapentin, Lidocaine patches and hot
packs, and PO and IV hydromorphone. He was still having
breakthrough pain at discharge, but wanted to make it to his
palliative chemotherapy appointment. He reported he would manage
and his pain was relatively well controlled at time of
discharge. Patient is chronic opioid patient (due to pain).
Advised him to discuss his pain regimen with his Oncologist, and
may consider increasing fentanyl patch as indicated.
# With positive UA - Initially managed as a acute complicated
UTI with IV ceftriaxone, but eventually stopped treating it.
Given he has an ileal loop instead of a bladder, it will be very
difficult to fully "treat" for a urinary tract infection and
sterilize that tract. Patient does not have a bladder, so the
positive UA more likely contamination vs bowel flora. He did not
have pain or signs of infection at his ostomy site.
# Confusion - Resolved. Possibly due to severe uncontrolled
pain, or high doses of gabapentin, narcotics, benzos he was
taking to compensate for the continuous fentanyl patch. Also
high likelihood he was actually withdrawing, as he was wearing
tegaderm instead of fentanyl. He was AAOx3 the morning after
admission after his pain regimen was restarted. Reduced
gabapentin slightly during inpatient but resumed at discharge.
Discontinued trazodone to reduce polypharmacy and confounding
medications, and patient did not require it.
# Constipation - Abdominal imaging negative for SBO, but patient
had recent admission for pSBO so must monitor. However, most
likely due to high dose narcotics. Treated him with a bowel
regimen with PO lactulose, PR bisacodyl and he was having bowel
movements by day of discharge.
# s/p Fall - likely mechanical, but concern for oversedation
with narcotics. Will need to balance pain and functionality.
Patient was able to ambulate safely by time of discharge and
final head CT read was negative. Neuro exam stable and intact.
# Recurrent urothelial carcinoma, with hydroureter and pyelitis:
s/p radical cystaprostatectomy in ___ for urothelial bladder
cancer but with metastatic nodes on recent imaging. Called
urology to inform them patient had returned, but they indicate
that they did not want to intervene before since no definitive
lesion was seen, and current imaging indicates known findings,
so no intervention likely. Primary outpt Heme/Onc attending
notified. Plan was to start palliative chemo ___ but given
UTI may have to delay | 85 | 460 |
19109135-DS-2 | 20,487,420 | You were admitted because you were very confused and weak. You
were found to have tumors in your brain. You underwent a brain
biopsy. A sample of tissue from the lesion in your brain was
sent to pathology for testing. This was consistent with lymphoma
(diffuse large b-cell). You had urgent chemotherapy called High
Dose Methotrexate. Please keep your dissolvable sutures clean
and dry. You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside. Call your surgeon if there are any signs
of infection like redness, fever, or drainage. You will need to
return to ___ for further chemotherapy.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment
with the neuro-oncology team here in the hospital.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ who presented with acute altered mental status and was found
to have primary CNS Lymphoma.
CNS LYMPHOMA
- He was found to have primary CNS lymphoma on this diagnosis.
He underwent a brain biopsy and then was urgently started on
urgent HD MTX at reduced dose, ___. He also received sodium
bicarb and leucovorin per protocol. He tolerated the
chemotherapy and his mental status improved. However his LFTs
started to rise the next day as expected but even though he
cleared (the MTX on ___ pm level was 0.05), his LFTs continued
to rise. They did eventually start to down trend. His HIV and
hepatitis serologies were negative. He had a leukocytosis which
was likely due to the steroids he was started on as he had
infectious symptoms. He needs an outpatient opthomology
evaluation. He was evaluated by ___ and OT and determined to be
most appropriate for discharge to a SNF. He will have labwork
repeated this week and will plan to return for his next cycle of
methotrexate on ___.
Normocytic Anemia
- Vit B12, and iron studies suggestive of inflammatory block.
Low TSH
- Mildly depressed but Ft4 normal so likely sick euthyroid. T3
low
likely from dex. | 452 | 197 |
15509957-DS-13 | 28,965,960 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- sudden onset of abdominal pain and vomiting
- lightheadedness and dizziness
What was done for you in the hospital:
- we diagnosed you with a UTI for which we treated you with
antibiotics
- we gave you IV fluids to treat your dehydration
- we arranged for you to have ___ visit you at home for a
check-up
What you should do when you get home:
- take your medications as prescribed on the attached
medication list
- attend your follow up appointments as scheduled on the
attached sheet
- contact your doctor or return to the ER if you have any
worsening symptoms or are concerned
[ ] MEDICATIONS STARTED: cefpodoxime (end date ___
[ ] MEDICATIONS STOPPED: none
[ ] MEDICAITONS CHANGED: none
Wishing you the best,
Your ___ Care Team | ___ female with PMHx notable for depression and dementia
(MoCa 21) who presented with acute onset diarrhea, pre-syncope,
and abdominal pain. Discovered to have Klebsiella UTI and
borderline ambulatory hypoxia. Treated with ceftriaxone and
fluid repletion with rapid improvement in symptoms. Hypoxia most
likely from atelectasis (visualized on CXR) and spontaneously
improved to 94-95% with ambulation on room air. Diarrhea
spontaneously resolved shortly after admission and so did not
pursue aggressive workup. Discharged home where patient has
24-hour care with plan for OT home evaluation.
#Dizziness/lightheadedness
#Klebsiella UTI:
UA obtained in ED notable for bacteruria and pyruia. No dysuria
or urinary frequency though considered symptomatic given
pre-syncopal symptoms prior to arrival. Initially received
Cipro/Flagyl in ED given concern for intra-abdominal infection,
subsequently narrowed to ceftriaxone to treat for UTI rather
than GI infection (as patient reported only one episode of
diarrhea which prompted admission and complete resolution of her
abdominal pain by the time she arrived on the floor). Lactate
down-trended from peak of 2.9. UCx later grew out pan-sensitive
Klebsiella pneumoniae and so she was discharged with plan for 2
additional days of PO cefpodoxime. Total 5-day course
antibiotics ___ - last day ___. At time of discharge,
patient was asymptomatic and feeling back to her baseline.
#Ambulatory hypoxemia:
No respiratory symptoms though noted resting O2 of 94-95% that
dropped to 88% with ambulation. No evidence of pulmonary
infection given afebrile, absence of leukocytosis. CXR with no
clear consolidation though notable for possible atelectasis. No
lower extremity edema and no history of significant immobility
or trauma, thus very low suspicion for PE as a cause of her
hypoxemia. Encouraged incentive spirometer, ambulation. Improved
to 94-95% with ambulation by morning of discharge.
#Diarrhea
#Abdominal pain:
Presented with sudden onset diarrhea with abdominal pain.
Underwent CTA and KUB with reassuring results. Diarrhea
spontaneously resolved. Abdominal pain determined to consistent
with her usual tenderness from known ventral hernia. No evidence
of strangulation or ischemia on CT. Given rapid resolution did
not pursue further workup of diarrhea.
#QTc prolongation: QTc 520 on admission. Repeat QTc 445 prior to
discharge.
#Depression: Continued BusPIRone 5 mg PO QHS and Citalopram 20
mg PO/NG DAILY
#Dementia: MoCa 21. AAOx3 throughout admission. | 147 | 356 |
13384248-DS-8 | 21,142,059 | ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- 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.
Activity:
-Continue to be full weight bearing on your right leg.
-Elevate right leg to reduce swelling and pain.
-Do not remove splint/brace. Keep splint/brace 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. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibia and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF right tibia, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patient had acute desaturations on POD 2 and a CT scan was done
to rule out PE. He did not have a PE however he did have a
picture that appeared to be related to aspiration pneumonititis.
medicine was consulted and recommended conservative treatment.
The patient continued to do well and remained afebrile without a
elevated wbc. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the right lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharg | 282 | 287 |
16008484-DS-13 | 28,953,893 | You were admitted with acute pancreatitis. After treatment with
IVF and pain management you improved significatly but were still
requiring very frequent pain medication so this was changed to a
long acting medication, which will be re-evaluated by your GI
doctor when you see him on the ___.
You also have a UTI and will complete antibiotics for 3 days. | 1. Pancreatitis: Presented with 3 days of abdominal pain in
setting of heavy alcohol use, with elevated lipase to 1800 and
CT scan confirming pancreatitis. CT scan read here just relevant
for acute pancreatitis with no evidence of pseudocysts or any
clear necrosis. Pain control was achieved with IV dilaudid
followed by PO dilaudid. Surgery consulted and did not see any
need for surgical intervention. When the patient had persistent
leukocytosis, repeat CT imaging was performed and showed
persistent necrosis but no organized fluid collection. SUrgery
was reconsulted and recommended returning to NPO status, which
improved the symptoms. SHe was slowly started on a diet but
continued to require dilaudid every 2 hours. Since it may take
additional time for her pain to recover, she was switched to a
long acting morphine and this will be re-assessed in 2 weeks
when she sees her GI doctor.
2. Alcohol withdrawal: The patient reported drinking one pint of
vodka every few days. She was placed on a CIWA scale with no
evidence of withdrawal.
3. Leukocytosis: U/A dirty, repeated U/A still with some WBC
and prior UCx >100,000 EColi so have started treatment for
umcomplicated UTI with Cipro for 3 days.
-WBC can also be due inflammation from pancreatitis
5. Tachycardia: HR into 130s on presentation. Improved with pain
control and IVF.
6. Hepatitis C: Unclear if treated. HCV viral load positive.
Patient should follow up with PCP.
7. COPD: Unclear if per PFTs, but has long smoking history.
Maintained on her albuterol nebs prn.
8. Drug use: Social work was consulted on the floor for her
alcohol and drug use. | 59 | 269 |
17326039-DS-18 | 27,940,684 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Mr. ___ is a ___ year old man with history of HTN, HLD, 3
vessel CAD(s/p stents to LAD and RCA), prostate cancer s/p cyber
knife who presents with transient slurred speech, word finding
difficulties, and question of facial droop as well as
intermittent chest pain with new ECG findings and troponinemia
consistent with NSTEMI, positive UA concerning for UTI, and
multiple left dental caries.
Patient with history of 3VD s/p stenting LAD and RCA with LAD
in-stent stenosis presenting with 1 week of intermittent chest
pain at rest, found to have ST elevations in aVR and V1-V3 and
reciprocal STD in V5-V6 concerning for unstable angina vs
NSTEMI. Troponin elevation to max of 0.13. He underwent cardiac
catheterization and was noted to have extensive three vessel
disease. Patient underwent CABG on ___ (LIMA>LAD,SVG>OM,
SVG>Diag, SVG< PDA.) Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
Plavix was started for poor targets. The patient had altered
mental status which existed preop and remained hemodynamically
stable. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. On POD4
his Hct dropped to 18 and he was transfused 2 units RBC. Echo
showed a small pericardial effusion and abdominal and chest CT
was negative for bleeding. On POD 4 he went into a rapid atrial
fibrillation and was bolused with Amiodarone and Amiodarone drip
was started. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD #7 the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to ___
in good condition with appropriate follow up instructions. Leg
staples are to remain in for 2 weeks. He will need outpatient
follow up with vascular for AAA and will outpatient US to follow
up thyroid nodule. | 108 | 358 |
12118132-DS-5 | 27,735,723 | It was a pleasure taking care of you at ___
___. You came to the hospital with an infection of
your left pelvic muscles causing severe pain down your side and
into your groin. This was found to be due to a large muscle
infection. You also were found to have a blood infection with
the same bacteria. This was treated with intravenous (IV)
antibiotics. Our Infectious Disease team reviewed your case and
recommended an extended course of IV antibiotics to ensure
resolution of this serious infection.
Your infection was caused by your self-injection of drugs. This
can cause serious infection, heart attack, respiratory failure,
and many other health problems. It can kill you. You should
seek help to stop drug use.
We added several medications:
- cefazolin, an antibiotic to treat your infections
- colace, a stool softener
- senna, bisacodyl, and miralax, all laxatives
Please follow-up with your physicians as listed below. | ___ with no significant medical history presents with left lower
back pain for 9 days, found to have pyomyositis.
# Pyomyositis: MRI demonstrated a large fluid collection ___ the
psoas and iliacus muscles on the left, new since prior MRI
imaging on ___. Patient admitted to needle drug use
several days prior (left arm injection site). ___ and surgery
were consulted, who agreed to pursue percutaneous drainage of
two sites with JP drain placement with return of purulent
material. Blood cultures (and abscess cultures) grew MSSA,
cultures ___ positive for GPCs. TTE and TEE negative for
vegetation, ___ u/s negative for DVT, tenal u/s negative for
renal involvement. He was treated with vancomycin from ___,
switched to cefazolin ___. Blood cultures were negative from
___ onward. Planned 4 week antibiotic therapy from last
positive culture (___). The Infectious Disease team was
consulted to guide his treatment and continue to monitor his
progress as an outpatient. He was transferred to rehab for
ongoing IV antibiotic therapy (___ line placed).
