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19027367-DS-21 | 29,164,042 | Dear ___,
___ was a pleasure participating in your care at ___
___.
You were admitted after developing profuse diarrhea at home.
The cause of your diarrhea was a minor gastrointestinal virus,
and you have recovered swiftly. You were found not to have a
serious infection, you did not loose a dangerous amount of
fluid, and we imaged your bowels and determined that you do not
have any structural problems with your bowel- it is healthy.
You do have a urinary tract infection and we have started you on
a three day course of Ciprofloxacin. The bacterium is sensitive
to ciprofloxacin.
Finally, we have given you a prescription for a physical
therapist to come to your home to offer general conditioning.
Medication Changes:
Started: Ciprofloxacin 250mg twice daily for a total of three
days, up to and including ___
Started: Physical therapy at home. | This is a healthy ___ F with a day of crampy diarrhea and poor PO
intake consistent with gastroenteritis.
1. Diarrhea with cramps: Likely viral gastroenteritis given
rapid onset and lack of associated symtoms like fever or BRBPR.
History and CT imaging don't support structural disease like
ischemic colitis, appendicitis or IBD. The patient was managed
conservatively with resolution of her diarrhea.
2. UTI: Urine grew pan sensitive E coli. Patient started on
three day course of ciprofloxacin
3. HTN: Pressures stable, continued
4. Deconditioning: The patient was seen and evaluated by
physical therapy who recommended no interventions. The patient's
son requested home ___ for overall conditioning and a
prescription was given. | 139 | 110 |
10911184-DS-19 | 27,361,747 | You were admitted to the hospital with cellulitis, an infection
of the skin. Your infection has improved dramatically with IV
antibiotics, and now you will be switched to oral antibiotics.
Your prescription for antibiotics has been sent to the ___
pharmacy at ___. Keep your left arm elevated. | ___ male with no significant past medical history who
presented with expanding erythema and swelling of hisleft elbow.
His olecranon bursitis was leaking and it appears it became a
nidus for
infection causing infection and overlying cellulitis. He has not
responded to oral antibiotics x 48 hours
He was started on vancomycin and CTX with rapid improvement in
his swelling, erythema, and pain. .Because Group G strep is
known to have clindamycin resistance, he was kept on ceftriaxone
alone and he had dramatic improvement in the pain, swelling and
warmth in his arm. He was discharged home with a one week
course of keflex. He will followup with his PCP prior to
finishing his course of antibiotics. HIs olecranon bursitis is
improving as well. | 51 | 128 |
14575931-DS-6 | 24,638,207 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were hospitalized
here for a fever, and we did a lumbar puncture which did not
show any concerns for infection, and also did an ultrasound
which showed a clot. We also performed a CT scan of your chest
which did not show any pulmonary emboli or pneumonia, and
therefore we believe that your fever is not from infection but
from this blood clot.
We have started you on a new medication called ___.
Please continue to take this medication as prescribed. If you
are ever hospitalized or in an accident, please notify
healthcare personnel that you are on this blood thinner given
higher risk of bleeding.
Because you do not have a spleen, we have also given you an
antibiotic to take in case you do have a fever in the future.
Take Care,
Your ___ Team. | Mr. ___ is a ___ year old male, with history of asplenia,
presenting with 1 day history of fevers, persistent cough and
headache.
.
>> ACTIVE ISSUES:
# Fever: Patient initially presented with fever, a chronic
cough, and headache. Given concern for asplenia, patient was
covered in the ___ ED with broad spectrum antibiotics
including vancomycin, ciprofloxacin, and patient underwent CT
Head which was negative and chest x-ray which showed bilateral
atelectasis without pneumonia. Given chronic cough and fever,
when patient was initially admitted he was continued on IV
antibiotics. Patient was found to have chronic right lower
extremity swelling, and given prior history of DVT now s/p
anticoagulation x 6 months, he underwent repeat ultrasound which
demonstrated DVT with complete occlusion. Furthermore, outside
records from ___ also reviewed which showed
that prior DVT involved femoral, popliteal (not peroneal however
not visualized and femoral), and this DVT involved popliteal and
peroneal. Given history of chronic cough, prior treatment for
pneumonia from PCP several weeks ago, patient underwent CTA
which was negative for both PE and pneumonia. Patient therefore
was given ___ for DVT and likely will require lifelong
anti-coagulation, and communicated results to PCP. Furthermore,
patient had previously undergone partial hypercoagulable workup
during initial diagnosis of PE/DVT at ___ which
was negative for Factor V Leiden and Prothrombin Gene mutation.
