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12952223-DS-42 | 22,387,333 | Dear Ms ___,
It was a pleasure taking care of you at ___. You were admitted
for chest pain and shortness of breath. You were found to have a
CHF exacerbation, and extra fluid in your lungs. For this, you
were treated with medications to remove the extra fluid.
Because of your heart failure, it is important to weigh yourself
every morning. Call your doctor if your weight goes up more than
3 lbs.
No changes were made to your medications | ___ with severe AS (valve area 0.8-1.0cm2 in ___,
diastolic congestive heart failure (EF>55%), NSTEMI s/p DES to
___ LAD ___, in-stent restenosis s/p DES x2 to mid-LAD
___, pAF not on Coumadin ___ GIB, presenting with sudden
onset shortness of breath and chest pain likely ___ flash
pulmonary edema due to increased catecholamines in the setting
of critical aortic stenosis.
.
# Dyspnea: Patient presented with dyspnea and with evidence of
acute pulmonary edema. She likely had increased catecholamines
from being under significant stress from witnessing her friends
engaged in a bitter argument. The patient subsequently felt
unwell and rapidly developed dyspnea and chest pressure and
tightness. The chest tightness was likely ___ increased wall
stress given the patient's severe aortic stenosis and acutely
increased intracardiac pressures. The patient's symptoms were
relieved shortly after diuresing almost 1L to Lasix 40 mg IV in
the ED, and she is feeling significantly improved this morning.
She will continue to be diuresed gently to near euvolemia as
blood pressure tolerates. CE's were initially mildly positive
but Trop has remained stable and CK, MB are both negative
trending two samples. EKG is also reportedly largely unchanged,
making ischemia unlikely. The mild troponin leak was likely ___
increased wall stress on cardiomyocytes leading to troponin
leak. She was diuresed on a higher dose of Lasix and
respiratory status significantly improved. She will be
discharged on her home dose of Lasix with close follow-up.
.
#. Aortic Stenosis: Patient with severe AS on TTE (0.8-1.0cm2)
with progressive symptoms. Her presenting symptoms are likely
___ her severe AS, which has likely continued to progress, as
described above. Repeat TTE was obtained for further
evaluation, as patient's prior 4+ TR had precluded her from
CorValve evaluation and the patient was expressing interest in
evaluation for CorValve. Repeat TTE showed progression of
aortic stenosis to critical AS with valve area of 0.6 cm2,
improved TR (___), making her a CorValve candidate. Evaluation
for CorValve was initiated in-house and Dr. ___ was
contacted after discussing with the patient's outpatient
cardiologist, Dr. ___. Cardiac surgery was consulted
in-house to begin the evaluation for CorValve, and the patient
will follow-up as an outpatient for further evaluation.
.
#. CAD: Patient s/p ___ LAD ___, in-stent restenosis s/p
DESx2 to mid-LAD in ___. Currently the trend of two sets of
CE's are negative for ischemia with stable troponin and negative
CK/MB as stated above. LDL within goal currently at 54. She
was continued on her ASA, BB, ___, statin per home regimen.
.
# pAF: Patient is not on coumadin ___ rectal bleeding in ___
believed to be due to colonic polyp (has history of multiple
colon polyps s/p removal) vs diverticular bleed while on
Coumadin.
.
# CKD: Creatinine of 1.6 on admission c/w recent baseline
1.4-1.7.
.
============================
Transitional issues
# Ongoing follow up with Dr ___ Dr ___
___ | 80 | 498 |
13280235-DS-18 | 22,940,907 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having nausea and vomiting, and you needed to start
treatment for your cancer.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given medicines to help stop your nausea and
vomiting.
- You were given intravenous (IV) versions of your seizure
medications during the time that you weren't able to take your
pills.
- You were started on chemotherapy.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- A prior authorization was needed to start lacosamide (vimpat).
You were given three days of this prescription. Please call your
pharmacy on ___ to confirm that this medication is available
to be picked up.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with history of newly
diagnosed metastatic colon cancer and seizure disorder s/p vagal
stimulator who presents with nausea and vomiting, course c/b
fever caused by post-obstructive PNA vs tumor fever, started
mFOLFOX on ___.
# Metastatic Colon Cancer:
Metastatic to lung, liver, and lymph nodes, as seen on ___
CT C/A/P. Imaging revealed likely further invasion of primary
lesion plus worsening lymphadenopathy consistent with disease
progression. Treatment plan was directed by Dr. ___. Due
to degree of hepatic dysfunction, the decision was made to start
FOLFOX this admission. She underwent port placement on ___.
C1D1 mFOLFOX on ___, minus ___ bolus. She was regularly
monitored for tumor lysis and she received symptomatic
management of nausea as below. Her next chemo will be due ___,
will likely be done as outpatient.
# Fever related to malignancy
She developed fever/tachycardia overnight ___ and was started
on vanc/cefepime/flagyl. Tachycardia resolved with 1L LR, though
she was noted to be tachy on admission, with ___ CTA showing
no PE. The most likely source of infection was post-obstructive
PNA, based on ___ CTA. CXR with near complete atelectasis of
RML and RLL. However, her fever is most likely secondary to her
malignancy. Stopped flagyl ___ and vanc ___. Cefepime was
stopped on ___ after a 6 day course for possible
post-obstructive pneumonia.
# Complex partial seizures
Longstanding seizure history, course c/b not tolerating her PO
AEDs this admission (due to gagging/choking on pills) and
complex partial seizures noted nearly daily. vEEG with expected
epilepticogenic focus. Baseline AED levels in target range for
Keppra, Zonegran, oxcarbazepine and subtherapeutic for her dose
of Topamax. She was given loading doses of Keppra and lacosamide
then given IV Keppra and lacosamide while not tolerating PO
medications, then was transitioned to PO Keppra and lacosamide
on ___. Zonisamide 100 mg PO BID was added. During the
admission she was monitored on tele, and aspiration and seizure
precautions were followed.
# Transaminitis
# Direct hyperbilirubinemia
Patient with increase in ALT/AST which is likely ___ advancement
of metastatic disease given known liver mets. Uptrended this
admission, now stable. RUQUS on ___ shows no biliary ductal
dilation to suggest obstruction and patent portal vein with
reverse flow the posterior right portal vein. LFTs and
fractionated bili were trended. She was treated with chemo as
above.
# Coagulopathy
INR was monitored during this admission and was noted to be
elevated. She was given IV vitamin K in case nutritional
deficiency is contributing to coagulopathy.
# Nausea/Vomiting
# Leukocytosis - resolved
No bowel obstruction seen on CT abd/pelvis. Her nausea/vomiting
were likely secondary to interval worsening of metastatic colon
cancer seen on imaging. Flu swab was negative, and while she was
noted to have leukocytosis early in the admission, this
resolved. She was given fluids and antiemetics, including
scheduled Compazine TID 30 mins before pills and Zofran as
second line. AEDs were transitioned to IV medications while she
was not able to tolerate PO, as above, and she was restarted on
PO Keppra and lacosamide on ___. | 133 | 494 |
10865237-DS-16 | 22,929,344 | Dear Ms. ___,
You were admitted to the Neurology service due to vertigo. You
had a brain MRI that did not show a stroke. You were continued
on your home warfarin. Because your INR was less than 2.0, you
were started on a heparin drip to bridge you to a therapeutic
INR. Today, your INR is 2.0, which is therapeutic.
We checked your stroke risk factors, and your cholesterol was
high. Because of this, we switched your simvastatin to
atorvastatin 20mg. If you get muscle aches, please call your
primary care physician.
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Team | ___ is a pleasant ___ year old woman with history
of atrial fibrillation
on Coumadin, HTN, R posterior fossa meningioma, and
hypothyroidism who presents with acute onset of room spinning
vertigo, nausea and right leg parasthesias. Clinical history
notable for persistent vertigo that is not episodic and not
positional. Exam notable for possible right sided ataxia
(overshoot on R mirror testing). She was found to be
subtherapeutic on Coumadin with INR 1.6. It was unclear if this
was due to a posterior circulation cardio-embolism vs.
peripheral vertigo. MRI brain did not show a stroke. However,
given high suspicion for a TIA, we touched base with PCP and
bridged her to therapeutic INR with heparin drip. She was
discharged with home ___ and INR 2.0. Her LDL was elevated, she
was switched from simvastatin 10 mg to atorvastatin 20 mg. | 106 | 138 |
17011637-DS-32 | 26,668,859 | Dear Ms. ___,
You were admitted to the gynecology service for an infection of
your incision called cellulitis. You were antibiotics to treat
this infection. You have recovered well and the team believes
you are ready to be discharged home. Please call Dr.
___ office with any questions or concerns. Please
follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* 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.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks from your
procedure.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication | Ms. ___ was admitted to the gynecology service as a transfer
from OSH for per-umbilical pain and incision site erythema with
a CT abdomen/pelvis concerning for abscess versus cellulitis.
She had an ultrasound that showed a 2cm fluid collection under
the incision that could represent an abscess or hematoma in the
setting of cellulitis. After review of OSH imaging and US
findings, Radiology felt it was likely a small hematoma that was
not amenable to drainage. She was given one dose of Ancef in the
ED and was then started on PO Bactrim for incision-site
cellulitis.
By HD#2, her pain was improved, she was tolerating a regular
diet, voiding spontaneously, and ambulating per her baseline.
She was then discharged home in stable condition with a 10-day
course of Bactrim and outpatient follow-up scheduled. | 191 | 133 |
16515451-DS-20 | 21,447,141 | Dear Ms. ___,
You were ___ to the hospital after experiencing severe
abdominal pain, which was caused by a partial small bowel
obstruction. This was managed conservatively with bowel rest
and intravenous fluids. Given return of bowel function, your
diet was advanced to a bariatric stage III diet, which was well
tolerated. You are now preparing for discharge to home and
should remain on the bariatric stage III diet until your
follow-up appointment with Dr. ___. Please note the
additional instructions as well:
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. | Ms. ___ is a ___ F s/p RNY bypass ___ who was recently
discharged after conservative management of a partial small
bowel resection. Her pain recurred prompting her to present to
the ___ ED where a repeat CT scan showed a proximal
small bowel obstruction with a transition point in the left
upper quadrant. Given findings, she was transferred to ___
for further management. Upon arrival, she was placed on bowel
rest and given intravenous fluids and admitted to the ___
Surgery service.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intravenous
acetaminophen and hydromorphone; this was transitioned to oral
oxycodone and then the patient's home suboxone dose.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On HD2, given +
flatus, her diet was advanced to clear liquids and then on stage
III, a bariatric stage III diet. She tolerated the diet well
without nausea, vomiting or increasing pain. She continued to
pass flatus and had several bowel movements.
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 pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 264 | 318 |
13198882-DS-6 | 20,690,215 | Dear Ms. ___,
You were admitted to ___ after
a fall and sustained a left upper arm bone (humorous) fracture
and a fracture in a bone in your neck at the level of C2
(cervical spine). You were seen by orthopedic surgery team for
the arm fracture and it was determined that this injury will be
managed non-operatively with a sling. Please continue to not use
this arm and keep it in a sling at all times. You were seen by
the neurosurgery team for the spine fracture and a it was
determined that this injury will be managed non-operatively with
a hard cervical collar. Please continue to wear your hard neck
brace at all times.
You have a fast heart rate while in the hospital and IV
medication were given to treat it. You were given a new pill to
help control your heart rate.
You are now doing better and ready to be discharged back to
rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | Ms. ___ is a ___ yo F who was brought to the emergency
department after an unwitnessed fall from standing. She was
found to have a left humerous fracture and Right C2 lateral mass
fracture. The patient was evaluated by neurosurgery for the C2
fracture who recommended non-operative management with a hard
cervical collar. The patient was evaluated for the humerous
fracture by orthopedic surgery who recommended non-operative
management with a sling. Of note, the patient baseline code
status if DNR/DNI/DNH but the family chose to reverse the DNH
(do not hospitalize) for evaluation and treatment related to
pain control.
The patient had adequate pain control with immobilization of
injuries, Tylenol, and Tramadol. She remained stable for a
neurologic standpoint. Neurology was consulted for abnormal
incidental finding on head vessel imaging of Multiple stenosis
of the intracranial vertebral arteries, including moderate to
severe stenosis of the proximal left V4 segment, moderate
stenosis of the proximal right V4 segment, and long severe
stenosis of the distal right V4 segment. Near complete occlusion
of the proximal basilar artery. Given her stable neurologic exam
and history of TIA no intervention was recommended and medical
therapy with statin and aspirin was recommended. The patient had
2 episodes of supraventricular tachycardia that was treated
successfully with adenosine. Medicine and geriatric medicine was
consulted and agreed with metoprolol XL for prevention. The
patient was monitored on continuous telemetry and did not have
any further events. She tolerated a regular diet with out
difficulty. She was seen and evaluated by physical and
occupational therapy who recommended discharge to rehab. Her
platelet levels dropped from 118 on admission to 58 on HD2 and
therefore subcutaneous heparin was held.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, getting out of bed with assistance, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 363 | 340 |
18111516-DS-15 | 24,950,505 | Dear Ms. ___,
You were recently admitted to ___ with fevers and confusion.
While you were here, you had evidence for a pneumonia, and were
treated with intravenous antibiotics.
You also demonstrated jerking movements, which were seizures,
confirmed also by EEG. We started you on medication to control
your seizures and they worked well. You will need to take per
rectum diazepam if you have any seizures lasting more than 5
minutes, or more than 3 short seizures in one hour. A repeat
CAT scan of your brain showed that you recently had a new
stroke. Most likely, it is from your irregular heart rate or
your high blood pressure. You are already on optimal medical
therapy for stroke prevention so we did not change any of these.
You were continued on hemodialysis while you were here, and it
is important that you continue to go to dialysis as an
outpatient. Your blood pressure was quite high and we adjusted
you medicines.
We have made a number of changes to your medications, the
updated list is included.
Please follow up in neurology clinic as scheduled below.
It was a pleasure taking care of you, we wish you all the best! | ___ woman with a h/o hypertension, DM, hyperlipidemia, afib not
on coumadin, multiple prior CVAs, CAD, and ESRD on HD MWF
admitted to the hospital on ___ with fevers / chills,
thought to be secondary to HCAP, who developed high blood
pressure and confusion at an HD session; she was transferred to
the ICU a second time for management of status epilepticus.
# Neurology: The stroke team was initially consulted while Ms.
___ was on the medicine service when she developed decreased
responsiveness and complete disorientation after hemodyalysis.
At that time, her confusion was most likely due to an underlying
infectious and/or metabolic issue, including an episode of
hypertension and hypoxia with O2 sats in the ___. A new ischemic
event was also considered as a cause. Her head CT demonstrated a
possible new parietal hypodensity that was of uncertain
significance but may represent a new intracerebral process.
Patient had no new focal deficits, however, exam was limited due
to noncompliance. At that time, thought ?parietal hypodensity
was was likely due to cut of the CT. Patient transiently became
more interactive, but continued to be disoriented and aphasic.
Of note, patient was transferred to the ICU at that time for
hypertension control. Following stabilization of her blood
pressures in the ICU, patient returned to the medicine floor.
She developed twitching of her left arm and eyelid, along with
lip smacking and decreased responsiveness, all attributed to
status epilepticus, in HED. She was treated lorazepam 0.5 mg IV
x1, and transferred to the medical ICU for EEG and airway
monitoring. She maintained her airway throughout the episode.
Upon discharge from the MICU, she was transferred to the
Neurology service. She was on LTM and her EEG showed diffuse
encephalopathy as well as intermittent epileptiform discharges.
Her AEDs were adjusted multiple times. On discharge, she was
maintained on Keppra 1000mg qhs and 500mg per HD protocol as
well as Dilantin 175mg tid. Of note, head CT was repeated given
the ?of new parietal hypodensity as above. On repeat head CT,
it was clear that she did indeed have a new infarct in that
area. Most likely, this stroke was embolic in the setting of
afib and no anticoagulation (hand caudate hemorrhage in ___ so
coumadin was stopped) vs. a hypertensive etiology. Carotid b/l
ultrasounds were obtained which did not show significant
stenosis. Did not make any changes to medications as cannot
anticoagulate and she is already on plavix. Controlled HTN as
below. On discharge, patient was more interactive, but waxing
and waning as per discharge exam.
# HCAP: On presentation, the patient's fever/chills were likely
secondary to HCAP given new RLL opacity on CXR. She did not have
a leukocytosis, but did have neutrophil predominance. She was
started on vancomycin and cefepime. Significant interval
worsening in CXR from admission to present with episode of
hypoxia (desat to 70%) likely represents fluid overload. Patient
dialyzed prior to MICU transfer with removal of 3L of fluid. In
the MICU, her respiratory status was monitored and remained
stable. Initial Bcx x3 (drawn on ___ show NGTD. Repeat
cultures drawn ___ secondary to change in mental status, also
show no growth. Urine legionella antigen negative. She was
continued on vanc/cefepime for HCAP.
# Hypertension: Initially, patient's systolic blood pressures
ranged 160s-180s while on the medicine floor. At the time of
her episode of pulmonary edema with desaturation, systolics rose
to the 200s, and this was unresponsive to ultrafiltration of 3L
in dialysis. She was given a labetalol push, and transferred to
the medical ICU. In the ICU, she was continue on her home
medications of Lisinopril 40mg q24h, Lopressor 50mg TID, and
amlodipine 5mg. She continued to be hypertensive o the 180s
systolic, so amlodipine was increased to 10 mg daily. She was
also started on hydralazine 75mg PO tid. Despite these chages,
she continued to be hypertensive, so she underwent dialysis to
remove volume. This normalized her blood pressure to 150-160s
systolic.
# Chronic renal insufficiency: She is on scheduled HD MWF. Her
hypertension was thought to be volume dependent, so she
underwent suscessful ultrafiltration on ___. We continued her
sevelamer for phso-binding. Other acute interventions with
regard to her kidney function were not acutely indicated.
# Anemia: Her hemoglobin and hematocrit are low, but similar to
prior levels. Her anemia is most likely due to her chronic renal
insufficiency and/or chronic disease. There was no evidence of
acute bleeding.
# Type 2 DM, uncontrolled: Patient is a brittle diabetic
complicated by retinopathy, neuropathy, and nephropathy. She
was continued on an ISS.
# History of Stroke: She is s/p left frontal MCA and occipital
PCA stroke. Her plavix was continued.
# Atrial Fibrillation: Was on warfarin in past, but not
anticoagulated at present. Warfarin discontinued ___ due to
caudate hemorrhage. Stopped aspirin in ___ due to infarcts.
In the MICU, she was rate controlled with toprol-xl.
# Coronary artery disease: Stable. Continue continue plavix,
beta blocker, statin, ACE inhibitor
# Hyperlipidemia: continue pravastatin
# Nutrition: Patient was intermittently awake enough to swallow.
Had NG tube in place, pulled it out several times. Discussed
possibility of PEG tube with the family who decided against it.
Patient is able to eat with assistance, so NG tube was
discontinued. | 199 | 895 |
14887088-DS-19 | 26,135,246 | Dear Ms. ___,
You were admitted to the ___ ICU with fever and altered
mental status. You were found to have pneumonia, which improved
after treatment with antibiotics. We also adjusted doses of your
blood pressure medications and weaned down your sedating
medication (valium) in order to improve your mental status.
.
Please attend the previously scheduled outpatient appointments
with Neurology, Neurosurgery and Orthopedics to follow up on
your hospitalization.
.
We made several changes to your medications. Please see the
following page for details. | ___ F with HTN and DMII s/p significant MVC in ___
resulting in numerous intracranial bleeds leaving patient with
prfound neurologic dysfunction requiring Trach and PEG now
admitted to ___ for fevers at ___.
# Sepsis: On admission to MICU patient met criteria for sepsis
with fevers to 102, tachycardia, elevated WBC with sources
urinary and presumed pulmonary. Patient with trach in place and
vent dependent so ventilator associated pneumonia highest on
differential. Cultures revealed ETT sputum Cx with pan-sensitive
MSSA and Klebsiella. She was initially treated broadly with
Vancomycin, Levofloxacin and Ceftazidime to double cover for
Pseudomonas which was narrowed to Bactrim once cultures returned
(will complete 10-day course, day 1 = ___, day 10 = ___. She
never required pressors, developed a lactatic acidosis or had
evidence of end organ ischemia such as renal failure.
# Encephalopathy: Patient with baseline Minimally Concious State
though admitted with acute toxic metabolic encephalopathy and
functioning below baseline which includes tracking to voice and
following commands. She initially was lethargic and only able to
stick tongue out on command though this improved with resolution
of sepsis suggesting fever and infection related encephalopathy.
Additionally she was on significant doses of sedating
medications including standing Diazepam, Seroquel, Keppra and
Clonidine which were all felt to be contributing to her poor
baseline mental status and encephatlopathy. Diazepam was
titrated down during hospitalization, and discontinued on
discharge (last dose was ___ on AM of discharge). Seroquel was
tapered down, keeping only 12.5mg HS for insomnia. Clonidine
also discontinued. Code status remained full with plan for
aggressive care per family. NEURO EXAM ON DISCHARGE = awake,
alert, able to mouth words. Follows simple commands (open/close
eyes, show tongue, wiggle toes). Proximal muscle weakness
throughout, no focal neuro deficits.
# Vent Dependence: Trach and intermittently vent dependent when
discharged to ___ during previous admission. Since being at
___ and during MICU admission she remained vent dependent 24
hours a day. Attempted vent weaning while in MICU though showing
low NIFs (-32) and easy fatigue becoming tired by the end of the
day requiring higher levels of pressure support. Initial
attempts at trach collar in MICU were limited by fatigue and
tachypnea. Once treated pneumonia, were then able to
successfully wean vent settings to PSV ___ with 50% FiO2, and on
afternoon of discharge she was tolerating trial of trach collar
well.
# Seizure Disorder: Chronic, stable and withoute evidence of
seizures during admissin to MICU. Continued LeVETiracetam 1500
mg PO BID
# HTN: Chronic and maintained on Clonidine at LTAC. During
admission antihypertensive regimen was adjusted. Clonidine Patch
discontinued since can also contribute to encephalopathy.
HydrALAzine and Metoprolol discontinued and Labetalol was
started at low standing doses (100mg TID) to prevent rebound
sympathetic surge after discontinued clonidine. ___ uptitrate
Labetalol as needed at ___.
# Anemia: Macrocytic and downtrended during MICU stay without
clear source. Received 1 unit pRBC transfusion ___ with
appropraite bump in hct.
# Eosinophilia: Slightly elevated WBC today with increase in Eos
with absolute eosinophilia now. Likely related to Cephalosporin
use and med effect. Ceftazidime discontinued anyway while
narrowing ABx.
# DMII: Chronic, non-insulin dependent Diabetes Mellitus, Type
II, well controlled and not known to be complicated. Placed on
Regular ISS while on tube feeds, Euglycemic during admission. | 82 | 571 |
17851073-DS-7 | 27,769,830 | Dear Mr. ___,
It was a pleasure taking care of you while at the ___
___. You were admitted for intensive care
after being found to have a celiac artery dissection. This
included blood pressure monitoring and we did start blood
pressure medications that you will need to be on life long. You
will also need to be monitored for worsening of this dissection
on a life long basis. We have arranged follow up with us and
cardiology (see below). It is very important that you make those
appointments. If you have worsening abdominal pain, dizziness,
low blood pressure you need to call our office or go to the
emergency room. These could be signs that your dissection are
worsening. Otherwise please follow the instructions below for
signs to watch out for. | Mr. ___ is a ___ man with no history of arterial
disease who presents with abdominal pain and was found to have a
spontaneous celiac artery dissection. he had a CT scan done on
admission (___) which revealed a dilated celiac trunk, up
to 1 cm in diameter, with associated dissection that extended
into the common hepatic artery and thrombosis of the false lumen
at the level of the hepatic hilum. There was also an incidental
11 x 11 mm right renal artery aneurysm. The patient was admitted
to the ICU for intensive blood pressure control and monitoring.
Vascular medicine was consulted. He was initially on an esmolol
drip and was eventually transitioned to oral blood pressure
medications (___). These included metoprolol and
captopril. He was transferred to the floor on ___
after being off IV blood pressor infusions for 24 hours. His
blood pressure remained within goal. On the ___, he
noted to have some mild pain. Repeat CT scan done on that day
did not reveal any extension of the aneurysm or dissection.
He tolerated regular diet and got out of bed. He ambulated
independently and he did not require physical therapy
evaluation. On the day of discharge he was voiding
spontaneously. He was discharged home on the ___
with plan for outpatient follow-up. He voiced understanding of
the discharge plan and all his questions were answered to his
satisfaction. | 131 | 232 |
12708817-DS-20 | 20,460,499 | It has been a pleasure taking care of you here at ___
___. You were admitted because of your
symptoms of transient speech difficulty, double vision,
sensation of dysequilibrium, and lower extremity weakness.
Your CT, MRI, and MR ___ scans showed a narrowing of some
of the vessels in the posterior circulation of your head as well
as some areas of stroke which were small and likely were
sub-acute.
You will be discharged on anticoagulation (medicine to prevent
future blood clots) which will include a daily Coumadin pill.
Please follow up with your primary care doctor, ___ on a
regular basis to ensure that your INR is within normal limits.
You should have your next INR checked on ___.
We also have had our physical therapists work with you over the
course of your hospital stay. They provided you with a walker
and recommended outpatient physical therapy for which we
provided you a prescription.
We also found that you had a urinary tract infection which we
will treat with Bactrim for 5 total days. | ___ W with a history of obesity, hypertension, insulin
dependent diabetes mellitus, thyroid cancer s/p thyroidectomy
and other medical problems who has now had four stereotyped
episodes consisting of slurred speech, poor fluency and
dysarticulation, binocular diplopia, dysequlibrium and diffuse
generalized weakness. Her CT scan identified a circular
hypodensity in the left cerebellar hemisphere that appears
subacute. MRA showed vertebrobasilar changes.
# NEUROLOGIC:
- MRI/A demonstrated bilateral subacute pontine infarcts as well
as stenosis of the vertebrobasilar system. We started Heparin
gtt weight based which resulted in a PTT <150. Heparin gtt was
held and PTT was rechecked with new IV rate at a substantially
lowered level such that the patient remained within or trivially
above goal 50-70 PTT throughout the remainder of the period for
which she was subtheraputic. An episode similar to that which
described as an outpatient was seen on ___ in the evening by
house staff which was remarkable for binocular diplopia (there
was a double of object in the patient's sight to the superoleft
of the actual object) which was present in all gaze directions
but extinguished with covering either eye. The episode was in
the context of blood sugar of >340, which occurred ___
prednisone 50mg which had been administered earlier in the day
as part of a planned iodinated contrast administration for CTA
which ultimately was cancelled. The episode lasted for only
~10min resolving without any symptoms after.
# CARDIOVASCULAR:
- The patient was started on Warfarin with Heparin bridge.
Atenolol was kept on with holding parameters and the patient was
started back on her home dosage of Losartan. Lipid panel was
remarkable for elevated cholesterol TC=162 ___ HDL=57,
LDLcalc=84 LDLmeas=104 for which a statin was started.
# ENDOCRINE:
- Sliding scale insulin was placed with home doses of Lantus and
Humalog. The patient was also managed on her home doses of ___-
and Levothyroid. Sugars ranged between 340 and around 100 for
the majority of the admission. A1c was measured at 6.2%.
# ORTHOPAEDIC:
- Knee XR was shot for left sided pain associated with one of
the patient's falls which ultimately proved negative for any
fractures. Pain control was managed with with Tylenol with good
effect.
# TRANSITIONS OF CARE:
- High-grade focal stenosis at the mid basilar artery
- Acute/Sub-acute infarcts in the pons
- Left Knee XRay unremarkable for any fracture
- On Warfarin with INR theraputic on d/c at 2.0 - Will see Dr.
___ on ___ at 11:10 for follow up
- UTI sensitive to Bactrim, will treat for 5 days total
- Will get Outpatient ___ with Walker supplied by our PTs | 176 | 430 |
13323674-DS-28 | 26,919,972 | Mr ___,
It was a pleasure taking care of you while you were in the
hospital You were admitted with DKA from not taking your insulin
and for alcohol withdrawl. You were treated with insulin and
seen by the ___ specialists and you were given medications
for your withdrawl and you improved.
It is important to not drink any more. It is also important to
not miss ___ dose of your insulin.
You had fevers three times in the hospital. Your cultures and
lab tests did not show any signs of infection. You had imaging
done that also did not show any signs of infection or
imflammation. You do have evidence of damage to your liver from
alcohol on imaging. There were labs pending when you leave the
hospital and you will be contacted with the results. You can
also call your primary care doctor for the results.
Please make sure you follow up with ___, with your
primary care doctor and with you ___ doctor.
Please make sure you have your labs checked again at your next
doctor's appointment.
We wish you the best.
Please take your medications as listed and follow up with your
appointments below. | ___ male with history of alcohol abuse, type 2 diabetes,
subdural hemorrhage, cardiomyopathy, hypertension, and
depression who presented to the ED with alcohol intoxication,
DKA S/p insulin gtt and gap closure, febrile daily every 24
hours, cultures negative to date and now afebrile x 24 hours.
# Fever: 3 days of fever to 102 without any localizing signs or
symptoms and resolved without intervention. CMV, EBV, HIV, CBC,
BCx all negative. NO lymphadenopathy on exam and CTA torso was
without source. Given resolution, recommend routine screening
with PCP and continue outpatient workup as needed.
- due for PPD
# Diabetic Ketoacidosis with underlying diabetes with
neuropathy: In the setting of EtOH abuse and not taking insulin.
Resolved and patient with elevated FSBGs throughout admission,
difficult to control similar to that in the outpatient setting.
Improved throughout hospitalization with ___ input, who will
continue to follow as outpatient. Patient encouraged to follow
up, given prescriptions for all of his medications including
insulin syringes.
# EtOH Withdrawal: Tolerated phenobarb protocol very well.
Continued until discharge. Continued folate, thiamine, MVI.
Social work assisted with placement and referral to ___.
Patient stated throughout admission desire for sobriety and
intent to follow up. Intake at ___ scheduled for ___,
___. Discharged to men's homeless ___ in time for intake
there.
# Elevated LFTs due to EtOH use: chronic, flunctuation noted
over time in OMR. Abdominal US and CTA suggest portal
hypertension.
- can repeat LFTs as outpatient
- encouraged sobriety
# Depression: continued sertraline and quetiapine
# Hypertension: Good control as inpatient. Poorly controlled ___
noncompliance as outpatient.
- Continued home lisinopril and metoprolol
# Cardiomyopathy: Reported history of cardiomyopathy though MIBI
in ___ is 63% and TTE ___ with EF 55%. Will need cardiology
follow up but currently prioritized sobriety and diabetic
control
- Continued metoprolol and lisinopril as above
- Continued ASA 81 mg
# Seizure disorder: Continued Keppra
# Hyperlipidemia: continued lovastatin
# Gout: Continued allopurinol
# Neuropathy: Continued gabapentin
# Communication: Pastor ___ (___)
# Code: Full Code
> 30 min were spent on day of discharge in coordination of care
and services | 197 | 365 |
13640252-DS-3 | 28,006,899 | Surgery
* Your incision is closed with staples. You will need staple
removal. Please keep your incision dry until staple removal.
* Do not apply any lotions or creams to the site.
* Please avoid swimming for two weeks after suture/staple
removal.
* 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. ___ 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.
Medications
* Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon. Your
Aspirin 81mg daily was restarted while in hospital - this is OK
to take.