# Lower back pain: Due to pyomyositis. Pain was controlled
with IV Dilaudid, changed to PO Dilaudid as drainage relieved
the pressure on his muscles. His medication requirement was
high, up to 50mg IV Dilaudid daily, indicating both the severity
of the pain and his potential tolerance due to opioid use prior
to admission.
# Thrush: Patient noted to have thrush on admission. Unusual
___ a patient without known immune supression, despite recent
steroid course. Nystatin was used to treat the thrush with
resolution of symptoms. HIV negative. A1c unremarkable.
# h/o IVDU: Recent history of IV drug use, injection site left
arm per patient report. HIV negative, HCV negative, HBV BsAg
and BcAb negative. Given the need for long-term IV antibiotic
therapy, he was screened for Rehab placement. Social Work
provided information to the patient and his father regarding
possible resources for treating his addiction.
# Constipation: The patient was constipated, likely due to
large amount of opioid pain killers used. He became distended
and uncomfortable. KUB normal. Relieved with aggressive bowel
regimen. | 158 | 363 |
11733112-DS-2 | 21,845,733 | You have undergone the following operation: ThoracoLumbar
Decompression With Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10
lbs for 2 weeks. You will be more comfortable if you do not sit
or stand more than ~45 minutes without getting up and walking
around.
- Rehabilitation/ Physical Therapy:
o ___ times a day you should go for a walk for ___ minutes
as part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound. | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical
therapy was consulted for mobilization OOB to ambulate with a
TLSO brace. The patient had difficulty in meeting all ___ goals
and was rehab facility care was recommended. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet. ___ was consulted for
high bllod suger levels. They recommended starting the patient
on 10 units of Glargine insulin at bedtime. The patient will
need dose adjustments in the postoperative period as as
outpatient in rehab. | 486 | 197 |
13919141-DS-6 | 28,313,718 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with a urinary tract infection
that spread to your kidneys, a condition known as
pyelonephritis. You were treated with antibiotics and it is now
safe to be discharged to continue treatment at home.
Please make sure you finish all antibiotics and follow up with
your PCP as detailed below to ensure that you continue to
improve.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with history of prior IVDU,
hep C (self-cleared) who p/w right flank pain radiating to
groin, tachycardia, fever and recent cystitis symptoms, c/w
pyelonephritis.
#Sepsis:
#Acute R pyelonephritis:
Pt presents with fever, leukocytosis, tachycardia, and right
flank pain radiating to groin, and CT imaging consistent with
acute right pyelonephritis without associated abscess. No
obstructing renal stones. Initially treated with empiric IV CFTX
but urine cultures ultimately growing E.coli resistant to CFTX
but sensitive to fluoroquinolones. She was transitioned to
ciprofloxacin BID initially at 250mg BID, but then increased to
500mg BID on ___ in setting of ongoing fevers. Her fevers
resolved and she was discharged to complete a full 7 day course
of antibiotics (day 1 = ___.
# Hx of IVDU:
Recently on suboxone, but patient plans to stop this medication.
In the setting of acute pyelonephritis, her pain regimen did
include opioid analgesics and no concerning behavior observed.
She voluntary stopped opioids prior to discharge.
# Limited IV access:
Midline attempted in ED by IV RN, unfortunately unable to thread
wire. EJ ultimately placed by ED team. Suspect will continue to
have issues with difficult access if required in the future.
# Hep C:
Previously followed w/ ___ liver clinic, was planned to get
treated for hep C but viral load noted to be undetectable. RUQUS
___ w/ course hepatic echotexture, but no official diagnosis of
cirrhosis yet. -per Dr. ___ as of ___, due for fibroscan
and none on our record, can be arranged as outpatient)
# Right ovarian cyst:
Likely hemorrhagic based on U/S in ED. ___ have contributed to
GI symptoms in addition to acute pyelonephritis.
# Complex right renal cystic lesion: Will require outpatient
monitoring
# Tobacco use -provided nicotine patch
TRANSITIONAL ISSUES:
==================
[] Discharged to complete 7 days ciprofloxacin for
UTI/pyelonephritis. PCP follow up appointment being coordinated,
please assess for resolution of symptoms on this visit. If
persistent symptoms without evidence of persistent UTI, then
suspect related to hemorrhagic ovarian cyst and should follow up
with gynecology.
[] Needs ongoing monitoring of complex renal cyst. Recommend
repeat imaging in 6 months with renal U/S.
[] Pt should follow up in the liver clinic for fibroscan as
above.
[] Blood cx x 4 pending at the time of discharge and will need
to be followed up. | 82 | 388 |
15672898-DS-16 | 24,548,351 | It was a pleasure taking care of you in the hospital. You were
admitted with facial swelling and a CT scan from an outside
hospital concerning for mass in your chest and enlarged lymph
nodes. You were seen by our surgery team for a biopsy of these
lesions. You were also seen by our oncology team because these
findings are concerning for cancer. You will need to return to
the hospital on ___ for surgical biopsy of the chest mass.
Please come to the ___ on the ___. Please
do not eat past midnight on ___. Do not eat on ___
morning before the procedure. The thoracic surgeon's office
will be contacting you with the exact time of the surgery and
more exact instructions.
There were no changes made to your medications. | ___ year old male with no significant pmh presenting with 3 weeks
of facial swelling found to have diffuse adenopathy and
mediastinal mass.
.
# Mediastinal mass/adenopathy:
Pt presented to OSH with facial swelling and had CT neck and CT
torso showing 13 x 7cm mediastinal mass, adenopathy extending
from left ear into superior mediastinum and right axilla,
abnormal right pectoralis muscle, and enlarged right
axillary/subclavicular lymph nodes. There was no evidence of
compression of his vena cava. He was evaluated by
hematology/oncology team given high suspicion for lymphoma based
on imaging. He was also evaluated by the surgical team for
possible excisional lymph node biopsy vs VATS procedure for
mediastinal biopsy. A repeat CT neck was performed because CT
neck images from OSH would not be available for several days.
He was scheduled for VATS procedure for ___. Pt requested
to be discharged on ___ evening. As there were no immediate
concerns warranting hospitalization, pt was discharged on
___ and given instructions to return to the hospital on
___ for re-admission to thoracic surgery service. Risks of
discharge were explained and pt and his family stated
understanding. They were informed of alarm symptoms to be
cautious of, including fever, chest pain, and shortness of
breath. Heme/onc team and surgical team were made aware of his
discharge and agreed that discharge with plans for surgical
procedure in the near future was reasonable. He was advised to
call the Hematology-Oncology office as soon as possible to
schedule a follow-up appointment (he was provided with the phone
number). It was also recommended that he have blood work
checked (electrolytes/tumor lysis labs) within the next week by
either his PCP or the oncologist. All questions were answered
and the patient expressed understanding of the discharge and
follow-up plan. Of note, radiology report of his repeat CT neck
was pending by time of discharge and should be followed up. He
should also have an HIV test performed.
.
# Substance abuse: Pt reported daily alcohol use for ___s cocaine/marijuana use. He was observed on a CIWA scale
but did not require benzodiazepines. He was given a nicotine
patch for his tobacco use.
.
# Wheeze: Pt reported asthma as a child. He had wheezes on exam
and was given albuterol nebs prn during his hospital stay. He
was not in respiratory distress; he was not tachypneic and
oxygen saturations were consistently > 90s on room air. | 141 | 427 |
12163263-DS-21 | 25,065,091 | Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
- Your family noticed that you seemed confused. You had recently
run out of your home lactulose.
WHAT HAPPENED WHILE I WAS HERE?
- You were given lactulose, as well as a new medication called
rifaximin, for your confusion.
- Your confusion cleared with these medications.
- You showed no signs of infection.
WHAT SHOULD I DO WHEN I GET HOME?
- Please take all of your medications (especially your lactulose
and rifaximin) as prescribed.
- You should have ___ bowel movements a day. If you are having
less than ___ bowel movements, please take more lactulose. If
you have having ___ bowel movements a day, please take less
lactulose.
- Please go to all of your scheduled doctors ___.
We wish you the best!
Sincerely,
Your ___ Care Team | SUMMARY:
=========
___ year old ___ speaking male with PMHx ___ A
alcoholic cirrhosis decompensated by gastric variceal bleeding
and volume overload s/p TIPS, ___ s/p RFA x3 who presents with
hepatic encephalopathy in the setting of running out of
lactulose. | 135 | 39 |
10320861-DS-13 | 20,458,450 | Mr ___,
It was a pleasure taking care of you at the ___
___. You were admitted for an L1 fracture
confirmed by MRI. In the hospital you were examined by
Neurosurgery and Orthopoedic surgery. They recommended a
Thoraco-Lumbar Sacral Orthosis (TLSO) Brace. The brace was
placed and fitted. Physical therapy discussed with you the
appropriate use of the brace after discharge. Nursurgery would
like you to follow up in 6 weeks. Prior to the appointment with
neurosurgery, you will need to do a CT scan. All follow up
appointments including CT scan have been made for you, please
find time/location below.
Please continue your home medication as before.
No changes were made to your medications. | ___ yo M presents to the ED with L1 burst compression fracture
diagnosed by outpatient MRI. Has PMH of non-cirrhotic portal
hypertension ___ portal vein thrombosis complicated by
esophageal varices and ascites, hypercoagulable chronically
anticoagulated.
# T1 Fracute: T1 compression fracture likely from recent boating
accident (~3 weeks prior to arrival). Seen by neurosurgery and
orthopoedics in the ED who recommended admission to medicine for
pain control and TLSO brace. Patient without focal neurologic
deficits on admission and with normal gait limited by pain. MRI
also reassuring without acute cord compression or compromise.
On day two of the admission the patient had a weight bearing
LSpine that did not show concerning signs. Neurosurgery
recommended a TLSO brace and an outpatient follow up. The TLSO
brace was fitted and the patient was given instruction on use by
___. The patient's pain was controlled with oxycodone and
morphine. The patient has a follow-up appt planned with
Neurosurgery in 6 weeks. On day of discharge the patient could
ambulate with the TLSO brace. On day of discharge the patient
tolerated a full diet, moving bowels and urinating with
problems, was afebrile, and had well controlled pain.
# Chronic Portal Hypertension: Chronic, stable. No ascites, ___
or weight gain to suggest diuretic refractory ascites.
Non-cirrhotic portal hypertension active on liver transplant
list, s/p TIPS, likely related to portal vein thrombosis ___
chronic hypercoagulable state. Portal hypertension also
complicated by ascites which is well controlled with diuretics
and also history of grade III varices without history of
variceal bleed currently on nadolol. The patient's home
medications were continued.
# Hypercoagulable state: Chronic, anticoagulated complicated by
Noncirrhotic portal hypertension ___ portal venous thrombosis,
also with SMV, splenic vein thrombosis and CVA in ___. The
patient's home warfarin regiment was continued as below:
- Warfarin 7.5 mg PO 3X/WEEK (___)
- Warfarin 7 mg PO 4X/WEEK (___) | 116 | 319 |
19960879-DS-15 | 29,288,546 | Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this when cleared by the neurosurgeon.
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. | Ms. ___ was seen in the ER and admitted to the step down
unit for monitoring. A repeat head CT on HD 1 did show expected
progression of her bleed. Her exam remained unchanged. Patient
is typically awake and alert, only oriented to self, MAE with
good strength. During her hospital stay she did become agitated
at times in the evening and overnight. She was noted to have
urinary retention and required a foley to be placed. She
remained unchanged in her exam and was discharged back to her
facility on ___. | 196 | 92 |
17781379-DS-20 | 27,677,070 | You were admitted to the hospital due to jaundice and pancreatic
mass. An ERCP was performed and your bile duct was stented,
which should relieve your pain. You also had a biopsy taken,
which should result in the next week. Finally, you had evidence
of right kidney swelling on your ultrasound. Please follow up
with your primary care doctor and urologist regarding these
findings. Return if your jaundice or abdominal pain worsen. Also
watch out for worsening flank (back) pain and difficulty
urinating. | ACUTE/ACTIVE PROBLEMS:
# Pancreatic head mass s/p ERCP with stent placement and
brushings
# Nausea, vomiting, abdominal pain
# Transaminitis, hyperbilirubinemia:
Patient presented with epigastric abdominal pain, nausea,
vomiting, and unintentional weight loss, found to have
transaminitis, hyperbilirubinemia, and elevated lipase as well
as pancreatic mass on CT suspicious for
malignancy.
- NPO, mIVF after ERCP done on ___.
- LFTs downtrended on day of discharge
- ___ pending
- PCP made aware of diagnosis and pending biopsy
___ (Cr 1.3-->1.2-->1.3) Unclear baseline
#R renal artery stenosis d/t mass effect seen on CT
#mild-moderate hydronephrosis on renal ultrasound with doppler
Pt Denied right sided flank pain and oliguria. Normotensive,
FeNa prerenal.