Patient's fever therefore was thought to be ___ to clot and not
infection, and stable for discharge.
.
# Right Lower Extremity DVT: As described above, patient was
started on ___ loading dose x 3 weeks, and patient to
follow up with PCP regarding further workup and maintenance.
Patient's DVT was thought to be unprovoked in this setting.
.
# Depression: Patient was continued on home lamictal,
brintellix, abilify and Deplin.
.
# Insomnia: Patient was continued on home clonazepam while
inpatient.
.
# Asplenia: Patient was given further information regarding
broad spectrum antibiotics and risk of sepsis in asplenic
condition. Patient also discharged with antibiotic prescription
for levofloxacin to have in case of future fever to reduce risk
of overwhelming sepsis.
.
>> TRANSITIONAL ISSUES:
# DVT: Patient started on ___ need loading doses x
3 weeks, and then maintenance dosing thereafter.
# ___ AV Block: Patient's EKG during inpatient, would
follow serially yearly
# Pending Labs: Patient has infectious studies pending,
including blood and CSF culture.
# Anemia: Patient found to be normocytic anemia, will need to
have follow-up workup.
# Frontal Abscess: Resolving upon discharge, to finished 3 day
course of levofloxacin
# Asplenia: Given high risk of sepsis, separate prescription for
levofloxacin was given to patient in case of fever
# CODE STATUS: Full
# CONTACT: Cousin, ___ ___ | 153 | 441 |
17827033-DS-7 | 26,138,905 | Dear Ms. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted on
___ because of sore throat, Fevers to ___, headache,
and a generalized feeling of being unwell. You were admitted
for observation, diagnosis, and treatment of your fevers.
In the emergency department, a CT scan of your neck showed a
palpable lymph node that was detected on physical examination as
well, which can become enlarged and tender in reaction to
bacterial or viral infections. The CT scan of your chest showed
no evidence of pneumonia or other lower respiratory tract
infections.
A CT scan of your sinuses was also performed, which did not show
any significant sinusitis (sinus infection). You were started
on an oral antibiotic (Augmentin), but continued to spike fevers
while on this medicine. Your fevers were treated with
alternating doses of Ibuprofen and Tylenol, with improvement in
your symptoms. As your fevers persisted despite antibiotics,
but improved with Tylenol, it was thought that your symptoms
were due to a viral infection.
Several different viral studies were drawn, including an EBV
viral load. The level of EBV in your blood is slightly higher
than it was at your last outpatient visit in the middle of ___, but it is uncertain that this change is what has caused
your symptoms.
Your fevers resolved and you were able to go more than 24 hours
without needing any Tylenol or ibuprofen. The decision was made
to discharge you, with close follow-up with Dr. ___
(___) and Dr. ___ disease).
It is important that you resume your medications as directed,
and attend your follow-up appointments. Should you need to
reschedule an appointment, please attempt to reschedule to a new
appointment as close to your original appointment as possible,
to ensure safe follow-up and treatment.
We wish you the best of health,
Your Care Team at ___ | ___ is a ___ year old female w/ PMHx of Hodgkin
disease s/p 1 cycle EACOPP, 5 cycles AVD followed by IFRT to
perivascular nodes, w/ 2 doses Rituxan for concomitant EBV
infection, who presented to urgent care on ___ w/ reported Tm
___, sore throat, headache, and cervical lymphadenopathy. | 319 | 50 |
15746410-DS-15 | 20,825,375 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with
shortness of breath and found to have an exacerbation of your
chronic obstructive pulmonary disease, and a possible pneumonia.