* You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
* It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
* Severe pain, swelling, redness or drainage from the incision
site.
* Fever greater than 101.5 degrees Fahrenheit
* New weakness or changes in sensation in your arms or legs. | #Cervical and lumbar stenosis s/p falls
MR. ___ was initially evaluated in the ___ ED on the
morning of ___ s/p fall. He was seen by ___ and was sent home
from the ED with plan to return for scheduled surgery for his
spinal stenosis. The same day he had another fall at his
heme/onc appointment and it was felt he was unsafe to go home.
He returned to the ED and was admitted to the floor on ___
for expedited surgery. He was evaluated by the neurosurgeon and
scheduled for surgery on ___. Pre-operatively he complained of
chest tightness which he reported has been intermittent for the
past several days. His vital sings were stable, cardiac enzymes
normal, and EKG showed normal sinus rhythm. He was cleared for
surgery and underwent C6-7 laminectomies, partial T1 laminectomy
on ___. The procedure was uncomplicated and a hemovac drain was
left in place. Please see separately dictated operative report
by Dr. ___ complete details of the procedure. He
was extubated in the OR and transferred to PACU for recovery
where he remained hemodynamically and neurologically stable. He
was placed in a soft cervical collar at all times. He was
evaluated by physical therapy who recommended dispo to rehab so
an occupational therapy consult was also placed. His hemovac
drain was removed and covered with steri strip. He was started
on sq heparin after drain removal and was resumed on his home
Aspirin on POD 3. The strength in his bilateral lower
extremities continued to improve post-operatively. PVR was 15
and his rectal tone was intact on ___. Patient complained of
___ mild chest pain, EKG was normal. Pain was thought to be due
to his left sided flank/torso pain and resolved spontaneously.
He was assessed by physical therapy.
#L groin/flank pain
Prior to admission the patient complained of Left flank pain. He
reports his last fall was on his left side where the wheel house
to his wheelchair was digging into his left side. He describes
the pain as a tightening that starts on his left side and
travels across his abdomen. The pain is from the nipple line to
the groin and is tender to light palpation. The pain is worse
with flexion of his hip or laying flat in bed. He was evaluated
in the ED and underwent xrays of the hips which were negative
for fracture and showed degeneration bilaterally. A CT chest,
abdomen, pelvis was negative for fracture but did comment on a
known right renal cyst for which he is followed by heme/onc as
an outpatient and will need a renal MRI once recovered from
surgery. His home lyrica was continued and the trauma service
was consulted after the patients surgery for trauma work-up of
the patient's persistent left flank pain. The Trauma service
reviewed patient records and evaluated patient and stated all
imaging for traumatic injuries were negative and recommended
neurology consult for hyperalgesia and signed off. Neurology was
consulted on ___ for continued complaints of left
flank/trunk/groin and hip pain. They recommended MRI total spine
due to concerns for radiculopathy in the thoracic region with no
MRI after most recent falls as well as MRI Brain for work-up of
right sided sensory abnormalities to rule out thalamic stroke.
Due to patient's pacemaker imaing required coordinating with EP
and radiology. He was cleared from a cardiac perspective and
imaging was delayed due to scheduling. He was scheduled for MRI
with EP to program his pacemaker however he was unable to
tolerate laying flat due to severe back spasms with pain
radiating across his abdomen. Anesthesia was consulted and
agreed to assist and provide general anesthesia for the MRI. The
plans were discussed with patient by radiology, the neurosurgery
NP extensively, as well as the EP PA. The patient agreed to
proceed with the MRI. He was made NPO for MRI on ___. MRI was
performed on ___ under general anesthesia, with cardiac EP
monitoring his pace-maker. MRI brain was read without pathology.
MRI spine was obtained - read via OMR. On day of discharge, he
had no complaints of left sided flank pain.
#Uptrending BUN
Patient was encouraged PO fluid and given a small fluid bolus
for uptrending BUN and started on IV fluids after midnight while
NPO for MRI with anesthesia. PO fluids were encouraged and his
BUN was downtrending leading up to day of discharge.
#Care coordination
Patient is very concerned that he will be lost to follow up and
that he will not get proper treatment for his renal disease or
from his primary care provider. Dr ___ Dr ___ both
emailed prior to patient's discharge in an attempt to help
facilitate the patient concerns.
#Disposition
___ evaluated patient and recommended discharge to acute rehab,
in which he refused to go to. ___ re-evaluated the patient on
___ and he was cleared for home with home ___ services. He was
discharged home on ___ after appropriate services were set up
for him. He was instructed to return to the Spine Clinic for
wound check and staple removal this upcoming week prior to ___,
and again in 6 weeks to meet with Dr ___. | 225 | 856 |
18662708-DS-26 | 27,907,129 | It was a pleasure caring for you at ___.
You were admitted after having low blood pressures while
undergoing dialysis treatment. This was most likely caused by
having recent diarrhea and being dehydrated, which can result in
low blood pressure during dialysis. In the hospital, we held
your blood pressure medications and gave you IV fluids. Your
pressures improved. You should not restart metoprolol until
after speaking with your doctor.
While in the hospital, you underwent two hemodialysis
treatments. Your blood pressures remained stable and you were
discharged to rehab.
You should weigh yourself every morning, and to call your doctor
if your weight goes up more than 3 lbs. Please be sure to eat
and drink plenty of fluids. | Mrs. ___ is a ___ year old female with ESRD on HD, T2DM on
insulin, A-flutter s/p ablation (___), asthma, and OSA on ___
BiPAP, who experienced symptomatic hypotension during her
scheduled hemodialysis session on ___ and was transferred to
the ___ for management of hypotension that was likely due to
hypovolemia in the setting of vomiting/diarrhea and fluids
shifts due to dialysis. | 118 | 63 |
18537315-DS-13 | 27,775,005 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted with lightheadedness, and we have ruled out stroke or
heart attack. Your blood pressures continue to be very high (as
high as 220/90), and you will need to follow up with Dr.
___ Dr. ___ this. Your hydroxyurea will
also be decreased back to 500mg daily (from 1000mg daily), and
you will need to follow up with Dr. ___ this.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. | ___ highly independent at baseline with h/o Polycythemia ___
(on hydroxyurea), PVD s/p R SFA stent, DMII, RAS-induced
resistant HTN, CKD, and dCHF who presents with lightheadedness x
1 day and gait abnormality x 2 weeks. | 92 | 37 |
11658675-DS-26 | 26,789,763 | It was a pleasure to participate in your care. You were admitted
with cough and dyspnea and found to have pneumonia, likely due
to aspiration. You were treated with antibiotics and your
symptoms improved.
Your enterocutaneous fistula appears to be healing. We discussed
this with your surgeon who recommended giving it another 2 weeks
to heal.
We discussed your risk for recurrent aspiration. Please follow
the recommended diet instructions (see below) as well as keeping
the head of the bed up at 35 degrees. Limiting narcotics may
also help mitigate your risk. | Mr. ___ is a ___ with h/o COPD on intermittent ___ NC,
recurrent aspiration pneumonia, eosinophilic pneumonia on
prednisone and azathioprine, and Pulmonary embolism s/p IVC
filter who presents with dyspnea and respiratory failure found
to have pneumonia likely from aspiration event as well as COPD
exacerbation.
.
# RESPIRATORY FAILURE / PNEUMONIA / ASPIRATION: He presented
with hypoxia on NRB, requiring emergent intubation, reflecting
acute hypoxemic respiratory failure superimposed on chronic
hypercarbic respiratory failure. CXR on admission revealed RML
and L lingular infiltrates, representing likely etiology of
acute decompensation in this patient with poor reserve due to
known COPD, restrictive lung disease, and eosinophilic
pneumonia. He aspirates frequently, and some food particles were
observed in his airway on intubation, suggesting causal
aspiration event. He was extubated the following day without
problem. Bronchial washing and sputum were sent for culture that
returned growing E. coli sensitive to zosyn. He was initially
covered with vancomycin and zosyn but vancomycin was stopped on
hospital day three. A picc line was placed and he will continue
zosyn for a total 10 day course.
.
#COPD, ACUTE: On exam the patient had diffuse wheezing with
dyspnea and increased cough consistent with acute COPD. He was
treated with methylprednisolone in the ED and then started on
prednisone 40mg for 5 day burst. He was continued on nebulizer
as needed. On discharge, no wheezing was appreciated. Would
examine after prednisone taper is stopped and if continues with
wheezing may need more prolonged taper.
.
#SINUS TRACT / FISTULA: He has had a healing sinus tract since
his PEG tube was removed in ___. There is a very small sinus
tract on exam. This was discussed with Dr. ___ recently
saw him, who recommended another 2 weeks of local wound care.
If does not heal then should follow up with GI for possible
closure.
Wound care recommendations were:
- Treat skin with Stomahesive powder, sprinkle on, rub in, and
dust off.
- Dab with no-sting barrier wipe to seal in.
-Use ___ sura 1 piece cut slightly larger than
opening.
- Place ___ ___ paste strip around wafer opening, molding
with fingers.
- Remove wafer backing, place pouch directly over site.
- Place disposal wipe and warm pack x 2 minutes to assist in
pouch adhering to skin.
.
#RECURRENT ASPIRATION: His current episode of pneumonia likely
reflects an aspiration event. He has a history of esophageal
dysmotility due to neurological disease (possible multiple
sclerosis) causing aspiration. As noted above, his G-tube was
removed on his last admission at his request following extended
discussion of risks and benefits. He was evaluated by speech and
swallow on his last admission, with nectar thick liquids and
moist soft solids advised. Strict aspiration precautions and
aforementioned diet were continued throughout admission. It is
unclear whether the patient had less aspiration events /
hospitalizations when he was getting nutrition through the
G-tube. The patient was not sure but ___ (his partner) thought
he did better with the G-tube. If there is evidence that the PEG
tube in this patient reduced his risk of aspiration AND he is
willing to be NPO and have his nutrition through the G-tube then
could consider replacing the G-tube. However, when I spoke ___/
___ about this he wants to continue nectar thickened liquids
PO if G-tube were to be replaced. Case discussed with his
pulmonologist Dr. ___. I discussed with the ___ and
___ at length that he is at high risk for recurrent
aspiration. We recommended keeping head of the bed up to >35
degrees (he does not always do this), limiting sedation due to
narcotics, aspiration precautions with small bites/sips,
alternate bites/sips,swallow 2x per bite/sip, sit fully upright
to eat and drink, remain upright for 60-90 minutes after meals,
assist with meal set up as needed, soft dysphagia diet with
nectar prethickened liquids, if meds ar esmall then can be given
whole otherwise crushed in apple sauce, oral care TID. We
managed to get him to have a Yankauer suction device at bedside
while at ___. Palliative care was consulted for
further discussion of this issue per patient request.
CHRONIC ISSUES:
# Eosinophilic pneumonia: He has known eosinophilic pneumonia
treated with azathioprine and prednisone in the outpatient
setting. Peripheral eosinophilia was 4.3% on admission then
reduced to <1%. Home azathioprine and Bactrim were continued. He
received a prednisone burst of 40mg daily for 5 days for COPD
exacerbation as above, but then returned to his chronic
prednisone dose of 7.5mg daily on completion of burst.
# Bipolar disorder: Home Seroquel, citalopram, and Risperdal
were continued.
# Chronic back pain: He has known spinal stenosis, as well as a
history of multiple compression fractures in the setting of
chronic prednisone use. Home gabapentin, calcium, vitamin D,
and calcitonin were continued. Home Fentanyl was held while he
was intubated and sedated. When extuated he was restarted on
fentanyl patch as well as morphine PRN for breakthrough pain. He
was continued on his bowel regimen while taking narcotics.
Unclear why on metoclopramide, potential medication interactions
so would d/c unless necessary.
# GERD: Home lansoprazole was continued. The omeprazole was
stopped.
# Hyperlipidemia: Home pravastatin was continued.
# Hypothyroidism: Home levothyroxine was continued.
# Preventive health: Home baby aspirin was continued.
.
# Pulmonary edema: He reported being started on lasix recently
for fluid in his lungs. This was held during the hospitalization
in the setting of infection. An echocardiogram showed an EF of
60%.
.
# Potassium supplementation: He was on potassium 40mg AM and
20mg ___ at home. These were held during the hospitalization. His
potassium remained normal and was 3.8 at discharge. Will not
start potassium supplemtnation at discharge as we are also
holding lasix. Would recommend checking a potassium level on
___. If potassium >4.8 would stop potassium supplementation.
If potassium <3.5 would consider additional potassium
supplmentation. Potassium level may be effected by whether lasix
is restarted.
TRANSITIONAL:
-check potassium on ___ to consider need for potassium
supplementation.
-blood cultures not finalized at discharge | 92 | 989 |
17597690-DS-3 | 22,700,889 | You were admitted to ___ after a gunshot wound. You were found
to have an injury to your kidney and a fracture of your lumbar
spine. You were taken to the operating room and underwent a
diagnostic laparoscopy to ensure there was no intra-abdominal
injury. You were then taken to the operating room with the Spine
surgeon and underwent L1-2 unilateral fusion. You should
continue to wear your TLSO brace when out of bed.
Urology was consulted for your kidney injury. They did not feel
this needed immediate surgical intervention but would like to
see you in follow-up in a month for repeat imaging.
You tolerated your operations well and have been cleared by
Physical Therapy to be discharged home with the TLSO brace to
continue your recovery.
Wound Care: Please apply saline-moistened gauze to the open
buttocks and leg wounds and cover with dry gauze. Change daily.
Please note the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry. | ___ otherwise healthy who sustained 4+ GSW to left torso and
left buttocks with retained bullet fragments near left thigh,
pelvis, and L2 fracture, L1-2 facet disruption, laminar fracture
with bony fragment in spinal cord, and dural tear. The patient
was hemodynamically stable and neurovascularly intact, however,
he had an
entrance wound in the left mid axillary line around the 10th rib
that traversed and ultimately went to the thoracic spine. He
also had multiple wounds on his left buttock and on the left
calf. A CT scan was obtained which showed a fractured
rib as well as a splenic laceration and left renal laceration.
Due to the concern for a diaphragmatic injury on the left side,
decision was made to perform a diagnostic laparoscopy with
possible diaphragmatic repair. Please see operative report for
more details regarding this procedure. There was no evidence of
large or small bowel injury. Patient was transferred to the
TSICU stable condition. Urology was consulted for the left renal
laceration with perinephric hematoma. They did not feel this
warranted any intervention but would follow along and see the
patient as an outpatient for repeat imaging. Spine was consulted
for the spinal injuries.
On HD2, the patient underwent L1,2 laminectomy and fusion/ dural
repair which went well. Due to concern for a CSF leak, the
patient was maintained on CSF precautions. Infectious Disease
was consulted and the patient was started on prophylactic
antibiotics.
Once CSF leak precautions were liberalized, Spine recommended a
TLSO brace when up out of bed and the patient was able to
ambulate. Pain was well controlled. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The Foley was removed on POD2 and patient voided without
problem. During this hospitalization, the patient was adherent
with respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. Physical Therapy worked with the patient and eventually he
was cleared for discharge home with the TLSO brace.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating in TLSO, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. He was given instructions to follow-up in
the ACS, Spine, and Urology clinics. | 414 | 412 |
15264952-DS-23 | 28,601,246 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had nausea,
vomiting and diarrhea.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were observed for signs of bowel obstruction, which you
did not have.
- You also needed oxygen. A CT scan showed emphysema caused from
cigarette smoking.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below).
At the pharmacy, please ask the pharmacist to teach you how to
use your new inhaler.
- Take your lactulose 3 times daily. You should be having 3
bowel movements every day.
- Please arrange an appointment with a new psychiatrist and
consider making an appointment with a cardiologist.
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds.
- Please maintain a low salt diet and monitor your fluid intake.
- Seek medical attention if new or concerning symptoms develop
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY
Ms. ___ is a ___ year-old female with history of alcohol
cirrhosis, complicated by portal hypertension, ascites, HE, and
GI bleed, who initially presented to ___ with
nausea/vomiting, abdominal pain and diarrhea, transferred to
___ given concern for partial SBO, though ultimately believed
to be due to a viral gastroenteritis given rapid resolution of
symptoms. | 213 | 57 |
19151601-DS-13 | 26,952,000 | Dear Mr. ___,
.
It was a pleasure taking care of you in the hospital. You were
admitted for cough, fever, and chills, and were found to have a
pneumonia. You were treated with IV antibiotics (Vancomycin,
levofloxacin, flagyl, cefepime), and your respiratory function
and cough improved. You also had pain in your right big toe, and
were diagnosed with gout. This is your first gout flair, and you
were treated with a medication called colchicine.
.
Please call your primary care physician to schedule ___ follow-up
appointment in the next ___ weeks.
.
Please start the following medications:
1. Levofloxacin 750mg once daily for 7 days until ___.
2. Colchicine 0.6mg once daily until your appointment with your
primary care physician.
.
Please return to the hospital if you develop any of the
following symptoms: fevers, chills, sputum production. Please
also follow up with your primary care physician regarding your
recent gastrointestinal bleed. | ___ h/o PUD, HTN, asthma presents with LUL pneumonia and gout
flair.
.
# LUL PNEUMONIA: He presented with one week cough, sputum
production, and feve. This is likely hospital acquired pneumonia
as he was recently admitted to the ICU. There is also concern
for aspiration pneumonia, however this is less likely in the
left upper lung fields. Most likely organism is Streptococcus,
although drug-resistant organisms also possible given history of
hospitalization. Gram negatives and anaerobes possible with
history of cough and possible aspiration. He was given Vanc /
levo / flagyl in the ED, and received Vanc/cefepime on the
floor. CURB-65 score = 1 (age >= ___). His symptoms improved, and
he was discharged on ciprofloxacin 750mg x 7 days.
.
# RIGHT TOE PAIN: presentation consistent with gout. He has a
positive family history, and recently ate two lobsters the
previous night. He was treated with colchicine 1.2mg with 0.6mg
1 hr afterwards in the ED, and discharged on 0.6mg daily. NSAIDs
were avoided given recent GIB, and steroids were avoided given
his pneumonia.
. | 146 | 174 |
12274603-DS-13 | 26,771,831 | Dear Mr ___,
You were admitted to ___ after you were found
to be confused. We believe that this is related to a growth in
your brain (meningioma) and that you might have had a seizure.
You were started on a medication and was not confused for the
rest of the hospitalization. Please make sure to continue taking
your medications and go to your doctors ___, which are
listed below.
It was a pleasure taking care of you!
Your ___ Team | ___ yom with history of MVA in ___ c/b central cord syndrome and
meningioma who presents with altered mental status, nausea,
vomiting, now asymptomatic.
# Meningioma
# Altered mental status
# ?Seizure
Patient presented with new onset confusion, headache, nausea and
vomiting in the setting of known meningioma. He was started on
keppra BID in the ED per neurology/neurosurgery. Possible that
this is related to seizure triggered by meningioma. Infectious
workup negative. 24 EEG was negative for seizures. Imaging with
CT and MRI show a meningioma that is intervally larger than last
imaging in ___ without evidence of active bleed. Patient will
follow up with neurology and neurosurgery.
# Indirect hyperbilirubinemia: Noted on admission labs.
Hemolysis labs negative. Asymptomatic. Likely ___.
# S/P MVA c/b central cord syndrome:
- Continued baclofen
- Continued docusate | 79 | 128 |
11745685-DS-19 | 26,101,361 | You were admitted on ___ for observation/treatment of a
left chest/breast cellulitis. Please follow these discharge
instructions:
.
-Continue to monitor your right breast area for continued
improvement. If the redness and swelling increase, please call
the doctor's office to report this.
-Should you have fevers and chills, please call the doctor's
office immediately to report.
-Continue both your antibiotics until they are finished. You
have a prescription for 14 days of each antibiotic.
-Since you are on two antibiotics for an extended period of
time, you should try to eat yogurt daily to replace the 'good'
bacteria in your intestinal tract. You should also purchase an
over the counter 'Probiotic' as a supplement choice. This will
help re-populate your gut/intestines with 'friendly' bacteria
while you are taking antibiotics.
-you have been given a prescription for 'diflucan' which treats
vaginal yeast infections. You are at risk for this because of
the antibiotic treatment. Take this only if needed.
-If you start to experience excessive diarrhea, please call the
doctor's office immediately to report this.
-Do not overexert yourself and no strenuous exercise for now.
-You may take either tylenol or advil (ibuprofen) for your
discomfort. Take as directed. | The patient was admitted to the plastic surgery service on
___ for observation and treatment of right breast
cellulitis. She was sent for an ultrasound to assess for fluid
collection upon admission. This showed a small collection of
fluid interposed between the subcutaneous soft tissues and
saline implant in addition to a small area of edema/phlegmon
located near the nipple. By hospital day #4, right breast
showed good improvement including a decrease in erythema,
swelling and tenderness. Patient was sent for a follow up
ultrasound on day of discharge which demonstrated decreased
fluid. At the time of discharge on hospital day #4, the patient
was doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The right breast with a small lateral area
of erythema close to axilla, minimal tenderness and minimal
swelling. She was discharged home to complete a course of
augmentin and ciprofloxacin. She will follow up in clinic for a
post-hospitalization visit. | 199 | 171 |
18556017-DS-50 | 28,231,639 | ================================================
Discharge Worksheet
================================================
Dear Ms. ___,
WHY WERE YOU ADMITTED?
-You came to ___ because you were having fever and pelvic
pain.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
-You were found to have a urinary tract infection and was
started on antibiotics.
Your infection was resistant to a number of antibiotics.
You were evaluated by the infectious disease team with the plan
to go home on ertapenem to complete your antibiotic treatment.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please be sure to attend your follow up appointments (see
below)
- Please take all of your medications as prescribed (see below).
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ female with Type 1 DM on insulin
pump, ESRD s/p renal transplant x2 (LURT ___ most recently),
recurrent UTIs who was recently admitted for MDR Klebsiella UTI
(completed 14 day course of ertapenem no ___ who re-presented
with fevers and pelvic pressure concerning for UTI. Given
history of prior multidrug-resistant urinary tract infection,
she was started empirically on meropenem. Urinalysis and urine
culture demonstrated infection. Culture speciated as
multidrug-resistant Klebsiella with similar isolate from prior.
Infectious disease evaluated the patient. Ultimately, the
patient was discharged home with services on a course of
ertapenem for total antibiotic course of 21 days (last day
___. | 133 | 109 |
11106524-DS-14 | 25,042,058 | Dear Mr. ___,
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management
of your left arm pain and swelling.
Here we managed your pain, took xrays of your wrist and elbow,
and attempted to get a sample of fluid from your wrist to
analyze. We also had the orthopedic and rheumatology doctors ___
___ you were here. Given your history your pain was most
likely due to a gout flare. We started you on prednisone that
you will taper over the next several days. Your blood sugars
have been higher due to the prednisone so you may require
additional insulin while you are taking it. We were concerned
when you first arrived that you may have had some infection in
your arm as well so you were treated with antibiotics but we did
not think they were necessary any longer. You also had your
normally scheduled hemodialysis while here.
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 pain, 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 pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain 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. | # Left upper extremity swelling: Most likely gout flare. Pain
began almost immediately after blood pressure cuff was cycling
on left arm ___ but was intermittent with inflation, swelling
developed gradually and pain is now almost constant. Swelling
concerning for upper extremity DVT, but LUE u/s with no evidence
of DVT. Cellulitis could be another possibility given warmth and
erythema, lack of response to cefazolin makes less likely but
organism may not be sensitive. Problems within the joint itself
are also possible. He has a history of gout with recent flare 2
months ago in bilateral knees (still on no medical management),
as well as history of bilateral swelling in elbows years ago
that resolved on its own, plus severe pain make a gout flare a
more likely possibility. After review of his stays here, he was
actually seen by rheumatology inpatient in ___ - his uric acid
was 7.2, inflammatory markers were elevated with ESR 85 and CRP
196.3; his knee was tapped and showed uric acid crystals, he was
started on prednisone 20 and noted significant improvement with
plan to taper the steroids by 5mg every 3 days with rheumatology
follow up. Septic joint should also be considered although
unlikely given involvement of multiple joints, fingers,
afebrile, no leukocytosis. Could also be nerve damage ___ trauma
of blood pressure cuff. Ortho unable to tap joint but agree that
gout is most likely.
- cont pred taper
- send RF, CCP
- rheum recs appreciated- will follow up as outpatient
- pain control
- hold abx
# CKD/HD: Currently on HD on a ___ schedule, followed by Dr.
___ at ___. His admission creatinine at 1.9 is
actually the best it's been in our system. Has a peritoneal
___ placed recently for anticipated PD in the near future,
not currently on PD.
- monitor creatinine
- continue nephrocaps 1 cap daily
- renal following
# Diabetes: now on prednisone.
- increase Lantus to 10u QHS
- QADHS finger sticks
- HISS while inhouse
# CAD:
- continue ASA 325, prasugrel 10mg, metoprolol tartrate 12.5
BID, atorvastatin 80
# HTN:
- monitor pressures
- continue home metoprolol tartrate 12.5 BID
#HLD:
- continue atorvastatin 80 daily
#OSA:
- CPAP overnight
# FEN: IVFs / replete lytes prn / regular diet
# PPX: heparin sq, bowel regimen
# ACCESS: PIV
# CODE STATUS: Full
# CONTACT: ___ (wife) - ___ | 323 | 372 |
19537959-DS-15 | 23,315,659 | Dear Mr. ___,
You were admitted for being confused and having fevers. You
needed to go to the intensive care unit, where you got better
with antibiotics and Lasix for too much fluid. When you were on
the regular floor we concentrated on getting you able to eat.
You still are at a high risk for "aspiration" or food going down
the windpipe. Take it easy when you eat.
You will need to continue on warfarin for stroke prevention.
Please get your INR checked on ___
While you were here we discussed with your wife about hospice
care. She will meet with some people at your facility about if
you would benefit from it.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you at ___. We wish you well
--Your Team at ___ | Mr. ___ is an ___ yo M w/ h/o CAD, PAD, afib on warfarin,
complete heart block s/p PPM, HFrEF (LVEF= 40 % on ___,
severe AS, DMII, vascular dementia who presented with fevers and
altered mental status requiring MICU transfer for respiratory
distress.
BRIEF HOSPITAL COURSE
# Respiratory distress: Pt with tachypnea to the ___ and
increased work of breathing after arrival to medical floor from
ED where he was mid ___ on RA. Concern was for pulmonary edema
in the setting of receiving a fluid bolus with his known severe
aortic stenosis. Patient received Lasix on arrival to the MICU
with good response, also started on broad spectrum antibiotics
for concern for HCAP. Patient was noted to have intermittent
___ Stokes breathing (RR ___ while sleeping. He continued
to receive intermittent Lasix boluses to maintain net negative
fluid balance. He completed an 5 day course of azithromycin and
8 day course of cefepime in hospital. His volume status was
maintained on 40 mg furosemide. Lasix was held the day of
discharge given hypernatremia, with instructions for the rehab
facility to assess volume status daily and add back ___ PO
Lasix prn to maintain euvolemia.
#Severe sepsis ___ Hospital Acquired Pneumonia: Patient
presented with altered mental status, fever, hypotension
responsive to fluid, leukocytosis, and elevated lactate. Likely
source thought to be pulmonary given patchy capacities on CXR
and cough. Less likely foot ulcer since no significant swelling
or major erythema on exam, no evidence of osteomyelitis on
x-ray. Patient ruled out for flu on admission. Blood, urine
cultures were negative, negative urine legionella antigen. He
was treated broadly Vancomycin/Cefepime/Azithromycin. Vanc d/c'e
after nasal MRSA negative. Patient finished 5 day course of
azithromycin (___) and eight day course of cefepime (___)
with resolution of fever and leukocytosis.
# ___ on CKD III: Creatinine elevated at admission, 2, compared
to a baseline of 1. likely due to congestion in the setting of
heart failure exacerbation. Resolved with diuresis.
# Chronic systolic heart failure: BNP elevated to 20,000 on
admission. TTE showed depressed EF, exam overall concerning for
worsening congestive heart failure. His Metoprolol and
diuretics were held initially in the setting of severe sepsis as
above. Patient restarted on low dose metoprolol 6.25mg BID. Home
Lasix were restarted at 40mg PO daily but held on discharge in
the setting of hypernatremia.
# Hypernatremia. Na was moderately elevated in the setting of
poor PO intake secondary to advanced dementia. Na downtrended
with D5 infusion and increased PO intake. Home Lasix was held on
the day of discharge in the setting of mild hypernatremia, with
instructions to the rehab facility to encourage PO intake,
assess volume status daily and recheck Na in 2 days to trend.
# Dysphagia/Aspiration Risk: Patient evaluated by speech and
swallow team. Patient with oropharyngeal dysphagia as
characterized by overt s/sx of aspiration with all trialed
consistencies, even when alert. Discussed with family. At this
time not within the patient's goals of care to have feeding tube
or G-tube. Given evidence of nutritional deficiency, and likely
chronic progressive nature of dysphagia as a result of the
patient's advanced dementia, patient trialed on pureed solids
and honey thick liquids. Repeat SS evaluation showed improvement
and he was discharge on diet of puree and thin liquids with
ensure supplementation TID.
# Goals of care: Goals of care discussed in MICU with attending
and patient's wife, ___ conversations continued on the floor.
Due to patient's significant decrease in QOL past 6 months, wife
confirms DNR/DNI, and advises against any advanced procedures
such as valvuloplasty, he should not have any feeding tubes,
G-tube or NGT. Met with patient and palliative care, and she is
interested in learning more about hospice care. She will meet
with a hospice liason at ___ to continue discussions regarding
home hospice. She filled out a MOLST form during this admission,
confirmed DNR/DNI, with permission for BiPAP, and permission to
transfer to hospital. She does not want any prolonging
procedures such as artificial feeding or advanced procedures.
==============
Chronic Issues
==============
# HLD: Continued home Atorvastatin.
# Thrombocytopenia: Chronic, dating back more than ___ years.
Spleen uremarkable on imaging ___ years ago. Not significantly
different from recent baseline.
# Anemia: Normocytic anemia, likely anemia of chronic disease.
No evidence of bleeding this admission.
# Severe AS: Valve area last noted to be 0.8cm2. Repeat ECHO
this admission with mean AV gradient of 60mm Hg suggesting
severe AS. Cardiology was consulted this admission for concern
that worsening heart failure was contributing to his respiratory
failure. Patient again was not thought to be TAVR candidate
given his goals of care. He was not thought to be in such
decompensated heart failure to require more urgent aortic
valvuloplasty.
# PAD s/p multiple bypass surgeries: Left lower extremity ulcers
seem stable per family, no signs of acute infection. Required
CVL placement for venous access given very difficult peripheral
veins and prior procedures.
# COPD: Patient has nocturnal oxygen requirement at baseline per
prior records. He continued Advair, Spiriva and prn Albuterol
this admission.
# Atrial fibrillation on warfarin: Patient on admission had
therapeutic INR, subsequently became supratherapeutic requiring
reversal with Vit K. He was restarted on home warfarin dosing
8mg and discharge without a heparin gtt as this was not within
the GOC per the wife with INR follow up in the rehab facility.
# Dementia with depression: Patient was continued on Bupropion.
He was noted to have difficulty with swallowing pills, concern
for aspiration. Patient was seen by speech and swallow who were
concerned for aspiration (as above). He remained AOx1 per his
baseline.