Creatinine did not improve after fluids - could represent loss
of function in one kidney. Ordered Doppler ultrasound of kidney
which showed preserved flow, but mild-moderate right sided
hydronephrosis. Urology and nephrology curbsided, felt findings
were not related to extrinsic mass as there was no correlate on
reread of CT. However could have intrinsic issue such as
stricture. Given lack of flank pain, oliguria and HTN, urology
felt patient could be followed up as outpatient.
# Depression with prior suicide attempt: When asked about this,
the patient became very upset and terminated the conversation.
Patient noted to have a depressed affect on exam.
- Social work consult for new diagnosis of likely cancer and
coping
Outstanding Issues
[ ] follow up biopsy results
[ ] pt should see nephrology for ___, recheck Cr
[ ] f/u in urology for mild-mod hydronephrosis.
>45 minutes spent on discharge planning | 83 | 239 |
16720812-DS-22 | 29,458,563 | Dear Mr. ___,
You were admitted with a pneumonia. You were also admitted
with a worsening of your congestive heart failure. We were able
to treat your pneumonia with antibiotics, and your congestive
heart failure with lasix. Part of your congestive heart failure
is likely due to the fact that your heart rate was a bit too
high. We increased your atenolol to help rectify this problem.
We made the following medication changes:
STOP Bactrim, this may have made your kidneys worse
INCREASE Atenolol to 50mg ___
START Levofloxacin for 1 more dose to be administered on
___ in the morning for a full course for community acquired
pneumonia
START home oxygen 2Lpm to be used when ambulating
Please continue all other medications as prescribed
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is an ___ year old man with a past medical history
significant for chronic diastolic heart failure, atrial
fibrillation, and Crohn's disease admitted with community
acquired pneumonia, acute on chronic diastolic heart failure,
acute renal failure, and subacute dyspnea on exertion
#Pneumonia:
Patient was found to have opacity in the right base along with
acute worsening of fever and shortness of breath. He was treated
with levofloxacin with improvement.
#Hypoxemia/Acute-on-chronic diastolic heart failure/atrial
fibrillation:
Patient was felt to be volume overloaded on presentation most
likely due to stress of acute infection as well as inadequate
rate control of his atrial fibrillation as he had heart rates in
the 120s-140s on arrival to the medical floor. He was diuresed
and his atenolol was increased with improvement in heart rate
and dyspnea. He was able to walk without increase in heart rate
over 110 prior to discharge and was discharged on his usual
regimen of diuretics as he was felt to be euvolemic. He was
continued on Pradaxa.
#Chronic dyspnea/Possible COPD:
Despite being euvolemic and pneumonia treated and being on
anticoagulation patient endorsed dyspnea with exertion similar
to his symptoms 2 weeks prior to discharge. He was noted to have
ambulatory desaturations to 86% on RA and was therefore
discharged on oxygen. His pulmonologist (Dr. ___ was
contacted who was currently working the patient up for lung
disease for his chronic symptoms and said he would continue
workup of ILD, pulmonary vascular disease, and other
obstructive/restrictive lung disease in the outpatient setting.
Patient was continued on his recently prescribed symbicort and
did well with oxygen with ambulation.
#Acute renal failure:
This was felt to be due to recent Bactrim. Bactrim was
discontinued and renal function improved.
#Cellulitis/lower extremity surgical wounds:
Patient had almost completed course of Bactrim for cellulitis
and leg looked well. DVT was ruled out with LENIs. Bactrim was
stopped as there was no evidence of persistent infection and for
acute renal failure as above. Mucoprocin ointment was continued
however, given the possibility that the granulation tissue
covering the wound might be dislodged. | 136 | 338 |
13178450-DS-19 | 23,495,537 | Dear Ms. ___,
You were hospitalized due to symptoms of headache and confusion
resulting from a central Dural thrombosis. This is a clot in the
large veins in your head. This causes increased intracranial
pressure that can cause headaches and confusion. Luckily you did
not have any ischemic strokes or bleeding from the clot.
You were started on a blood thinner to help breakup the clot and
to prevent it from getting bigger. You were started on a
medication to help reduce the pressure in your head that will
help with your headaches.
We are changing your medications as follows:
- Start taking lovenox sq twice a day
- Start taking Diamox twice a day for headaches
- Start taking flowmax to help with your urinary retention
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).
- Increase in severity or duration of your headaches. If they
are not getting better with the medication that worked prior.
- 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 | ___ year old woman with stage 1 head neck SCC of unknown primary
being treated with cisplatin and radiation who presented with
headache, found to have venous sinus thrombosis on CT scan.
#Neuro: On MRI remonstrated dural venous thrombosis of the
superior sagittal sinus and bilateral transverse sinuses without
evidence of acute infarct or hemorrhage. She was started on
heparin. Repeat CT head was stable and she was transitioned to
lovenox. Initially she was very confused and somnolent. EEG was
done and showed generalized background slowing suggestive of
mild to moderate encephalopathy from non specific etiology. It
also showed some intermittent focal slowly over left hemisphere.
Her exam markedly improved over the hospitalization and she was
walking back to baseline cognitive function at time of
discharge. She continued to have headaches that were worse with
laying down so Diamox was started and uptitrated with
symptomatic relief. Risk factors were notable for LDL 86, HbA1c
5.6. Likely etiology of hypercoagulability is underlying
malignancy. She was discharged home with ___ services.
#UTI:
#Contaminated blood culture: Patient grew Coag negative staph
overnight from ___
bottles. Started on vancomycin for 2 days but screening blood
cultures were negative and she did not have any infectious
symptoms suggestive of bacteremia so this was stopped. UA was
done and was suggestive of infection with symptoms of dysuria.
She was treated with ceftriaxone for 3 days.
#Urinary Retention: Patient had brief period of urinary
retention that required straight cath. This was possibly due to
immobility and opiates she was given for pain while
hospitalized. She was able to ambulate and voided but was still
retaining some. She felt comfortable going home with toilet hat
to monitor urine output and to start flowmax. She will call her
PCP if she has any issues with retention.
#SCC of head and neck: Patient was followed by radiation
oncology and continued to receive her scheduled radiation
treatments while admitted. Her outpatient oncologist was aware
of admission followed her while she was here. She will follow
with her oncologist. Will continue anticoagulation per oncology.
Transitional Issues
====================
[] please monitor if patient is voiding. If she is retaining may
need straight cath or foley placement.
[] please monitor headache. Any acute changes or increased pain
patient should go to emergency room.
[] Please monitor orthostatic vital signs. Patient was
discharged on Diamox for headaches but has difficulty getting
tube feeds and taking in fluids PO. If she is orthostatic
consider giving fluids or reducing Diamox.
[] Patient encouraged to keep up enough po fluid intake during
the day.
[] Patient should have repeat CT head in 1month prior to
Neurology appointment
[] Length of anticoagulation to be determined by oncology
[] Patient had difficulty tolerating tube feeds due to nausea.
Please monitor intake and if patient is tolerating them at home
[] Patient will have ___ at home and family will be staying with
her in the acute period to help out
[] Please stop Diamox if patient's headaches resolve
#Contact: ___
Relationship: Ex-Husband
Phone number: ___ | 281 | 500 |
10124367-DS-25 | 27,078,967 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted for a heart attack, for which
a cardiac cath was performed. You received a drug-eluting stent
(DES) to help open a blockage. It is VERY important that you
never miss ___ dose of aspirin and clopidogrel (Plavix) without
discussing with your cardiologist. Please review the
medications changes below carefully | Mr. ___ is a ___ year old gentleman with a PMH of CAD s/p
CABG (___) and multiple PCIs most recently ___, GERD, HTN,
HLD, CKD who presented with chest pain and was found to have an
NSTEMI.
ACUTE ISSUES
# NSTEMI:
The patient has a significant cardiac history s/p CABG with
multiple PCIs who initially presented with CP and was found to
have an NSTEMI with EKG changes inferolaterally. Cardiac
catheterization revealed severe native vessel disease, and a
drug eluting stent was placed at the distal LMCA into the LCX.
He was continued on his home Atorvastatin, Metoprolol, Aspirin,
and Plavix. Of note, despite his chest pain he refused
sub-lingual nitroglycerin or morphine as he said they did not
relieve his pain. He was started on a nitroglycerin drip with
some relief in chest pain.
CHRONIC ISSUES
# HTN:
The patient presented with a significantly elevated blood
pressure, likely in the setting of pain. He was continued on his
home Lisinopril and Metoprolol. A nitroglycerin drip was started
for further chest pain and blood pressure control.
# CKD:
The patient has a known diagnosis of chronic kidney disease, and
his creatinine was at his baseline of 1.5. His Cr was trended
and remained stable.
# GERD:
The patient has a known diagnosis of GERD and was continued on
his home PPI.
# HLD:
The patient has a known diagnosis of HLD and was continued on
his home statin. | 65 | 242 |
19267933-DS-6 | 27,851,676 | You were admitted for evaluation of arm pain and redness
consistent with a skin infection and abscess from injecting IV
drugs.
In additional you were seen by Psych with agitation and
non-cooperation, you were kept on hold.
You are feeling better today and you were re-evaluated by Psych
and hold was removed.
You were advised to stay for antibiotics and arranging safe
discharge plan for you but you have decided to leave now against
medical advice realizing the risk of worsening infection at
home, sepsis and possible death.
Please follow with infection disease specialist and your PCP, as
soon as possible as outpatient. | ___ yo M with hx HIV, hep C, ongoing
polysubstance drug use presenting with arm abscess/cellulitis.
# Cellulitis/abscess: due to IVDU. Pt has presented several
times in the last few months with infx complications of his
IVDU.
Pt has been declining further eval and I+D of his arm. Per RN
this area burst and was oozing this am. Pt initially treated
with IV vanco, wound spontaneously opened.
On my exam today, affected area is dry and no fluctuance,
redness and tenderness improved.
Plan to continue Doxycycline for 3 more days.
# polysubstance IVDU: Very high risk drug use with multiple
recent infx complications and risky behavior with needle
sharing.
Unfortunately patient is not expressing any desire to get
treatment for his substance abuse disorder currently and shows
little insight into the implications of his addictions. Unclear
how much of this is affected by his underlying psychiatric
disease and depression. Psychiatry and SW saw him.
Seen by addiction psych, resources were provided and he is not
willing to get any additional help at this point and leaving
AMA.
# Hx cough: during last admission plan was made for TB
r/o--although pt is at risk due to homelessness, he is not
currently having any sxs to suggest TB therefore low concern for
active TB. CT chest showed resolution of nodule and no other
acute process.
Leave AMA
Advised to follow with ID as outpatient.
# SI, HI
Improved now.
Psych recommended removing section/hold today and patient left
AMA.
# Untreated HIV: pt requesting treatment
CD4 ct
-ID follow up information provided.
# Hepatitis C
-ID follow up as OP.
Patient leaving against medical advise. | 104 | 257 |
17890530-DS-63 | 22,552,406 | Dear Ms. ___,
You were admitted to ___ due to bleeding from your fistula.
What happened while I was in the hospital?
-You were evaluated by ___ and had a tunneled dialysis line
placed
-You were seen by Infectious Disease doctors and were continued
on antibiotics for the infection in your leg
-Your blood pressure was noted to be low and a number of your
blood pressure medications were stopped
What should you do when you go home?
-Stick to a low salt diet and do not drink more than 1 liter of
fluid per day
-Take the following blood pressure medications: 1) metoprolol XL
50mg every morning and 2) imdur 30mg every morning
-Follow-up with infectious disease doctors for your ___ leg
cellulitis
-Follow-up with dermatology doctors for your leg swelling
Thank you for allowing us to participate in your care.
- Your ___ Team | ___ year old female ___ IDDM, ESRD on HD, Afib (on Coumadin) and
recent hospitalization for cellulitis presents for dizziness and
bleeding from her fistula site during hemodialysis. Hospital
course complicated by ongoing right lower extremity cellulitis
vs. lymphedema as well as intermittent hypotension requiring
titration of home anti-hypertensives.
# Hypotension: thought initially to be due to poor PO intake vs.
infectious vs. cardiogenic causes. Hypotension persisted
intermittently over the course of patient's stay despite
de-escalation of anti-HTNs.
- Have d/c or lowered several of her BP medications: stopped
HydrALAZINE 100 mg PO Q8H, lowered isosorbide mononitrate from
60 mg to 30 mg daily, switched Labetalol 400 mg PO TID to
Metoprolol Succinate XL 50 mg Daily. Discontinued Tamsulosin 0.4
mg PO QHS, Torsemide 25 mg PO DAILY.