You were treated with steroids, nebulizers, oxygen and
antibiotics with some improvement. You were evaluated by
physical therapy and it was recommended that you go to pulmonary
rehab.
After your steroids were discontinued, you developed a headache
that was not relieved with ibuprofen or tylenol. We tried
anti-migraine medication but this was not effective. In
addition, because your headache was on your left temple, we
became concerned that you had an inflammation of your temporal
artery. We started you on high dose steroids and consulted
rheumatology who arranged a biopsy. The biopsy was negative for
inflammation of the artery and we are tapering your steroids.
Because we were concerned about inflammation in your arteries, a
CT scan of your abdomen and head was performed, both of which
were normal. You were experiencing some numbness in your face
and vision changes which were concerning for a stroke or a clot
in one of the veins in your head. Imaging of your head was
reassuring. You were evaluated by neurology for your headache
and they recommended muscle relaxers and medication to prevent
future headaches.
You will need to undergo another sleep study to determine
whether you need CPAP for obstructive sleep apnea. This can be
ordered by your primary care doctor or your new pulmonologist.
Wishing you all the best! | ___ with history of COPD on ___ home O2, OSA not on CPAP,
admitted with worsening cough and shortness of breath consistene
with a COPD exacerbation.
# COPD exacerbation: Most likely viral exacerbation in setting
of 1wk of feeling unwell with poor PO intake, nasal congestion,
muscle aches. CXR could not exclude pneumonia. ABG showed
significantly elevated pCO2 at 83 with associated somnolence and
the patient was admitted to the ICU for BiPAP. She was started
on levofloxacin IV but developed redness in her hand and was
changed to doxycycline. She was started on 40mg predisone burst
for ___s nebulizers. She had an echo with bubble
which showed no evidence of shunt, lvef 50%, right ventricular
cavity is dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. Once she was stabilized,
she was transferred to the floor on ___. On ___ she developed
increased shortness of breath and chest x-ray showed worsening
right lower lobe infiltration. Antibiotics were changed from
doxycycline to IV levofloxacin as it was believed that the
previous redness at the infusion site was due to infiltration
and not allergic reaction. She was evaluated by physical therapy
and it was recommended that she go to pulmonary rehab.
# Headache: Patient complained of left sided, frontal headache
that began after admission and was not relieved with ibuprofen.
She initially did not have any neurological complaints, however
on ___ began to complain of vision changes and facial
numbness. Her neurological exam was remarkable for decreased
sensation in the distribution of the V3 branch of CN V and some
periorbital muscle spasms. Noncontrast head CT was obtained and
showed no acute intracranial process. SHe was changed from
ibuprofen to indomethacin with minimal improvement. There was
concern for temporal arteritis based on the fact that HA emerged
after prednisone was discontinued and pt. is tender to palpation
over L temporal region. ESR is not elevated, however, and CRP is
only mildy elevated which is less consistent with ___ was
negative and complement levels were normal. Rheumatology has
high suspicion for ___. CTA abdomen/chest WNL. MRA/MRV was
negative for dural sinus thrombosis. Temporal artery biopsy was
done and was negative. The patient was seen by neurology and
tried on flexeril with no improvement in headaches. After
concerning causes of headache were ruled out, the patient was
started on nortriptyline for headache prophylaxis and will
follow up with her PCP as an outpatient.
# Decreased Urine output: On the day prior to admission, patient
had not voided for 8 hours. She was bladder scanned for 250cc
without sense of urgency. Likely dry given being NPO for
procedure and poor PO intake in the setting of headache and
abdominal pain. She was given IV fluids and urine output
improved. Creatinine remained stable and UA was negative.