# Diabetes Mellitus Type II: Oral hypoglycemics were held on
admission. He was on insulin sliding scale this admission, with
frequent blood sugars in the 200-300 range. He was started on
Glargine 12 units QHS with HISS, which was continued on
discharge to rehab. Home glipizide was not restarted.
===================
Transitional Issues
===================
Cardiology
- Discharge weight: 72kg
- Discharge Cr: 1.0
- Diuretics: Home Lasix 40mg HELD on discharge given
Hypernatremia. Please assess volume status daily and consider
restarting Lasix 20mg daily prn for volume overload. If weight
increases by more than 3 lbs in 3 days, contact Cardiologist Dr.
___ ___
- Medication changes: Metoprolol decreased to 6.25mg tartrate
daily
- Follow up appointment with Cardiology (scheduled)
- Follow up appointment with device clinic for pacemaker (call
to arrange if needed)
Anticoagulation
- Next INR to be checked on ___ at rehab
- Current warfarin dosing 8mg daily with goal INR ___
- Bridging with heparin gtt not within GOC per discussions with
wife
___
- ___ with 12 units Glargine qHS and Humalog ISS with
meals. Please continue to assess blood sugar control and
consider transitioning back to home glipizide as appropriate
Hypernatremia
- Na 147 on discharge likely ___ poor PO intake and ongoing
diuresis. Please recheck Na on ___ to trend and continue to
encourage PO intake.
Goals of Care
- Continue ongoing discussions regarding home hospice with wife
# Communication: HCP: ___ (Wife) ___
# Code: DNR/DNI confirmed. No transfer of care to ICU for
aspiration. Ok for non invasive BiPAP | 141 | 1,200 |
15565649-DS-2 | 27,124,586 | You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures or staples along your incision dry
until they are removed.
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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | On ___, the patient was consulted by Neurosurgery for an
incidental finding of a large left SDH with midline shift. He
was taken to the OR for a left craniotomy and evacuation of ___.
He underwent a post op NCHCT that revealed expecetd
postoperative changes with pneumocephalas. For treatment of
pneumocephalus, he was placed on 100% oxygen via a
non-rebreather mask. The subdural drain was leveled at the hip.
On ___, the patient's neurological exam was stable. His
subdural drain output was 125cc in 24 hours and 42cc from
midnight.
On ___, the patient's neurological exam remained stable. His
subdural drain output was 1.5cc overnight, and therefore was
removed. Repeat NCHCT showed a stable appearance of his known
subdural hematoma status post evacuation with continued residual
hemorrhage, layering fluid, and expected pneumocephalus with
interval drain removal and no new hemorrhage or infarct. He was
transferred to the floor.
On ___ Patient was neurologically intact. He was tolerating an
advanced diet. He was evaluated by physical therapy who
recommended he remain in the hospital for ___ more evaluations
prior to discharge.
On ___ He remained stable. He again worked with physical
therapy.
On ___, physical therapy cleared the patient for discharge home
with home ___. | 591 | 204 |
19149780-DS-20 | 21,633,693 | Dear Mr. ___,
You were hospitalized due to symptoms of unsteadiness and
difficultly walking resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms. The part of your brain that
was affected is called the cerebellum and that is responsible
for making coordinated movements on the left of your body.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Diabetes (your metformin was not given while you were in
hospital but it can be resumed after discharge)
- High blood pressure (we replaced your chlorthalidone and
losartan with amlodipine)
We are changing your medications as follows:
START ASA 81 daily
START Atorvastatin 40 mg daily
START Amlodipine 5 daily to increase with your primary care
doctor
___ STOPPED your chlorthalidone and valsartan as your kidney
recovers; these are replaced by amlodipine
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
You had a mild and temporary impairment in your kidney function
while you were here which seems to have been from dehydration
and returned to normal by time of discharge.
Sincerely,
Your ___ Neurology Team | Patient was admitted with new onset dysequilibrium. MRI revealed
a left
___ territory cerebellar infarct. His examination initially
showed direction changing nystagmus, a subtle left Horner
syndrome and a left hemiataxia. Exam improved during hospital
stay and Physical therapy cleared him for home. CTA did not
reveal dissection or intracranial atherosclerosis. TTE was
normal; telemetry did not capture any atrial fibrillation, so he
was discharged on ___ of hearts for paroxysmal afib. Given
there was no clear source, may consider hypercoagulability
studies as outpatient ___ unrevealing. His home medications
were changed to inclue ASA 81, amlodipine 5 and atorvastatin 40.
Hospital course c/b pre-renal ___ with positive orthostatics
that was responsive to fluid resuscitation. He improved to
discharge home. | 375 | 120 |
18858092-DS-10 | 29,872,244 | Dear Ms. ___,
You were admitted to the hospital because your left elbow was
red and infected. Fluid from your elbow collected by Dr. ___
___ an organism that has not yet been identified but looks most
similar to M. abscessus, which was the cause of your previous
arm infections. You were evaluated by the Infectious Disease
doctors ___. You were given IV antibiotics
(Tigecycline and Imipenem) and you underwent an uncomplicated
left elbow bursectomy on ___. You are being discharged with
IV Tigecycline and Imipenem and will follow up with Dr. ___
in ___ clinic to determine the course of your antibiotics.
Here are the instructions for your elbow wound care:
Elbow Wound Care:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week orthopedic surgery follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left upper extremity. Gentle range
of motion while incision heals.
We also found that you had low IgG levels. This is an antibody
produced by B cells and your low levels are most likely caused
by the immunosuppression that you need for your vasculitis. Dr.
___ you follow up with an ___
doctor, so you will see Dr. ___ in clinic.
Please continue to follow up with your outpatient providers.
It was a pleasure to take care of you during your hospital stay.
We wish you a speedy recovery,
Your ___ Team | ___ with pANCA-positive GPA (Wegner's) vasculitis on Cellcept
(1.5g/day) and methylpred (4mg BID) and with history of
extensive UE M. abscessus infection who was admitted for
management of her left elbow bursitis with culture positive for
acid fast bacilli. She is s/p uncomplicated left elbow
bursectomy ___ by Orthopedic Surgery. She is currently doing
well and being discharged home with continuation of IV imipenem
and IV tigecycline.
# LEFT ELBOW BURSITIS: The patient was admitted with warm,
erythematous, and edematous left elbow bursitis, likely
secondary to M. abscessus infection. She was started on empiric
treatment with IV tigecycline and imipenem, but she did not show
clear clinical improvement over several days. She then PICC line
placement ___ by ___ and left elbow bursectomy on ___ by
orthopedic surgery for source control. Bursa tissue and fluid
were sent to Micro and Pathology for analysis, reports pending
at the time of discharge. The patient maintianed good active
range of motion without elbow pain and without concern for
sepsis or septic arthritis while inpatient. She was also
maintained on Nystatin swish and spit while on antibiotics. She
is being discharged home on empiric treatment of M. abscessus
based on previous sensitivity data in ___. She will continue IV
Tigecycline 50mg Q12H and Imipenem 1g Q8H (day 1 = ___ via
her PICC line with close followup with Infectious Disease.
Pathology and microbiology of left elbow bursa fluid and tissue
should be followed up by Infectious Disease. She will also
follow up with Orthopedic Surgery for her status post
bursectomy.
# FEVER: She spiked to 100.7 on ___ overnight but afebrile
since then. Most likely not secondary to left elbow bursitis but
more likely secondary to atelectasis seen on CXR on ___.
# HYPO IGG: The patient was found to have low IgG level this
admission (<500), similar to prior. Hypogammaglobulinemia is
likely secondary to immunosuppression from Cellcept and previous
cyclophosphamide. ID Dr. ___ that the patient
follow up with Dr. ___ as outpatient an
outpatient to work this up and evaluate the need for IVIG.
# DIABETES MELLITUS TYPE II STEROID-INDUCED: Well-controlled
insulin-dependent diabetes with A1C 7.8 ___. The patient's
lantus was downtitrated while inpatient due to decrease PO
intake and being NPO for procedure. She will be discharged on
her home insulin regimen.
# GPA VASCULITIS: Currently, the patient's symptoms are
well-controlled on Cellcept and methylpred. She was continued on
Cellcept at home dosing 500mg PO TID and per Dr. ___
(___), tapered her methylprednisone from 6mg to 4mg PO
BID on ___. She continued home omeprazole 20mg daily while on
steroids.
# LEFT SKIN TEAR: On admission, the patient had a small skin
tear secondary to trauma on her left forearm. This at first
looked red and slightly edematous but resolved after leaving the
wound open to air.
# ALLERGIC RHINITIS: Continued home Flonase.
# ELEVATED LACTATE: Resolved after 1L NS.
TRANSITIONAL ISSUES
# LEFT ELBOW BURSITIS: Most likely secondary to M. abscessus
infection. The patient is s/p uncomplicated left elbow
bursectomy by Orthopedic Surgery. She is being discharged home
on empiric treatment of M. abscessus based on previous
sensitivity data in ___. She will continue IV Tigecycline 50mg
Q12H and Imipenem 1g Q8H (day 1 = ___ with close followup
with Infectious Disease. Pathology and microbiology of left
elbow bursa fluid and tissue from the bursectomy are pending on
discharge. She will also follow up with Orthopedic Surgery for
her status post bursectomy. | 247 | 566 |
13317548-DS-3 | 26,696,539 | Dear ___,
It was a pleasure in taking care of you at ___
___ in ___. You presented with to
the ED with abdominal pain, where your nausea and pain were
treated with medications appropriately. Imaging
(Abdominal/Pelvic CT scans and pelvic ultrasound) and laboratory
tests ruled out more potentially serious diagnoses, but could
not identify a specific cause. The gynecological team was
consulted and they concluded that your present pain is not
gynecologic in nature. As your pain and nausea are currently
controlled, you are being discharged from the hospital with
outpatient follow-up:
You are scheduled for an appointment with Dr. ___ at ___
___ and with your primary care provider.
You were also told during this admission that an incidental
liver lesion was found during your Abdominal/Pelvic CT scan,
which could represent a benign process known as focal nodular
hyperplasia. It may be associated with OCP (birth control) use,
but current recommendations do not suggest stopping OCPs for
this reason. Please follow up with your PCP for an outpatient
MRI study to better characterize the lesion.
Medication changes:
1) Recommend that you take Tylenol (no more than 3 grams/day)
and Ibuprofen for pain control.
2) The gynecological physicians recommended that you take your
OCP (birth control) continuously, skipping the placebo (sugar
pill) week. | In the ___ emergency department, the patient's normal
laboratory values (negative hcG, normal Chem 7, CBC with diff,
LFTs, Lipase, UA) and unremarkable abdominal/pelvic CT imaging
ruled out more acute diagnoses (ectopic pregnancy, appendicitis,
pancreatitis, nephrolithiasis, pyelonephritis) and the patient's
pain was managed appropriately with dilaudid and toradol and her
nausea with zofran. On admission to the floor, the patient's
nausea worsened and was accompanied by more emesis than she had
at home, attributed to dilaudid, which was discontinued.
Patient's pain was adequately controlled with around the clock
tylenol (not in excess of 3 grams/day) and toradol. The patient
rapidly improved with conservative management and was able to
tolerate regular meals with no nausea and minimal residual
abdominal pain. H. pylori serology came back negative. Because
of the relation of her abdominal pain to her dysmenorrhea and
menorrhagia, GYN was consulted for a potential diagnosis of
endometriosis. The GYN team did not think her abdominal pain was
GYN in nature and recommended that she (a) continue her OCPs
continuously, skipping the placebo week (b) receive CT/NG
testing (c) receive a pelvic ultrasound (d) follow-up with Dr.
___ on an outpatient GYN basis. CT/NG testing and pelvic
ultrasound were all unremarkable. The patient's final diagnosis
is abdominal pain of unclear etiology, though endometriosis
remains possible. On discharge, the patient complained of
minimal abdominal pain and was tolerating a regular diet. She
was given prescriptions of tylenol and ibuprofen. She was to
follow-up with several outpatient appointments that had been
made for her - her primary care physician at ___
(and to see whether she needed a GI physician referral from her
PCP) and Dr. ___.
The patient was also informed of an incidental finding on her
Abdominal/Pelvic CT: left hepatic lobe 2.5cm of "focal nodular
hyperplasia". The benign nature of this potential diagnosis, its
potential relationship with OCP use (though current
recommendations do not warrant discontinuation of OCPs for this
reason), and the need for outpatient MRI imaging as follow-up
were all discussed with the patient, who verbally consented her
agreement and understanding. | 208 | 342 |
19097239-DS-20 | 21,154,269 | Dear Mr. ___,
It was a pleasure taking care of you during this admission.
You were admitted because you had chest pain. You had changes on
your EKG and labwork that was consistent with a heart attack.
You got a test that showed you had diffuse coronary artery
disease which could not be treated with stents. Therefore, we
treated you with medications. We also found on an ultrasound
that you have a hardened aortic valve that could be worsening
your heart failure. You and your family determined that they did
not want any surgical correction of this valve at this time.
This option is still available for discussion, should you change
your mind. You can always talk with your cardiologist about your
options. You also had some mild fluid overload and a fever which
we treated with some diuretics to help get the extra fluid off
and antibiotics. We determined that it was safe for you to
continue your normal diet and that you might need a study in the
future to determine how you swallow. Please continue to take all
of your medications and keep your follow-up appointments.
Best,
The ___ Cardiology Clinic | Mr. ___ is a ___ with PMH of AS, sCHF, HTN/HLD/DMII who
presented with ischemic EKG changes and elevated cardiac enzymes
concerning for NSTEMI, s/p cath being medically managed and
declines TAVR.
# NSTEMI: Mr. ___ presentation was concerning for diffuse
ischemia from 3-v disease vs. AS vs. left main disease. Given
his history, age, and functional status, goals of care were
clarified and patient/HCP agreed to undergo cardiac
catheterization. He was medically managed with ASA, s/p Plavix
load 300mg (given low probability of surgical intervention
despite high probability of 3 vessel disease), hep gtt and pain
control. Trops were elevated. Cardiac cath with diffuse disease,
not amendable to PCI, so treated medically. Patient/family
declined TAVR. He was maintained on ASA/plavix, and metoprolol
25mg BID.
#Cough/CAP: Patient with cough productive of thinnish, yellow
mucus. He also had evidence of worsening pulmonary edema on CXR
which could likely be related to acute decrease in EF compared
to prior in the setting of recent NSTEMI and diffuse coronary
disease. Concern for superimposed infectious process given newly
productive cough, increasing leukocytosis, borderline temps. CXR
without clear infiltration, but clinical symptoms concerning. He
was started on Levaquin 750mg q48h (renally dosed) d1: ___
for 5 days. He also received IV diuresis with good effect.
Speech and swallow was consulted and did not reccomend any
changes to his diet therapeutically, however they did mention
that a barium swallow may help determine if there is any risk
for postprandial aspiration.
# AS: Patient with known history of AS, prior echo from approx ___
years ago when valve area was listed as 1-1.2cm. Echo from ___
showing severe aortic stenosis with valve area of 0.8-1cm.
Physical exam with appreciable systolic murmur. His AS could be
exacerbating his diffuse ischemic disease. Patient is not a
surgical candidate, but could be considered for possible TAVR,
however patient and family declined. Paient should avoid
nitroglycerin gtt given decrease in preload.
# new systolic heart failure: Patient with EF last of >60% on
echo a number of years ago. Echo this admission with EF 35-40%,
a notable decrease in function most likely ___ NSTEMI. Appeared
fluid overloaded with some trace ___ edema and congested lung
exam, and received increase in Lasix to 40mg IV with moderate
result, although difficult to tell given incontinence. He was
placed on Lasix gtt briefly overnight with good result, however
Cr uptrending and gtt was discontinued. Diuresed to dry weight
of 59.7kg on discharge. Restarted home dose 20mg daily. He
should be weighed daily and lasix dose adjusted accordingly.
# CKD: Unclear what stage. Cr on admission 1.9. Currently
uptrending given attempt at more aggressive diuresis to 2.5.
Will hold further aggressive diuresis and restart home regimen
for goal of net even.
# HTN: Patient with SBP in 140s on arrival to floor. Concern for
worsening AS, should hold medications that could reduce preload.
Discontinued lisinopril, restart home lasix and increase
metoprolol to 25mg BID for tachycardia.
# HLD: Chronic. Stable. Transitioned to atorvastatin 80mg daily
from simvastatin.
# Depression: Chronic. Stable. Continued mirtazapine.
# Prostate Cancer: Chronic. Continued Bicalutamide daily.
# Bladder cancer: Chronic. Localized.
# Chronic pain: Patient with significant spinal stenosis that
causes back and lower extremity pain. Chronic opiate user.
Continued fentanyl patch q72h. Held home gabapentin and vicodin
while in-house.
# History of questionable flu exposure: Some positive and
confirmed cases of flu from patient's nursing home. He did have
a cough, although this is somewhat chronic per family. Patient
denies muscle aches and fevers. Flu negative. | 194 | 589 |
19871967-DS-15 | 24,301,152 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because you had pain in your hip. You
were also found to have extra fluid in your legs and body
because of your heart failure.
WHAT HAPPENED IN THE HOSPITAL?
- You were given medications to reduce swelling in your hip and
hands and to help with your pain. You were also given
medications to help remove extra fluid from your body and help
reduce your leg swelling. You received an MRI to look at your
hip and an echocardiogram to look at your heart.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- Your dry weight is 129 pounds (this is a bed weight). Weigh
yourself every morning, call your doctor if your weight goes up
more than 3 lbs.
- You should take all of your other medications as prescribed.
We wish you the best!
Your ___ Care Team | PATIENT SUMMARY STATEMENT FOR ADMISSION
==========================================
___ female with past medical history significant for
CVA, rheumatoid arthritis, on warfarin presents with lateral hip
pain w/overlying skin hyperpigmentation, anasarca, bilateral
pleural effusions on CXR, inspiratory crackles, and microcytic
anemia. Her clinical picture was consistent with a RA flare. She
was activity diuresis and was seen by rheumatology who increased
her prednisone, restarted MTX and plans to initiate a biologic.
She was also found to have interval worsening in her aortic
stenosis from moderate to severe, but denied any symptoms. She
was discharge to a rehab facility for further strengthening.
ACUTE MEDICAL/SURGICAL ISSUES ADDRESSED
==========================================
#Lateral Hip pain with difficulty moving legs
#Migratory joint pain in hands, rights, and arms
The patient has been experiencing chronic hip pain for over a
year, but presented with an acute increase in R hip pain that
prevented her from walking. Her pain is likely multifactorial in
origin. Xray showed chronic degenerative changes, likely due to
osteoarthritis. Patient also has a history of rheumatoid
arthritis, which may be contributing, and she was found to be
having an RA flare. She had point tenderness on exam, which may
also be indicative of trochanteric bursitis. Additionally,
patient has significant volume overload on exam in the setting
of holding Lasix. This extra weight on her legs was likely also
contributing to her pain. Patient was diuresed with IV Lasix
120mg IV BID to reduce volume overload and leg swelling.
Rheumatology was consulted to assess for an RA flare in the
setting of shooting pains in the hands and legs and recommended
increasing prednisone to 20 mg daily. Steroid injection for
trochanteric bursitis was also considered, but may be performed
in the outpatient setting if symptoms persist after further RA
treatment. Geriatrics was also consulted and provided
recommendations about ways to improve mobility and day to day
function at home. For symptomatic pain relief, the patient
received lidocaine patches and ointment, as well as Dilaudid 0.5
mg q8h PO PRN. Rheumatology recommended outpatient follow-up
with possibility of starting another medication, such as
rituximab, to optimize her RA control. She was discharged home
with methotrexate 12.5mg daily ___ and plan to follow-up
with rheumatology as an outpatient
#Acute on Chronic HFrEF
Decompensated heart failure with volume overload in the setting
of holding diuretics. Her BNP on admission was ___. Her last
echo in ___ showed EF of ___ and repeat echo during this
admission showed stable EF with progression to severe aortic
stenosis. To reduce volume overload she received 4 days of 120mg
IV Lasix BID. Over the hospitalization, her cumulative net fluid
balance was -4782 mL. Her home Atenolol 25 mg PO BID was
switched to Metoprolol Succinate XL 50 mg PO QHS. At discharge,
her leg swelling had markedly decreased and she was still
slightly volume up on discharge. She was started on torsemide
60mg to take daily at home and had scheduled follow-up with
cardiology.
#Microcytic anemia
Hemoglobin was 6.2 on admission without gross signs of bleeding.
She received 1 unit PRBC with an appropriate increase in her
hematocrit. Patient has a history of iron deficiency and anemia
of chronic inflammation, she's been on methotrexate, and history
of CKD may also be contributing. GI bleeding was also
considered, and stool guiac was positive. Additionally, given
patient's aortic stenosis, she may have ___ syndrome and GI
AVMs. At discharge, her hemoglobin was 9.1 and concern for brisk
GI bleed remained low.
#Seropositive RA
Patient had wide-spread joint pain during her stay, most notably
in her right hand, hip, shoulder and hands. Appeared to be
having an RA flare with increased pain. Rheumatology increased
prednisone to 20 mg initially, the 35mg daily. Because she did
not have further relief at the higher dose, she was again
deescalated to 20mg for discharge. She was also started on
omeprazole for ulcer prophylaxis with this. Based on geriatrics
recommendations, she received 0.5 mg q6h PRN PO Dilaudid for
pain. She was restarted on methotrexate 25mg (12.5mg BID on
___. Plan for rheumatology follow-up with possibility of
starting another medication or biologic on discharge.
#Hyperpigmentation on lateral thigh, may be early stage of
pressure ulcer. Monitored and did not progress.
#CXR with possible underlying PNA
Patient remained does not have cough, fever, and is satting 95%
on RA, making pneumonia unlikely. She did not require
antibiotics during this hospitalization.
CHRONIC ISSUES PERTINENT TO ADMISSION
======================================
#DVTs on warfarin, therapeutic INR
Continued 2mg daily warfarin.
#Bone Health
Continued high dose D, Fosamax.
TRANSITIONAL ISSUES
===================
# Patient has severe aortic stenosis but does not have symptoms
of dyspnea on exertion, angina, or syncope/pre-syncope. She
needs to be followed closely by cardiology and TTE should be
repeated in ___ months.
#Patient's RA is still not adequately managed. Her outpatient
rheumatologist is planning on starting her on a biologic for her
refractory symptoms as an outpatient. This should be arranged in
the coming days weeks, possibly while she is in rehab.
# Should there be any question of insurance coverage of her
medication for rheumatoid arthritis, please contact ___
___ (clinical pharmacist) for further information and
help with obtaining insurance coverage.
# Patients prednisone increased to 20 mg daily. Should it be
continued at this high a dose or higher for 30 days, she will
need to start PCP ___.
# Started on 0.5 mg PO Dilaudid q8h PRN for severe pain. Would
stop this if she has better symptomatic control of RA.
# Ensure daily bowel movement with narcotics
#Patient discharged on Torsemide 40 mg daily. At rehab, standing
weights should be obtained daily, if her weight is increasing by
3 pounds or more, torsemide should be increased to BID until
back to her original weight.
#Patient continues to have low H/H. CBCs should be obtained in
rehab and if signs of bleeding persist, would speak to patient
and family about goals of care with regard to pursuing
colonoscopy.
#Warfarin was increased to 2.5mg daily on ___ due to
subtherapeutic INR. Check INR on ___ to monitor for response.
#Restarting methotrexate on ___ and will need Chemistry,
BUN/Cr, LFTs, CRP/ESR in 2 weeks (___) and have these sent
to outpatient rheumatologist (fax ___
# Patient is currently full code, should her mobility and
functional status not improve, overall goals of care including
CPR and intubation in event of arrest should be further
discussed. These were broached, but ultimately it was decided
that patient make effort to improve quality of life with
aggressive medical treatment, should this not go well, plan was
to readdress goals and focus more exclusively on comfort and
remaining at home as long as possible.
NEW MEDICATIONS
================
DILAUDID 0.5MG QHS AND Q8H PRN SEVERE PAIN
OMEPRAZOLE 40MG DAILY
CHANGED MEDICATIONS
===================
TORSEMIDE 40MG DAILY
PREDNISONE 20MG
Warfarin 2.5 daily
HELD MEDICATIONS
=================
NONE
Code Status: Full confirmed | 160 | 1,095 |
12758388-DS-18 | 20,162,635 | Dear Ms. ___:
You were admitted to ___ for
septic shock. You were found to have both yeast and bacteria in
your blood stream as well as bacteria in your urine. You were
treated with broad antibiotics and antifungals intially, and
then narrowed to fluconazole for your fungemia and levofloxacin
for the bacteria in your blood (acinetobacter). Your urinary
infection was treated with 5 days of zosyn while you were in the
hospital. You will continue your course of levofloxacin and
fluconazole through ___.
While you were in the hospital, you were also given stress dose
steroids. These were gradually tapered down to your home dose.
The only addition to your home medications are the fluconazole
and levofloxacin. All other medications remain the same.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team | ___ woman with h/o ___ danlos, recurrent UTIs with
indwelling foley, addisons disease, chronic cystitis and UTIs
who is transferred from ___ with septic shock.
# Sepsis: Blood cultures at OSH positive for GPCs vs GPRs with
cultures here positive for yeast. TTE without evidence of
endocarditis and we await repeat blood cultures. She remains off
vasopressors and we continue vancomycin, pip-tazo and micafungin
pending final culture data. Given no diarrhea since admission we
will stop oral vancomycin. Ophthalmology was consulted and did
not see any evidence of ___ in the retina. The blood
cultures speciated to acinetobacter sensitive to levofloxacin
and ___ sensitive to fluconazole. She was transitioned to PO
regimens for a course from ___.
#Addisons: stress dose steroids were gradually tapered to her
home dose.
#UTI: speciated out to ESBL E coli, sensitive to zosyn. She was
treated for a 5day course of zosyn.
# Chronic pain / fibromyalgia
- cont fentanyl patch
- cont home dilaudid PO
# depression: cont home duloxetine
# htn: normotensive after ICU discharge. Her home metoprolol was
initially held given hypotension and was held while she was
normotensive. | 133 | 182 |
15533649-DS-10 | 29,728,210 | Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You are cleared by your neurosurgeon to resume Aspirin 5 days
after surgery. Please do NOT take any blood thinning medication
(Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction (7 days
total). It is important that you take this medication
consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | On ___, Ms. ___ was transferred to ___ ED from an
outside hospital with left acute on chronic subdural hematoma.
She was admitted to the neurosurgery floor for close neurologic
monitoring.
#SDH
Overnight on ___, she experienced an episode of mental status
change with symptoms of decreased speech and right arm weakness.
Keppra was increased to 750mg BID and she was given an
additional 250mg dose for concern for seizure and symptoms
improved. On ___, she had an episode where she was slumped over
with her mouth open wide and had tremors. On exam, she was
aphasic and hypotensive. She was given a fluid bolus and a
repeat NCHCT was obtained, which was stable. An EKG was
performed and revealed normal sinus rhythm. Symptoms resolved. A
CTA head/neck was completed, which showed no obvious vascular
abnormality but it did show a spiculated nodule in the right
upper lobe. Her Keppra dose was increased to 1 gm BID and
Dilantin was added. She was transferred to the ___. NeuroMed
was consulted (see below, no seizure activity on EEG). On ___
she went to the operating room for evacuation of the ___ with
Dr. ___. The surgery was completed without difficulty. A
subdural drain was in place. Please see operative report for
complete details regarding the procedure. Post-operatively, her
neuro exam was much improved. She was alert and oriented x 3 and
was much more conversant. Drain was removed on ___. Head CT on
___ was stable. She was re-evaluated by speech and swallow and
her diet was liberalized. She remained neurologically stable on
___ and was discharged to rehab.
#Fluctuating aphasia
Neurology was consulted for concern for seizure activity given
fluctuating aphasia. She continued to have recurrent episodes on
expressive aphaisa. EEG negative for seizures, so no clear
indication that the patient had seizures, but she was started
and discharged on Keppra 1000mg BID and Dilantin 100 mg TID for
prevention. Corrected Dilantin level was 17.3 on ___. Level
should continue to be monitored (with albumin) at rehab. She
will follow up with neurology in 2 months for further
management.
#Lung nodule
A 2.4 x 1.6 cm speculated nodule was incidentally found in the
right upper lobe on CTA. A CT chest/abdomen/pelvis was ordered
for workup. The CT chest revealed four nodules in the lung
concerning for bronchus carcinoma. She also has two liver
lesions that were suspicious for cysts vs. hemangioma. An
ultrasound of the liver was completed to further clarify these
lesions and revealed 1 cyst and 2 hemangiomas. A MRI Brain
showed no evidence of metastatic lesions. Hem/onc was consulted
for further recommendations. She was seen by Dr. ___
indicated that further workup would be done on an outpatient
basis and will need biopsy for tissue diagnosis. She will need
follow up in thoracic ___ clinic (office
notified).
#Afib
H/o afib on aspirin at home. Aspirin was held given SDH and
surgery. She is cleared to resume on POD#5 per neurosurgeon. | 607 | 491 |
18664755-DS-21 | 20,519,074 | Dear Mr ___,
You were originally brought to the hospital because you lost
consiouness and fell down a flight of stairs. You were intubated
and placed on breathing machines to protect your airway as it
appeared you had difficulty breathing. You were evaluated for
stroke, heart problems, and pneumonia, but we could not
identintify a source. As your clinical condition continued to
improve you were taken off the breathing machines and transfered
to the hospital floor. There, you continued to do well and were
not dizzy.
You will be sent home off your blood pressure medications as we
believe they may have contributed to your dizziness. Please call
your primary care phsycian and schedule a folow up appointment
within two weeks.
It was a pleasure taking care of you!
Your ___ Care Team | ACUTE ISSUES
# Altered mental status s/p head injury: Patient presented to
the MICU intubated and sedated with fentanyl and versed.
Etiology of altered mental status most likely associated with
etiology of syncope. Negative serum drug screen and urine drugs
screen (+) benzos in the setting of receiving versed/ativan
makes toxic etiology less likely. Infectious work-up pending;
however patient was afebrile with only a mild leukocytosis at
the OSH making infection also less likely. Overnight, the
patient tolerated discontinuation of his sedation. He was able
to be successfully extubated on ___. He was evaluated by who
cleared his c-spine.
# Syncope: differential includes hypotension in the setting of
new BP meds vs poor po intake vs cardiac etiology vs vertigo in
setting of instability x 1 week. His troponins were negative on
admission. His home blood pressure medications were held.
Workup including echo were negative for causal factors.
# Hypotension: differential includes over-correction by new BP
meds vs poor po intake. Upon transfer to ___ the patient's
peripheral levophed was discontinued. His blood pressure
remained stable in the 140s/80s with MAP>65. Upon transfer to
the floor, patient's pressures remained within normal limits.
Anti-hpertensives held at time of discharge.
# Questionable PNA: Per OSH, CT chest was concerning for RLQ
infiltrate. Differential diagnosis includes aspiration PNA in
the setting of nausea/vomiting after fall vs aspiration
pneumonitis vs infectious etiology. Patient received x1 dose
vancomycin/ceftriaxone in ED. Due to no obvious sign of
infection, antibiotics were not continued. | 132 | 244 |
10142844-DS-23 | 22,340,248 | Dear Ms. ___,
You were brought to the ___ after a fall
and you had an episode that was though to be a seizure in the
ED. You needed a breathing tube and were admitted to the
Intensive Care Unit for monitoring after this episode. You were
given a very long lasting medication to protect yourself against
features (phenobarbital).