# R leg cellulitis/lymphedema: pain remains an issue but exam is
stable according to ID team who saw her previously. Labs and
imaging were reassuring. Patient will continue on vanc/ceftaz
until ___ and will be seen by ID as outpatient. Dermatology
consulted and feel that RLE edema and erythema due to chronic
lymphedema with venous stasis ulcers. Recommended topical
steroids and lymphedema wraps. Also in the differential is
calciphylaxis, but unlikely due to exam findings as well as
ratio of calclium to phosphate. Had ___ evaluate for ambulation
in which Ms. ___ had pain, but was able to walk. She will
need ___ ___ sessions at home after discharge.
# Supratherapeutic INR: Elevated on admission.Reversed during
hospitalization for tunneled catheter with vit K and FFP.
Warfarin started again post ___ procedure without bridging due to
CHADS2 score of 3. Patient remained subtherapeutic which was
thought to be due to Vitamin K and FFP reversal. Patient will
need close follow-up of INR as outpatient. Discharge INR 1.3.
# ESRD: on a ___ schedule prior to hospitalization.
Missed session over weekend for bleeding from fistula. Patient
continued HD during hospitalization. Cinacalcet d/c'd due to low
PTH and low Ca. Due to issues with fistula, patient received
tunneled HD catheter by ___. Sevelemer switched to phoslo
(calcium acetate) 1334 with meals and then discontinued in the
setting of normal calcium. Regimen will need to be evaluated by
patient's nephrologist.
# LUE Fistula, surrounding superficial bruising. Renal and ___
followed throughout clinical course. Fistulogram revealed 2
outflow tracts from fistula but no evidence of significant
stenosis. There were persistent difficulty accessing and using
her fisutula. ___ placed a tunneled RIJ catheter for HD.
#Pulmonary hypertension: seen on echo and compared to previous
seems to be worsening. Mostly likely due to patients underlying
OHS, HFpEF, ESRD and anemia. Currently on digoxin, home O2 with
good saturation, and anticoagulation. Cannot diurese ___ anuria.
Have discussed with Dr. ___ cardiologist, and agreed to
de-escalate anti-hypertensives.
# S/p bleeding fistula: in the setting of elevated INR. Fistula
is relatively new, only been on dialysis ~ 3 months. No active
bleeding or expanding bruising in the arm throughout hospital
course.
#Afib on Coumadin: CHADs-3. Patient switched from labetolol to
metoprolol as above. Continued digoxin .125 mg PO q 48H.
Continued on Coumadin for a/c but was reversed for ___ procedure.
Restarted without bridge due to low CHADs score.
#Pulmonary hypertension: Patient has documented pulmonary
hypertension on echocardiograms and follows with Dr. ___. This
is thought to be due to her underlying lung disease, heart
failure, renal failure and chronic anemia. LENIs were
unrevealing as patient could not tolerate ___ pain. In terms of
pHTN treatment, patient is on digoxin, anticoagulation, O2
therapy, but not diuretics ___ anuria.
CHRONIC ISSUES:
==========================
#dCHF: LVEF 50-55% with grade III/IV LV diastolic dysfunction
with multiple hospitalizations for decompensation. Labetolol
switched to metoprolol as above. Isosorbide Mononitrate
(Extended Release) switched from 60 mg PO DAILY to 30 mg PO.
Stopped torsemide secondary to anuria and hypotension. Stopped
tamsulosin due to hypotensive effects. Daily weight monitored
with strict 1.0 L fluid restriction. Digoxin Q48H continued.
Echo showed moderate pulmonary hypertension. EF preserved.
# HTN: Hypotension complicated this hospitalization and the last
according to OMR. We discontinued and changed anti-HTN meds as
listed above.
# T2DM: Continued home insulin regimen (15U glargine) and ISS.
# Chronic pain: Discharge regimen was oxycodone 5 mg Q4 and
acetaminophen 650 mg Q8H.
# Hypothyroidism: Stable; Continued home levothyroxine 88mcg
daily
# HLD: Stable. Continued home atorvastatin 80mg qpm.
# Obstructive sleep apnea: Stable; Continue CPAP at night.
# Restrictive lung disease: O2 requirement remained at baseline
(3L).
TRANSITIONAL ISSUES
====================
[] weight on discharge 115.3 kg, still clinically overloaded on
exam
[] She was continued on her IV antibiotics for her RLE
cellulitis with Vanc and ceftaz being dosed post HD. End date
___.
[] if HD is ___- then pt should get ceftaz 2 g (MON/WED) and 3
g (FRI); if HD is T, TH, ___- pt should get 2 g (T/TH) and 3g on
(___)
[] Pressures intermittently soft during hospitalization: d/c or
lowered several of her BP medications: stopped HydrALAZINE 100
mg PO Q8H, lowered isosorbide mononitrate from 60 mg to 30 mg
daily, switched Labetalol 400 mg PO TID to Metoprolol Succinate
XL 50 mg PO DAILY, Tamsulosin 0.4 mg PO QHS, Torsemide 25 mg PO
DAILY .
[] Please titrate warfarin to INR of ___, patient being
discharged on 15mg PO daily.
[] Will need derm f/u for lymphedema. There is a possibility
they can connect her with a ___ clinic.
[] will need ligation of one of the fistula outflow tracts.
Please follow up with surgery team/Dr ___ as outpatient
[] will need PTH, Ca and phosphate monitoring to assess utility
of cinacalcet in future (we d/c'd due to low PTH and low Ca).
Sevelemer also dc'd in consulation with nephrology for elevated
phos.
[] Patient will need ___ ___ sessions at home
[] Patient will need evaluation for electronic wheelchair for HD
transport by PCP
#CODE: full
# CONTACT: ___ (daughter) ___ | 136 | 960 |
16160770-DS-17 | 20,236,999 | You were admitted after you experience a fall, and sustained
nasal fratures and an orbital fracture. You went to the
operating room for ___ fracture repair. Post-operatively,
your pain was well controlled on an oral pain regimen and you
were tolerating a diet. Physical therapy evaluated your mobility
and recommended rehab.
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.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Ms. ___ is a ___ yo Female transferred from ___ after falling
down 14 stairs. She was admitted to the ICU. A head cat scan
revealed ___ type II, nasal fractures, and orbital fracture.
The patient's Hct was 20.8; she was transfused 1 unit PRBC, Hct
25.8. Mental status waxed and waned, with agitation at night
consistent with sundowning. Given seroquel and haldol prn.
Narcotics discontinued.
On ___/, the patient was able to protecting her airway and
oxygen saturations were within normal with face tent. Hct stable
at 25.6. She was transferred to floor.
The patient underwent Lefort fracture repair on ___.
Post-operatively, her pain was well controlled with oral pain
medications. On ___, the patient had packing removed out of her
nose. She had a bedside swallow evaluation and the speech
pathologist recommended advancing to a PO diet of thin liquids
and ground solids as medically appropriate. The patient was
tolerating a mechanical soft diet. Her vitals were stable and
she was afebrile. Her hematocrit was stable at 27.8. She will
have followup in the ___. | 310 | 177 |
12979390-DS-21 | 26,115,925 | Dear Ms. ___,
You were admitted for ongoing headaches with strange episodes.
You were evaluated by the neurology team, EEG and a lumbar
puncture. The results of these evaluations were reassuring that
there is no acute process. It was a pleasure taking care of you
and we wish you all the best. | ___ with hypothyroidism and depression transferred from ___ after presenting with 3 months of progressive headache and
presyncopal events.
ACUTE CARE
# Headache accompanied with loss of postural tone: the patient
reported headache x 3 months with episodes in the week prior to
admission of loss of postural tone. Per the neurology note, the
following occurred, "We were able to observe an episode that was
representative per the family. During that, she announced that
it would happen before she slid into our arms and then onto the
floor. She has never lost consciousness or injured herself
during one of those episodes." Neurology discussed a broad
differential and recommended LP with EEG. When these results
were non-revealing and relatively normal (except for beta spikes
due to benzodiazepine use on EEG), neurology ultimately
concluded that these episodes do not fit with any known
neurological disorder. They may be a manifestation of complex
migraine or possibly a conversion disorder. The possibility of
conversion disorder was not broached with the patient. She was
organized for an outpatient tilt table test, neurology follow
up, and multiple tests (see below) are pending that will require
follow up upon discharge.
# Migraine: the patient was very bothered by a throbbing facial
headache associated with photophonophobia and nausea, aggravated
with movement and relieved with sleep. She was initially treated
with Tylenol and Naproxyn, the latter was causing reflux
symptoms and the former was ineffective. She was then started on
Imitrex which was effective although only short-lived. She was
then started on daily amitryptiline, which was also helping
although does take a few days to have effect. She was warned
that Imitrex should not be taken more than 15 times per month
and she was also warned about medication-overuse headache and
thus to avoid excess tylenol/nsaids. As above, it is possible
that the patient's loss of postural tone is a manifestation of
complex migraine, so control of the headache may result in
resolution of symptoms.
CHRONIC CARE
#Hypothyroidism: Con't home levothyroxine, TSH slightly low but
T4 is normal, will defer redosing to outpatient.
#Anxiety: Con't home meds: sertraline, clonazepam
TRANSITIONS IN CARE
# Code: Full
# Emergency Contact: Husband ___ ___
# Issues to discuss at follow up: consider re-dosing
levothyroxine.
# Pending Studies:
- CSF viral culture
- Blood culture x2
- CSF cytology
- EEG
- SPEP
- CSF: HSV, Lyme and MS panel | 51 | 390 |
12246674-DS-19 | 23,896,887 | Dear Mr. ___,
You were admitted to the Vascular Surgery service for a badly
infected L foot wound which required operative debridement with
podiatry and broad spectrum antibiotics. Your procedure went
well without complications and you are recovering well. At this
time, you are eating normally, able to use the restroom without
difficulty and have been restarted on all of your home
medications. You are now ready to continue your recovery at
rehab with the following instructions.
ACTIVITY:
You will be non-weight bearing on the side of your wound and
debridement.
You should keep this site elevated whenever possible
You may use the opposite foot for transfers and pivots
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot
WOUND CARE:
A wound vac has been placed, that will be changed every 3 days
or as needed.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which ___ turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE at ___ FOR:
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the wound.
Thank you,
Your ___ Vascular Surgery Team | Mr. ___ was admitted with a worsening wet gangrene of his
left foot latral wound. He underwent 2 debridements by podiatry
___ the OR. The patient tolerated the procedure well. After his
second debridement, he required 3U PRBCs for a slowly drifting
Hct. He eventually responded well and his Hct stabilized. The
wound was carefully inspected for any signs of larg bleeding, of
which there were not. He tolerated both procedures well. Please
see operative note for further details. He was started on broad
specturm antibiotics, vanc/cipro/flagyl. Micro taken from a
specimen during the first case grew mixed flora. He remained
afebrile with a persistently elevated white count which
eventually normalized by discharge. A wound VAC was placed on
___ with overlying retention sutures by Podiatry. It was changed
as needed. An angiogram was done to evaluate the vessels and
potential for healing. It showed that the common femoral patent,
profunda patent, the SFA was occluded. The left common femoral
to
posterior tibial artery bypass looks excellent and there was no
stenosis ___ the graft itself or at any of the anastomoses.
Podiatry closed the distal portion of the wound. Plastic surgery
was consulted to evaluate for reconstruction options. They
recommended outpatient follow-up after vac therapy.
Hyperbaric oxygen therapy will be started after the patient is
discharged from the hospital. He is medically cleared for
hyperbaric oxygen therapy whenever podiatry sees fit. | 241 | 234 |
12202164-DS-17 | 28,650,030 | 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 LLE, splinted
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 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.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
TDWB in LLE in splint
Treatments Frequency:
Please keep splint on | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Left tib/fib fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for Left tibial IMN and ORIF medial malleolus fracture,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications 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 <<>>>>>>>>>>>>> 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 LLE, and will be discharged on Lovenox 40mg QD for 4
weeks for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. | 324 | 259 |
11725523-DS-7 | 25,093,942 | You were admitted to the hospital with abdominal and back pain.
You were reported to have an inflammed gallbladder. You were
taken to the operating room to have your gallbladder removed.
You are now preparing for discharge home with the following
instructions:
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 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r 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.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. 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 folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | The patient was admitted to the hospital with abdominal pain.
Blood work done at an outside hospital showed an elevated
lipase. He underwent an ultrasound which
showed findings consistent with gallstone pancreatitis. The
patient was transferred here for further management. Upon
admission, he was made NPO, given intravenous fluids, and
underwent an MRCP which showed active calculus cholecystitis, a
small stone within the proximal cystic duct. The patient then
underwent an ERCP where a biliary sphincterotomy was performed
with the removal of sludge. The patient's liver enzymes and
lipase were trended.
On HD #4, the patient was taken to the operating room where he
underwent removal of the gallbladder. Intra-operative findings
were notable for a very inflamed gallbladder with a thick rind
on it. Attempts to remove the gallbladder via a laparoscopic
approach were unsuccessful and the procedure was converted to an
open approach. The remainder of the operative course was stable
with a 500 cc blood loss. At the close of the procedure, ___
drain was placed in the gallbladder fossa. The patient was
extubated after the procedure and monitored in the recovery
room. In the recovery room, the patient had an epidural
catheter placed for pain management.
The post-operative course was stable. The patient's incisional
pain was controlled with the epidural catheter. The patient's
liver enzymes began to normalize. The foley catheter was
removed on POD #1 and the patient voided without difficulty. He
was started on a regular diet. The epidural catheter was
removed on POD #2 and the patient was transitioned to oral
analgesia. The ___ drain was removed on POD #3. The patient
was discharged home on POD # 3 in stable condition. An
appointment for follow-up was made with the acute care service
and with his primary care provider. | 843 | 315 |
17608878-DS-9 | 21,800,440 | Dear Ms. ___,
WHY DID YOU COME TO THE HOSPITAL?
- You were feeling weak and had pain in your back
- This was caused by a bacterial infection in your blood
WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY?
- You were evaluated by the Infectious Disease team and started
on IV antibiotics
- You were evaluated by the Spinal Surgery Team, they did not
recommend surgery
- You were evaluated by the Neurology team and they found that
you need close outpatient monitoring given the infection in your
spine and possibly your brain
- We took fluid off with IV diuretics and changed your home
dose
- We started treating an infection in your gut called c.
difficile
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
1) Please take your medications as below
2) Attend all of your follow-up appointments with your primary
care provider and as scheduled. In particular you must have your
MRI performed on ___ and follow-up with a neurologist. We sent
information to ___ Neurology, please call to book
appointment ___ (ask for ___ on ___ if you have
not head from them. Also please bring the imaging disk we
provided to you to your visits.
3) Please weight yourself every morning and call your doctor if
your weight increases or decreases by more than 3 pounds per
day. Your weight on discharge is 196 lbs.
4) You need to get a blood test next week to make sure your
electrolytes are normal.
We wish you the best in your recovery and it was a pleasure to
care for you. | ___ year old F with a history of decompensated cirrhosis ___ hep
C (s/p treatment)- c/b variceal bleed s/p TIPS in ___ and HPS
with marked hypoxemia on 5L O2 at home, presented with left
lower back and hip pain, admitted to MICU for respiratory
distress, and found to have c.diff colitis and MRSA blood stream
infection with epidural abscesses. Stabilized on HFNC in MICU,
weaned to home ___ O2 and then transferred to the floor where
she underwent gentle diuresis with 80mg IV Lasix BID. She will
discharged to complete course of IV vancomycin, PO vancomycin as
well as follow-up MRI and neurology assessment.
# MRSA bacteremia/epidural abscesses: High grade MRSA
bacteremia, sensitive to vancomycin. Possible translocation from
the gut vs. from soft tissue infection on face. Imaging notable
for posterior epidural abscess in the lumbar spine and L3-L4
area. No sensory change. No incontinence no saddle anesthesia no
change in rectal tone. Spine surgery consulted for abscesses,
however they recommended that in light of patient's coagulopathy
and lack of focal neuro symptoms, risks of surgery outweighted
benefits. Infectious Disease Team followed, PICC line was placed
IV vanc (___), last positive blood culture was ___. ID OPAT
following, at some point she should be transitioned to
daptomycin. Patient was consulted on warning signs of cauda
equina and to seek immediate medical attention.
# c/f ventriculitis: T2 hyperintensities seen in occipital horns
c/f proteinaceous blood vs ventriculitis ordered for f/up MRI at
___ with request for follow-up with ___
Neurology. Patient and partner counseled extensively on need for
follow-up imaging and to call if any issues for referral here at
___.
# severe c.diff: PO vancomycin to continue for two weeks post IV
antibiotic course. Her diarrhea has resolved.
# hypoxia, hepatopulm syndrome: chronic, likely worsened from
fluid resuscitation iso sepsis on presentation, back at baseline
5L NC and interval improvement on CXR, she was discharged on her
home O2 requirement.
# decompensated HCV cirrhosis: s/p HCV treatment, portal HTN and
esophageal varices s/p TIPS listed but now inactivated for liver
transplantation with hepatopulmonary syndrome with MELD
exception points. On rifaximin and lactulose for new this
admission HE. Increased oral diuretics after IV diuresis on ___
to Lasix 40mg and spironolactone 100mg. No h/o SBP.
==========================
Transitional issues
==========================
- changed home meds: increased Lasix, spironolactone
- new medications: IV vancomycin, PO vancomycin, rifaximin,
lactulose
- ___ R PICC is in the mid SVC
- would likely benefit by transitioning from vancomycin to
daptomycin, have asked case management to help screen for this,
but at time of discharge is being sent home on IV vancomycin
- has rx for 14d IV vancomycin, plan is to transition to
daptomycin per ID OPAT intake, however unable to do this over
the weekend (discharged on a ___
- please ensure patient follows-up with ___ clinic to
receive a prescription to either switch to daptomycin or for the
remainder of her IV vancomycin
- f/up MRI in 3 weeks for possible ventriculitis (arranged at ___
___
- TTE when treatment course completed
- f/up with ___ neurology (in process, patient must
confirm appointment)
- weekly OPAT labs (ATTN: ___ CLINIC - FAX: ___
ICD: ___ VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr,
Vancomycin trough, CRP) with ID follow-up to determine course of
IV abx and po vancomycin
- should have chem-10 checked at next outpatient apt
# Discharge weight: 196 lbs
# Discharge creatinine: 0.6
# Contact/HCP: ___, husband, ___
# Code status: Full | 270 | 566 |
12135369-DS-28 | 29,137,563 | Dear Ms. ___,
You were admitted to the hospital with a COPD exacerbation,
initially to the ICU and then to the medicine floor. We treated
with you with nebulizers and steroids and you improved. You are
now ready for discharge, and we will reinstate visiting nurses
for you at home.
It was a pleasure taking care of you!
Sincerely,
Your ___ team | Ms. ___ is a ___ w/ history of COPD (on home 4L, currently on
prednisone taper) who presents with progressive shortness of
breath over the past several days, found to have increased WOB
with rising hypercarbia and academia, who is admitted to the ICU
for hypercapnic respiratory failure initially requiring BIPAP,
but now doing well on home 4L O2 NC.
#COPD exacerbation
#Hypercapnic respiratory failure
Patient has COPD with frequent exacerbations and is chronically
on 4L home O2. She was in the process of completing a prednisone
taper for recent minor exacerbation. She presented with
hypercapnic resp failure initially requiring BiPAP, but was
weaned down to her home O2. Inciting event for this exacerbation
is unclear, but may be due to URI with recent mildly productive
cough and leukocytosis. She received IV solumedrol 125mg x2 in
the ICU, and then was subsequently started on prednisone 60mg qd
(___), followed by a prednisone taper, continued on
discharge. She also received home COPD medications along with
chronic azithromycin 250mg qd (prescribed by her outpt
pulmonologist, Dr. ___. She has outpatient pulmonology
scheduled.
#Leukocytosis
WBC 15 on arrival and remained elevated during admission, likely
due to steroids vs reactive iso COPD exacerbation vs URI
triggering COPD exacerbation.
#Urinary frequency
Patient notes increased urinary frequency over past few days
with "strong smell." UCx mixed flora.
#Social
Her main support, her mother, passed away recently. She is
followed by SW as an outpatient, but recently lost all ___
services. Her PCP saw her while admitted and requested that we
arrange for home ___ services, which have been arranged on
discharge.
======================
CHRONIC ISSUES
======================
#Chronic Sinus Tachycardia
Seen by PCP (Dr ___ while she was admitted, who
told us her sinus tachycardia is chronic (HR typically in
~110s). She was continued on home Verapamil 240 mg QAM 120 mg
QPM.
#Anxiety
Continued on home duloxetine and lorazepam.
#Insomnia
Continued home trazodone.
======================
MEDICATION CHANGES
======================
[]Started prednisone 60mg qd x 5 days (___), continued by
prednisone taper.
======================
TRANSITIONAL ISSUES
======================
[] outpatient pulmonology and PCP follow up scheduled
======================
CODE STATUS/HCP
======================
Code Status: Full Code, presumed
HCP: ___
Contact: ___ | 58 | 330 |
14170158-DS-9 | 23,230,588 | Ms. ___,
You were admitted to ___ after being in a motor vehicle crash.
Your imaging upon admission showed no fractures, but did show a
bruising of your left lung. You are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
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. | This is a ___ year old female, who was admitted from an outside
hospital for a trauma evaluation. She is status post motor
vehicle crash. Patient had a CT scan of head, torso, and spine
which showed no fractures. Chest X-ray showed a possible
lingular contusion. Patient complained of back pain and left leg
pain upon presentation to the ED. Imaging done at that time
showed no fractures of the shoulder or femur. She was
transferred to the trauma surgical floor for further monitoring,
as well as for pain management. A repeat chest X-ray on ___
showed opacity in the left mid-lung, likely reflective of a
pulmonary contusion. She remained hemodynamically stable on the
floor.
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. She was set up with an
appointment to see her PCP at discharge. | 227 | 181 |
18628529-DS-8 | 23,163,622 | Dear Mr. ___,
As you know, you were recently hospitalized for a pain crises.
Your workup including labs and a chest xray was reassuring. We
treated your pain initially with intravenous diluadid and then
you were transitioned back to your home medications. It is very
important that keep well hydrated during the heat this ___ to
prevent sickle cell crises. It is equally important that you
follow up with your outpatient doctors, including your primary
care doctor and hematologist as scheduled. You should also
consider making an appointment with a pain clinic for further
management of your pain. | ___ with Sickle Cell Disease presents with worsening pain in his
ribs, upper R chest, and bilateral shoulders for 4 days.
ACTIVE ISSUES
# Pain: likely rebound pain secondary to opiate dependence and
running out of pain medications. Ddx also includes pain crises,
vasoocclusive crises and musculoskeletal strain secondary to
vigorous exercise. He did not report triggers for sickle cell
crises, though he does report that the heat was a contributory
factor. His workup was reassuring. He did not have signs
concerning for acute chest - he was afebrile with negative CXR,
good O2sat, and clear lungs on exam. He did not have
reticulocytosis or signs of hemolysis, given normal haptoglobin,
bili, near-baseline LDH, and hct at his baseline. His EKG was
within normal limits. He was given IV fluids and IV pain
medications initially, then transitioned to po oxycodone. Of
note, he had not followed up with his outpatient providers or
received prescription pain medications from them for many months
(since ___. He has had multiple hospital admissions since ___
for pain. He was encouraged to keep his outpatient appointments
to further discuss his pain regimen and for consideration of a
referral to a pain specialist. He was discharged on methadone 10
mg TID, oxycodone 15 mg Q4H, doses confirmed by his PCP's office
with just enough medications until his scheduled follow up
appointment.
CHRONIC ISSUES
# Social/support issues: pt has not been attending outpatient
appointments due to poor planning and lack of money for bus. He
was provided with the ___ new patient hotline number for
transition of care if he desires, as he reports that ___ is
closer to his home than ___. He was prescribed 1 week supply of
pain medication and given a follow up appointment with Dr. ___,
___ primary care provider ___ 1 week. He was also scheduled for
an appointment with his hematologist, Dr. ___.
# High BP (SBP to 140s-150s): management was deferred to
outpatient setting
# Asthma: Stable
TRANSITIONAL ISSUES
# CONTACT: ___ (brother) ___
# CODE STATUS: Full (confirmed)
# PENDING STUDIES: none
# TRANSITIONAL ISSUES:
-pain control
-BPs were high 140s-150s | 97 | 346 |
16293434-DS-9 | 21,415,906 | Dear Mr. ___,
You were admitted to the hospital with significant pain on
swallowing and difficulty eating. Your symptoms were thought to
be due to an infection in your esophagus as well as effects from
radiation. Your symptoms were treated with several pain
medications and an antifungal medication (fluconazole) to treat
your possible infection. You had a PICC line (long IV) placed
and began receiving nutrition through your vein while we treat
your esophagus infection and inflammation.
You also noted some increased urinary frequency over the last
two days. You did not have any evidence of infection or urinary
retention on bladder scan. However, if your symptoms persist,
you can talk with your doctor about starting a medication for
BPH (prostate enlargement).
It was a pleasure taking care of you!
Your ___ Care Team | ___ year old gentleman with 60 pack year smoking history with
metastatic lung adenocarcinoma being treated with weekly ___
AUC 2 and taxol 50mg/m2 and concurrent XRT (4 weeks into
treatment) admitted with worsening odynophagia, reflux and
weight loss.
# Odynophagia: Presented with pain under sternum with swallowing
which was felt to be most consistent with severe radiation
esophagitis given timing with radiation, however, could not rule
out ___ esophagitis in setting of low WBC count. No evidence
of mechanical obstruction. Patient was treated empirically with
IV fluconazole 200mg IV for total of 14 day course (Day ___,
finishes on ___. Pain was managed with IV morphine prn in
addition to sucralfate slurry, magic mouthwash, PPI BID and
ranitidine BID. Given his severe dysphagia, a PICC line was
placed for TPN while pain managed conservatively. He was
initiated on TPN per nutrition which will be continued until his
symptoms improve and he is tolerating PO nutrition.