Fortunately, you were able to come off the breathing machine and
had no further episodes.
Unfortunately, you chose to left the hospital against medical
advice.
You understood the risks of leaving and especially of drinking
alcohol while the medication (phenobarbital) is active in your
body which include:
- Death from not breathing
- Low blood pressure
- Coma
We urge you NOT TO DRINK ALCOHOL as this may be life threatening
while the medication (phenobarbital) is in your system
We urge you to MAKE AN APPOINTMENT WITH YOUR PRIMARY CARE
DOCTOR.
___ do not take BUPROPION (WELLBUTRIN) or FIORICET or
CLONAZEPAM as these have interactions with the phenobarbital
that stays in your system for days.
Please talk your doctor about restarting these medications
We wish you the best in health,
Your ___ Team | ___ with history of migraines/cluster HA, anxiety, EtOH use
disorder, depression and syncopal episode in ___ who was
brought to ___ ED by EMS after a witnessed syncopal episode
with headstrike, with progressive AMS and hypoxia requiring
intubation in the ED, admitted to ICU for syncope and hypoxia
workup, no evidence of arrhythmia, LV dysfunction, valvular
disease, further seizure activity on EEG. Patient was loaded
with phenobarbital and extubated. He chose to leave against
medical advice and demonstrated capacity to make this decision.
#POSSIBLE SEIZURES
#EtOH USE DISORDER
Witnessed syncope in the setting of drinking, with no obvious
seizure activity until possible clenching/gaze deviation the ED.
No known history of withdrawal seizures. Blood tox screen
negative except for EtOH; Utox only with benzo. Neg PE, neg trop
x2, neg CT head, TTE without obvious abnormality. Does have
history of head trauma more likely. Has syncopized in ___ (also
in setting of drinking)for which he was admitted to cardiology
here with negative extensive workup for malignant arrhythmia,
coronary pathology, or other etiology. On buproprion and
paroxetine can lower seizure threshold. CIWA 4. Phenobarb loaded
___. Patient left AMA ___. PCP was contacted and warm hand off
accomplished. Patient advised not to drink alcohol, take
bupropion or Fioricet or clonazepam given interactions with
phenobarbital.
#SYNCOPE
No evidence of arrhythmia, LV dysfunction or valvular disease.
Possibly due to withdrawal seizures. Orthostatic vital signs
were planned but patient left AMA.
#COFFEE GROUND EMESIS:
Coffee grounds coming up with OG, resolved with PPI, H/H stable,
tolerated regular diet after extubation. Discharged with script
for omeprazole 20mg QD. | 185 | 258 |
14924251-DS-14 | 25,172,039 | You were admitted for evaluation and treatment of cholangitis
(infection in your bile ducts). For this you underwent an MRI
which showed concern for cholangitis and did show suspicious
appearing kidney lesions (that you are already aware of). You
underwent an ERCP which showed a mass in your bile duct
concerning for metastasis. Several biopsies were taken and they
show metastatic renal cell cancer. Your diet was advanced after
the procedure successfully. You should follow up closely with
Dr. ___ to discuss further treatment. | ___ y.o male with h.o prostate ca, metastatic renal cancer, PAF,
CKD, metastatic pancreatic lesion s/p Whipple, prior
cholangitis/bacteremia who presents with concern for recurrent
cholangitis.
.
#cholangitis with obstructive mass in the bile duct
#metastatic RCC to the bile duct
MRCP revealed cholangitis. ERCP performed which revealed 1.5 cm
fraible polypoid mass in the distal common bile duct concerning
for metastasis, multiple large biopsies were taken. Mass is the
likely reason for recurrent cholangitis. Bcx were NGTD during
admission. Pt was continued on ceftriaxone and flagyl for
cholangitis. ___ oncologist's office was called and updated
with current hospitalization. Pathology returned as metastatic
renal cell carcinoma. The ___ team felt that the multiple
biopsies with removal of a large portion of the mass should help
prevent recurrent cholangitis in the short term. He will follow
up with his oncologist Dr. ___ staging imaging and to
discuss systemic therapy. He is also being set up for follow-up
in the ___ clinic. His LFTs should be followed every ___ weeks
as an outpatient, if elevating Dr. ___ ERCP fellow
should be called at ___ or the ERCP fellow on call
should be paged at pager ___ to discuss need for repeat
resection of mass or stenting of bile duct. He was discharged
on ciprofloxacin and flagyl for a total 10 day course.
#metastatic RCC with recurrence-Pt with know recurrence and
masses on the R.kidney. Now, appears to have metastasis to the
bile duct. Prior recurrence in the HOP s/p Whipple. Pt's primary
oncologist and primary care physician was updated.
.
#CKD-stable Cr during admission. Cr on discharge was 1.3.
.
#C.diff dx as outpt ___, on PO flagyl. Plan for 7 more days of
Flagyl after last dose of ciprofloxacin for cholangitis.
#OSA-non compliant with CPAP
.
#PAF-continued metoprolol, ASA on hold during hospitalization
for procedures/ERCP/biopsy. Resumed upon discharge.
.
#GERD-home PPI and H2 blocker, tums
#depression-continued home SSRI
.
FEN: regular diet, IVF prn
.
DVT PPx: hep SC TID | 86 | 349 |
14065325-DS-19 | 24,768,170 | Dear ___,
___ were admitted to the hospital because ___ had a breakthrough
seizure. We controlled your seizures during your admission with
a high dose of ATIVAN which required ___ to be intubated for
airway protection.
Your seizures were controlled and ___ were extubated without
complication on ___. We believe ___ had a seizure because ___
did not take your seizure medications as prescribed. We didn't
find any infections that could have precipitated a seizure.
We would like ___ to take Keppra XR 2000mg at bedtime. That is 4
tablets of your current Keppra XR prescription which are 500mg
each.
Medication changes on this admission:
___ XR 2000mg at bedtime
Please resume all remaining medications as prior to admission.
It was a pleasure taking care of ___ and we wish ___ the ___!
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ old right-handed woman with a history of
generalized epilepsy of unclear etiology, followed by Dr. ___ presents in convulsive status epilepticus. She initially
required intubation for airway protection in the setting of high
ativan load. Her seizures were controlled and she was extubated
with no complications ___.
Seizure etiology believed to be secondary to noncompliance.
Infectious workup was negative. She was started on keppra to
2000mg extended release every night (this dosing regimen thought
to improve compliance), with no further epileptiform activity
seen on EEG. She remained stable for discharge with outpatient
follow up with Dr. ___.
- Confirm medication compliance as outpatient
- F/U with Dr. ___ | 132 | 112 |
16318752-DS-6 | 26,086,702 | You were re-admitted to the hospital with rib pain after a fall.
Your rib pain was controlled with oral analgesia. The Thoracic
service was consulted for rib plating which they did not see
advice. You are being discharged home with a pain regimen and
recommended follow-up with your primary care provider and the
acute pain clinic. You are being discharged with the following
instructions:
Your injury caused right sided 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 antiinflammatory 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 ).
In addition to the above instructions, please follow these:
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. | ___ year old male, s/p ___ feet fall off a ladder landing onto
his right side. The injury occurred in ___. The
patient presented here with worsening displacement of rib
fractures and chest wall hematoma. He was seen at an outside
hospital where a CT scan showed multiple right sided rib
fractures. He was treated symptomatically and discharged. He
returned to the same hospital in late ___ where a repeat CT
again showed right sided rib fractures and he was once again
treated symptomatically and discharged home. On ___, he
again presented to an OSH with worsening right sided rib pain. A
cat scan at that time showed right sided rib fractures (right
___ posterior, and right ___ anterior) with interval
worsening of displacement. He was transferred here for further
evaluation and admitted to the Acute Care Surgery service.
The patient was started on a pain regimen which provided
adequate relief of his rib pain, allowing him to participate in
ADL's. He was instructed in the use of the incentive
spirometer. Because of the extent of the rib fractures, Thoracic
surgery was consulted to evaluate the utility of rib plating.
They determined that there was no role for rib plating at this
time. The patient's pulmonary status remained stable.
During his hospitalization, family member's voiced concern about
the patient's safety at home and poor judgment. The Psychiatry
service was consulted and they evaluated the patient. They
determined that there was no safety concerns. The hospital
social worker met with the patient and recommendations were made
for ___ services at discharge to assist the patient with his
ADL's.
In preparation for discharge, the patient was evaluated by
Occupational and Physical therapy and recommendations made for
discharge home with ___ services. On HD #7, the patient was
discharged home under the supervision of his brother. The
Attending physician, ___ a 1 week course of
MS contin, in addition to his tramadol for rib pain management.
At the time of discharge, the patient's vital signs were stable
and he was afebrile. He was tolerating a regular diet and
voiding without difficulty. Appointments for follow-up were
made with the patients primary care provider and with the Acute
care clinic. Discharge instructions were reviewed and questions
answered. | 478 | 389 |
14673060-DS-9 | 26,335,175 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-Your kidneys were not functioning properly. We think this was
due to a large prostate preventing you from urinating.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-A catheter was placed in your bladder to help drain urine. Your
kidney function quickly improved after that.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-It is very important that you follow-up with your primary
doctor and urologist. Please see appointments below.
-Keep your Foley in place until you follow-up with your
urologist.
-Flush your Foley with 60 milliliters of saline when urine isn't
draining.
-Take your new prostate medication (tamsulosin) every evening.
-Drink 1 to 2 quarts of water per day.
We wish you all the best!
Sincerely,
Your ___ Care Team | ___ male with hypertension admitted for incidental acute
renal failure in the context of bilateral hydronephrosis and
prostatic hypertrophy suggestive of obstructive nephropathy.
Rapidly improved after Foley decompression.
#) Hyperkalemia
#) Acute kidney injury
Patient presented to outpatient provider to establish care,
where he was incidentally found to have creatinine 6.7,
potassium 5.9. Presumably obstructive in the context of
bilateral hydronephrosis and prostatic hypertrophy on background
chronic overflow incontinence among other prostatic symptoms.
Renal parameters rapidly improved after Foley decompression, in
keeping with obstructive uropathy. Suspect obstruction is
chronic in nature, given magnitude of injury and circumferential
bladder wall thickening. Likewise, cannot exclude chronic kidney
disease secondary to chronic obstruction +/- hypertension in the
absence of regular care. Normocytic anemia and
hyperparathyroidism furthermore suggestive of chronic disease.
Profound post-obstructive diuresis ensused, though no rebound
pre-renal injury, hypernatremia, or hypokalemia noted. His urine
output had fallen to <3L by time of discharge. Encouraged
adequate oral intake in the interim. Tamsulosin 0.8 mg QHS added
for prostatic hypertrophy. Urology recommended that he maintain
Foley for bladder rest until follow-up in one to two weeks.
Voiding trial thereafter with replacement of Foley for post void
residual >250 cc.
#) Anemia, normocytic: with narrow RDW. Hemoglobin in 10-range
on unknown baseline. Iron studies consistent with anemia of
inflammation/chronic disease. Hemolysis studies unremarkable.
Other cell lines preserved. Minor worsening likely secondary to
hematuria. At discharge, hemoglobin = 9.4
#) Hypertensive urgency: 205/85 on arrival. 181/79 on admission.
Suspect component of hypervolvemia, given low-normal systolic
after diuresis. Labetalol discontinued altogether in that
regard.
#) Hematuria: did not pre-date hospitalization. Likely secondary
to traumatic Foley placement, rapid bladder decompression, or
prostatic hypertrophy. Urology follow-up, as above. | 129 | 275 |
11809167-DS-14 | 21,109,005 | Dear Ms. ___,
You were admitted to the hospital for confusion that occurred
while you were getting dialysis. The reason for your confusion
may have been that your blood pressure might have gotten a
little low during treatment. During your stay at the hospital,
your blood pressures have been normal and well-controlled.
Because you were a still a little confused during your stay at
the hospital and have had strokes in the past, we had the
neurologist (brain doctors) see you and did a scan of your brain
with an MRI that showed no evidence of a new stroke. Your
confusion significantly improved while you were here.
Please continue to follow-up with your neurologist as planned
given your prior history of strokes.
Physical therapy saw you while you were here and recommended you
go to rehab after leaving the hospital before you go home to
ensure your safety and health.
After you leave the hospital, you will need to continue to
receive hemodialysis on your usual schedule of
___. | ___ with Hx HTN, HLD, T2DM with ESRD on HD since ___, single
vessel CAD s/p PCI, PVD, dementia with amyloid angiopathy, and 2
recent CVA in ___, presents from dialysis with AMS.
.
*** Active Diagnoses ***
.
# Altered mental status:
Pt initially presented from dialysis with altered mental status,
most likely due to fluid shift and possible hypotension
secondary to dialysis superimposed on baseline dementia. Per
pt's family, pt also have had recent fluctuating mental status.
CT scan negative for bleed. Neuro eval'ed pt given concern pt
had new visual loss to rule out stroke - given concurrent
delirium / metabolic encephalopathy her neurologic exam was very
difficult to ascertain. MRI/MRA performed with no acute
abnormalities, though study limited by patient movement. Pt did
not appear acutely infected on admission with no leukocytosis or
fever. Blood culture were sent which were negative to day of
discharge (pending). Additional chem labs were stable, RPR, TSH
and EKG were unremarkable as other secondary causes. Urine
culture abnormal so treated with oral antibiotics in case UTI
was trigger for this episode. Symptoms improved markedly prior
to discharge; tolerated repeat dialysis session without symptom
recurrentce. ___ recommended rehab following discharge.
.
# UTI
Coag neg staph. Placed on 3 day course of Bactrim DS (dose
halved given imparied renal fxn).
.
*** Chronic Diagnoses ***
.
# ESRD:
Pt is on HD MWF and continued while in the hospital.
.
# Hx of CVA
Continued asa, plavix with pt to continue to follow-up with
neurology given her prior 2 strokes.
.
# Hypothyroidism
TSH wnl on levothyroxine.
.
# DM2
Stable
.
# CAD
Stable, no evidence of ACS. Per family, pt only on asa and
plavix for anticoagulation as she cannot tolerate coumadin due
to bruising/bleeding
.
# HTN
Pt hypertensive to 190's on admission the the MICU and was given
hydral 10mg IV with good effect. Normotensive since restarting
home medications.
.
# Glaucoma:
Stable on home eye drops
.
*** Transitional Issues ***
.
- Pt sent to rehab following hospitalization.
.
- Pt to continue to f/u with neurology given prior history of
strokes
.
- F/u on final blood cultures (negative on day of discharge)
.
- Continue regular HD MWF schedule | 165 | 352 |
16102517-DS-7 | 23,258,877 | Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With Fusion
Follow-up Appointments
After you are discharged from the hospital and settled at home
or rehab, please make sure you have two appointments:
1.2 week post-operative wound check visit after surgery
2.a post-operative visit with your surgeon for ___ weeks after
surgery.
You can reach the office at ___ and ask to speak
with your surgeons surgical coordinator/staff to schedule or
confirm your appointments
Wound Care
If not already done in the hospital, remove the incision
dressing on day 2 after surgery.
You may shower day 3 after surgery. Starting on this ___ day,
you should gently cleanse the incision and surrounding area
daily with mild soap and water, patting it dry when you are
finished.
Some swelling and bruising around the incision is normal. Your
muscles have been cut, separated and sewn back together as part
of your surgical procedure. You will leave the hospital with
back discomfort from the surgical incision. As you become more
active and the incision and muscles continue to heal, the
swelling and pain will decrease.
Have someone look at the incision daily for 2 weeks. Call the
surgeons office if you notice any of the following:
Increased redness along the length of the incision
Increased swelling of the area around your incision
Drainage from the incision
Weakness of your extremities greater than before surgery
Loss of bowel or bladder control
Development of severe headache
Leg swelling or calf tenderness
Fever above 101.5
Do not soak or immerse your incision in water for 1 month. For
example, no tub baths, swimming pools or jacuzzi.
Activity Guidelines
You MAY be given a RIGID BRACE that you will wear whenever
sitting up, standing, or walking. You will wear it for ___
weeks after surgery. See the last page of these instructions for
details on wearing the brace.
Avoid strenuous activity, bending, pushing or holding your
breath. For example, do not vacuum, wash the car, do large
loads of laundry, or walk the dog until your follow-up visit
with your surgeon.
Avoid heavy lifting. Do not lift anything over ___ pounds for
the first few weeks that you are home from the hospital.
Increase your activities a little each day. Walking is good
exercise. Plan rest periods and try to avoid hills if possible.
Remember, exercise should not increase your back pain or cause
leg pain.
Reaching: When you have to reach things on or near the floor,
always squat (bending the knees), rather than bending over at
the waist.
Lying down: when lying on your back, you may find that a pillow
under the knees is more comfortable. When on your side, a
pillow between the knees will help keep your back straight.
Sitting: should be limited to 40-60 minutes at a time for the
first week. Slowly increase the amount of sitting time,
remembering that it should not increase your back pain.
Stairs: use stairs only once or twice a day for the first week,
or as directed by the surgeon. Climb steps one at a time,
placing both feet on the step before moving to the next one.
Driving: you should not drive for ___ weeks after surgery. You
should discuss driving with your surgeon /nurse practitioner
/physician ___. You may ride in a car for short distances.
When in the car, avoid sitting in one position for too long.
If you must take long car rides, do not ride for more than 60
minutes without taking a break to stretch (walk for several
minutes and change position.).
Sexual activity: you may resume sexual activity ___ weeks after
surgery (avoiding pain or stress on the back).
Reduction in symptoms: patients who have experienced back and
radiating leg pain for a short window of time before surgery
should anticipate a significant decrease in pre-operative
symptoms. If the pain has been present for a longer period
(months to years), the pre-operative symptoms will recover on a
more gradual basis week by week. It is not practical to expect
immediate relief of symptoms. Routinely, pain will gradually
improve on a weekly basis, weakness on a monthly basis, and
numbness in a range of 6 months to ___ year.
Physical Therapy
Outpatient Physical Therapy (if appropriate) will not begin
until after your post-operative visit with your surgeon. A
prescription is needed for formal outpatient therapy.
You may be given simple stretching exercises or a prescription
for formal outpatient physical therapy, based on what your needs
are after surgery.
Medications
You will be given prescriptions for pain medications and stool
softeners upon discharge from the hospital.
Pain medications should be taken as prescribed by your surgeon
or nurse practitioner/ physician ___. You are allowed to
gradually reduce the number of pills you take when the pain
begins to subside.
If you are taking more than the recommended dose, please
contact the office to discuss this with a practitioner ___
medication may need to be increased or changed).
Constipation: Pain medications (narcotics) may cause
constipation. It is important to be aware of your bowel habits
so you ___ develop severe constipation that cannot be treated
with simple, over the counter laxatives.
Most prescription pain medications cannot be called into the
pharmacy for renewal. The following are 2 options you may
explore to obtain a renewal of your narcotic medications:
1.Call the office ___ days before your prescription runs out and
speak with office staff about mailing a prescription to your
home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS)
2.Call the office 24 hours in advance and speak with our office
staff about coming into the office to pick up a prescription.
If you continue to require medications, you may be referred to
a pain management specialist or your medical doctor for ongoing
management of your pain medications
Avoid NSAIDS for ___ weeks post-operative. These medications
include, but are not limited to the following:
1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam,
Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin,
Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen,
Tolectin, Toradol, Trilisate, Voltarin
Blood Clots in the Leg
1.It is not uncommon for patients who recently had surgery to
develop blood clots in leg veins.
Symptoms include low-grade fever, and/or redness, swelling,
tenderness, and/or an
aching/cramping pain in your calf.
You should call your doctor immediately if you have these
symptoms.
To prevent blood clots in legs, try walking and/ or pumping
ankles several times during the day.
If the blood clot breaks free from the leg vein, it can travel
to the lungs and cause severe breathing difficulty and/or chest
pain. If you experience this, call ___ immediately.
Questions
Any questions may be directed to your surgeon or physician
___.
1.During normal business hours (8:30am- 5:00pm), you can call
the office directly at ___. Turn around time for a
phone call is 24 hours. After normal business hours, you can
call the on-call service and we will get back to you the next
business day.
If you are calling with an urgent medical issue, please tell
the coordinator that it is an urgent issue and needs to be
discussed in less than 24 hours (i.e. pain unrelieved with
medications, wound breakdown/infection, or new neurological
symptoms).
Lumbar Corset or (TLSO) Brace Guidelines
You MAY have been given a rigid brace that you will wear for
___ weeks after surgery.
You should put on your brace as you have been instructed by the
orthotist (brace maker). Instructions will be reviewed in the
hospital by the nursing staff and Physical Therapist.
It is a good idea to start practicing with your brace before
surgery (putting it on/taking it off, sitting, standing,
walking, and climbing steps with the brace) so you can assist
with your post-operative care in the hospital.
Keep the name and phone number of the person who fitted and
dispensed your brace close by in case you need to have the brace
checked and/or adjusted.
You should always have a barrier between your surgical incision
and the brace. For example, you may want to put on a light
t-shirt and then the brace before getting dressed for the day.
During periods of rest, take off the brace and expose the
incision to the air by lying on your side for a few hours. This
will reduce the chance of your wound breaking down.
1.The brace must be worn at all times with the following 3
exceptions: 1.Lying flat in bed during a rest period or at
night to sleep.
2.Getting out of bed at night to go to the bathroom, returning
to bed immediately when you are finished.
3.Showering. You may wish to use a shower chair to help prevent
bending/twisting while bathing. You should have someone help
wash your back and legs.
Physical Therapy:
Activity: Activity: Ambulate twice daily if patient able
high back lumbar corset brace when OOB or ambulating
Treatments Frequency:
eval wound daily
cover with dsd as needed
keep clean and dry | Patient was admitted to Orthopedic Spine Service on ___. On
___ underwent the above stated procedure. Patient tolerated
the procedure well without complication. Please review dictated
operative report for details. Patientwas extubated without
incident and was transferred to PACU then floor in stable
condition.
During the patient's course ___ 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 painmedication. Diet was
advanced as tolerated. Foley was removed in routine fashion and
patient voided without incident. Lumbar epidural catheter was
removed on POD#1. Hemovac was removed in routine fashion once
the output per 8 hours became minimal.
Physical therapy and Occupational therapy were consulted for
mobilization OOB to ambulate and ADL's. Hospital course was
significant for acute anemia requiring transfusion of
plateletets and PRBCs. He was also worked up for
thrombocytopenia and heme/onc was consulted. His work-up
revealed known iron deficiency anemia and likely myelodysplastic
syndrome. He continued to improve daily.
Now, Day of Discharge, patient is afebrile, VSS, and neuro
intact. Patient tolerated a good oral diet and pain was
controlled on oral pain medications. Patient had weakness in
bilateral IP. Patient's wound is clean, dry and intact. Patient
noted improvement in radicular pain. Patient is set for
discharge to *** in stable condition. | 1,687 | 231 |
13839254-DS-20 | 29,502,911 | Dear ___,
___ was a pleasure taking care of you in the hospital!
WHY WERE YOU ADMITTED:
- You had a fall and we needed to see if you had any broken
bones that needed to be fixed.
WHAT HAPPENED IN THE HOSPITAL:
- You had X-rays which showed you had had fractures in your
spine and hip.
- The surgeons came and saw you and did not feel that you needed
to have surgery for your fractures.
- We gave you medications to get extra fluid out of your body.
- You were seen by the palliative care team who helped us
optimize your medications in order to make you comfortable
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL:
- Please follow-up with your doctors as ___.
- Please take your medications as prescribed.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to take part in your care!
Your ___ team | ORTHOPEDIC SURGERY COURSE
===========================
___ history of afib s/p PPM on Coumadin, prior cardiac ablation,
diastolic CHF with TR (last EF 70%) who presents s/p unwitnessed
fall from standing with unclear mechanism, potentially syncopal.
patient initially presented to ___, where initial work-up
was notable for X-rays revealing new left pelvic fracture and
new compression fractures of L2 and L3, as well as chronic
compression fractures
of T12 and L4. Imaging also demonstrated chronic T12/L4
compression fractures as well as a right orbital wall lucency
without clinical correlate of bony TTP, visual disturbance, or
extraocular muscle limitation to prompt further evaluation. She
also had an INR of 8.4 and a UA with WBC 42, and urine culture
grew >100,000 CFUs of Proteus mirabilis. She was given 5mg IV
vitamin K. She was transferred to ___ and admitted to trauma
surgical service. patient was evaluated for spine orthopedic
surgery, who recommended non-operative management of injuries
with TLSO brace for stability. After stabilization, patient was
transferred to the heart failure service for further management.
CARDIOLOGY COURSE
==================
Mrs. ___ is a ___ woman with PMH chronic right-sided heart
failure secondary to severe TR following surgical WPW ablation,
atrial fibrillation on warfarin, and complete heart block s/p
PPM, who initially presented for management of fall with pubic
ramus fracture and L2 compression fracture managed
conservatively later transferred to ___ for management of volume
overload. The patient was diuresed and palliative care was
consulted given overall poor prognosis. After discussion with
the patient and her family, the decision was made to focus on
comfort measures at this time. She was ultimately discharged to
a rehab facility where she will receive hospice care.
# CORONARIES: unknown
# PUMP: HFpEF with RV dilation , EF 75%
# RHYTHM: V-sensed, V-paced. Pacer- Biotronik - VVIR 70.
ACTIVE ISSUES:
==============
# Right-sided heart failure exacerbation:
Patient has a history of right-sided heart failure. She was felt
to be inadequately diuresed at an outpatient appointment with
her cardiologist one week prior to presentation. Likely triggers
for current exacerbation include inadequate outpatient diuresis
vs holding medications and IVF resuscitation during initial
presentation while she was being managed for her fractures. The
patient was started on lasix gtt with boluses of chlorothiazide
with good diuresis. She was then transitioned to PO diuretics
prior to discharge. Given overall poor prognosis from her right
sided heart failure, palliative care was consulted. After
discussion with the patient and her daughter, the decision was
made to focus more on comfort and transition to hospice care.
She will be discharged to a rehab facility where hospice care
will be provided.
# Pelvic fracture:
# Compression fracture:
# Fall:
Patient presented following fall at home. X-rays revealing new
left pelvic fracture and new compression fractures of L2 and L3,
as well as chronic compression fractures of T12 and L4. She is
unable to recall circumstances surrounding her fall, but denies
dizziness or loss of consciousness preceding the episode. EP
device interrogation without evidence of significant arrhythmia
detected during the patient's fall. Surgical intervention was
deferred by orthopedic surgery. As a result, she was given a
TLSO brace for comfort and recommended outpatient orthopedics
follow-up. Palliative care was consulted and she was continued
on tyelnol and oxycodone prn for pain control as well as a bowel
regimen to prevent constipation. As detailed above, she will be
transitioned to hospice care at her rehab facility.
# Supratherapeutic INR:
# Malnutrition
Patient had supratherapeutic INR of 8.4 at presentation to
___, which resolved with 5mg IV vitamin K. Likely
secondary to poor nutritional status. Improved following vitamin
K, but re-elevated after redosing warfarin. Possibly secondary
to poor nutritional status. After discussing with Dr. ___
___ cardiologist), the patient was started on apixaban,
however, given focus on comfort measures, this was later
discontinued.
# UTI, resolved:
Patient had UA with >42 WBCs. Urine culture grew >100,000CFUs
Proteus mirabalis. Patient endorses dysuria over the past
several days. Treated with three days of ceftriaxone.
CHRONIC ISSUES:
==============
# Atrial fibrillation: Stopped anticoagulation given transition
to hospice care. | 150 | 664 |
19271750-DS-17 | 29,617,869 | Dear ___,
You were admitted to ___ after coming in with shaking of your
arm and confusion. We examined you for any possible infection
but were unable to find signs of infection. Your blood counts
were at their normal baseline.
You were given 1 dose of antibiotics, as well as some IV
hydration (with albumin) and monitored.
At the time of discharge, you were feeling improved.
Please follow up with your doctors ___. No changes in your
medications were made.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure caring for you. We wish you the very best.
- Your care team at ___ | ___ M with a h/o EtOH cirrhosis, HCC, and ischemic chronic
systolic CHF (EF ___ who presents with several days of
weakness and fatigue as well as shaking.
ACTIVE ISSUES
# SHAKING: Unclear if were tremors, potentially rigors in the
setting of an infection though UA and CXR negative. Blood &
urine cultures NGTD x24 hours. Unclear if asterixis, or related,
though does not appear so. RUQ US with Doppler without ascites,
unlikely SBP. No convincing evidence of infection otherwise (no
fever, leukocytosis, localizing symptmos). He has mild
leukopenia which is also at baseline, and has no localizing
symptoms for infection. He received one dose of Zosyn 4.5g in
ED, as well as albumin. FSG normal. Symptoms rapidly resolved
with lactulose and hydration with colloid.
# HYPOTENSION: Has low pressures (SBP ___, on chronic
midodrine, likely secondary to both cirrhosis. Current symptoms
not likely attributable to this, though daughter was concerned
that he may have had a lower pressure than usual and trouble
keeping up hydration in the heat. Given albumin 50 g x2 with
good response. Continued home midodrine.
# HEPATIC ENCEPHALOPATHY: history of TIPS (___) with
downsizing in ___ for recurrent HE. Daughter notes that after
this, baseline mental status seems slightly off (difficulties
with orientation, though is able to keep conversation without
difficulties). Lactulose and rifaximin continued. Patient had 4
BM while in house/1 day.
CHRONIC ISSUES
# ISCHEMIC CHRONIC SYSTOLIC CHF (EF ___: Currently does not
appear in acute exacerbation, though does have some ___ edema.
Continued home regimen of torsemide (40 mg M-F, 60 mg S-S),
spironolactone.
# PRE-DIABETES: continued metformin.
# GIB/VARICES: H/o varices, s/p banding ___, most recent EGD
showing small esophageal varices ___. H/o TIPS ___,
downsizing TIPS ___. Continued pantoprazole. No nadolol
given hypotension.
# EtOH CIRRHOSIS: MELD-Na on admission is 16.
# CAD: complicated by ischemic cardiomyopathy. Continued
atorvastatin 40mg. Intolerant of beta blocker due to
hypotension. Not on ASA due to GI bleeds.
# COAGULOPATHY: INR 1.5 which is at baseline, consistent with
coagulopathy due to cirrhosis.
# ASCITES: No tappable pocket in ED. Diuretics restarted on
discharge.
===========================================
TRANSITIONAL ISSUES
===========================================
- Monitor fluid status cautiously
- Regular follow up with outpatient physicians as scheduled
- No adjustments to medications made | 109 | 377 |
16337802-DS-16 | 24,450,082 | It was a pleasure to participate in your care. You were
admitted with fever and found to have Klebsiella bacteremia.
There was concern that the source may be your line. You were
given antibiotics IV. You were also given antibiotics to dwell
in the line. Your symptoms improved and you were discharged
home with close monitoring of your INR and electrolytes.
Your INR was found to be high. This was likely due the
antibiotics and the infection. You were given a small dose of
vitamin K and your INR became more appropriate. We are
decreasing your dose of coumadin and monitoring the INR closely
while you are on antibiotics. This will be checked by New
___ Home Infusion on ___. | ___ with significant for hollow viscous s/p multiple bowel
resections c/b short gut syndrome on TPN c/b multiple line
infections with most recent being Burkholderia cepacia (___)
admitted with rigors, fevers and headache found to have
Klebsiella bacteremia.
. | 127 | 38 |
12602845-DS-10 | 22,338,147 | Dear Ms. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted with a severe sore throat and pain
with swallowing. You had a CT scan of your neck which showed an
area of swelling that was not an abscess, but warrants
antibiotic treatment. We have started you on Augmentin 500mg
twice a day. You should continue this for 5 days. Also, for
your sore throat you can continue using viscous lidocaine as you
have been doing at home.
With regards to your abdominal pain, we do expect you may have
intermittent mild right upper abdominal pain as a result of your
likely viral infection, however if this worsens please call Dr.
___. An ultrasound of your liver was reassuring.
Furthermore, your liver enzymes continued to trend down.
Most likely the symptoms you have been experiencing the past 3
weeks are the result of a viral syndrome. However, we have
added two more tests to rule out 1) strep throat and 2)
toxoplasmosis. These results were pending when you were
discharged. Dr. ___ be able to give you the results of
these tests.
You will be seen in followup next week. The appointment is
listed below. | ___ with 3 weeks of fever, pharyngitis, transaminitis and
symptoms consistent with mononucleosis now presenting with
worsening sore throat.
ACTIVE ISSUES:
==============
# Pharyngitis / Odynophagia: In the setting of a resolving 3
week viral syndrome of pharyngitis, low-grade fever,
lymphadenopathy, she presented with acute worsening of
right-sided throat pain and difficulty swallowing. CT neck
obtained and there was evidence of enlarged heterogeneous
palatine tonsils concerning for phlegmonous change. She was
placed on Augmentin x 5 days and pain control with oxycodone an
ibuprofen. With regards to original etiology of pharyngitis:
negative results include hepatitis and HIV. Labs pending
include EBV serology, toxo, ASO titers.
#RUQ pain: Likely due to hepatic capsular stretch from mild
hepatomegaly after viral syndrome. This improved prior to
discharge.
# Transaminitis: Thought to be secondary to viral illness that
she experienced over the past 3 weeks. LFTs continued to trend
downward. RUQ ultrasound with only mild hepatomegaly. Also on
the differential was autoimmune hepatitis, for which ___ was
pending on discharge.
# Erythematous plaques on upper extremities: these have
preexisted viral syndrome by months. Clinically most consistent
with ring worm versus nummular eczema (less likely). No
specific treatment for these were given.
CHRONIC ISSUES:
===============
# Depression: stable, she continued escitalopram.
# Neuropathic pain: s/p cervical herniations that resulted from
trauma ___ years ago. She continued gabapentin
# ADHD: on adderall at home, This was held for drug holiday
while she was inpatient.
# Continuing other pre-admission meds: vitD, ferrous sulfate,
pantoprazole. | 215 | 251 |
18606906-DS-11 | 20,103,395 | Dear Ms. ___,
You were admitted to ___ after being found having
seizures at your nursing home. During your hospitalization, you
were noted to have left > right twitching of your arms and legs
and EEG showed that you were in status epilepticus. MRI showed
changes consistent with inflammation. You were diagnosed with
HSV encephalitis. Initially, you were treated with IV AEDs and
antivirals but you were not intubated secondary to your
previously established DNR/DNI status. Your seizure frequency
decreased but the prognosis of your condition is very poor. A
family discussion was had with your daughter who is your health
care proxy and the decision was made to stop all advanced
medical management. Your AEDs and anti-virals were stopped. You
were discharged back to your nursing home for hospice services. | ___ is a ___ p/w encephalopathy and intermittent
left sided twitching found to be in status epilepticus on EEG.
LP on admit was negative for frank meningitis. The patient was
previously made DNI/DNR and goals of care were discussed with
her daughter who opted for conservative medical management. She
was started on dilantin, keppra, lacosamide and acyclovir as
empiric treatment for HSV encephalitis. MRI showed
leptomeningeal enhancement consistent with HSV encephalitis. A
family discussion was had with the patient's daughter, the
patient's health care proxy, and the decision was made to stop
all advanced medical management. AEDs and anti-virals were
discontinued. She was discharged back to her nursing home for
hospice services and comfort care measures including morphine
for pain control and ativan for seizure control. | 136 | 126 |
10898945-DS-22 | 20,571,313 | Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ with fatigue and
anemia (low red blood cell count). While here you underwent an
upper endoscopy and colonoscopy to examine your gastrointestinal
tract for bleeding. We did not find a source of bleeding. While
here you received red blood cell transfusions and your blood
level stabilized. On the day of your discharge, you underwent a
small capsule endoscopy study. You will need to follow-up with
Dr. ___ to discuss the results of this study.
Since you have esophageal varices, we started you on a
medication called nadolol. This will REPLACE your metoprolol.
Additionally, you will need a repeat EGD in ___ year to reassess
your varices.
Finally, please continue to take Cipro 500mg daily for 2 days
after discharge (last day ___. Starting ___ take Cipro 250mg
daily.
Again it was a pleasure to meet and care for you!
-Your ___ team | PRIMARY REASON FOR HOSPITALIZATION:
___ year old man with h/o NASH cirrhosis c/b HCC (now in
remission), with h/o ascites, SBP, HE, and portal gastropathy,
who presents with anemia and increasing abdominal distension. | 157 | 32 |
18602613-DS-8 | 25,462,265 | Dear Ms. ___,
It was a pleasure to take care of you at ___. You were brought
into the hospital for pain in your hips which resolved with pain
medications. You also had nausea which was thought be a delayed
reaction to cytoxan. You underwent stem cell collection from
___ to ___, for a total of 5 days of collection.
Please call Dr. ___ at ___ on ___ to schedule a
follow-up appointment.
All the best,
Your ___ Team | Ms. ___ is a ___ h/o MM on high dose cytoxan therapy w/
neupogen in preparation for AutoSTC presents with severe bone
pain.
# Bone Pain
Patient was referred to ED for significant pain in her hip. Her
pain was quickly controlled in the ED with IV Dilaudid. She
recently had a skeletal survey in ___ which did not
show any evidence of lytic lesions. Exam is reassuring for
absence of a new pathologic fracture, so will not obtain hip
imaging. Pain likely ___ neupogen and well-controlled. Patient
was discharged pain free and not requiring pain medication.
# MM
Patient had prior planned line placement and stem cell
collection during her admission for her auto transplant in the
future. Here acyclovir and ciprofloxacin were continued. Stem
cells were collected over the course of 5 days and she had a
total of about 9x10^6 collected. There were no complications.
# Thrombocytopenia
Drop in platelet count starting around ___ day of
hospitalization and reaching nadir around day 7 of >50% drop.
Two potential etiologies are dilutional secondary to stem cell
harvesting and heparin induced thrombocytopenia. Was exposed to
heparin during past hospitalization. 4T score of ___
representing intermediate intermediate pretest probability.
Heparing dependent antiboides were negative, reassuring not due
to HIT. Platelets were stable at time of discharge and will be
monitored at follow-up.
# Hypotension
Patient had brief episode of hypotension in the ED on arrival
with sbps in the ___. This resolved w/o intervention. Etiologies
include hypovolemia ( N/V in car ride prior to admission),
infection vs vasovagal related to pain. Labs in the ED showed
Granulocyte count of 220. In setting of hypotension and low PMN
count, ED administered cefepime out of infectious concern. CXR
reasurring, blood cultures pnd and afebrile in the ED.
Antibiotics were stopped and her blood pressures were normal
throughout her admission. | 78 | 307 |
13108511-DS-19 | 22,253,058 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- Because you had pneumonia
WHAT HAPPENED TO ME IN THE HOSPITAL?
- WE gave you medication and you pneumonia got better
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ is a ___ with PMHx of bronchomalacia without
tracheomalacia, recurrent pneumonia, HFpEF ___ LVEF 65%)
with diuretic noncompliance, Asthma, UC (on mesalamine,
entyvio), prior PE (not on AC) who presented as transfer from
___/pleuritic chest pain and is found to have an
atypical pneumonia and heart failure exacerbation. | 83 | 50 |
11521042-DS-11 | 20,811,605 | 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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. Your last
dose will be on ___. It is important that you take this
medication consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
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 | Patient was admitted for observation after fall. CTA head showed
no vascular anomaly and a CT cspine was negative for fracture.
Patient was admitted to floor. She remained stable overnight. On
HD 1, she had some neck tenderness to palpation and her collar
was kept in place. Syncope workup was started. A Cspine flex/ext
film was ordered and were negative for fracture.
On ___, an OT consult was ordered. Dr. ___ the hard
cervical collar. Orthostatic vital signs were negative.
On ___, the patient remained neurologically stable. Physical
Therapy requested to work with the patient for a couple
additional sessions while she is an inpatient.
Mrs. ___ was seen by physical therapy and based on their
evaluation, felt that she would benefit from rehab. Based on
Occupational Therapy's prior evaluation, they felt the patient
was unsafe to go home alone. She was discharged to rehab in
stable conditions, all discharge instructions and follow up were
given to the patient prior to discharge. | 478 | 164 |
15451693-DS-26 | 22,796,062 | Dear Mr ___,
It was a pleasure taking care of you at ___ during your
admission. You presented to the hospital with right sided chest
pain, and your blood tests showed that you had damage to your
heart (a "heart attack"). You went for a catheterization that
showed blockages in the vessels of your heart. You had
angioplasty (used a balloon to clean the vessels) and a stent
placed.
After your procedure, you developed light-headedness and had low
blood pressure when you stood up. This was because your blood
count decreased from the procedure. You had imaging that showed
no active bleeding. You were given a blood transfusion and your
symptoms improved. You should make an appointment with your
hematologist to follow up as an outpatient.
You had difficulty urinating during the admission and required a
foley catheter to be placed. It was a difficult procedure and
you were given antibiotics post-placement to prevent infection.
While at the hospital, you were noted to have "pauses" in your
heart beat on telemetry. You did not feel these pauses. If you
begin feeling lightheaded or having periods of weakness, please
tell your doctor about these pauses as you may need further
cardiac monitoring.
Please see the attached medication list for changes to your
medications. You should follow up at the appointment below. | ___ M with seizure disorder, coronary artery disease (s/p CABG
and PCI in past) who presents with chest pressure and found to
have NSTEMI with uptrending TnT that peaked 0.85.
#) NSTEMI: Pt presented with right sided chest pain and was
found to have an NSTEMI with trop leak that peaked at 0.84. He
underwent cardiac catheterization which was difficult given his
cardiac history/anatomy. He had a ROTA to his PDA with balloon
angioplasty and a stent placed in his pRCA. Post procedure he
had symptomatic orthostatic hypotension and noted a drop in his
hemoglobin. He received 1 unit of pRBCs with an appropriate
increase in his hemoglobin. He had a CT scan that ruled out
retroperitoneal bleed and a chest xray that was within normal
limits. An echocardiogram showed an EF of 40-45%. He should
remain on ASA 81mg and Plavix 75mg daily indefinitely. He is
also on atorvastatin 80mg daily, Metoprolol Succinate XL 25 mg
PO DAILY, and Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY.
#)Anemia: Post procedure patient had symptomatic orthostatic
hypotension and noted a drop in his hemoglobin. He received 1
unit of pRBCs with an appropriate increase in his hemoglobin. He
had a CT scan that ruled out retroperitoneal bleed and a chest
xray that was within normal limits. His Hgb on discharge was 8.9
#)Hyponatremia: Patient sodium downtrended with a nadir at 138.
He was asymptomatic, and the hyponatremia resolved. His na on
discharge was 136.
#)Decreased Urine Output: Patient was noted to be unable to
void. He was a difficult foley placement and required urology to
place foley with cytoscope guidance. They visualized a false
passage at the level of bulbar urethra posteriorly d/t traumatic
foley cathterizations. He had the foley for 3 days then passed a
voiding trial. He recieved 1 dose of fosfomycin for prevention
of UTI. He was continued on flomax.
#) Asymptomatic Bradycardia: Patient had periods of pauses on
telemetery longest lasting 4.2Sec and he was completely
asymptomatic. His case was discussed with EP attending and
fellow and decided pauses were likely ___ to inschemia. Pauses
resolved after catheterization. His metoprolol was held during
this period then restarted post-catheterization.
#) SEIZURE DISORDER: No evidence of seizure recently, but was
admitted with seizures prior admission. He was continued on
prescribed regimen of lamotrigine and levitiriacetam.
CHRONIC
#) DM: ISS, hypoglycemic protocol
#) ESSENTIAL TREMOR: Continue primidone
#) DEPRESISON: Continue sertralie
#) MILD COGNITIVE IMPAIRMENT: Continue B12
# CODE: FULL CODE
# CONTACT: Patient, ___ (wife/HCP) ___
___ ISSUES:***
-continue ASA and Plavix
-outpatient monitoring of heart rate and adjustment of
metoprolol prn
-outpatient f/u re seizure medications as previous admission
found the levels to be subtherapeutic.
-___ rehab
-recheck CBC at PCP appointment
-___ at PCP appointment
-___ HEME f/u macrocytic anemia, thrombocytosis
-___ f/u | 220 | 448 |
14099582-DS-20 | 21,322,607 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for bleeding from your
rectum
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were taken to the ICU because the amount of blood you were
losing from your rectum was very serious
- A picture of the blood vessels in your rectum was taken and it
showed a lot of bleeding
- A scope was used to visualize your rectum and showed that you
had a lot of clots in your rectum, but you seemed to have
stopped bleeding
- You were taken to the general floor after you got better in
the ICU, and you were treated for your constipation
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- If you feel extremely down about your health or in general, do
not hesitate to call your therapist or the hospital.
- We strongly discourage the use of your finger to help make it
easier to have a bowel movement. This is extremely risky and
makes the chance of bleeding from your bottom very high.
- Eat a lot of foods with fiber- this includes fruit and
vegetables, and this will help prevent a future bleed in the
future. The bleeding was most likely caused by your
constipation, and so it is important to continue taking your
bowel medications to prevent constipation and to continue eating
foods high in fiber.
We wish you the best!
Sincerely,
Your ___ Team | ___ with HFrEF (EF 25%), CAD s/p CABG x4, SVT s/p ablation, CKD,
pAF not on AC iso history of GAVE and AVMs, who initially
presented with BRBPR and anemia, source found on CTA to be
pulsatile arterial rectal bleeding iso multiple colonic
diverticula, which had self-resolved in the MICU, and now
transferred to the medical floor for continued management with
no repeat large volume bleed per rectum.
TRANSITIONAL ISSUES
===================
[] Patient will need outpt screening colonoscopy
[] Will benefit from outpt referral to out-pt mental health
therapy
[] Pt is on iron, known to cause constipation, would re-evaluate
iron supplementation strategy in outpt setting
[] Noted to have normocytic anemia on D/C, would repeat CBC as
outpt
[] Discharge creatinine 1.7, Pt w/ known CKD, would continue to
monitor renal function as outpt | 289 | 128 |
11900721-DS-28 | 20,516,801 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital from rehab for shortness of breath. The
shortness of breath was a combination of a pneumonia and too
much fluid in your body. We treated ___ with 7 days of IV
antibiotics and also gaive ___ IV diuretics to take fluid off of
your body. We also tapped the fluid from your lungs, and the
fluid did not look infected.
As ___ have been very sick on and off because of your underlying
liver disease, we asked our palliative care doctors to ___ to
___ too. Your goals of care includes being home as much as
possible. Your goals of care also includes continuging to have
___ come back to the hospital as needed though when ___ do come
back we will not perform CPR or breathing tube into ___.
Please continue to check your weight daily. At the time of
discharge your weight is 117lb (53kg). Your weight should be
between 117-120lbs. If it drops below 115 lbs, ___ should call
your primary care doctor to possibly decrease your water pill
dose. If your weight is above 120lb ___ should also call your
primary care doctor to ___ your water pill.
___ have an appointment with ___ at ___ on
___. Prior to that, pelase to go ___ and have your
labs checked on ___.
We wish ___ only good days in the future,
Sincerely,
Your ___ Care Team | ___ with history of cryptogenic cirrhosis complicated by hepatic
encephalopathy, refractory ascites requiring weekly paracentesis
and variceal bleeding s/p banding and TIPS (___) who presents
with abdominal distention and worsening shortness of breath. CXR
significant for left pleural effusion and marked pulmonary
edema.
# Shortness of breath/Pneumonia: Patient was volume overloaded
on admission with bilateral pleural effusions and pulmonary
edema. SBP 190 on admission, came down to 130-150s throughout
rest of admission. Elevated blood pressure may have lead to mild
flash and pulmonary edema. Minimal improvement with diuresis.
During hospitalization, she spiked a fever to ___, and was
covered with Vanc/Cefepime and then narrowed to Cefepime for
HCAP (completed full 8 day course of HCAP coverage during
hospitalization). ___ and CTA negative for PE. Underwent
thoracentesis with 500cc transudative fluid removed.
Symptomatically improved after ___ and switched from IV to PO
diuretics. During hospitalization she was on furosemide and
started on amiloride (as had reported allergy to
spironolactone). However, given hyperkalemia at times during
hospitalization (up to 5.3) amiloride was discontinued prior to
discharge. She was discharged on furosemide 40 mg PO daily. She
appeared relatively euvolemic at the time of discharge. Weight
at the time of discharge 53.2 kg. Creatinine at discharge 0.9.
Of note, patient underwent echocardiogram which revealed
increase in left atrial volume index, LVEF 65%, mild mitral
regurgitation, and moderate pulmonary artery systolic
hypertension.
# Cryptogenic cirrhosis/Goals of Care: complicatd by hepatic
encephalopathy, coagulopathy, SBP, refractory ascites requiring
weekly paracentesis and variceal bleeding s/p banding and TIPS
(___). MELD score of 20 on admission, down to 15 on
discharge; not a transplant candidate. No tapable ascites. Given
3 days of Vitamin K for elevated INR. Continued on lactulose and
rifaxamin. Pt made decision to be DNR/DNI during this admission.
Palliative care was consulted during hospitalization to discuss
goals of care discussion and whether patient would want to
return to hospital for interventions if her medical condition
were to change. She noted she would want to be brought to ___
for further evaluation/management as she still sees benefits
from the interventions performed at the hospital. She preferred
not to go back to rehab per her wishes. She was discharged home
with ___ services.
At the time of discharge she was on furosemide 40 mg PO daily
(given history of ascites and volume overload), ciprofloxacin
250 mg PO daily (for SBP prophylaxis), lactulose 15 mL PO TID,
rifaximin 550 mg PO BID, sucralfate 1 gram PO QID.
# Type II Diabetes: During hospitalization, she was continued on
an insulin sliding scale as well as 12 units lantus. However,
based patient was diet controlled with recent HbA1C of 6.0%.
Etiology of the need for insulin during hospitalization was
likey in the setting of acute illness. She was not discharged on
insulin. If blood sugars become difficult to control as an
outpatient, starting insulin should be considered.
# Hypertension: previously hypertensive to the 190s on admission
likely leading to mild flash pulmonary edema. Improved with
hydralazine and diuretics. Blood pressure returned to baseline
and was SBP 138-158 at the time of discharge. She was discharged
on furosemide 40 mg PO daily.
# Elevated PTT: Pt with PTT of 107.7. ___ 19.1 and INR 1.7 at
peak during hospitalization. This was likely in the setting of
subcutaneous heparin compounded by her underlying liver disease.
Her SC heparin was discontinued at the time of discharge.
#Anemia: Stable. Likely related to underlying liver disease. She
remained hemodynamically stable. H/H at the time of discharge
9.8/30.0.
# Thrombocytopenia: Stable and near baseline during
hospitalization (64K to 84K). Likely related to splenic
sequestration. Platelet count at the time of discharge 79K. | 246 | 610 |
18260092-DS-17 | 29,732,168 | You were admitted with lethargy and found to have bile
obstruction from gallstones, as well as bacterial infection. A
stent was placed into your common bile duct. You were treated
with antibiotics for your infection and will need to complete a
full course.
Your course was also notable for an abnormal heart rhythm called
atrial fibrillation. After discussing this with your family, it
seems that this is not a new problem for you. You should note
that atrial fibrillation puts you at an increased risk of
stroke. After discussions with you and your family here, the
decision was made not to start anticoagulation right now given
your recent procedure, your need for a repeat procedure soon,
and your history of GI bleeding. You should discuss this
further with your PCP and cardiologist to review the risks and
benefits of long-term anticoagulation to reduce your risk of
stroke.
Please follow up closely with your PCP. You will need to return
for ERCP to remove your stent. | ___ yo M with CAD/MI with DES 5 months ago, COPD, HTN, BPH,
presents with lethargy and nausea, found to have
choledocholithiasis with cholangitis, E.coli BSI. Underwent ERCP
with stent placement. Course also c/b atrial fibrillation.
# Acute GNR BSI/Septicemia due to cholangitis
# Choledocholithiasis
Patient presented with atypical symptoms, without pain or fever.
Imaging findings impressive for choledocholithiasis. Given
E.coli septicemia, concurrent cholangitis presumed.
Cholecystitis was also mentioned on imaging though clinically it
is not clear, and HIDA reportedly negative. He underwent ERCP
with stent placement. He was initially on broad spectrum abx;
however, once OSH cx returned with pansensitive Ecoli, he was
narrowed to ciprofloxacin monotherapy with planned ___fter discussions with patient, he decided for watchful
waiting rather than surgery given his high perioperative risk.
Prior to discharge, he was noted to have a mild uptrend in his
transaminases. He remained asymptomatic and was monitored for
one more night. LFT's subsequently downtredned again.
Of note, while he is at risk for bleeding given sphincterotomy,
he was maintained on ASA. He is not on Plavix but his ASA must
be continued due to his DES. He was monitored closely with no
evidence of bleeding.
# AFib: Noted during routine exam during hospitalization. On
further discussion with his dtr, PAF is apparently a chronic
problem. Already on ASA. CHADS score of 2, CHACS-Vasc of 3.
Discussed risks / benefits of anticoagulation with patient and
family. Did not start at this time given recent sphx as well as
h/o GI bleeding. Pt should further discuss with PCP/cardiology
in close f/u. Not on nodal agent currently, but rates overall
relatively controlled.
# CAD s/p MI with DES: Continued ASA. Not on nodal agent.
# COPD: Continued Spiriva with nebs.
# HTN, primary: Initially held antihypertensives, but restarted
them prior to d/c.
# BPH: Continued finasteride and tamsulosin
# HYPOTHYROIDISM: Continued home Levothyroxine. | 171 | 301 |
14637230-DS-14 | 22,427,467 | You were admitted with diarrhea and abdominal pain and found to
have a c.diff infection of your bowels which you will continue
antibiotics for. Your breast wound also opened up and is being
packed to help it heal. You radiation treatments are on hold due
to your breast wound. | ___ Farsi-speaking with ID-T2DM, HTN, DL, OSA on CPAP, and stage
IIA (pT1c pN1) grade 3 IDC Her2+/ER+/PR- breast cancer, dx
___, s/p lumpectomy/SLNB ___ now on C6D10 TCH
(taxotere/carboplatin/Herceptin) and XRT (started ___
who
was admitted with abdominal pain and N/V/D and found to have
colitis.
C.diff Colitis
- The patient presented with abdominal pain and diarrhea and has
a positive c.diff test. She was originally started on flagyl and
then switched to PO vanc per ID. She will complete a ___s an outpatient. She also was not eating much on
admission but her diet was slowly advanced and she was
tolerating eating well with no nausea or abdominal pain. He
abdominal pain resolved during the admission and her diarrhea
significantly decreased.
Breast Wound Dehiscence
- She was evaluated by surgery and radiation oncology as well as
primary
oncology team. ID was consulted. A breast ultrasound was done. A
wound culture was done and grew some serratia but ID felt that
this was a colonization. The overall consensus was that the
wound was not infected. It has been packed wet to dry and
changed twice a day and will continue to be changed daily which
will continue as an outpatient with home care. She will follow
up with her surgeon and primary oncologist as an outpatient.
Breast Cancer
- Completed 6 cycles of TCH and plan to resume trastuzumab only
in
2 weeks. Radiation therapy currently on hold due to wound
dehiscence.
DM
- Decreased PO intake and subsequent decreased blood glucose
levels. Home insulin decreased to ___ BID 10 units and
metformin being held. Patient to monitor glucose levels at home
and talk to endocrinologist if increasing. | 49 | 266 |
14347103-DS-4 | 20,612,510 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You were in the hospital because you seemed to be more confused
at times. You also had a (small) aura of one of your seizures.
In the hospital, we did tests of your blood and urine which did
not show any signs of infection. You had an MRI of your brain
which was unremarkable, except some narrowing of some of the
blood vessels in your neck and head- this likely comes with age.
You also had an EEG (brain wave test).
Overall, we think that you may have been more confused from the
urinary tract infection you had. Things seem to be improving. We
do not think you need a seizure medication at this time.
When you go home, you should continue to take your same
medications as prescribed. If you have any more confusion or
possible seizures, please call your doctor or return to the
Emergency Department.
Best wishes,
Your ___ team | Mrs. ___ is an ___ year old woman with history of
hypertension, hyperlipidemia, peripheral neuropathy and remote
seizure history thought to be due to temporal lobe mass (likely
cavernous angioma) who presented with episodic confusion, in the
setting of a recent urinary tract infection. She reported having
at least one of her usual seizure auras (epigastric rising
phenomenon) but did not have any seizures that she was aware of.
She was admitted to the Neurology service, given concern for
either seizure or ischemic event. Labs on admission were notable
for lactate of 2.1, which improved without significant
intervention. She also had a mild leukocytosis of 11.9, again
which improved on its own. Labs, including urinalysis, were
otherwise unremarkable. MRI and MRA showed only some
atherosclerotic narrowing of the proximal left middle cerebral
artery, with good distal filling. Otherwise there was minimal
atherosclerotic disease. Her previously seen non-enhancing
calcified mass in the right inferomedial temporal lobe was also
present. It measures approximately 2.1 x 1.6 cm. We also
obtained a routine EEG, with results pending at time of
discharge.
Overall, we suspect etiology of her confusion is likely related
to infectious/metabolic encephalopathy in the setting of recent
urinary tract infection. A breakthrough seizure is possible,
though at this time we elected not to restart anti-seizure drugs
as it was not clear that she had a seizure. We do not feel this
represents TIA or stroke. | 161 | 233 |
14265567-DS-4 | 27,322,715 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were admitted and found to have fevers,
low blood pressures, and diarrhea. You spent 48 hours in the
Cardiac ICU where you received antibiotics and a cardioversion
to convert your heart back into a normal rhythm. Your heart
converted back into the abnormal rhythm atrial
fibrillation/atrial flutter again and you underwent a second
cardioversion. After the second cardioversion, you became
unresponsive and were found to have torsades de ___, a type
of ventricular tachycardia. You were shocked out of this
abnormal rhythm and you were re-admitted to the cardiac ICU. It
was thought that your arrhythmia could have been caused by some
of the antibiotics and other medications you were taking, so
these were discontinued. You were started on some medications to
help with your abnormal rhythms. Ultimately, you were given a
pacemaker. You will need to follow up in device clinic in 1
week.
Please remember to weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
Sincerely,
Your ___ Treatment Team | ___ year old female, with past history of CHF (EF 45% in ___,
Atrial fibrillation, hypothyroidism, and history of subdural
hemorrhage in ___, mechanical AVR, who presented with increased
dyspnea. Prior to admission, she experienced 3 days of DOE with
presyncope.
She was initially admitted to the ___ floor, triggered for Afib
with RVR and hypotension 70/30s. She spiked a temperature to
102.9, with abdominal discomfort. She was transferred to the
CCU. In the CCU, bedside echo showed collapsible IVC, in setting
of potential viral illness and diarrhea interpreted as overall
hypovolemia. She received a total of 3L of fluid over the course
of 24hrs during her stay in the CCU. She was also started on
Vanc/Zosyn after CXR was concerning for a retrocardiac process,
likely PNA. She was transferred back to the ___ general floor
after being narrowed to Ceftri/Azithro.
She returned to the floor and was managed with regards to the
following main issues:
# Acute on chronic systolic heart failure. She remained mildly
volume overloaded but was not actively diuresed given SBPs
80-90s, asymptomatic.
# CAP. She developed a fever several hours after returning to
the ___ floor from the CCU. Antibiotics were rebroadened to
Vanc/Zosyn. ID was consulted, with the recommendation to
complete an 8 day course of treatment with Ceftriaxone and 5
days with Azithromycin.
# Afib: she underwent TEE cardioversion but developed recurrent
AF shortly thereafter. However, she converted back into Afib
with RVR and triggered for rates 150s with hypotension 80/50s.
She was treated with PO metoprolol with stabilization in rate of
blood pressures. Amiodarone was started and she had a repeat
cardioversion. She was maintained on a heparin gtt, which was
discontinue ___ AM as INR 2.6. She was continued on both
warfarin and ASA. However, she had Vtach with cardiac arrest
secondary to torsades. She was transferred back to the CCU, and
her course by problem list was:
==========
CCU COURSE
============
# Cardiac Arrest | Torsade de Pointes
On the floor, telemetry stripes demonstrated polymorphic VT that
was felt to be secondary to bradycardia, amiodarone,
azithromycin and fluoxetine use and frequent ventricular ectopy
triggering VT. No history to suggest new ischemic event leading
to event. Electrolytes were normal from AM. Was transferred to
CCU, then had repeat torsades overnight on ___, requiring
defibrillation x1. Lidocaine was initiated which successfully
suppressed her ventricular ectopy and she was later transitioned
to mexilitene. All QTc prolonging medications (amiodarone,
azithromycin, fluoxetine) were discontinued. Lidocaine was
titrated down on ___, and replaced with Mexiletine. Metoprolol
was restarted on ___ once heart rates had increased. EP was
consulted, and placed a dual chamber ICD with His bundle pacing
on ___. Procedure was uncomplicated and patient was discharged
on ___.
# Atrial Fibrillation/Flutter w/ RVR
Patient was s/p cardioversion ___, in NSR until 4am ___,
when she converted back into Afib with RVR, and triggered for
rates 150s with hypotension 80/50s. She was cardioverted on ___
with subsequent cardiac arrest as above. Last dose of Warfarin
was on ___. INR remained elevated until ___, when it dropped
to 1.8. Metoprolol was restarted on ___ once heart rates had
increased. Heparin to Warfarin bridge was used. Patient had
BiV-AICD placed on ___. Amiodarone was resumed on discharge.
# Acute on Chronic Systolic Heart Failure
Per old records, patient had EF 45-50% in ___, but was EF
22% on repeat TTE this admission. BNP on admission ___.
Appears volume overloaded on exam, repeat BNP 33,000 on ___.
Patient was diuresed with IV Lasix for net negative goals of
___ L per day. Diuresis was limited by hypotension during
admission.
# ___
Cr uptrended 1.9 from 1.1. Was thought to be pre-renal and
patient was diuresed but creatinine continued to worsen. Unclear
what the etiology of her worsening kidney function is.
# Bicuspid Aortic Valve and Stenosis s/p Mechanical AVR
- INR was supratherapeutic so warfarin was originally held. Then
patient was bridged with heparin to warfarin again prior to
BiV-AICD placement. Patient will be discharged on warfarin.
# Community Acquired Pneumonia: Treated & resolved
Started antibiotics on ___, initially treated with vancomycin
and Zosyn, and then transitioned to ceftriaxone and azithromycin
for planned 8 and 5 day course respectively until ___ and ___.
Completed course of ceftriaxone 1gm Q24H until ___.
# Hypothyroidism
- Continue home levothyroxine 150mcg/day
# Psoriasis
- Continue Triamcinolone TID
# Anxiety/Depression
- Hold fluoxetine due to prolonged QTc / Torsades. Consider
restarting as outpatient now that BiV-AICD placed.