#GERD: Pt contines to have pain despite maximal PPI, H2 blocker,
and antacid. Not similar to anginal pain in character, onset, or
alleviating factors. Thought to be related to radiation injury
and inflammed tissue. He was continued on lansoprazole,
ranitidine, TUMS and tylenol prn.
# TPN: Temporizing measure for short-term nutrition while
esophagus heals. Cannot tolerate esophageal instrumentation for
enteral feeds. Surgical g-tube would be inappropriate for such a
short course of nutritional supplementation. TPN started cycling
on ___. Currently starting 18hour cycle on ___ ___.
#Urinary frequency: Pt has had multiple small voids ___
without dysuria and with negative UA. He had post-void bladder
scans ranging from 130-260cc. If persists, can consider sending
urine culture or starting tamsulosin.
#Lung CA: Metastatic adenocarcinoma on palliative
chemo/radiation c/b severe radiation esophagitis. Patient's
radiation is on hold until follow-up with Dr. ___ on ___ and
chemotherapy on hold until follow-up with med onc on ___.
# Anemia: Likely due to chemotherapy. Stable at time of
discharge.
# Perirectal bleeding: Patient with perirectal bleeding felt to
be secondary to perianal fissure. No blood in stools, only has
small amount of blood when wiping. Hgb stable. Resolved prior to
discharge.
# Chest pain: Pt had some exertional chest pain after doing
sitting/standing exercises with ___. Described as
"indigestion"-like in quality, identical to prior exertional
angina but slower to resolve. No radiation. EKG unchanged from
previous.
#Back rash: Maculopapular rash extending 10cm x 14cm over medial
back. Also has rash in same area over sternum. Likely ASE of
radiation. Improved with sarna cream for itching.
# Constipation: Noted to have significant constipation on ___
(5 days without BM), improved with BM on ___ after receiving
docusate and senna. Prefers to avoid miralax as this caused
diarrhea previously requiring loperamide earlier in
hospitalization.
#Leukopenia: Patient with WBC count ranging in the ___ range
likely due to chemotherapy. | 132 | 473 |
17406546-DS-6 | 21,984,776 | Dear Ms. ___,
It was a pleasure taking care of you.
Why you were admitted?
-You were admitted because you were having a upper respiratory
infection and was vomiting.
What we did for you?
-You were given some fluids through IV because you were
dehydrated. We monitored you and you were feeling better.
What should you do when you leave the hospital?
-Please take all your medications and attend your follow up
appointments.
We wish you the best,
Your ___ team | Ms ___ is an ___ with CHFpEF, GERD, HTN, osteoarthritis,
IBS, temporal lobe epilepsy, fibromyalgia, and diverticulitis
who presents with URI symptoms and vomiting. Patient with
initial lactate of 3.4 and ___ and was given IVF with
improvement in creatinine and lactate. Patient was monitored and
she was tolerating PO with improvement in her URI symptoms and
was discharged back to her assisted living facility.
#Viral Illness: Patient likely has a viral illness, which others
seem to have had at her assisted living. Flu negative in ED. Her
symptoms improved with symptomatic management. She was able to
tolerate PO and was discharged home with Zofran PRN
#HFpEF
Patient appeared euvolemic. Furosemide was held given ___, but
can be restarted as outpatient.
___: Cr 1.3 with Cr of 1.0 during last admission. Likely
pre-renal in setting of poor PO intake and vomiting that
improved to baseline with IVF
# SEIZURE DIAGNOSIS:
Continued on home lamictal, primindone, and ativan.
# HYPERLIPIDEMIA: Continued simvastatin.
# HYPERTENSION: Held lisinopril in setting of ___. Was restartd
on home lisinopril 10mg at discharge
TRANSITIONAL ISSUES
========================
[]Please ensure patient uses her unna boots/compression
stockings
[]Follow up patient's URI symptoms and nausea
# CODE: full
# Name of health care proxy: ___
___ number: ___
Cell phone: ___ | 74 | 198 |
16064855-DS-16 | 23,379,509 | Dear Ms. ___,
It was a pleasure taking care of you. You were admitted for
chills and tachypnea. You had a Chest X-ray that showed no
evidence of pneumonia. You had no evidence of a urinary tract
infection. You received some IV fluids and improved.
We made no changes to your medications. | This is a ___ woman with a pmhx. of dementia,
depression, and vitamin B12 deficiency who presents with low
blood pressure and labs consistent with dehydration.
# HYPOVOLEMIA: Patient with decreased blood pressure at
___, ?confusion, feeling unwell; labs with elevated
hemaglobin and elevated lactate. Unfortunately, no orthostatics
were done before patient received fluids. Patient likely
dehydrated in setting of decreased PO intake and insensible
losses from high temperatures outside. No signs of infection
(no PNA, u/a not consistent with UTI, patient denies GI
distress, diarrhea, vomiting, etc), though blood and urine
cultures still pending. With 1 liter of fluid and adequate PO
intake, patient's clinical status improved. Although lactate
was 2.4 on morning after admission (up from 2.2), patient looked
so well (her daughter confirmed this) and felt so much better
that this lab was not repeated. Patient was discharged with
instructions to return if she continues to feel unwell or any of
her previous symptoms returned.
# B12 DEFICIENCY: Continue cyanocobalamin
# DEMENTIA: Continue donepezil
# DEPRESSION: Continue sertraline
Addendum: Urine culture negative. | 54 | 184 |
13309508-DS-22 | 23,315,393 | Dear Mr. ___,
You were hospitalized on ___ due to forgetfulness as well as
mild abdominal discomfort. It is thought that these symptoms are
due to your worsening liver disease. You did not have enough
ascites to remove any fluid and we did not find any other source
of infection.
The hospice team saw you while you were in the hospital. Your
and your famly did not come to a decision whether or not hospice
care would be the best option for you at this time. Please
contact hospice as soon as you come to a decision regarding
whether you would like hospice care or not. The phone number is
___.
If any questions, please call Dr. ___ at ___.
Please note your new medication for pain: Dilaudid 2 mg by mouth
every 6 hours as needed for pain.
It was a pleasure meeting and taking care of you while you were
at ___.
-Your ___ Team | Mr. ___ is a ___ with DM, dCHF, and cryptogenic cirrhosis
with cholestasis who presents with acute encephalopathy as well
as mild abdominal discomfort x 1 day.
ACUTE ISSUES
>>>>>
# Encephalopathy: Improved throughout hospital course to the
point where patient was able to tell his name, where he was, and
that it was ___. He had asterixis throughout hospital stay.
The etiology for his acute decompensation is unclear at this
time. ___ be related to inadequate lactulose
dosing/constipation. No apparent signs for medication
non-compliance. Infectious etiologies are less high on the
differential, as patient afebrile, all VSS, UA clean, bcx NGTD,
no pneumonia on CXR. SBP a concern, but patient without
leukocytosis and on US, ascitic pocket is not big enough to tap.
RUQ US negative for portal vein thrombosis. Patient started
having bowel movements with lactulose q2 standing, so it was
decreased to q8 standing
#Worsening kidney function: Likely HRS as patient has worsening
Cr in the setting of advanced cryptogenic cirrhosis. Cr stable
for now (1.8). Could also be ___ medications (lasix,
spironolactone). While the patient was in the hospital, we held
Lasix and Spironolactone and trended CMP, until patient started
refusing labs on his last hospital day.
# Cryptogenic cirrhosis: His MELD score was 27 on discharge (25
on admission), Childs Class C. OSH biopsy revealed stage IV
fibrosis. He was admitted with decompensated liver disease with
ascites, hepatic hydrothorax, as well as jaundice and
encephalopathy. He was given 50g albumin and lactulose while he
was in the hospital. He is currently followed by Dr. ___ in
the outpatient liver clinic, but not listed for transplant. Dr.
___ spoke with family to relay to them that unfortunately
there is no treatment for his disease. After a long discussion,
patient reports that he wants to go home and the family decided
to meet with hospice. After a long discussion with hospice, the
family seemed to be leaning towards it, but did not make a final
decision before the patient went home. They were asked to
please call hospice regardless of the decision that they make.
CHRONIC ISSUES
>>>>>
# Asthma: Continue Advair and albuterol nebs
# GERD: Stable. Continue protonix
# DM: Continue home on Glargine 20qAM and start ISS
# Hx of CVA: Continue aspirin
TRANSITIONAL ISSUES
>>>>>
The patient did not want to remain in the hospital, and after
the conversation between the family and Dr. ___ family
decided that they wanted to take the patient home. The family
spoke at length with hospice and came to the conclusion that
they wanted to make the patient comfortable at home, but needed
to discuss the option of hospice care with the rest of the
family before coming to any concrete conclusions. They family
was instructed to call hospice when they decided whether or not
they wanted to pursue home hospice. | 153 | 483 |
13483200-DS-2 | 25,822,839 | Dear Mr ___,
You were admitted at ___ after you had multiple seizures
(called status epilepticus). This was probably triggered by a
viral upper respiratory tract infection and fever. You were
initially treated with strong medications and required a
breathing tube in the ICU but these were quickly weaned off and
you did well. We changed some of the doses of your
anti-epileptic drugs in order to better control your seizures.
We have made an appointment with you outpatient neurologist Dr
___ on ___ at 9am. Please make sure to attend
this appointment for outpatient management of your epilepsy
disorder. In addition, you were evaluated by our physical
therapist and occupational therapist. They both recommended
___ rehab. Unfortunatly, we were unable to find a bed. Per
your request and your mother's request (your health care proxy),
you were discharged home with outpatient ___ rather than
staying in the hospital pending a rehab bed. It was a pleasure
caring for you during your hospitalization. | ___ is a ___ year-old veteran with a history of TBI
from a blast injury complicated by hydrocephalus (s/p VPS),
empyema, and epilepsy who presented with multiple GTCs requiring
multiple ativan doses and a dilantin load in the setting of
probable viral URI.
# Status epilepticus: The seizures were consistent with his
typical seizures though lasted longer and he had a cluster of
multiple. He has no missed meds or recent medication changes.
He was intubated for airway protection. He was initially covered
with vanc/CTX/Acyclovir given his fever but his LP was
unremarkable and HSV PCR returned negative so these were
discontinued. CT head shows multiple findings related to his
traumatic brain injury and surgical interventions but no acute
findings. He was monitored on EEG and had no further seizures so
this was discontinued. His tox screen was negative. Phenytoin
was later discontinued. He was continued on his home depakote
dose 250 QHS secondary to report of an eosinophilic pneumonia
from previous up-titration of depakote (while at a different
hospital). He keppra was increased to 1500mg BID and he
continued on his home dose of lacosamide 200mg BID.
# ?Viral URI: He was mildly febrile while inpatient and his
brother at home reportedly had a viral URI. Apart from a
probably URI, his infectious workup was unremarkable. His WBC
count trended down to normal. His LFTs were mildly elevated by
trended back down to normal and may have been a reaction to his
viral illness.
# Hypotension: Initially his blood pressure decreased to the ___
systolic in the setting of propofol. He was switched to
midazolam and treated with IV fluids. He was noted to have lower
BP at baseline (mostly ___ systolic, intermittently in
___. He was asymptomatic.
Prior to discharge, close follow up was arranged with his
outpatient neurologist Dr ___ on ___ at 9am. He
was evaluated by our physical therapist and occupational
therapist. They both recommended ___ rehab. Unfortunately,
we were unable to find a bed with 24 hours. Per the patient and
his mother's request (health care proxy), he was discharged home
in stable condition with outpatient ___ rather than staying in
the hospital pending a rehab bed. | 163 | 367 |
17572570-DS-44 | 23,889,523 | You were admitted with anal fistula, concern for
urethral/urinary involvement weight loss, anorexia, depression.
You were evaluated with MRI which showed a complex fistula. Dr.
___ surgery) and Dr. ___ saw you in
consultation and recommended medical management at this time.
You were seen by GI team, who recommended a long course course
of metronidazole and cefpodoxime (at least one month) and
initiating Remicade infusion. This was given ___ and will
need to be given EVERY EIGHT WEEKS. Your methadone was decreased
to 85mg daily in an attempt to decrease nausea, and with your
permission HABIT ___ clinic was notified. You endorsed
significant depression and anxiety for which psychiatry and
social work saw you, and for which inpatient psychiatry was not
felt to be necessary. They facilitate follow up with your
outpatient psychiatrist and therapist for next week. You have a
new PCP ___ next week | ___ with PMH significant for IBD-U that presents with several
anorexia, reported low grade fevers, increased output from
rectal fistula and pneumaturia concerning for IBD flare.