TRANSITIONAL ISSUES
====================
# Antiarrhythmic Therapy: Pt. discharged on amiodarone 400mg PO
BID Day #1 ___ with a 3 week load. She should transition to
200mg Daily on ___. Pt. was placed on mexiletine during her
hospitalization. This was discontinued at discharge.
# Lap Band: F/u with Dr. ___ Bariatric ___ as an
outpatient
# Mag Goal: 2.5, continue outpatient magnesium supplementation
# MCV elevated to 102; f/u as outpt; not anemic
# INR 2.1 on day of discharge. Discharged on 5mg warfarin. Will
need INR f/u with ___ clinic. Close frequent INR
follow-up in the short term is needed given that she is being
started on amiodarone.
# Will need 1 week follow up in device clinic ___ office
with Dr. ___ on ___ Pt. will be called with
timing.
# Will need 1 month follow up with cardiology, to be arranged by
At___ Office.
# Fluoxetine: Held at discharge given that this medication can
prolong QT interval. Dr. ___ monitor ___ QT on
amiodarone and decide when it is appropriate to start fluoxetine
as an outpatient.
# CODE: Full
# CONTACT: Patient, Daughter ___ ___ | 183 | 912 |
10871272-DS-20 | 21,476,336 | Dear Mr. ___,
You were hospitalized due to symptoms of being unable to speak
or move resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1) DM: A1c 11.2%
2) Hyperlipidemia: LDL 81
3) Atrial Fibrillation not previously on anticoagulation
An echocardiogram did not show a PFO on bubble study, though
the image quality was poor.
We are changing your medications as follows:
- continue apixaban
- continue atorvastatin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | In brief, Mr ___ is a ___ year old M w/ diabetes, HTN, pAF not
on A/C presented to OSH ___ with a large L ___
transferred to ___ for surgical evaluation of left ischemic
limb. Initial NIHSS 23.
NCHCT shows evolving L PCA infarct but no hemorrhage. Patient
was not a tPA or thrombectomy candidate as he presented outside
the window for intervention. The patient has several vascular
risk factors. His stroke is likely cardioembolic given that he
has known atrial fibrillation and is not on A/C. | 317 | 89 |
12032388-DS-16 | 26,971,837 | Dear Mr. ___,
You were admitted to the hospital because of belly pain and
finding that your TIPS was occluded. The radiologist fixed the
TIPS and removed fluid from your belly. Unfortunately, you were
found to have liver tumors on some of the imaging - the liver
tumor board is working to find the best option for you. Overall,
you were improved and ready to be discharged home.
We wish you the best,
Your ___ Care Team | Mr. ___ is a ___ man with history of HCV/ETOH
cirrhosis status c/b diuretic refractory ascites s/p TIPS, hx of
SBP, hepatic encephalopathy, inguinal hernia, chronic pain, who
is referred for admission after after outpatient U/S revealed
occluded TIPS now s/p TIPS revision; with course complicated by
discovery of new HCC.
# HCV/ETOH cirrhosis
MELD 16 on admission. Has HCV/ETOH cirrhosis c/b diuretic
refractory ascites s/p TIPS, hx of SBP, hepatic encephalopathy.
He has been having increasing abd pain/distention likely related
to his occluded TIPS. Diagnostic paracentesis not consistent
with SBP. ___ performed a successful TIPS revision on ___
without complication. Otherwise, for volume was continued on
home Lasix and Spironolactone - he also received a large volume
paracentesis on ___. His diagnostic paracentesis did not
demonstrate SBP, and as such he was continued on his
Ciprofloxacin prophylaxis. For bleeding, his last EGD in ___
demonstrated grade 1 esophageal varices now s/p TIPS. And
finally, for encephalopathy he was continued on home Lactulose
and Rifaxamin.
# HCC
Had lesions on U/S concerning for new HCC, which were further
characterized on triphasic CT as a 3.4cm HCC lesion. AFP 33.7
(from 10.9 in ___. CT Chest and MRI Liver w/o evidence of
metastasis. His case is being discussed at tumor board, and he
should follow up with the ___ liver tumor clinic. Social work
was consulted.
# Hypotension
Upon record review, SBP typically 70-90s likely in setting of
cirrhosis physiology. His blood pressure were monitored
carefully.
# Thrombocytopenia
Likely iso cirrhosis and splenic sequestration. His SC heparin
was held when platelets were <50
# Coagulopathy
INR 1.8 likely iso synthetic liver dysfunction vs. poor
nutritional status. Did a Vit K challenge 10mg qd x3 days with
partial improvement in INR to 1.5. Nutrition was consulted. | 76 | 289 |
11250458-DS-11 | 22,250,320 | Dear Ms ___,
It was our pleasure to take care of you during this hospital
stay.
You were hospitalized due to symptoms of right hand weakness
and vertigo resulting from a small ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. History of radiation that can damage the blood vessels.
2. history of high cholestrol level.
3. History of high blood pressure.
We are changing your medications as follows:
We added baby Aspirin 81 mg po daily, it will help to prevent
more stroks.
We also added bactim 1 tablet every 12 hours for 3 days as your
urine test showed that you have urinary infection.
We will prescribe you meclizine in case for dizziness.
You need an Echo cardiography, the department will call you
regarding the date.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms;
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body;
- sudden drooping of one side of the face;
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech;
- sudden blurring or doubling of vision;
- sudden onset of vertigo (sensation of your environment
spinning around you);
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | 1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (x) Yes (LDL = pending) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (xx) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for follow up) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
_
_
_
_
_
________________________________________________________________
___ year-old right-handed woman with a PMH of remote pituitary
adenoma resection with cranial radiation, HTN, and HL who
presents with headache, head spinning, and right hand weakness.
These symptoms were present since ___ and she was seen at
___ on ___. Neuro exam shows right hand weakness
and sensory changes. Imaging shows new left cerebral peduncle
hyperintensity, most likely representing subacute infarct. MRA
shows patent large vessel vasculature, however, most vessels in
the circle of ___ appears irregular and show segmental
narrowings, possibly the long-term effects of being exposed to
radiation. It was thought that this radiation vasculopathy and
possibly some secondary atherosclerosis might have contributed
to her left cerebral peduncle stroke. She was started on aspirin
81 mg , we assessed the stroke risk factor and schedule an echo
as an outpatient.
her exam improved at the end of the day and she was discharged
home.
Her urine showed bacteriuria and she was started on Bactrim for
3 days.
She was evaluated with physical therapy service and discharged
home. | 384 | 354 |
17852092-DS-15 | 25,582,166 | Dear Ms. ___,
It was our pleasure participating in your care here at ___.
You were admitted with concern for an infection of your buttocks
where you had silicone implants. On our exam, fortunately there
were no signs of infection so your antibiotics were stopped.
You will have outpatient appointments with Plastic Surgery for
further evaluation of the bumps in your buttocks as well as with
Dermatology to better identify what is causing your itchiness.
It will be very important that you make these appointments!
If you should have more pain, drainage from the bumps in your
buttocks or have fevers, please let your doctors know ___
away.
Again, it was our pleasure participating in your care.
We wish you the best!
-- Your ___ Medicine Team | PRIMARY REASON FOR ADMISSION: This is ___ yo transgender male to
female with a history of HIV (CD4 847 this month) and buttock
silicone implants ___ years ago, presents with L buttock swelling
and intergluteal cleft pruritis.
ACTIVE ISSUES
#Silicone Implant Toxic Effects (buttocks): The most likely
cause of the buttocks lesions are granlumatous lesions formed by
the silicone implants. This is not an emergent issue and given
that they are clearly visible on both buttocks by CT, this is
not a single ruptured implant. She will refer to outpatient
plastics surgery clinic for further workup. If this is
granlumatous disease from the silicone there are a variety of
therapies (mostly immunosuppresive) which will need close
coordination with her HIV physician. There is no evidence of an
acute infection for the buttocks leasions, given lack of
leukocytosis or fevers, so she was not given any antibiotics.
# Anal Fistula: The fistula could be consistent with polynoidal
cyst, but will defer to a dermatology outpatient appointment.
Given that there is no evidence of acute infection and that her
symptoms have been ongoing, her antibiotics were discontinued as
acute abscess or cellulitis seem less likely.
# Goals of Care: The patient reported not wanting to be
rescucitated and that she would 'not want to be brought back'.
She noted that she 'had this disease for too long'. She also
reports that she has not had this discussion with her PCP or
family members. She may benefit from further conversation about
her goals and code status. | 123 | 253 |
15229355-DS-6 | 21,413,617 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" , 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:
- WBAT with walker
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 have no surgical wound and You may shower, baths or ___.
Physical Therapy:
WBAT, ROM as tolerated, Troch precautions, Limit Abduction
Treatments Frequency:
___ | Hospitalization Summary
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L hip with intertrochanteric fx and was admitted to the
orthopedic surgery service. The patient did not need surgical
intervention at this point. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications after deciding to continue with non
surgical management. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab facility 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
WBAT with troch precautions in the LL extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 154 | 209 |
14562183-DS-11 | 22,094,446 | Dear ___ was a pleasure caring for you.
You were admitted for abdominal pain. You were found to have an
infection in your blood as well as pancreatitis (inflammation of
the pancreas) caused by gallstones. For this you received
antibiotics and a surgery to remove your gallbladder. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
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. | ___ w/ hypertension, hyperlipidemia who presents with acute
onset of abdominal pain. Possible pancreatitis, potentially
gallstone mediated, +/- cholecystitis, also with GPCs and GNRs
in blood. Transferred from medicine to surgery for
cholecystectomy. | 751 | 34 |
16830390-DS-21 | 26,043,771 | Dear ___,
___ were admitted to the hospital for pain and weakness in your
right arm. We felts your weakness was due to the extension of
your breast cancer into the brain. The pain is thought to be due
to muscle inflammation and we provided additional pain
medications. After a long discussion with a large team of
doctors ___ your best option is to go for the clinical trial
of a new drug at the ___ Cancer ___.
Please take your medications as indicated and do not forget your
appointment on ___ morning. | Ms. ___ is a ___ woman initially diagnosed ___
with Stage IB (T1cN0) ER/PR+ HER2 negative left invasive ductal
carcinoma s/p lumpectomy w/o further therapy who presented
___ with widely metastatic breast cancer with involvement of
brain,upper thoracic lymph nodes and liver w/p WBRT completed
___. She has been on treatment with palliative taxol. Her course
has been complicated by recurrent malignant pericardial
effusion, SVC syndrome and LUE DVT on BID lovenox. She is now
admitted from the ED with RUE weakness, pain and fatigue.
# Right Upper Extremity Weakness/ Multiple Enlarging Brain
Metastases: Patient with focal right arm weakness that has been
noted previously but appears to be worsening over past several
weeks. Likely from progressive CNS disease as demonstrated by
brain MRI showing progressive increase in size of multiple brain
metastases. TSH and AM cortisol were found to be within normal
limits. She was started on dexamethasone 4mg every 6h with
intent of reducing vasogenic edema and thus perhaps improve
neurologic deficit. Home levetiracetam was continued. A
multidisciplinary discussion including neuro-oncology,
neuro-surgery, radiation oncology was held. As she had gotten
maximum dose of WBRT she is not a candidate for repeat WBRT. She
was also not a candidate for surgical resection and she would
not want surgery either. There were no significant improvements
to her neurological deficit while on steroids which were started
to be tapered prior to discharge and will be tapered further per
DC instructions. She may still be a candidate for cyberknife for
some selected lesions but unlikely to change overall prognosis
or to improve neurologic deficit. Given this the best option
considered was systemic chemotherapy as below. Multidisciplinary
decision was to send her to ___ for chemotherapy trial.
# Right Arm Pain: Patient noted worsening right arm muscular
pain on admission. Denies other muscle pain. MRI showed
intramuscular edema within the muscles surrounding the right
shoulder and distal right humerus compatible with myositis.
Differential includes medication-induced, inflammatory, and
infectious. Unlikely to be infectious given no fever, no
leukocytosis prior to steroids or purulent inflammation. On
review of medication list, colchicine is associated with
myositis, nonethless CK was normal at all times. There may be a
component of edema from chronic venous occlusion or adenopathy.
She did not have any improvement with a prolonged course of high
dose steroids which argues against myositis. Rheumatology was
consulted and felt that no additional investigation/therapeutic
intervention was to be offered if this was indeed a myositis,
and felt that lack of CK elevation argued against inflammatory
myositis. Alterntive etiologies included radiculopathy or
plexopathy. This was discussed with patient who felt she would
like to focus her efforts on her cancer at the moment. It was
also felt that her brain lesions were very likely contributing
to her RUE weakness. Her oxycodone was increased to 10mg q4h:prn
from 5mg q4h:prn and gabapentin 300mg tid was added with
symptomatic improvement. Colchicine was held without recurrence
of chest pain or rub. It was continued to be held upon
discharge. Given new need for help with medications and
dexterity and mobility rehabilitiation ___ services were
arranged for her.
# Metastatic ER+ HER2- Breast Cancer: Noted to have progressive
CNS disease on MRI ___. Has previously received WBXRT,
maximum dose. Cyberknife is a possibility but unclear if highly
beneficial given multiple. Her very poor prognosis progressing
through multipl regimens was discussed at length with her and
her sister. Even though she seemed to understand she views her
disease through the lens of her faith and believes "if God made
me survive the earthquake it will make me survive my cancer".
She would like to continue trying new therapeutic approaches. I
discussed at length with her and her sister that these
approaches will at best temporize her disease and improve her
quality of life. She understands but would still like to view
this with hopes of cure since she believes that will help her
anyway. She was offered to attempt inclusion into clinical trial
___ ___ of Abemaciclib
(CDK4/6 inhibitor) at the ___ and or
bevacizumab/capecitabine per Dr. ___. She
opted for the trial at ___. Referral was made to Dr. ___
___ who ___ see her on ___ 8am. The release of her ___
records and staging CTs and brain MRIs were arranged. This DC
summary was sent by email to Dr. ___. The patient was given
CDs with all her imaging to bring to the appointment.
# Malignant Pericardial Effusion: Resolved on TTE, s/p
pericardial window. Colchicin was held as above. She did not
have any recurrence of pain or pericardial rub.
No recurrence of chest pain.
# LUE DVT: She was continued on enoxaparin 60mg q12h.
# Graves Disease: TSH normal x2. Was continued on methimazole.
Scheduled to see endocrinology as an outpatient for follow-up
# Anemia: No evidence of active bleeding. Hemoglobin was
monitored in house without significant changes
# Sinus Tachycardia: During previous hospitalization baseline HR
was 110-120s. TTE stable. HR on DC in the ___. | 92 | 820 |
18115365-DS-36 | 29,229,210 | Dear ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I IN THE HOSPITAL?
- You had a pneumonia
- Your kidney function was slightly decreased
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- You were given antibiotics
- Your torsemide was held then restarted
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Talk to your kidney doctor about whether your torsemide dose
should be adjusted.
Be well!
Your ___ Care Team | Ms. ___ is a ___ year old woman with a PMH of ESRD ___ type 2
diabetes on insulin s/p LRRT ___ (on immunosuppressive therapy)
HTN, OSA on CPAP, GERD, HLD presents with productive cough, SOB,
and focal opacities on CXR c/w pneumonia. She was treated with
ceftriaxone/azithro -> cefpodoxime/azithro for 5d course with
improvement. Diuretics were held during admission for mild ___
thought to be ___ intravascular volume depletion, restarted on
d/c per renal transplant team. Appeared somewhat overloaded, but
aggressive diuresis held per renal transplant team. Tacro levels
at goal during hospitalization (___). | 86 | 92 |
19101100-DS-20 | 28,208,930 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for volume overload. We held many of your blood pressure
medications to allow for more fluid to be removed during
dialysis. We successfully removed a significant amount of fluid
by dialysis this admission and your condition improved. We have
discussed your new dialysis settings with your kidney doctors.
You will continue to recieve dialysis after discharge.
The following changes were made to your medications:
STOP hydralazine
STOP isosorbide mononitrate
STOP amlodipine
CHANGE labetalol to 300mg twice daily | ___ yo M with DM c/b nephropathy and retinopathy, ESRD on HD
(MWF), HTN, HCV (not treated) and other medical issues, recently
admitted from ___ for abdominal pain possibly ___ ascites
thought to be from volume overload who returned for recurrent
dyspnea, likely related volume overload. During the admission,
his dry weight was re-established, with concern that he had lost
significant weight recently and therefore needed a new dry
weight. | 91 | 70 |
17462187-DS-7 | 22,156,657 | Lumbar Fusion
Dr. ___
Keep your wound clean and dry until they are removed.
You should wear your brace when out of bed or when your head
of bed is above 45 degrees.
You may put the brace on at the edge of your bed.
You may use a shower chair to bathe without the brace on.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101.5° F.
Loss of control of bowel or bladder functioning | Ms. ___ was admitted to the the neurosurgery department for
continued monitoring and evaluation. On ___ she underwent a CT
torso which revealed lung and hepatic metastasis. Her TLSO brace
arrived and she was OOB with ___. It was determined she would go
to the OR on ___ for a L1-2 laminectomy and a T10-L5 fusion.
On ___, patient remains stable on examination. She was
transferred to ___ for a breast u/s to rule out breast
metastatsis which revealed bilateral breast cysts. She was taken
to the OR.
On ___, she remained stable on exam. Pain cotroled with PCA
dilauded, which was weaned to po Oxycodone and dialuded IV fro
breaktrhu pain. She became hypotensive last night and early this
morning to sbp in the low 80's and her urine was low, she was
given 500cc IVF bolus x2. Her hgb and hct dropped to 8.3/___.9,
she was transfused with 1 unit of PRBCs. Her hemovac since OR
drained 370cc. Repeat H/H on ___ were ___. Platelets
were 92 at that time. Repeat platelets were 99.
On ___, Mrs. ___ was out of bed to chair wearning her TLSO
brace. She had one instance of urinary retention for which she
was catheterized once. IV fluids were initiated since she
wasn't taking in much oral fluids. The patient was tolerating a
regular diet. Standing films of her thoracic and lumbar
vertebrae while in the TLSO brace were obtained.
On ___, the patient was symptomatically orthostatic in the
morning, and repeat Hct was 21.6, down from 28.9. The patient
was transfused 2u pRBCs, and post-transfusion Hct was
On ___, The ptaients Hemovac drain output 995cc in the
morning. The drain output slowly decreasing. The patient was
orthostatic when out of bed in the morning and the morning
hematocrit was 21.6. The patient was transfused with 2 units of
packed red blood cells. The patients post transfusion
hematocrit was 29.6.
On ___, The patient was found to have a urinary tract
infection and was initiated on a course of ciproflxacin. The
patient's intravenous fluid was discontinued. The patient was
noted to have bilateral feet edema and her feet were elevated.
The hemovac drain output was 780 cc overnight. A CT of the
thoracic & lumbar spine was performed. The hemovac was
discontinued.
On ___, The patient serum potassium, magnesium, calcium were
low and were repleted. Physical therapy was asked to reevaluate
the patient for rehabilitation. The patient dressing was dry,
clean, and intact. The patient' shemoglobin and hematocrit were
stable at 9.6/29.7.
On ___, she remained hemodynamically and neurologically stable
and was prepared for planned discharge on ___.
On ___ she underwent an MRI scan of the brain and was deemed
fit for discharge to home with in home physical therapy. She was
given prexcriptions for required medications, instructions for
follow-up, and all questions were answered prior to discharge. | 267 | 492 |
11055094-DS-22 | 23,999,098 | Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted to the hospital because you were short of breath
and had a fever. The most likely cause is a flare of your COPD,
so you were given antibiotics and steroids. We performed a scan
which showed that you did not have pneumonia. You improved
during your time in the hospital and so you were discharged
home.
Please take note of the following:
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Continue levofloxacin for 1 more dose of 500mg on ___
- Continue prednisone for 2 more days ___ and ___. Take 1
dose of 40mg each day.
- Start using the fluticasone nasal spray
- Resume taking the rest of your home medications as you've been
instructed
- Followup with Dr. ___ primary care doctor, on ___
___ at 1:30 ___ at ___.
Remember to take your Spiriva (or equivalent) and Advair every
single day. Use the albuterol nebulizer only for worsening
breathing. This will help avoid future episodes that require you
to come to the hospital.
If you have any concerns please let us know. It was a great
pleasure taking care of you!
- Your ___ team | ___ w/ PMH of ESRD on HD (MWF), COPD, HFpEF, HTN, DM, Carotid
artery stenosis & retinal artery embolus (on clopidogrel/ASA),
prostate CA s/p bracytherapy, and urethral strictures s/p
multiple dilations who presented to the ED with SOB and fever,
likely due to COPD exacerbation.
#Dyspnea/COPD Flare: The patient presented with leukocytosis,
productive cough and fevers initially concerning for pneumonia,
and the patient was initially started on Vanc/Cefepime for HCAP
coverage as the patient undergoies HD. However CXR and
subsequent non contrast CT chest were not consistent with
pneumonia, and all cultures remained negative. Vanc/Cefepime was
discontinued. The presentation was thought likely secondary to a
COPD flare, possibly in setting of improper use of home
medications. The patient was started on a 5 day course of
prednisone with improvement in symptoms. Given recent course of
azithromycin, the patient was continued on levofloxacin with HD
dosing for a 5 day course. Patient was placed on standing nebs,
continued advair, as well as loratidine and fluticasone.
Acapella valve was also utilized. Given the subacute shortness
of breath and cough, in the setting of the patient's heavy
smoking history, the patient underwent a non contrast CT Chest
negative for evidence of ILD or malignancy. The patient was
weaned to RA by HD # 2, with improvement in symptoms. Ambulatory
O2 Sats were 92-95. Proper use of medications was encouraged.
Patient was discharged home on room air to finish 5 day course
of levofloxacin HD dose and prednisone 40mg.
# ESRD: The patient had no history of prior missed sessions and
no evidence of volume overload on exam. Underwent HD on ___ as
inpatient without issue. Patient continued on nephrocaps,
sevelamer, low K and low phos diet.
# HTN: Patient remained normotensive. Continued home amlodipine,
hydralazine, and labetolol. Torsemide held while inpatient given
initial concern for infection and no evidence of volume overload
but restarted upon discharge.
========================
CHRONIC ISSUES
========================
# Carotid artery stenosis: Continued on home aspirin and Plavix.
# ANEMIA: Chronic and at baseline, multifactorial ___ CKD and
aemia of chronic disease). Epo per renal.
# CAD/HLD: Continued home Atorvastatin
# dCHF: No overt signs of decompensation clinically. Continued
hydralazine, labetolol. Torsemide held as above.
# DM2: Placed on HISS while inpatient. Sugars remained well
controlled despite prednisone burst.
# GERD/PUD: Continued home Omeprazole.
# Hx of prostate CA and BPH w/urethral strictures: Patient
produces a small amount of urine. Continued home terazosin and
finasteride.
========================
TRANSITIONAL ISSUES
========================
[ ] Continue levofloxacin for 1 more dose ___ (total 5 day
course)
[ ] Continue prednisone for total 5 day course (___)
[ ] Ensure MWF dialysis
# CODE: Full (confirmed)
# CONTACT: ___ (wife) ___ c: ___ | 204 | 426 |
15880144-DS-14 | 22,280,928 | Dear ___,
You were admitted to the hospital with abdominal pain, which we
think is most likely from your fibroid.
Your pain improved with pain medication.
It is now safe to discharge you home.
We are discharging you home with some dilaudid for pain control
to take as needed. If you do need to take it, you should call
Dr. ___ office to let her know.
Dr. ___ will set you up for an appointment next week.
Please call for any of the following:
- Worsening abdominal pain
- Vaginal bleeding
- Leakage of water or concern that your water broke
- Nausea/vomiting
- Fever, chills
- Other concerns | Ms. ___ is a ___ G1 who was admitted with abdominal
pain, thought to be mostly likely secondary to a degenerating
fibroid. She was evaluated by the Acute Care Surgery service
who had low suspicion for appendicitis. She had a pelvic
ultrasound that showed a fibroid uterus with 11cm right fundal
fibroid. MRI showed a 14cm pedunculated fibroid with internal
edema, suggestive of either degeneration or torsion. The view
of her appendix was equivocal, but appeared normal. Her white
blood cell count was trended, and decreased (16 -> 13 -> 12).
She received 48 hours of Tylenol and indomethacin with an
improvement in her pain and her abdominal exam. Her diet was
advanced as tolerated. She was kept on her home acetazolamide
for her history of pseudotumor cerebri. She was discharged home
from the hospital in stable condition with plan for close follow
up. | 112 | 153 |
17738546-DS-4 | 27,747,125 | Discharge Instructions
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.
· 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) for 1 week. You may resume your
Aspirin after 7 days, and resume Plavix after 9 days.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· 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:
· 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 | Mr. ___ was admitted to the neurosurgery service on
___ s/p assault, found to have small parafalcine SDH.
Aspirin and Plavix were held and he was given 1 unit of
platelets. He remained confused, but neurologically at his
baseline. Repeat imaging on ___ showed stable hematoma.
Case was discussed with outpatient social worker/case manager,
who is familiar with patient/family. Family member involved with
assault is not in jail and will not be allowed to return to
house. Patient was cleared to discharge home on ___ with home
___ and his prior ___ supervision/home health aides. Recommend
hold Aspirin for 7 days and Plavix for 9 days. Patient will
follow up with neurosurgery in 8 weeks with repeat CT scan. | 415 | 121 |
10407740-DS-20 | 23,788,011 | Dear Mr. ___,
It was a pleasure caring for you at the ___.
- WHY WERE ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because your bilirubin
levels were high.
- WHAT HAPPENED WHILE YOU WERE ADMITTED?
- Due to consumption of alcoholic beverages, you had acute
inflammation of your liver, a condition called alcoholic
hepatitis.
- You were found to have a urinary tract infection for which you
were treated with antibiotics.
- You were treated with a 7 day course of steroids for your
alcoholic hepatitis. However, due to lack of appropriate
response, this was stopped.
- You were found to pneumonia and were treated with IV
antibiotics.
- You had feeding tube placed to help you get enough nutrients
and help your liver to recover.
- WHAT SHOULD YOU DO WHEN LEAVE THE HOSPITAL?
- You should continue to take your medications as prescribed.
- You should attend your follow up appointments listed below.
We wish you all the best!
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES
=================
[] F/U labs to be drawn on ___ and faxed to Transplant
Hepatology (Fax ___
[] Will need ongoing adjustment of insulin for blood glucose
control while on tube feeds
[] Started on tube feeds for nutritional support to be continued
after leaving the hospital
[] Held spironolactone
BRIEF SUMMARY
=============
Mr. ___ is a ___ year-old male with history of decompensated
alcoholic cirrhosis (inactive on transplant list) who was
referred from outpatient clinic due to hyperbilirubinemia.
Patient found to have alcoholic hepatitis failed trial of 7-day
course of steroids. His hospital course was complicated by UTI
and hospital acquired pneumonia. He was started on tube feeds
for nutrition.
ACTIVE ISSUES
==============
# Alcoholic hepatitis
# Worsening hyperbilirubinemia
# Malnutrition
Patient was referred from outpatient clinic for
hyperbilirubinemia. Reported drinking non-alcoholic beer,
positive ethanol level at ___ on ___. On admission,
there was no evidence of PVT, GI bleed, no tappable ascitic
pocket was found. Blood cultures were negative. CXR was clear.
On admission, his MDF was 50.7. However, patient was not started
on steroids as he had UTI. After completing a 5-day course of
antibiotics and due to continued worsening of his numbers, he
was started on 7-day trial of prednisone 40mg on ___ till
___. His MDF on ___ was 74.3 and 67. Lille score on ___ > 0.45 (discontinued steroids given nonresponse and
hyperglycemia). Patient also had a dobhoff placed but vomited it
out on ___. Dobhoff was replaced on ___ under direct
visualization. Tube feeds were initiated. Rate was increased to
65 cc/hr, unable to tolerate further increases due to emesis.
Continued ursodiol 300mg BID.
# Esophageal varices with h/o bleeding s/p banding
# Portal hypertensive gastropathy
# Hematemesis
EGD ___ with 3 cords of grade I varices in the distal
esophagus. He had a small amount of hematemesis on initiation of
tube feeds with stable CBC which resolved and he was able to
tolerate tube feeds prior to discharge in addition to oral
intake. Nadolol was restarted on discharge.
# Viridans strep UTI (resolved)
UA from ___ showed WBC and bacteria. UCx grew gram positive
bacteria speciated to viridans strep. Patient was treated with
5-day course of ceftriaxone between ___.
# RLL Infiltrate c/f HAP (resolved)
# Leukocytosis
Patient had worsening SOB, mild tachycardia, leukocytosis, and
CXR c/f HAP. Possibly in setting of aspiration ___ emesis. U/A
with negative leuks/nitrites.BCx/UCx were negative. Repeat
abdominal ultrasound showed trace perihepatic ascites. Patient
was converted initially with cefepime for 7 days (D1:
___. Vancomycin was discontinued due to negative MRSA
swab.
# ___
Patient had a rise in his Cr to 1.4 on ___ that was thought to
be pre-renal in the setting of sepsis. He was started on
ceftriaxone as above and albumin challenge with 75g of 25%
albumin with subsequent improvement in kidney function to base
line of 1.0-1.1. Subsequently, patient was another rise in Cr to
1.4 on ___ that was also thought to be related to HAP. Patient
was treated with cefepime for HAP and albumin challenge. Cr was
stable at discharge at 1.5.
# ___
Discussions were held with patient and girlfriend about poor
prognosis with consideration of home hospice. Not eligible for
transplant until 3 months sobriety given recent ethanol level.
After discussion, he expressed his wish to continue with
treatment and placement of feeding tube.
# Metabolic acidosis
Likely due to chronic diarrhea from lactulose and renal
dysfunction. He was trialed on bicarbonate 1300mg TID but mild
acidosis persisted and this was discontinued due to lack of
improvement and concern for sodium load.
# Elevated CEA
Unclear etiology. Recent MRI showed a 5.5x4.5cm liver lesion
that appeared similar to background liver tissue rather than ___
or metastasis. No lesions on colonoscopy ___ at ___ nor
EGD ___ at ___.
# Alcohol use disorder
Counseled patient to avoid non-alcohol beer and continue his
current efforts to maintain sobriety. Multivitamin and thiamine
were started.
# DM2 on insulin
Home basal/bolus insulin regimen was adjusted with increased
requirements while at steroids. Blood glucose increased with
tube feeds and will likely need continued adjustments to insulin
regimen based on po intake. | 167 | 666 |
16954175-DS-20 | 28,340,285 | Dear Ms. ___,
You were admitted to ___ due to concerns about your safety at
home. You were found to have a urinary tract infection for which
you were treated with antibiotics. You were also seen by our
psychiatry service due to concerns regarding visual
hallucinations.
We are discharging you home and would like you to follow up with
your outpatient psychiatrist for further evaluation.
It was a pleasure to take care of you during your hospital stay.
Sincerely
Your ___ Team | ___ year old female with h/o HTN, cardiomyopathy, dCHF, ___
s/p cardiac arrest, DM, strokes, referred in by outpatient
providers for concerns regarding hallucinations and her safety
at home, found to have a UTI.
# Psychosis NOS/probable Dementia: Patient was seen as an
outpatient by Dr. ___ (Psychiatry) on ___ who
diagnosed the patient with psychosis NOS. The patient was
reportedly experiencing visual hallucinations and had delusions
regarding people living in the basement of her home (the home
did not have a basement, nor additional tenants). She was seen
by the inpatient psychiatry consult service who, after speaking
with both the patient and her daughter (with whom she lives),
agreed that the patient had evidence of delusions and prior
visual hallucinations (no active hallucinations at present). The
etiology of her psychiatric disturbance is not entirely clear
but was deemed by psychiatry as appropriate for management as an
outpatient. There were no safety issues or concerns about the
patient's ability to perform ADLs/IADLs, however, so the patient
was discharged home where she lives with her daughter and
grandchildren. She will continue to see with her outpatient
psychiatrist Dr. ___. Neuropsychiatric testing is
recommended in the outpatient setting.
# UTI: Urinalysis with >182 WBCs and many bacteria on admission.
Urine culture was contaminated and grew skin flora. Though she
was asymptomatic, she was treated with 2 days of ceftriaxone IV
then switched to cefpodoxime PO at discharge and provided with a
prescription to complete a total of 7 days of antibiotic
treatment.
# DMII: Pt had an episode of hypoglycemia on the day of her
fall/ admission. During hospitalization she was hyperglycemic.
Insulin regimen was adjusted as noted below.
# Code Status: Confirmed full code
# Emergency Contact: ___ (daughter, cell: ___ | 78 | 287 |
13363525-DS-3 | 22,854,335 | Dear Ms. ___,
You were hospitalized due to symptoms of room spinning resulting
from a possible ACUTE ISCHEMIC STROKE, a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High cholesterol
We are changing your medications as follows:
Start aspirin 81mg and atorvastatin 20mg
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | MS. ___ was admitted after an acute onset episode of vertigo
and emesis. On exam, she was found to have R torsional
horizontal nystagmus on R gaze. Upon admission, vertigo
resolved.
CTA revealed L frontal AVM and possible subtle signs of a
fibromuscular dysplasia of her carotid arteries. This location
would be difficult to visualize with a carotid US. There does
not appear to be any moderate or high grade stenosis in this
location.
She will follow-up with neurosurgery as an outpatient given
intracranial AVM.
MRI was unable to be obtained because she had multiple coils
placed in her lungs, and the prior operative note did not detail
the type of all coils placed, so it was unclear if they are MRI
compatible. Given possibility she had a cerebellar stroke versus
peripheral vestibulopathy not able to be determined without
imaging, her secondary stroke prevention was optimized with ASA
81mg and atorvastatin 20mg.
LDL 129, A1C 5.4. She was monitored by telemetry without
arrhythmia. Echocardiogram could be obtained as an outpatient.
Her BP remained mostly SBP 110s-140s. After stairs she had
increased BP to 180 that immediately improved with rest to 150s.
She will be working with home ___, but we discussed with family
to monitor BP during activity to prevent spikes given known AVM.
She will follow up with PCP this week for BP check.
She was evaluated by ___ who felt she was safe for discharge to
home with 24 hour supervision, home ___, and rolling walker. | 267 | 249 |
15104346-DS-13 | 22,689,291 | 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:
-Touchdown weightbearing of the left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take subcutaneous heparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
TREATMENT/FREQUENCY:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be left
open to air unless actively draining after POD3. If draining,
you may apply a gauze dressing secured with paper tape. You may
shower and allow water to run over the wound, but please refrain
from bathing for at least 4 weeks postoperatively.
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 greater than 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 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a mild traumatic brain injury and left femoral shaft
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for left
femur intramedullary nail, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. He will follow up in the
___ clinic as needed. 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. | 612 | 275 |
19391563-DS-13 | 27,232,493 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated left lower extremity
- non-weightbearing left upper extremity; okay to do pendulums.
-Use splint for comfort and when out in public for
protection.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
LUE: non weight-bearing, pendulums OK
LLE: weight-bearing as tolerated
Treatments Frequency:
Apply gauze to surgical incision site and change daily as needed
for continued oozing or drainage. ___ leave to air if dry. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left hip intertrochanteric fracture and left shoulder
fracture dislocation and was admitted to the orthopedic surgery
service. Prior to admission, patient's shoulder was close
reduced in the emergency department. Post-reduction films
acquired during admission showed a well-located shoulder joint
and a comminuted greater tuberosity fracture. Her shoulder way
managed non-operatively and placed in a sling for comfort. The
patient was noted to be neurovascularly intact. The patient was
taken to the operating room on ___ for left trochanteric
fixation nail of the left hip, 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. On
POD1, the patient was given one unit packed red blood cells for
a hematocrit of 19.9. On POD3 patient give addition 1u pRBC for
HCT of 22 with appropriate bump to 30. The patient was noted to
be asymptomatic from an anemia standpoint. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
nonweight bearing in the left upper extremity and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 317 | 365 |
19533644-DS-20 | 22,827,305 | You were admitted to the hospital for management of perforated
diverticulitis for which you have recovered well from. You
underwent a drainage of an intra-abdominal abcess by
interventional radiology which was successful and have completed
a course of antibiotics.
You may return to your normal activities including a regular
diet. Please call the office or return to the ED if you
experience in fevers/chills, nausea/vomiting, increased
abdominal pain, or any other symptoms that may concern you.
Your TSH was checked and noted to be elevated during the
admission. You should follow up with your PCP regarding this. | Ms. ___ was admitted on ___ for abdominal pain/cramping.
She underwent a CT scan which revealed severe sigmoid colitis
with microperforation. She was stable and so conservative
management was pursued. She was started on unasyn (as well as
flagyl at her request). A c. diff was check which was negative.
After her abdominal pain started to improved she was advanced
back clears and then to a regular diet, however she again
developed more pain. A repeat CT scan was performed which showed
a worsened inflammatory process w/ a 2.6 cm developing abscess
near the medial sigmoid. She was back down to NPO. She was
switched to meropenam for broader coverage and were WBC trended
as it had started to increase. Given her tenderness, failure on
antibiotics, and rising WBC the decision was made that she would
like need a colectomy however the patient adamantly refused
surgery. A GI consult was call and recommended drainage of her
sigmoid abscess. Interventional radiology was consulted. They
performed a transvaginal drainage in which 4cc of purulence was
removed. She finished her course of Meropenam on ___ and
was discharged on ___ with no antibiotics. At the time of
discharge she was ambulatory, afebrile with stable vital signs,
tolerating a regular diet with no nausea or vomiting, having
bowel function, and voiding freely. | 96 | 224 |
10746056-DS-27 | 24,027,961 | Dear ___,
___ were admitted to ___ for nausea and vomiting likely due to
accidental removal of your J tube. The J-tube was replaced with
a new one during your stay. The J tube is for feeding and
medication administration. All of the medications on your
medication list can be given through your J tube. Your G-tube is
for venting and draining fluid from your stomach. ___ may eat as
tolerated and use the G-tube to vent. Please be cautious in
terms of your oral intake, and if ___ are feeling nauseous then
allow your G-tube to vent, take Zofran 4mg through your J-tube,
and do not take in anything orally until ___ are feeling better.
If the nausea is persisting, ___ can call your
gastroenterologists office at ___. ___ will resume your
tube feeds as ___ had been taking them prior to hospitalization.
___ can clean any crusted drainage from your tubes with warm
soap and water. ___ can flush your tubes with clean tap water
after each use.
There were no changes made to your medications.
Please attend your follow-up appointments as listed below. If
Palliative Care does not reach out to ___ by ___, please
call them at ___ to set up an appointment. Please also
call your PCP to make an appointment within one week.
Thank ___ for choosing ___ for your healthcare needs. It was a
pleasure taking care of ___.
Sincerely,
Your ___ Team | MS. ___ is a ___ ___ DM, legal blindness, severe
gastroparesis s/p recent surgical G and J tube placement ___
who p/w nausea and vomiting secondary to J-tube displacement. ___
replaced the J-tube on ___ with tube feeds and medications
restarted through the J-tube on ___. For pain, she received IV
dilaudid 1 mg as needed. She was weaned to her home regimen of
oxycodone 20mg q6h and methadone 5mg BID. On ___, an area of
fluctuance and erythema was noted around her G-tube site.
Surgery saw her and stated that it had been seen previously;
their suspicion for infection was low and nothing was done. She
continued to remain clinically and hemodynamically stable and
was discharged with instructions on how to properly use and
clean her G/J-tubes. She was advised to follow-up with her PCP
and palliative care within the week of discharge and to attend
her GI appointment in ___. | 235 | 152 |
12886551-DS-4 | 22,429,495 | You can resume your home medications (hydrochlorthiazide and
enalapril at the previous dose).
.
You will need to see your hematologist Dr ___ on
___ ___, we could not schedule an appointment today. Please
call ___ on ___ to schedule the follow up
appointment. | PRINCIPLE REASON FOR ADMISSION
This is a ___ year old woman with newly diagnosed CLL; admission
complicated by leukostasis with vision changes.
ACTIVE PROBLEMS
# Leukemia with Leukostasis: The patient was sent to the
emergency department for vision changes associated with a WBC of
600k. On admission, she was found to have blurry vision, and
was transferred to the ICU for leukophoresis for presumed
leukostasis retinopathy (later confirmed by ophthalmology - see
below). She underwent bone marrow biopsy that showed CLL
(CD5+,CD19+,CD20+DIM,CD10-,CD38+). While awaiting results of
the bone marrow biopsy, the patient was started on hydoxyurea.
She was also started on allopurinol for prophylaxis. She
underwent her first cycle of IV bendamustine while in house
without signficant side effects. Tumor lysis labs remained
stable.
# Visual Changes: Red spot in right eye 3 weeks prior to
admission suggestive of a retinal hemorrhage which has now
resolved. On admission, she reported ongoing blurry vision
bilaterally which she thinks is improving. She underwent
leukophoresis for presumed leukostasis retinopathy, as above.
She was seen by ophthalmology of following leukophoresis, and
was noted to have continued evidence of leukostasis retinopathy.
She was treated with hydroxyurea and prednisone before
ultimately starting her first cycle of bendamustine.
# Anemia and thrombocytopenia: Likely related to CLL. HCT
remained between 24 and 30 during admission, with overall slight
down trend. In preparation for discharge, patient received 1
unit pRBC day of discharge. She should continue to have frequent
monitoring of blood counts as an outpatient.
# HTN: On HCTZ and ACEi at home. Antihypertensives were held
while in house. She SBP's noted to run in 140's while off
medications. She was restarted on home regimen on discharge.
# DMII: Per patient was being worked up for diabetes, per record
appears last A1c was 7.1. Not on outpatient meds. The patient
was started on QAHCS with HISS. With initiation of prednisone
for leukostasis retinopathy, she began to require insulin
sliding scale. She was not discharged on diabetic medication,
and this should be followed up as an outpatient.
TRANSITIONAL ISSUES
- Monitor blood sugar and consider initation of blood sugar
lowering agents
- Continue to monitor blood counts as outpatient
- Complete treatment course of rituxan/bendamustine as per
outpatient recommendations | 43 | 371 |
12244789-DS-16 | 24,089,050 | You have undergone the following operation: ANTERIOR/POSTERIOR
Cervical 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:
o2-3 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.
oLimit 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 collar. This 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. No
NSAIDs.
-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.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: as tolerated
Cervical collar: when OOB
Treatments Frequency:
Please continue to change the dressing daily. | Ms. ___ was admitted to the ___ Spine Surgery Service on
___ and taken to the Operating Room for an ACDF C4-7. Please
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
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#3 she returned to the operating room for a
scheduled C3-7 decompression with fusion as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. She was kept NPO
until bowel function returned then diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Foley was removed on POD#2 from the
second procedure. She was fitted with a collar for ambulation.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. | 359 | 207 |
17761752-DS-18 | 25,645,360 | Dear Ms. ___ and your family,
It is a pleasure taking care of you in the medicine service at
___. You were found to be on the floor after an unwitnessed
fall. When you are in the hospital, we conducted imaging studies
and did not see any evidence of fracture. We have given you some
intravenous fluid for hydration. We have also given you some
albuterol nebulizer to relieve your bronchospasm and help with
your breathing. We also gave you antibiotics (bactrim) to treat
for a presumed urinary tract infection, which may account for
your fall. We think that now you are stable to be discharged to
a rehab facility.
*
Please follow up with your primary care doctor, ___. | ___ F w/h/o memory problem was found on the ground s/p
unwitnessed fall, unclear how long, with lab notable for
leukocytosis, elevated CK, and imaging negative for fracture.
*
# Fall: the fall was unwitnessed and patient couldn't provide
history. No fracture/dislocation revealed on imaging. Etiology
unclear and includes urinary tract infection (given patient's
dementia, difficult to assess symptoms; although initial UA was
poor sample with numerous epithelial cells; but given initial
leukocytosis, patient was started on TMP-SMX (Bactrim; day 1 =
___, last day - ___ see below. All subsequent UA and
Urine Cx were started after bactrim). For the workup of
potential syncope, pneumonia was considered but deemed less
likely, given no fever and CXR negative for pneumonia. Cardiac
etiology was considered but EKG wnl, CK-MB and troponin
negative, no risk factor such as HTN/HLD/DM, and telemetry
revealing occasional PVCs but no arrhythmia overnight. Repeat UA
did not show UTI (though pt already on bactrim). Urine culture
from ___ and ___ both showed contamination of
skin/genital flora. Physical therapy saw the patient and
recommended rehab. As patient was hemodynamically stable,
patient was discharged to a rehab facility for further recovery.
*
# Leukocytosis: Initial WBC 14.0 may be ___ mechanical fall or
infectious process. Patient has been afebrile throughout this
admission. Leukocytosis resolved rapidly on HD#2 and stable
since, while patient was treated for a presumed urinary tract
infection with a 6-day course of Bactrim (day 1 = ___ last
day ___, finishing her last dose Bactrim while in-house.
*
# Rhabdomyolysis: Initial CK 2470 at admission, downtrended
after IV fluid in the ED and on the floor. Patient was
encouraged on PO intake. Renal function stable throughout this
admission.
*
# Episodes of bronchospasm/tachypnea: On HD#2, patient had an
episode of wheezes/tachypnea overnight, which resolved after
given ipratropium/albuterol nebs x1. She presents with wheezes
on lung exam, CXR revealing no pneumonia. This is thought to be
likely ___ pulmonary edema from IV hydration. Patient was given
albuterol nebs and oral lasix, and by HD#3 her respiratory
status and lung exam improved. On HD#6, patient had an episode
of transient hypoxemia, tachypnea, and tachycardia after
drinking water+pill and choking. She was given nebs which
relieved her symptoms, CXR showed no evidence of aspiration
pneumonitis, and speech and swallow evaluation showed that
patient can continue on diet of regular consistency solids and
thin liquids; however, pills should be taken with nectar thick
liquid rather than thin liquid to minimize aspiration.
*
# Memory loss: memory slowly declining over last several years
but no acute recent changes; mini-mental status exam score ___
___ for 5-min recall; ___ for orientation). Given her dementia
and risk of delirium, she was given trazodone 50mg HS for sleep
to minimize delirium, as well as standing bowel regimen to
minimize constipation. She was also given frequent
re-orientation to tell her that she was in the hospital rather
than at home.
* | 117 | 477 |
19448760-DS-16 | 20,890,878 | Dear Ms. ___,
Your were admitted for management of an infection of your left
foot. You were placed on IV antibiuotics and recovered well. You
were ready for discharge home with a PICC line and IV
antibiotics with appropriate follow-up, with the following
discharge instructions:
Please call the clinic or come to the ED if you experience any
of the following:
CALL THE OFFICE at ___ FOR:
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Thank you,
Your ___ Vascular Surgery Team | Ms. ___ was admitted for worsening cellulitis of the left
lower extremity. She was started on IV antibiotics. Her Cr at
arrival was initially elevated which resolved with some fluid
resuscitation. Her WBC normalized, however she spiked a
temperature on HD5, CXR was normal and cultures were no growth.
Her initial mental status was signficantly different from
baseline. She was lethargic, but improved along her hospital
stay. Her mental status waxed and waned and she was
intermittenly delerius but improved with resolution of her
infection. Her cellulitis improved, she remained afebrile and
WBC was normal. The decision was made to continue with a full
course of IV antibiotics. She developed on rash on HD5 and
complaints of tongue swelling, with the thought that this may be
a drug rash. She was switched from ceftazadime to cipro. The
rash continued and her complaint of tongue swelling continued,
although she had no issues swallowing, there was no evidence of
progression and her only evidence of any issue was slurred
speech. However, decision was made to eliminate both vancomycin
and cephalosporin and start ertapenem. She was given one dose
prior to discharge with no adverse reaction and sent home with a
PICC and IV ertapenem. Of note, she was continued on her
anticoagulation bridge upon arrival. Her INR was therapeutic by
HD6 and her lovenox was discontinued. She was evaluated by ___
who recommended a ___ lift which she was given a prescription
for. Her vitals were monitored and remained stable. She was
ready for discharge to home with ___ and physical therapy
services on ___. | 100 | 264 |
17091207-DS-17 | 20,960,504 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch-down weight bearing in right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
tdwb in the right lower extremity in unlocked ___ brace
Treatments Frequency:
please monitor incisions for signs/symptoms of infection | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of the femur with ___ plate,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient
experienced some post-operative delirium that was accentuated by
sundowning. She received seroquel with good effect, and
subsequently Haldol due to agitation. By POD3, she was alert and
oriented x4 and was no longer receiving antipsychotics. The
patient is touch-down weight bearing in a Bledose brace,
unlocked in the left lower extremity, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. | 271 | 300 |
10354791-DS-15 | 25,842,784 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
Why you were admitted to the hospital:
- You were having pain over your right side
What happened while you were here:
- Imaging showed progression of your known urothelial (lining of
bladder and urinary tract) cancer with some blockage of the tube
connecting your kidney and your bladder
- The urology team evaluated you and recommended a stent to help
drain your kidney. This will be set up as an outpatient.
- Additionally, your pain was treated medications
What you should do once you return home:
- Please continue taking your medications as prescribed and
follow up at the appointments outlined below
- You should have further discussions with your primary care
provider and your urologist regarding your goals of care and
which, if any, tests or treatments you wish to pursue moving
forward
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ y/o male with a history of right papillary
urothelial carcinoma s/p stent placement and removal, colon
cancer s/p colectomy and chemotherapy (___), HFpEF,
chronotropic incompetence s/p PPM, severe TF s/p repair (___),
PFO s/p repair (___), MR, AF not on anticoagulation (s/p ___
stapling), h/o TIA, cardiac cirrhosis, CKD stage III, and MGUS
who presented with R sided flank pain, found to have worsening
urothelial carcinoma with moderate hydronephrosis and likely
pulmonary metastases. Urology was consulted and recommended
percutaneous nephrostomy tube for palliation. The patient
ultimately chose to pursue outpatient stenting.
# Right Flank Pain
Presented with right-sided flank pain described as a dull ache
with episodes of sharp pain with movement. His pain felt
different from prior pain associated with hydronephrosis. A
renal ultrasound showed mild hydronephrosis and then a follow up
CT abd/pelvis demonstrated progression of his known urothelial
carcinoma with encasement of the right ureter and associated
moderate hydronephrosis. It was felt that his pain was due to
his disease progression with some contribution from the
hydronephrosis. Urology was consulted and recommended placing a
percutaneous nephrostomy tube as a palliative measure. The
patient decided to pursue outpatient stenting with his
urologist. Additionally, his pain was managed with Tylenol prn
and a lidocaine patch.
# Right Hydronephrosis
# R Papillary Urothelial Carcinoma
The patient had been followed by urology for urothelial
carcinoma managed with stent exchanges. Most recently his stent
was removed and not replaced given adequate urine output. Repeat
imaging as described above showed progression of his malignancy
with encapsulation of the ureter and moderate hydronephrosis.
Additionally, CT chest showed multiple bilateral pulmonary
nodules concerning for metastases. Etiology was unclear though
differential included metastatic disease from his known
urothelial cancer. Urology was consulted recommended either PCN
versus stent. Patient chose stent, to be done as outpatient.
His home tamsulosin was also continued. He should follow up with
urology as an outpatient for further management and for stent
placement. The patient was also scheduled for outpatient
Oncology follow-up.
# Acute on Chronic Hyponatremia
The patient's recent baseline had been between 128-130. Sodium
on admission was 125 without associated symptoms. Etiology was
unclear but felt to be multifactorial from several medical
comorbities. Exam was difficult but appeared to be mildly volume
overloaded with trace ___ edema and JVP elevation (though in the
setting of known valvular disease). Additionally, BNP was
elevated to ~6000, concerning for volume overload. However, the
patient's weight has been at baseline and his creatinine had
actually improved over the prior few weeks with decreasing doses
of torsemide. Urine lytes were consistent with a sodium avid
state, which could have been hyper or hypovolemic in nature.
Decision was made to hold home torsemide and monitor. His Na
improved and torsemide was restarted. His discharge Na was 128.
# Lung Opacities c/f Metastatic Disease
Noted to have bilateral opacities on CXR; follow up CT chest
showed many nodules bilaterally concerning for metastatic
disease. Etiology was unclear though there was concern for
progression of his known urothelial carcinoma vs less likely due
to recurrent colon cancer or an additional primary. Patient will
follow up with oncology as an outpatient.
# Liver Lesion
Noted to have 1.1 x 1.0 x 1.2 hypoechoic lesion in the left
hepatic lobe on ultrasound, though the lesion was not present on
repeat CT scan w/o contrast. There was concern for further
metastatic disease (urothelial, less likely colon cancer
recurrence) vs primary liver malignancy in the setting of his
cirrhosis. AFP was normal pointing against ___. Discussed with
radiology who recommended triphasic MRI for further
characterization as an outpatient.
# Chronic Anemia
Hemoglobin around ___ at baseline, presented with a Hgb of 9.
Prior iron studies were normal. Blood counts were monitored
daily without much change.
# Chronic Stage III CKD
Followed by Dr. ___ as an outpatient. Baseline Cr 1.5-1.7.
Cr 1.9 on admission and improved to baseline with holding
torsemide.
# Atrial Fibrillation
# Chronotropic Incompetence s/p PPM
The patient has a history of atrial fibrillation, on metoprolol
at home. He was not on anticoagulation per outpatient providers
given recurrent bleeding. He was continued on his home regimen
without any issues.
# Cardiac Cirrhosis
History of cirrhosis 2/p HFpEF. Childs B. He had no signs of
hepatic encephalopathy, varices or ascites. He was continued on
his home lactulose and rifaximin. Last EGD in ___ showed no
varices. He should follow up with GI for management and possible
repeat EGD.
# Chronic Diastolic Heart Failure
# Severe TR s/p Repair, MR, PFO s/p Closure:
Followed by Dr. ___. Last TTE on ___ notable for EF
>60%, 4+ mitral regurgitation and 4+ tricuspid regurgitation,
with dilated LA and RA. JVP elevated on exam though likely in
the setting of valvular dysfunction. The remained of his volume
status was difficult as he had trace edema though improvement in
Cr with holding torsemide. Decision was made to hold home
torsemide and monitor given hyponatremia. He was ultimately
discharged on his home dose of torsemide. He should follow up
with his primary care provider for further management.
# Coronary Artery Disease
The patient was continued on his home statin and metoprolol
dosing. He was not given aspirin as no longer needed per
outpatient providers notes.
# H/o Colon Cancer s/p Resection & Chemotherapy
Unknown treatment history. Last colonscopy in ___ was normal.
CT abd/pelvis without contrast did not find a malignancy though
the study was limited and the likely metastases in the lungs was
concerning for possible recurrence vs disease progression of his
known urothelial carcinoma. He should consider outpatient
colonoscopy/imaging pending results of pulmonary nodule biopsy
(if within goals of care). | 148 | 938 |
11438336-DS-30 | 29,503,954 | Dear Ms. ___,
You were admitted to the hospital with confusion which may have
happened after you received morphine. You needed extra oxygen,
which is why you were in the intensive care unit, where you
stayed due to elevated blood sugars.
You had abnormalities of your liver tests which may have been
caused by a medicine called prasugrel. This medicine was
stopped. You were seen by the vascular surgery teams who felt
this was safe. You will continue aspirin to protect your stents
in your legs from clotting.
The following changes were made to your medications:
1. STOP PRASUGREL
2. INCREASE LANTUS to 25 units at breakfast, and icnrease
sliding scale as the attached sheet suggests
3. START ASPIRIN 325mg daily
No other changes were made to your medications, please continue
all other previously prescribed medications | Primary Reason for Admission: ___ y/o woman with recent admission
for AMS found to have L great toe osteomyelitis s/p discahrge
with PICC on vanc presenting from rehab with AMS requiring MICU
admission for noninvasive ventilation.
. | 131 | 36 |
10714685-DS-23 | 20,947,606 | Dear Mr. ___,
You were admitted to the hospital for aspiration pneumonia. You
were treated with IV antibiotics initially, which were narrowed
to oral antibiotics. You should continue to take the antibiotics
as an outpatient to complete the course as directed. You were
evaluated by the Speech Language Pathology team who recommended
a pureed solid diet and thin liquids. They recommended you
follow up with speech language pathology as an outpatient as
well.
Your blood pressure was also high so your amlodipine was
increased from 2.5 mg to 5 mg daily.
Best of luck with your continued healing.
Take care,
Your ___ Care Team | SUMMARY/ASSESSMENT:
Mr. ___ is a ___ year old man with history of vascular
dementia, AFib on Coumadin, CKD and HTN, and prior aspiration
pneumonias requiring ICU admission ___ referred to the ED
from ___ for a cough found to have likely aspiration pneumonia.
# Aspiration pneumonitis
# Pneumonia, aspiration
Patient presented after observed aspiration event w/ hypotension
at facility, leukocytosis, and CXR showing RLL consolidation,
but without significant hypoxemia. He has not been hypotensive
since arrival to the ED. He received a dose of IV Zosyn in ED.
This was changed to ceftriaxone and azithromycin on admission.
The following day, ceftriaxone was changed to Augmentin for
aspiration pneumonia (7 day course total, end date = ___ and
azithromycin was continued for atypical coverage (end ate
___. Speech language pathology was consulted. They did not
see any overt evidence of aspiration and recommended continuing
the same pureed solid and thin liquid diet. They did recommend
continued outpatient SLP follow up and video swallow study as an
outpatient.
# Atrial fibrillation
# Supratherapeutic INR
Rate-controlled and anticoagulated with warfarin. His INR was
supratherapeutic in the setting of antibiotic use so his
warfarin dose was reduced from his home dose of 2 mg daily to
1.5 mg daily while he is on antibiotics. This should be watched
closely, and likely increased back to his home dose once he is
off antibiotics.
# Chronic kidney disease, stage 3:
Baseline Creatinine is 1.1 and his Cr since admission has been
1.2-1.3.
# HTN
Home amlodipine 2.5 mg increased to 5 mg daily due to
hypertension (SBPs as high as 180).
# GOC:
Per discharge summary from last admission "patient's daughter
re-iterated DNR/DNI but would still want less invasive measures
such as CVL, a line, pressors if needed. She requests palliative
care consult to help with these decisions." Discussed with his
daughter at the bedside and she reaffirmed these wishes.
# Vascular dementia:
Chronic, stable at baseline mental status. | 100 | 327 |
14153717-DS-3 | 27,387,686 | 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:
- non weight bearing left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
- ___ LLE
Treatments Frequency:
Pin Site Care Instructions for Patient and ___
For patients discharged with external fixators in place, the
initial dressing may have Xeroform wrapped at the pin site with
surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions. | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L trimalleolar ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for L ankle ex fix, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ one week of discharge for wound
check. 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. | 307 | 264 |
12730796-DS-18 | 28,953,430 | Dear Mr. ___,
You were admitted to the hospital for a stent exchange due to
persistently elevated bilirubin. You tolerated this well and
will be discharged home. Please follow up in the ___ clinic
at your visit this afternoon.
For your itching, you may try Benadryl over the counter or Sarna
lotion.
Please note that your paperwork indicates you have pending test
results but this is in error. You had a CT of your chest which
showed indeterminate nodules and will need to discuss the
significance of this finding at your oncology visit this
afternoon.
We wish you the very best!
Sincerely,
Your care team at ___ | ___ with hx of htn, osteoarthritis of knee, HLD, recent
admission to ___ for ERCP due to painless jaundice now returns
with persistent jaundice and pruritus, also new diagnosis
pancreatic adenocarcinoma. S/p ERCP ___ with stent exchange.
#Pancreatic adenocarcinoma
#Jaundice
#Hyperbilirubinemia
Pruritus and jaundice persistent despite ercp w stent placement,
therefore stent was exchanged with repeat ERCP ___. Overall
bilirubin is still elevated but expect some mild elevation post
procedurally. He has no abdominal pain and diet was advanced w/o
pain or difficulty. LFTs remained elevated but trended down very
slightly by the time of discharge. A CT chest for staging
purposes showed a 1mm indeterminate left upper lobe pulmonary
nodule and a 2mm calcified granuloma in the right upper lobe,
the significance of these findings is unclear. He has an ___
oncology appointment scheduled immediately after discharge where
he can discuss these results.
#Pruritus
In the setting of elevated t bili. Continued on cholestyramine,
dose increased to 8mg BID. Also continued on Benadryl and Sarna
prn. Would consider a trial of steroids such as a Medrol dose
pack, which could be discussed at his oncology visit. Unclear if
there would be any contraindication to steroid initiation based
on his oncologic plan.
___ - resolved
Cr baseline around 1.0-1.2, up to 1.4 upon admit likely due to
decrease PO intake with pain, now resolved, off fluids and has
good PO intake.
#HTN - cont home amlodipine
#CV - discontinued atorvastatin as an outpatient prior to this
admission due to elevated LFTs, remains held at this time
Code status - full
Dispo - discharge today, to oncology appointment
Time spent: 50 minutes
Plan of care discussed with the patient and his wife at bedside. | 106 | 276 |
10488906-DS-2 | 25,817,228 | Dear Ms. ___,
You were transferred to the hospital due to a very severe
infection that impaired your circulation, clotting, lungs, liver
and kidneys. You recovered with antibiotics and aggressive
support in the ICU. Your kidneys took longer to recover and you
needed dialysis for a while. Your kidneys recovered and you no
longer need dialysis. You are going to rehab to work on getting
you stronger to go back home. We wish you a continued recovery.
Your ___ Team | ___ year old woman with a history of hypertension, CAD,
hyperlipidemia, asthma, OA, depression, anxiety presenting as a
transfer from ___, where she presented with
the chief complaints of gingival bleeding after teeth cleaning,
hemoptysis, and diarrhea, found to be in shock with likely
pyelonephritis (abnormal UA, perinephric stranding on imaging)
as source, with multiple lab abnormalities concerning for DIC.
She is transferred to the MICU for management of shock and DIC.
Received broad spectum antibiotics which were narrowed
empirically to meropenem in setting of culture negative sepsis.
Required intense pressor support, CRRT for renal failure, blood
products for DIC and intubation for respiratory support. She was
able to be liberated of pressors and ventilation in the MICU,
upon call-out to the floor she remained on intermittent HD for
renal failure. Her renal function progressively recovered on the
floor and was taken off HD, discharge creatinine of 1.6.