#Crohn's with fistulizing disease: CRP elevated, reported 30+lb
weight loss last ___ months. Recent C. Diff infection. Stool
without any other infection. MRE abd/pelvis was pursued and
found complex fistulous track as reported in MR report. Flagyl
and Cefpodoxime started (Cipro not given due to high QTc) and
will be continued for at least 1 month per GI and until follow
up. EGD/sigmoidoscopy without evidence of ileitis or severe
bowel inflammation, though because of fistuous disease, would be
a candidate for reintroduction of biologic at this point. Will
need to demonstrate ability to follow up with GI/outpatient
providers. Colorectal (___) and Urology (___) consults were
placed and recommended medical treatment for now. Patient
received first dose remicade ___ without difficulty. After
completion of loading protocol, this medication will be able to
be given q 8weeks. He was discharged to home and will follow up
with GI. The GI team will be in touch with him with respect to
his next remicade infusion in 2 weeks (he and his mother were
informed of this plan by me and GI fellow).
# Mild Prolonged QTc: undoubtedly related to Methadone.
Cefpodox given instead of Cipro for his fisutla Abx regimen.
Consideration should be given in future with further QTc
prolonging agents with repeat ECG checks.
# C. Difficile diarrhea: Documented from ___ records
from last week. Despite PCR negativity here, is covered with
Flagyl which is part of his antibiotic regimen for fistula. In
light of anticipated prolonged course for flagyl/cefpodoxime
(for fistula), would recommend continuance of Flagyl for 2 weeks
past his end date for that regimen.
#N/V, reported fevers: No documented fevers in house. No signs
of ileal disease on scoping, there was some gastritis, and also
lots of retained fluid in stomach. Thought was that
methadone-opiate side effect was at play here. He agreed to
decrease in methadone to 85mg daily and tolerated improved oral
intake well.
#Pain control / Opioid dependency: H/o narcotic abuse limiting
pain management options, though abdomen was relatively benign
throughout his course. Methadone was voluntarily decreased to
85mg daily. His ___ clinic HABIT ___ in ___ was
contacted (with patient's release signed) and informed of the
change and strategy behind the change. Letter of last dose was
given to patient. The abdomen remained largely non-tender
throughout hospitalization.
#Major Depression / Passive Suicidal ideation: In setting of
depression, contracted for safety. Seen by SW and Psychiatry,
no need for inpatient care at this time per them. Has outpatient
therapist who is trying to help him move to a group home (though
needs to be approved). Mirtazipine continued, clonidine,
gabapentin continued with added prn dose for anxiety (per
psych). Psych facilitated follow up with his psychiatrist and
therapist for 3 days after discharge.
#Anxiety/PTSD: Continued alprazolam and clonidine with increase
Gapapentin prn
dosing per psych consult.
#GERD/gastritis: Seen on EGD. In light of ch abd complaints,
will take trial of several months PPI
Patient set up for new PCP in ___ at ___ with Dr. ___.
Informed of f/u | 147 | 534 |
12097647-DS-21 | 26,286,842 | Dear Ms. ___:
You were admitted to ___ and
underwent nasogastric decompression. You are recovering well and
are now ready for discharge. | Patient is a ___ with a TAH and partial colectomy who presented
to the ED with epigastric pain, nausea, and emesis. A CT was
obtained and was concerning for SBO. The patient was evaluated
by and admitted as an inpatient to ACS. A NGT ___ was placed and
put to wall suction, but a followup film revealed the tip to be
in the distal esophagus within an anatomical curve created by
the patients large hiatal hernia. The patient was noted to have
poor UOP and was bladder scanned (673cc) and foley placed.
Multiple attempts were made to advance the NGT, without success
secondary to inability to pass by her large hiatal hernia.
The following day the patient underwent fluorscopic guided NGT
placement which also failed. Finally, the NGT was successfully
placed and advanced into stomach as confirmed by a follow film.
The NG tube was placed by GI via EGD and advanced endoscopically
into the stomach. On limited exam, the esophagus appeared to be
normal. Given poor patient tolerance, a full endoscopic exam was
aborted. Otherwise normal EGD to third part of the duodenum. The
drainage tube was confirmed to pass through & decompresses the
hiatus hernia.
The patient's foley catheter was subsequently removed without
complication or further urniary retention. The NGT was clamped
and with only 20cc residual and subsequently removed. The
patients diet was normalized and well tolerated. A stasis ulcer
was noted on theright leg and treated with silvadene.
The patient was subsequently discharged after clearance by ___ to
her assisted living facility in stable condition. She should
follow-up in 12 months for pulmonary nodules noted on films
obtained during her hospitalization. | 21 | 277 |
13608739-DS-21 | 25,567,500 | Dear Ms ___,
WHY YOU WERE ADMITTED
- You were having shortness of breath from heart failure.
- Your blood sugar was also dangerously high.
WHAT WE DID FOR YOU
- Fluid was removed from your body with medications
- Your blood sugars were elevated and controlled with
medications
- Your medications were changed so that they would be easier to
take at home
WHAT YOU SHOULD DO WHEN YOU LEAVE
- Continue to take your medications as prescribed
- Follow up with your doctors as below
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | ___ with COPD, HFrEF (LVEF 23% in ___ who presented with
significant volume overload with hypoxemic hypercarbic
respiratory failure requiring BIPAP in CCU and DKA. Long
hospital course highlighted by aggressive diuresis, management
of anti-hypertensive medications, ___ consultation for poorly
controlled T2DM culminating in transition to ___ insulin, UTI
with hypotention requiring readmission to ICU, and significant
___ on CKD.
# Likely CAD
# Hypoxemic Hypercarbic Respiratory Failure
# Decompensated CHF, HFrEF (LVEF 35% with WMA's c/w multivessel
CAD): Presented volume overloaded requiring BiPAP in setting of
likely medication non-compliance of home bumex at a weight of
48.5 kg. Volume was primarily intravascular with minimal amounts
of edema. Etiology of her cardiomyopathy thought to be ischemic
by e/o multivessel disease seen on TTE RCA and distal LAD versus
large RCA with apical involvement). In the setting of volume
overload, she was particularly hypertensive requiring nitro gtt
and transitioning to high dose hydralazine. It became apparent
from discussions with patient that she was only taking
medications once daily, as ___ was coming in AM administering
medications and keeping them in a lock box at all other times.
Concern for compliance was the reason MIBI or cath was not
pursued during this hospitalization as adherence to
anti-platelet in case of PCI would be unreliable. Patient
required Bumex gtt at 4 mg/hr for diuresis in CCU, discharge
weight was 39.69 kg. Discharged on 3 mg bumex daily (which she
does respond to), but based on her intermittent dietary
indiscretion when not coached by nursing in the hospital, her
home diuretic needs remains unclear and will likely need further
adjustment as an outpatient.
- Discharge Afterload: None (stopped in setting of hypotension
from UTI and escalating doses of home anti-hypertensives.)
- Discharge Preload: Bumex 3 mg daily
- Discharge NHBK: Metoprolol Succinate 50 mg daily
- Discharge plan for work-up and treatment of underlying
ischemic cardiomyopathy: Would likely benefit from diagnostic
coronary angiography as may ultimately be a candidate for CABG
in setting of likely mutlivessel disease and T2DM.
- Discharge secondary prevention for CAD: Continue aspirin,
Plavix, and atorvastatin 40 mg.
- ___ benefit from primary prevention ICD given low EF, NYHA II
symptoms, likely ___ ischemic cardiomyopathy.
# DKA
# Poorly controlled ID T2DM: Initially presented in DKA
requiring insulin gtt. As with her CHF, compliance and stress
from CHF exacerbation thought to be etiology of DKA. Treated
with insulin gtt and transitioned to subQ insulin. Hospital
course complicated by labile blood glucose with both
hypoglycemia and hyperglycemia, exacerbated by unpredictable
eating habits and frequent high carb snacks. Due to her
limitations s/p TBI, ___ was arranged for BID post-discharge and
insulin regimen was transitioned to a ___ regimen.
# ___ on likely CKD (likely DM and hypertensive):
Unknown baseline. Initial Cr 2.5, remained elevated despite
aggressive diuresis and eventually went up to peak of 3.3 with
associated contraction alkalosis with continued aggressive
diuresis likely past her dry weight. Diuresis held for several
days before restarting. Discharge Cr 2.0 (likely GFR worse than
Cr). Would benefit from outpatient nephrology physician.
# UTI: ___ urine + for KLEBSIELLA PNEUMONIAE, pansensitive
except to macrobid. Developed hypotension in setting of UTI and
cross-titration of anti-hypertensives. Will complete course of
ciprofloxacin 250 mg daily ___.
# S/p TBI, History of medication non-adherence: Set up with BID
___ for close monitoring and help with medication
administration. Would not tolerate TID medication schedule
including short acting insulin by our assessment.
# Hypothyroidism:
Decreased levothyroxine dose given TSH 0.02/Total T4 wnl/Free T4
high/low T3. Continued levothyroxine 112.
# Anemia:
Hgb 6.5 on admission from unclear baseline, microcytic. Iron
low, ferritin WNL. s/p 1 unit pRBCs and iron repletion and
improved. Has received 2U PRBC this hospitalization. LDH 287,
hapto 138, dbili 0.2 so not consistent with hemolysis. Stable on
discharge. Discharge hgb 9.5.
# GERD:
Continued home pantoprazole.
TRANSITIONAL ISSUES
===================
DISCHARGE WT: 39.69 kg
DISCHARGE CR: 2.0
NEW MEDICATIONS:
Ciprofloxacin 250mg ends after ___
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Multivitamins W/minerals 1 TAB PO/NG DAILY
Veltessa 8.4g oral DAILY | 87 | 655 |
15812368-DS-19 | 27,001,744 | Mr. ___:
You were admitted with alcohol withdrawal. You were treated
with medications and you improved. You are now ready for
discharge home. You reported that you have an outpatient alcohol
support program.
It is important that you stop drinking, as this can be life
threatening.
During your hospital stay, you were started on a new medications
for high blood pressure. It is important that your follow up
with your primary care doctor within ___ week to have your blood
pressure rechecked and potentially have your labs drawn. | This is a ___ year old male with past medical history of alcohol
abuse complicated by prior withdrawal, hypertension, admitted
___ with alcohol intoxication and subsequent alcohol
withdrawal, treated with CIWA scale, now able to be discharged
home
# Acute Alcohol Abuse with intoxication and delirium
# Alcohol withdrawal
Patient initially presented after being found down, with initial
alcohol level > 500. Patient denied any other illicit
substances, or other alcohols. He had a nonfocal neurologic
exam and a CT head without acute intracranial processes. He
subsequently began to withdraw from alcohol in the emergency
department. At time of admission he was scoring very high on
CIWA, and given his high risk for complications he was initially
managed with IV ativan CIWA scale, which as he improved over
subsequent 12 hours, was transitioned to PO vailum, and then
after 72 hours, stopped. He was treated with thiamine and
folate. He was observed for 24 hours off CIWA without issue and
was able to be discharged home. He reported having a plan to
rejoin an outpatient program. Of note, team was concerned about
patient possibly overreporting his CIWA score for secondary gain
during this admission.
# Gait instability Patient initially reported feeling unstable
on his feet in setting of his acute illness. As he clinically
improved he was able to walk unassisted without issue.
# Hypertension - Patient reported that he used to be
antihypertensives but that he had not been taking them recently.
His blood pressure was elevated during this admission,
prompting initiation of amlodipine + lisinopril. Would consider
rechecking chem panel at follow-up.
# Hand swelling - Course was complicated by bilateral hand
swelling, thought to be iatrogenic in the setting of large
amount of IV fluids. This was notable only in that it required
the medical team's attention to remove his rings, which had
become stuck on his fingers. He was treated with pain
medication and they were able to be removed without issue. He
subsequently had full use of his hands without difficulty and
swelling resolved.
Transitional issues
- Discharged home
- Would consider chem panel check at follow-up visit given
initiation of ACE-I
- Would continue counseling on alcohol cessation | 90 | 372 |
13411558-DS-18 | 28,874,342 | Dear Ms. ___,
You were admitted to ___ for
chest discomfort and shortness of breath. Based on your
studies, you did not have a heart attack. We think that you
likely had a mild exacerbation of your underlying heart failure,
so we treated you with medication (diuretics) to help you
urinate out the excessive fluid. We changed your furosemide
(Lasix) to torsemide. In addition, because of your heart
failure, you are now requiring oxygen supplement.
In addition, because of your kidney function, you can no longer
take the pills for your diabetes. We started you on an insulin
called glargine (Lantus). This is a once a day medication. You
will need to learn how to use it.
You also were given antibiotics to treat for a possible
pneumonia. You were started on antibiotics on ___, and
you will complete your course by ___. Your last dose of
antibiotics will be today.