#Shock: Patient came in with severe septic shock and refractory
acidosis. Presumed to be urinary source, she was started on
broad spectrum antibiotics vancomycin, Meropenem, doxycycline,
and one dose of tobramycin. Most likely primary infectious
insult is pyelonephritis (abnormal UA, perinephric stranding on
imaging). She was intubated and placed on the vent. She was
started on CRRT day one for refractory acidosis. She was given
stress dose steroids empirically. She required blood pressure
support with pressors maxing out on norepinephrine, vasopressin,
and epinephrine. Over the course of several days she was
gradually weaned off pressors with some changes in agents based
on perceived need for positive inotropy, although formal TTE
revealed that cardiogenic shock was not the primary underlying
problem. Cultures of urine and blood returned negative giving
the diagnosis of culture negative sepsis. She was taken off of
pressors and bridged with midrodine on ___, upon call-out from
MICU midodrine was discontinued. Due to the low concern for MRSA
sepsis, vancomycin was discontinued on day 6 of treatment and
she continued to improve. She completed a 14 day course of
Meropenem for culture negative sepsis. Doxycycline was
discontinued on ___ as Anaplasma phagocyticum antibodies
returned negative.
#DIC: Patient presented with prolonged bleeding after dental
cleaning, with septic shock, thrombocytopenia, prolonged ___,
low plasma fibrinogen, elevated D-Dimer, schistocytes on smear,
all consistent with DIC, likely provoked by culture negative
sepsis. Hematology consult felt that given her clinical picture,
other causes of DIC such as TTP or APML were unlikely.
She got FFP and cryoprecipitate x2 on ___. Hematology
recommended FFP if fibrinogen < 100. Her ___ PTT plt and
fibrinogen was trended and she did not require any further
products. Her coagulation studies remained normal on the floor.
#Acute renal failure: Patient was anuric since arrival. She was
started on CRRT early in her course for refractory acidosis in
the face of a normalizing lactate. Basline creatinine was
unknown, but she has a h/o CKD per records. She was continued on
CRRT until ___ where it was discontinued with her 1 L positive
for admission. Her HD line in her R IJ was kept in after
stopping CRRT due to concern that patient would need
intermittent HD going forward. She remained nearly anuric as she
was being called out from the ICU. She received intermittent HD
on the floor as she began having little then brisk urine output,
likely reflecting post-ATN diuresis. Her last HD session was on
___, since then her renal function has steadily improved. Her
temporary HD line was pulled on ___. Creatinine on discharge
was 1.6.
#Hepatic injury: Transaminases peaked in the 1300-1500s on ___
which is time most intense need for pressor support.
Hepatocellular (ALT>AST pattern) without cholestasis (normal ALP
and Tbili) are atypical for ischemic hepatopathy though. ALT
continued trending down and nearly normalized as her infectious
injury resolved. HBV and HCV have been ruled out. Leptospira and
anaplasma were ruled out.
#Respiratory Failure: Intubated initially due to concerns for
worsening mental status and inability to protect her airway. Was
put on the ARDSnet protocol. She was Extubated on ___.
# L visual field deficit (resolved): This was transient noticed
on ___ and resolved by ___. Workup with MRI, carotid ultrasound
and EEG was all reassuring that this patient did not have CVA,
seizure, or mass effect.
#Antibiotic Associated Diarrhea: Developed multiple loose bowel
movements on the floor. Was negative for C.difficile NAAT.
Likely secondary to antibiotic therapy. Was kept on yogurt 1 cup
tid with progressive improvement and resolution at the time of
discharge. | 78 | 737 |
15147683-DS-20 | 26,935,008 | Dear Ms. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
You were having blood bowel movements and abdominal pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
You had imaging of your abdomen which showed inflammation in
part of your colon, which we think is due to a condition called
ischemic colitis. This happens when you have a short period of
decreased blood flow to part of your colon, and this condition
resolves on its own.
WHAT SHOULD I DO WHEN I GO HOME?
Continue to eat and drink as you are able
Take your medications as prescribed
Monitor your stools for blood - the bleeding should resolve
entirely by ___. If you are having increased amounts of
bleeding, fevers or chills, lightheadedness or dizziness, chest
pain or shortness of breath, or other symptoms that concern you,
please return to the emergency department
Thank you for letting us be a part of your care!
Your ___ Team | ___ woman with a medical history of hypertension and
hyperlipidemia, who presented with abdominal pain, diarrhea, and
BRBPR after eating with CT showing segmental colitis and lab
work negative for acute blood loss anemia. Her symptoms resolved
without intervention and she was tolerating a regular diet
without abdominal pain prior to discharge. Etiology of bright
red blood per rectum thought to be due to ischemic colitis. She
and her daughter were counseled on warning signs of worsening
problems, including ongoing or increased bleeding, fevers or
chills, lightheadedness or dizziness, chest pain or shortness of
breath, or other symptoms that concern you, she was encouraged
to call her primary care doctor and return to the ED
TRANSITIONAL ISSUES
[] Stool studies pending on discharge
[] Patient should follow up with PCP ___ x1 week | 148 | 130 |
13031146-DS-8 | 20,274,880 | Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you had a fall while you were
at home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While in the hospital, you were give a brace for your neck
because the fall you had at home caused the bones and muscles in
your neck to become unstable.
- While in the hospital, some of the electrolytes in your blood
were abnormal. You received some fluids to help correct these
electrolytes.
- Due to some concern about your ability to swallow, a tube was
placed into your stomach, and you are getting all your
nutrition, medications, and fluids through this tube.
- There is a wound on your bottom from the amount of time and
positioning you are required to keep in bed at this time. This
was evaluated by the surgeons and debrided once.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Some appointments need to be scheduled, so please be sure to
schedule those in follow-up.
- Keep wearing your brace at all times, until you are told it is
safe to stop by the spine surgeons.
We wish you the best!
Sincerely,
Your ___ Team | Patient was admitted to the ___ after being evaluated in the
ED on ___.
#NEURO: The patient was alert but disoriented throughout his
stay in the ICU. Due to his history of EtOH withdrawal &
Wernike's encephalopathy, patient was placed on a phenobarb
taper. Given that the patient was extremely somnolent after
receiving 10 Valium, the dose was halved. He did not show signs
of withdrawal since then. Nevertheless, he was given Folate and
Thiamine. His mental status continued to improve. Pain was very
well controlled.
#CV: The patient was found to be in afib w RVR when he first
presented. This was rate controlled with metoprolol. He 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 had a Foley catheter placed in the ED
that was switched to a condom catheter. He had good UOP. The
patient was made NPO given his poor mental status. On HD3, he
was found to fail speech and swallow and so a dobhoff placement
was attempted but failed twice.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices. His home Xarelto has been held since his injury.
#MSK: Patient was found to have a C6-C7 ligamentous injury
without neurology deficits. Per spine recommendations, he is to
wear a CTO long-term. Because he was also found down for unknown
period of time and so a CK was sent in the ED that was normal.
He was also found to have a right acetabular fracture for which
orthopedic surgery recommended touch-down weight bearing and
follow-up as outpatient with a plain-film in 2 weeks.
#FEN: patient was found to have hypernatremia of 162 when he
presented to the ED. ___ was given to correct it but he
persistently was hypernatremic and so this was switched to D5W.
He, however, continued to be hypernatremic.
================ | 222 | 355 |
12582649-DS-21 | 20,446,530 | Dear ___,
You were admitted to ___ because you were experiencing
abdominal pain. You were in the hospital previously (___)
for perforated appendicitis with an abscess and had a drain,
which was subsequently removed in clinic. Imaging done this
admission showed a recurrent periappendiceal abscess. Thus, you
were admitted for IV antibiotics and ___ drainage which was done
on ___. You have since been doing well. You are tolerating
a regular diet and your pain has been well-controlled. You are
ready to be discharged home with the drain. Please follow the
instructions below:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid driving or
operating heavy machinery while taking pain medications.
Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
- If you develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10ml for 2 days in a row,
please have the ___ call Interventional Radiology at ___ at
___ and page ___. This is the Radiology fellow on
call
who can assist you.
***Please call the Acute Care Surgery Clinic if you have any
questions or concerns at ___. | Mr. ___ was admitted to the Acute Care Surgery service
for evaluation and treatment of abdominal pain. Of note, patient
had recent admission in ___ for perforated appendicitis
with an abscess that was drained. He was subsequently seen in
the ___ clinic where his drain was removed. He had been doing
well until he developed acute abdominal pain and presented to
the ___ emergency department on ___. Admission
abdominal/pelvic CT revealed perforated appendicitis with
adjacent abscess. The patient underwent an ___ guided drain
placement on ___, which went well without complication and
the abscess was aspirated and sent for culture.
The patient was started on a regular diet after his ___
procedure, which he tolerated well. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. On HD3, there was some concern as the patient was
experiencing pain at the ___ drain site with flushing. After
speaking with the ___ service, the patient was ordered for an
abdomen/pelvis CT to assess the ___ drain. The CT showed adequate
position of the ___ drain and interval collapse of RLQ abscess.
Per the ___ team, the drain no longer needed to be flushed and
the patient could be discharged home from their standpoint.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without issue, and reported no
abdominal pain. The patient was discharged home without
services. The patient and his wife received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. A ___ was at
the bedside and all questions were answered. Drain care teaching
was done with the patient via interpreter and the patient stated
that he was comfortable with taking care of the drain at home.
The patient will finish a two week course of oral antibiotics
and he will follow up in the ___ clinic next week with Dr.
___. | 449 | 348 |
10063848-DS-3 | 26,880,153 | Dear Ms. ___,
You presented to the hospital with small bowel eroding into your
wound. You were admitted to the hospital for wound management.
In the hospital,
- A methylene blue test revealed that you have a fistula in your
wound, which is leaking enteric content (small bowel content).
- You were seen by our wound care specialist.
- An ostomy appliance was placed to help with wound healing and
help prevent infections.
- You received teaching to care for your wound.
- ___ was set up to help mange your wound.
When you leave the hospital
- Record your Ostomy output daily. When it is ___ full, empty
the pouch.
- If the Ostomy output starts to increase significantly, call
your MD and/or seek medical attention.
- If you develop fevers, chills, nausea, worsening abdominal
pain, or other concerning symptoms seek medical attention.
Further "Danger Signs" are listed for you in this document.
For your reference, we have provided dressing change
instructions for you.
It was a pleasure taking care of you,
-Your ___ Care Team.
CARE INSTRUCTIONS
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs and should continue to walk several times
a day.
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 10 lbs until cleared by your surgeon.
(This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children.
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/showers 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 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 You may have sponge baths with covering your ostomy appliance.
Pat dry, do not rub. Do not shower, bathe, soak, or swim until
cleared by your surgeon
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to your wound.
o Do not use any ointments on the incision unless you were told
otherwise.
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 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 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. | ___ 3 weeks s/p exploratory laparotomy with small bowel
resection presented with foul smelling feculent discharge from
her wound with areas concerning
for fascial dehiscence and enterocutaneous fistula.
# Entero-cutaneous fistula:
# Fascial Dehiscence:
On presentation, exam was concerning for feculence in wound. CT
scan was notable for fascial dehiscence at the wound site and
also there was concern for an anastomotic leak. On HD 2, a
methylene blue test was done confirming an enterocutaneous
fistula. Patient was seen by the wound care nurse and fitted
with an ostomy appliance over her open wound and EC fistula. She
was set up with home ___ to assist with dressing changes and was
provided teaching on her ostomy device. Prior to discharge
patient's pain was controlled, she was tolerating a regular
diet, and patient was ammenable to ___ services and caring for
her new ostomy appliance.
TRANSITIONAL ISSUES
[] will need re-assessment of wound by Dr. ___ in one week.
[] Patient discharged with ostomy appliance with ___ for home
dressing changes.
WOUND CARE RECOMMENDATIONS
Equipment:one piece drainable ( )
one piece convex drainable ( )
two piece drainable ___ ( )
two piece drainable ___ ( )
one piece urostomy ( )
two piece urostomy ___ ( )
two piece urostomy ___ ( ) | 695 | 203 |
16557461-DS-19 | 28,140,835 | Dear Mr. ___,
You were admitted to ___ after being diagnosed with B-cell
lymphoma in your nasal cavity. We treated you with chemotherapy
for two cycles. We also tested your spinal fluid for any cancer
which was inconclusive and gave some chemotherapy in spinal
fluid as well. While you were here, one of your IV sites was
infected for which we treated you with antibiotics. You will
need to continue these antibiotics through your IV until
instructed to stop. You also had a clot in an IV site for which
you will receive a daily shot of Lovenox. You should continue
this as well.
You also had a reaction to rasburicase which we felt was due to
a condition called G6PD deficiency. Make sure to tell all your
healthcare providers about this so that they can avoid
prescribing any drugs that can exacerbate this condition. Please
avoid eating fava beans as well.
You should continue all of your medications as instructed and
follow-up with your primary oncologist and with the infectious
disease physicians. It was a pleasure taking care of you.
-Your ___ Team | Mr. ___ is an ___ year old man with a recent diagnosis of B-cell
lymphoma located in the nasopharynx who was treated with R-CHOP
in stages and intrathecal methotrexate due to high risk location
of the malignancy. His stay was complicated by severe hypoxemia
thought to be secondary to reaction to rasburicase (possible
G6PD) in the setting of tumor lysis. Also complicated by MSSA
bacteremia due to an infected PICC line (left side) with a DVT
in the paired brachial veins in the same side. Also complicated
by atrial fibrillation with occasional RVR. Had ___ in the
setting of nafcillin for MSSA and was switched to cefazolin. He
was discharged on Lovenox for the DVT.
#High Grade Diffuse Large B Cell Lymphoma : Initially with
visual changes and epistaxis. Located in the right nasal cavity
confirmed by biopsy on ___. s/p C1 R-CHOP (staggered) D1:
___. C2 R-CHOP D1: ___. Also C2 IT MTX D1: ___. LP on
___ was non-diagnostic, no neurologic signs indicating CNS
spread during inpatient stay. He tolerated these treatments well
with resolution of facial swelling and cervical lymphadenopathy.
# ___ on CKD: Baseline Cr 1.2, ranged from 1.1 to 1.4 while
inpatient. Urine electrolytes were indicative of an intrinsic
etiology. As a result of the CKD, antibiotics for MSSA
bacteremia were switched from nafcillin to cefazolin. He was
encouraged to drink an adequate amount of fluids.
# Bacteremia: A left PICC line was found to be infected on ___
and was removed. The wound and tip culture grew MSSA as did the
blood culture. He was treated initially with nafcillin and
switched to cefazolin for concern for ___. Surveillance blood
cultures were negative through ___. A right sided PICC line
was placed after 48 hours of negative surveillance cultures.
#LUE DVT: Involving paired brachial veins per ___ on ___.
Lovenox was started on ___ when his platelets rose over 50.
# A fib with RVR: He intermittently had RVR into the 120-130's,
particularly in the setting of the bacteremia as above. His rate
was controlled well on metop 12.5 TID.
#Latent TB: Diagnosed with TB in ___ in ___, received
treatment unsure of agent or duration. CT CHEST (___)
suggestive of granulomatous disease concerning for LTB. While
the quantiferon gold had a positive mitogen suggestive of true
negative, in conversation with infectious disease, the risk was
determined to be too high to not treat. Thus, he was started on
INH 300 mg QD and B6 50 mg QD (Consider stopping if
transaminitis in the setting of chemotherapy)
#G6PD Deficiency: He had an episode of respiratory failure
though to be secondary to hemolysis after receiving rasburicase
in the setting of TLS early in his admission. ___ bodies were
seen on his smear which was suggestive of this diagnosis. He was
given blood and his hemolysis trended to normal. G6PD levels
were drawn once at that time (normal) and again later in his
admission, but should be repeated as they may not be indicative
in the acute setting given blood transfusions. All G6PD drugs
should be avoided in the interim.
# HTN: Metoprolol as above. | 189 | 522 |
11426924-DS-16 | 25,924,746 | Dear Mr. ___,
You were admitted to the hospital because you were having
worsening chest pain. Your blood work and EKG show no evidence
of heart attack and the cardiac catheterization showed no area
of active new heart damage. You were discharged with medication
changes and you should follow up with a cardiologist.
Please make the following changes to your medications:
1. START lisinopril 2.5mg by mouth daily
2. START ketoconazole shampoo. 1 wash and rinse to face and
scalp weekly
3. START hydrocortisone 0.2% cream. Use one application to
affected area on face twice daily as needed for facial rash. Do
not use for more than one week at a time as this can cause
thinning of the skin if used too often.
4. CHANGE warfarin dosing to 5mg by mouth daily Your INR should
be monitored at the rest home and dosing adjusted to INR goal
2.5-3.5
5. START Imdur 60mg by mouth daily
6. STOP metoprolol tartrate
7. START metoprolol succinate 25mg by mouth once daily
Please follow up with your PCP and cardiologist
___ yourself every morning, call MD if weight goes up more
than 3 lbs. | PRIMARY REASON FOR HOSPITALIZATION:
Patient is a ___ male with PMH of mechanical AVR (x3), s/p CABG
___ with SVG-PDA, SVG-LAD, SVG-LCx, s/p CABG ___ with SVG-D1,
SVG-OM, SVG-RCA, SVG-PDA to PLB, DES to proximal LCx, DES to
SVG-PDA graft, CVA ___, and severe COPD who presents with two
weeks of intermittant chest pain. He last had chest pain 2 days
prior to admission. Cardiac enzymes were negative for acute
event, ECG showed no acute changes, and persantine MIBI showed
no areas of reversible ischemia. He was discharged from the
hospital on Imdur for prevention of angina.
.
ACUTE CARE:
1. ANGINA: The patient has an extensive cardiac history
including CABG x3 and DES to LCx and DES to SVG-PDA graft. He
presented with 4 episodes of exertional chest pain for the past
___ weeks concerning for unstable angina. He had been chest pain
free for at least 48 hours prior to admission. Each time the
pain occurred, it happened in the context of physical exertion
and was located to the left of the sternum. The pain is relieved
by sublingual nitro. On presentation, cardiac biomarkers were
negative x3, and EKG showed no ischemic changes. Patient had a
persantine MIBI which revealed areas of fixed perfusion defect
but no areas of reversible ischemia. Patient was placed on Imdur
60mg PO daily which he tolerated well, after having one instance
of chest pain relieved with nitro while on imdur 30. He was
continued on aspirin, plavix, and atorvastatin, and started on
lisinopril 2.5mg PO daily. He was continued on metoprolol as
well and placed on a heparin gtt bridge to coumadin with target
INR2.5-3.5 for his mechanical aortic valve. He was discharged
back to his rest home with instructions to call the cardiology
clinic for a followup appointment.
. | 180 | 300 |
10014610-DS-34 | 20,579,647 | Dear Mr. ___,
It was a pleasure caring for you. You were admitted because you
had a fever, which we believe was caused by bacteria in your
knee and blood. This got better with antibiotics and the removal
of your prosthetic joint. You also got blood after your
operation because of how much you lost as well as another
transfusion when your blood count was low. You received fluids
for a mild kidney injury which has resolved. | ___ yo man with complicated PMH including AI/CAD s/p CABG, h/o
bilateral TKAs c/b infection on chronic suppressive antibiotics
who presented with R knee pain and ___, found to have high grade
enterococcal bacteremia and septic arthritis.
# R knee pain s/p TKR, and h/o R knee prosthetic joint
infection: presented with acute knee pain with a warm and red
joint. CRP was > 200. He was also found to have high grade
enterococcal bacteremia. He was started on daptomycin given
multiple antibiotic allergies and continued on chronic
suppressive antibiotics (levofloxacin rather than moxifloxacin,
then back to moxifloxacin on recommendation of ID team due to
better coverage of his previously grown bacteroides). He
underwent ___ guided arthrocentesis on ___ which was
significant for WBC count of 12,000 (on antibiotic therapy X 2
days) with 90% PMNs. Culture later grew enterococcus. He was
evaluated by orthopedic surgery, who recommended placement of an
antibiotic spacer. This was placed on ___, with repeat I&D and
ORIF ___. Intra op cultures grew enterococcus as well.
Final ID regimen.
"Now that the prosthesis is explanted, our plan is to treat with
6
weeks for all bacteria previously found in the knee, inc dapto
~6mg/kg for VSE (but pcn allergic) BSI & septic arthritis s/p
explantation, fluc for ___, and moxifloxacin for GNR &
anaerobes. This was intended as curative, "mop up" therapy.
Consideration for d/c abx if no concern persistent infxn at the
end of the course. We also Rx'd treating 14days Bactrim for new
E coli in urine
culture, esp as pt had recent TURP."
Final ortho plan to be discussed at follow-up. Please do not
remove sutures until follow-up as wound closure was tenuous.
Daily dressing changes by RN.
Long term plan unclear. Hope is that if infection is effectively
cleared than there is a possibility of a new knee implant.
However, given the long term nature of the infection, loss of
viable bone, that eventually he may need an above the knee
amputation.
# blood loss anemia: had 1L blood loss after procedure on ___,
requiring 3U PRBCs, IVF, FFP. Remained intubated
prophylactically and admitted to ICU, but did quite well and was
quickly extubated and returned to medical floor. He then had a
very slow drop in hgb through ___. There was a
reticulocytosis, but insufficient. We attributed this to blood
draws and anemia of chronic disease (infection). We transfused 1
uni on ___ without incident.
# Bacteremia: blood cultures from ___ and ___ positive for
enterococcus. He remained hemodynamically stable without signs
of shock. He was started on daptomycin. Given his history of
aortic valve replacement there was high suspicion for
endocarditis. As above he was also found to have septic
arthritis. TTE and TEE both unrevealing for endocarditis.
antibiotics as above.
# femur fracture: noted post op, Went for ORIF ___
# UTI: UA with pyuria, urine culture grew E. coli. Per ID
guidance he was started on nitrofurantoin BID given his multiple
antibiotic allergies, but when ___ was resolved this was
switched to Bactrim for planned prolonged course.
# ___: mild ___ on admission, resolved with IVF. Likely
pre-renal.
CHRONIC ISSUES
#CAD/AI s/p CABG, Bentall procedure (___): continued
metoprolol, asa 81 (these were held briefly after blood loss)
but restarted.
#HTN: held home lisinopril 5 mg in s/o ongoing infection and
lower bp.
#BPH s/p TURP ___: pt recently passed voiding trial in ___
at outpatient urology follow up. Patient reports no longer
taking tamsulosin at home.
# Multiple drug allergies: patient has previously seen allergy
but no plans for desensitization per patient/daughter. Would
consider going forward. | 76 | 586 |
16524406-DS-6 | 20,570,736 | Dear ___,
It was a pleasure caring for you at ___. You were admitted
with an acute onset of severe abdominal pain. After looking
into several tests you were found to have ascites, another name
for fluid in your abdomen. This is likley a result of some
underlying liver disease. We drained that fluid from your
abdomen and you improved. You were seen by the liver docitrs who
will see you in follow up in one week (see below).
.
You also have a suppression of your blood counts. This was
likley a result of the antibiotics you were on for your previous
infection. We stopped these and your counts began to return to
normal. You will need close follow up with your primary care
doctor. Your blood will be drawn at home by ___ and they will
transmit your labs results to your doctor.
.
We have made the following changes in your medications:
STOP pencillin G
START ALDACTONE
START FUROSEMIDE (LASIX)
START CIPROFLOXACIN 500MG DAILY
.
You should continue taking your other medications as prescribed | ___ with complicated recent history of GBS bacteremia
complicated by L3 osteomyelitis (still on PCN G), and GB
distention of unclear etiology requiring percutaneous draiange,
now presenting with acute severe epigastric and RUQ abdominal
pain since ___ AM last night with abdominal CT showing inflamed
bowel loops, urinary bladder thickening, and ascites.
. | 170 | 54 |
11049412-DS-23 | 21,129,381 | Dear Ms ___,
It was a pleasure to care for you at the ___
___. You were seen in our hospital because you were
having nausea, vomiting, and diarrhea with fevers and belly
pain. We found a large kidney stone that was hurting your
kidneys, as well as evidence of a severe urinary tract infection
that had spread to your bloodstream. The Urology doctors were
___ to place a stent to help relieve this obstruction and allow
urine to flow. You had some low blood pressure after the
procedure, partly related to your infection and partly due to
some blood loss after your procedure. We gave you blood
transfusions, and your bleeding stopped. We treated your
infection with antibiotics through the IV, and monitored your
kidney function. When your kidney function was improving, we
were able to send you home.
We wish you the best,
Your ___ Care Team | Ms ___ is a ___ with history of infliximab-induced liver
failure s/p DDLT in ___ on tacrolimus, Crohn's disease, and
recurrent nephrolithiasis who presented to the ___ ED with
N/V/D, abdominal pain, and fevers to 102.5 of sudden onset. She
was found to have E. coli bacteremia and sepsis, with R-sided
hydronephrosis and pyelonephritis secondary to a UPJ stone. Her
course was complicated by a retroperitoneal hematoma, as well as
acute kidney injury (thought due to a combination of
obstruction/prerenal in setting of sepsis/intrinsic in setting
of supratherapeutic tacrolimus dosing). Pt initially hypotensive
on the floor, requiring blood transfusions and fluid boluses to
maintain stable pressures. Her infection was treated with
ceftriaxone, to improvement of her blood pressures. She had
gradual improvement of her renal function after relief of her
obstruction, as well as in the setting of temporarily holding
tacrolimus due to supratherapeutic dosing. Although initially
polyuric, her fluid balance was kept net-even with maintenance
and bolus dosing fluid. At discharge, her kidney function was
continuing to improve. | 153 | 170 |
11680612-DS-4 | 28,163,292 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- paraspinal/epidural abscess
What was done for you in the hospital:
- the infection (abscess) in your back was drained
- you were treated with IV antibiotics for infection
- your symptoms of opiate withdrawal were managed with other
medications
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ with active polysubstance IV drug use, anxiety, depression,
and hepatitis C admitted for paraspinal L2-L4 abscess s/p
drainage with clinical improvement and plan for prolonged course | 182 | 28 |
15947373-DS-23 | 22,061,018 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you were having hallucinations.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received IV vitamins and IV fluids
- You received lactulose to help you go the bathroom more and
clear tocins from your body.
- You met with the social worker and psychiatry teams and
discussed options to help you stay sober going forward.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Call ___, the addition social worker, at
___ to make an appointment with addiction psychiatry
for follow up. If you are not able to get in touch with her, ask
your primary care provider about referring you to an addiction
psychiatry team, or referral to a day program or sober house.
We wish you the best!
Sincerely,
Your ___ Team | ___ PMH ETOH Cirrhosis, ETOH Withdrawal, Metastatic Breast
Cancer w/ calvarial mets (on Palbociclib, fulvestrant), SDH
(being surveilled), presented to ED with visual hallucinations,
likely due to delirium vs acute Wernicke's encephalopathy, vs
hepatic encephalopathy. | 177 | 37 |
10808090-DS-24 | 26,346,806 | Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight-bearing as tolerated on your left leg,
with anterior precautions.
- Elevate left leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Please check electroyltes, including phosphorus and magnesium
in addition to a Basic Metabolic Panel, and replete
appropriately.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Please call the office of Dr. ___ to schedule a follow-up
appointment with ___ in 2 weeks at ___.
Please follow-up with your primary care physician regarding this
admission.
Physical Therapy:
WBAT LLE with anterior precautions
Ambulate twice daily if patient able With Assist: Walker
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: daily; please overwrap any dressing bleedthrough with
ABDs and ACE | Mr. ___ was admitted to the Orthopaedic Surgery Trauma
service from the Emergency Department on ___ for further
management of a left femoral neck fracture, including
pre-operative work-up. The following day, he was taken to the
Operating Room to undergo a left hip hemiarthroplasty. The
patient tolerated the procedure well. Please see Operative
Report for full details. Post-operatively, the patient was
taken to the recovery room before being transferred to the floor
for further monitoring and care. He was given Lovenox for DVT
prophylaxis. His pain was well controlled with narcotic
medications, which were eventually transitioned to oral pain
medications. Physical Therapy was consulted, and the patient
made gradual progression and was able to ambulate with
assistance by the date of discharge.
On ___, the patient was transfused 1 unit of packed red
blood cells for acute blood loss anemia. He responded well to
the transfusion, and his hematocrit increased appropriately.
On ___, the patient was in good spirits and expressed
readiness for discharge to a rehabilitation facility. His
incision was clean, dry, and intact, and he was able to tolerate
a regular diet. He was discharged to rehab in stable condition
with detailed precautionary instructions as well as instructions
regarding follow-up. | 348 | 212 |
17860833-DS-10 | 25,705,229 | ___ were admitted to ___ with complaints of rectal bleeding.
___ were found to have an elevated INR and were observed in the
ICU. ___ were sent to the floor and ___ ultimately got a
colonoscopy which showed multiple polyps and diverticula. ___
were given blood and your blood counts stabalized. ___ will be
sent home with close follow up with ___ PCP and ___. ___ will
need a repeat c-scope in ___ weeks.
.
Medication changes-see below
. | ___ M PMHx of HTN, DM-2, CAD s/p stent and CRI and AF recently
started on coumadin admitted for BRBPR found to have a
supratherapeutic INR, s/p 1 bag FFP, admitted to the ICU for
monitoring
.
# LGIB:
Pt p/w BRBPR in setting of initiating coumadin, INR 4.0, was
transferred to the ICU for Hct from 35 to 27, never becoming
hypotensive. Bleeding resolved without further intervention in
the ICU. CTA was done which did not show any obvious source of
bleeding. GI followed the patient while in house and eventually
did a colonoscopy on ___ which showed pancolonic
diverticula, but no active source of bleeding. There were
multiple polyps found. The patient also received 2 units of
PRBC's given that he had CAD and had mild to moderate symptoms
of fatigue. The patients coumadin and ASA were held in the
acute setting. ASA was re-started on discharge. The patient
was sent home with a prescription for a CBC check in 1 week and
if this is stable, can consider re-starting AC.
# AFib recently started on coumadin
The patient has a CHADS2 score of 3 and a CHADS2VASC score of 5
which places the patient in the moderate to high risk. The
patient presented with an active, likely lower, GIB, with a Hgb
drop from 11.5 to 8.1 requiring 2 units of PRBC's. The patient
was placed back on his full dose of ASA and the decision to
re-start his coumadin will be defered to the patients PCP.
# CAD:
The patient was ultimately continued on ASA and isosorbide. It
was noted that the patient was on simvastatin 80 QD which,
according to a recent FDA warning, can cause muscle damage at
this high dose. The patient reported that he has had no signs
of myopathy and had been on this medication for some time, so
this was continued.
# HTN
The patient blood pressure ultimately became elevated once his
GIB stopped. He was re-started on his home medications and his
blood pressure normalized.
.
# TRANSITIONAL ISSUES
- The patient needs a repeat colonoscopy in ___ months for polyp
removal
- The patient should follow up with his PCP ___ ___ weeks
. | 81 | 370 |
19016834-DS-12 | 23,177,132 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You came in with increasing sputum production and found were to
have Pneumonia. You were started on antibiotics and improved.
The speech and swallow team also saw you and found that you have
aspiration when swallowing thin liquids and recommended
thickened liquids. You should continue to take the full course
of antibiotics for Pneumonia after discharge.
The following new medications were added:
- START Levofloxacin 750mg daily for 10 more days
- START Metronidazole 500mg every 8 hours for 10 more days
- START Albuterol and Ipratropium Nebulizer treatments as needed
for shortness of breath
Please continue the other medications you were taking prior to
this hospitalization. | BRIEF COURSE:
Mr. ___ is a ___ yo M with a PMHx of RA on prednisone and
esophageal cancer s/p esophagectomy c/b esophageal stricture s/p
multiple ditlations who p/w increasing cough and sputum
production, leukocytosis and a CXR with a right lung base
opacification and right sided pleural effusion. | 117 | 48 |
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