Please note the following changes to your medications:
- Please STOP furosemide
- Please STOP glipizide
- Please STOP Janumet XR (sitagliptin-metformin)
- Please STOP meclizine
- Please STOP lorazepam
- Please STOP omeprazole
- Please START Torsemide 40 mg daily
- Please START hydralazine 50 mg three times a day
- Please START insulin glargine (Lantus) 12 units, inject
subcutaneously at bed time
- Please INCREASE isosorbide mononitrate (Imdur Extended
Release) 90 mg once a day
You will need to weigh yourself every day. If your weight goes
up by 3 lbs, you need to let your doctors ___. Your discharge
weight was 141.3 lb (64.1 kg).
Please have an outpatient laboratory draw on ___.
Please be sure to follow up with your doctors as ___
below. | ___ yo ___ speaking female with hx severe aortic stenosis s/p
AVR ___ bioprosthesis ___, diastolic
CHF (LVEF in 65-70% in ___, HTN, HLD, DMII and multiple
medical comorbidities including essential thrombocythemia and
bladder cancer s/p resection in ___ presents with 2 weeks of
increasing DOE and chest pain.
# Acute on chronic diastolic heart failure. She was ruled out
for MI. Echo did not show new wall motion abnormality. She had
elevated filling pressure. Patient was diuresed initially with
lasix, but later transitioned to torsemide. The plan is to keep
her even with In's and Out's. She is discharged on 40 mg
torsemide daily. Her discharge weight is 141.3 lb (64.1 kg).
She will need to have her electrolytes monitored and weight
monitored closely. Her cardiologist should be called if her
weight is 3 lbs higher than discharge weight. Because of her
persistent O2 requirement (desat to 88% with ambulation and
occasionally 89-90% at rest on RA), she was started on O2
supplement at 2 L.
# Probable community acquired pneumonia. Patient was started on
levofloxacin for community acquired pneumonia on ___.
Levofloxacin was dosed renally, and ultimately at q48h schedule.
Her last dose of antibiotics is ___, which will allow
her to complete a ___y ___.
# Hypertension. Patient was kepted on her home metoprolol. Her
Imdur was titrated up to 90 mg daily. Hydralazine was started
and titrated up to 50 mg TID. Her goal SBP should be < 130
given T2DM, if she is able to tolerate higher doses of
antihypertensives.
# Acute on chronid kidney disease (baseline ~ 1.1-1.3). Mostly
likely result of aggressive diuresis. It stabilized at around
1.6-1.7 at the time of discharge. This will need to be
monitored. All of her medications will need to be dosed
renally.
# Type 2 diabetes mellitus. All of her oral glycemic agents
were held. She was initiated on insulin sliding scale and
ultimately titrated to 12 units of Lantus qHS with sliding
scale. Patient will require continue teaching of insulin
administration.
# Lactic acidosis. Resolved. Her home metformin was
discontinued.
# Essential thrombocythemia. Patient was continued on home dose
hydroxyurea.
# Medication reconciliation. Patient has not required lorazepam
or meclizine while in house. Therefore, they are discontinued
upon discharge. Omeprazole was also discontinued for concern of
drug-drug interaction and potential adverse effects from long
term PPI as she was also on ranitidine 150 mg BID. | 273 | 426 |
19238097-DS-10 | 27,642,642 | Dear Ms. ___,
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ 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
POD 0 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 POD #1, she was discharged home in stable condition. | 731 | 169 |
13071041-DS-12 | 26,650,576 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
hospitalized for worsening shortness of breath due to
progression of your chronic heart failure. You were treated with
intravenous diuretics to remove fluid from your body and your
symptoms have improved. You are also currently awaiting a TAVR
procedure and your surgical team has been closely following you
during this admission. The plan right now is to tentatively
schedule you for the procedure sometime next week, pending on
how your kidney function is doing. The warfarin for your atrial
fibrillation was held during this admission in anticipation of
undergoing the procedure. However, since the procedure will be
delayed to next week, you will be discharged to home on lovenox,
which you will take twice daily at home until you return next
week for the procedure. You will hear from the surgical TAVR
team when the procedure will be and when to stop taking the
lovenox. You should not take your coumadin unless you hear
otherwise from the TAVR team. Please follow up with your
scheduled appointments in the meantime until you return for
surgery.
Best wishes and good luck. | ___ w/hx of CHF, paroxysmal afib on coumadin, CKD, TIA,
hyperlipidemia, hypertension, DMII, and AVR x 3 for severe AI
who presented with shortness of breath and orthopnea. Pt has
been undergoing an evaluation for TAVR and was admitted from due
to being dyspneic while trying to lie flat for a scheduled preop
CT scan. He was diuresed with IV lasix with symptomatic
improvement. Aggressive diuresis has been limited by elevation
of Cr in the setting of underlying CDK. Pt did receive the preop
CT scan during this admission and is tentatively scheduled for
TAVR next week. His coumadin had been discontinued and he was
temporarily bridged with heparin gtt in anticipation of TAVR.
Due to the procedure being further delayed to next week,
however, pt is being discharged on lovenox with plans to remain
on lovenox until he returns for TAVR next week. | 192 | 145 |
12137011-DS-32 | 28,807,084 | 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 shortness of breath and chest
discomfort.
What happened while I was in the hospital?
- You underwent a stress test and an echocardiogram. Both of
these tests were not significantly changed from prior.
- Your pacemaker setting were adjusted to be more responsive
when you exercise.
What should I do after leaving the hospital?
- Please have your INR drawn on ___
- Please take your medications as you were prior to your
hospitalization.
-Your weight at discharge is 245. Please weigh yourself today at
home and use this as your new baseline
-Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | Mr. ___ is a ___ with h/o prosthetic AVR and MVR on warfarin
(goal INR 2.5-3.5), CHF (EF 41-50%), inducible VTach s/p ICD and
on Amiodarone, thromboembolic MI s/p balloon angioplasty of the
LCX in ___, HLD, CKD (baseline creatinine ___, Gout,
Crohn's who
presents for dyspnea and chest "rush" that is similar to past
anginal equivalents. He had been having dyspnea on exertion for
the past few months but on the day of presentation he had
brought his wife to the ___ after she fell and was having
symptoms at rest. He underwent a nuclear stress test which
showed fixed perfusion defects similar to prior and a reduced EF
(25% from 40% at last TTE). Repeat TTE showed EF of 35-40% and
similar WMA to prior. Of note, during the exercise potion of his
test his device switched from a-paced v-sensed to v-paced at 80.
He was evaluated by the EP team and his devices activity
Threshold under Rate response changed from Low-Moderate to "Low"
to lower the threshold for ADL mode. Suspect that there is a
component of deconditioning to his symptoms as well. | 172 | 186 |
19031279-DS-9 | 24,418,921 | Mr. ___,
You were admitted to the hospital for shortness of breath. The
most likely cause of your symptoms are due to your chronic
obstructive pulmonary disease (COPD) give you improved on
treatement with steroids and your cardiac catherization
procedure and echocardiogram did not determine you had extra
fluid on board that could explain your symptoms. However, you
will need follow up by Cardiac Surgery given you have known
coronary artery disease as well as follow-up with Interventional
Cardiology based on your known Aortic Stenosis. They will see
you in their ___ clinic to address these issues.
Your discharge weight was 57.9 kg (128 lbs). If you see an
increased by 3 lbs in one week you should call your
cardiologist.
It was a pleasure taking care of you and we wish you a speedy
recovery. | ___ y/o M h/o O2 dependent-COPD, CAD, AS, worsening DOE for the
past 3 weeks with recent cath at OSH showing 100% occlusion RCA
with collateral formation, aortic valve area 1 cm 2, here as OSH
transfer for ___ opinion given his DOEx3 weeks.
# DOE x 3 weeks most likely related to COPD exacerbation given
he is wheezy on exams and improve after neb treatment. CXR
unremarkable for consolidation despite leukocytosis.
Contributing to his sx could be that he may be volume overloaded
with worsened cardiac fxn given his reports of more frequent
angina since his last hospitalization although his exam does not
support volume overload. Does have significant vessel disease on
recent cath. He was treated with a Prednisone burst 60mg qD for
5 days and then tapered with 40 mg x 2 days, 20 mg x 2 days and
10 mg x 2 days. He completed a course of Azithromycin 500mg qD
for 5 days during his stay. He was started on PO furosemide 40mg
but given he appeared dry on exam and this cause a bump in his
Cr this was stopped and patient was not discharge on lasix.
# Multi-vessel disease and severe AS
100% RCA with L to R collaterals, 85% ___, 70% origin of
DA1, 50% ___ LAD on recent cath 3 weeks prior. AS of 0.9 sq cm.
No intervention undertaken at the time. His cardiologist
requested a ___ opinion. Pt may be symptomatic from these with
intervention to be considered. A Repeat TTE revaled EF 50-55%
with Moderate AS (area 1.0-1.2cm2) Moderate (2+) AR. Cardiac
surgery consulted who discussed with patient regarding possible
CABG and valve replacement. PFTs done which are pending and to
be followed up as outpatient. There is less than 40% stenosis
within internal carotid arteries bilaterally.
# Leukocytosis
Could be due to CHF exacerbation or COPD. Pt has been afebrile
and was treated with antibiotics for COPD exacerbation.
Leukocytosis resolved upon discharge.
# HTN
Well controlled; home HTN meds
# Hypothyroidism; home levo
# HL-Continue statin
*** TRANSITIONAL ISSUES ***
.
- Follow-up as outpatient with cardiac surgery for evaluation
regarding CABG and aortic valve replacement. Will need pulmonary
consult prior to proceeding to intervention. Patient still
uncertain on what intervention he may want.
. | 134 | 367 |
14597448-DS-7 | 22,738,855 | Ms. ___,
You were admitted to the hospital with severe headaches and low
platelets. You were also found to have rapid turnover of your
red blood cells and fevers. You were evaluated for a viral
infection as a source of your symptoms, but our testing did not
return positive for any of the common viruses. We treated you
with steroids and IVIG while you were in, to decrease the
immune-mediated component of your anemia and thrombocytopenia.
We also supported you with transfusions.
It is very important for you to have very, very close follow-up
in the outpatient setting. Also, please call your primary
oncologist if you are having any symptoms at all that are
worrisome to you.
The following changes were made to your medication regimen:
- ADD senna, colace and miralax, as needed for constipation
- ADD prednisone 60mg every day for five days. You should
discuss the duration of this steroid with your primary
oncologist
- ADD folic acid 1mg by mouth every day
- ADD tylenol ___ by mouth up to every 6 hours, as needed
for pain or headache
- CHANGE cyclosporin to 250mg by mouth twice per day | Brief Clinical Summary:
==============
___ year old woman with hypoplastic MDS who presents with
thrombocytopenia, headache, and fevers; admission complicated by
transaminitis and jaundice with ongoing difficulty maintaining
RBC and plt counts. | 194 | 31 |
14644973-DS-15 | 28,813,042 | You were evaluated at ___ for
your symptoms of room-spinning vertigo and left-sided
discoordination which were concerning for have fortunately
resolved. We performed an MRI study of the brain and CT study
of the blood vessels which were unremarkable for any stroke or
obstruction of blood flow. It is likely that the attack you
suffered was due to a peripheral problem with your inner ear
which is resolving at this time, rather than any stroke.
We also performed an evaluation of your stroke risk factors
which demonstrated good control of your blood sugar, as well as
good control of your cholesterol. As a result of this we
recommend continuing your medications as written. We also are
prescribing a medication called Meclizine which can help should
another attack of Peripheral Vestibulopathy occur.
We did find that you had a small urinary tract infection, for
which we prescribed a short course of antibiotics. Please
complete this prescription to ensure appropriate treatment of
the infection. | ___ RH woman with history of superficial venous thromboses,
hypertension, and chronic pancreatitis presented with sudden
onset vertigo, left-sided dysmetria and dysdiadochokinesia, and
left neck pain concerning for posterior circulation stroke
versus vertebral artery dissection. Initial examination
demonstrated several signs concerning for central pathology
including a negative head impulse test, and marked difference in
speed with coordination testing on the left compared to the
normal right. Her story is also concerning for vertebral artery
dissection given the abrupt onset of symptoms in the setting of
a sharp posterior neck pain.
# Posterior Circulation Evaluation:
CTA of the head and neck showed no dissection or acute
intracranial processes. MRI demonstrated no infarct. Her
symptoms resolved with rest and hydration. Wrote for Meclizine
PRN and outpatient ___ per the patient's ___ evaluation.
# UTI:
UA suggested infection, with Cipro rx'ed to complete a course
for uncomplicated UTI. No other signs of infection were seen on
CXR, examination.
# Risk Factors:
LDL 97, A1c% was 6.0. Continued home medications
# Transitions of care:
- Meclizine 25 mg was given prn for vertigo/nausea
- Simvastatin 10mg PO QPM was continued as LDL was WNL
- Atenolol 12.5 mg daily was continued. | 164 | 197 |
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