# Community acquired pneumonia: RLL infiltrate on ___ CXR was
increased from previous, patient still hypoxic and with
increased O2 requirements. ABG done showed CO2 retention and
hypoxemia. Levofloxacin was added (d1 = ___ for a total of 5
days and the patient improved.
# Pulmonary edema: Likely related to amount of IV medications
since admission, with EF 50%. She was treated with lasix 20mg
daily with additional as needed for shortness of breath.
# Polycythemia: Consistent with prolonged hypoxia, further
evidenced by clubbed digits on exam. EPO level was sent and is
pending at the time of discharge.
# OSA: Has refused CPAP during this admission and says she does
not wear it at home. She has had a sleep study at ___
___ which, per patient report, was inconclusive. She was
evaluated by respiratory therapy while inpatient and was started
on nasal CPAP at night. She tolerated this poorly however, and
did not always wear the device despite counseling. She will
follow up with pulmonary as an outpatient for possible sleep
study.
# Hypertension: Continued on home hydrochlorothiazide 25 mg PO
daily.
# Gastritis: Seen on recent EGD. Continued on home PPI
# Constipation: Placed on a bowel regimen.
# Depression: Continued on venlafaxine and abilify. Lamictal,
xanax, diazepam were held. | 255 | 674 |
14745196-DS-11 | 29,863,535 | Dear ___,
___ was a pleasure taking care of you during your hospitalization
at ___. You were admitted with abdominal pain. A CT scan of
your abdomen and an MRI of your spine did not show any
concerning findings. Likely you pulled a muscle in your abdomen
and this will get better with time. Sit up and stand up slowly
to avoid pain. You can take Tylenol and use heating pads to make
the pain better.
Senna, colace and miralax were added to your medication regimen
to help with constipation. | Ms. ___ ___ ___ speaking woman s/p C4-7 Posterior
cervical laminectomies for evacuation of epidural hematoma in
___ presenting with abd pain that remains stable.
# Abdominal Pain: Etiology unclear, less likely to be
intra-abdominal in origin given benign exam and positional
component. On differential is radicular pain or muscle
spasm/strain. MRI reassuring, not impacted based on imaging, had
several BMs. Lidocaine patches were applied. MRI T and L spine
showed chronic fracture only that would not explain patient's
pain. Ortho spine was consulted and did not feel surgical
intervention was warranted. She worked with ___ and was
discharged home to follow up with outpatient providers.
# Vertebral compression fractures: Appear chronic on CT ___.
MRI read pending. Ortho spine consulted and felt that bracing
would only weaken muscles.
# Constipation: Hx of constipation with no BM for 3 days.
Unclear reason but susceptible post-surgery. She underwent an
aggressive bowel regimen and successfully had several bowel
movements.
#Pyuria: She remained asymptomatic. Urine culture was negative. | 89 | 162 |
14096083-DS-20 | 23,489,388 | Dear Mr. ___,
You were admitted to ___ for shortness of breath and chest
pain. You were found to have a bloodstream infection similar to
what has brought you to the hospital a number of times.
You had a workup for your infection which found that the
infection probably spread to your heart valves. It will be
extremely important that you finish a six week course of IV
antibiotics with dialysis (until at least ___. After your
release, you should follow up with an infectious disease doctor
in ___ to make sure that your infection has fully
resolved.
It was a pleasure taking care of you, and we are happy that
you're feeling better! | Mr. ___ is a ___ man with history of ESRD on HD (TTS),
HTN, pHTN, COPD, polycystic kidney disease, prior MSSA
bacteremia, recent admission for RUE AV graft pseudoaneurysm,
who presented with altered mental status and shortness of
breath, found to have high grade MSSA bacteremia. | 111 | 46 |
13641998-DS-21 | 25,046,278 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for fever, low blood pressure
and confusion. We believe the fever you experienced is related
to your liver abscess. Your low blood pressure is likely the
result of a number of factors including fluid removed at
dialysis, lisinopril and the liver abscess. As part of an
evaluation of your low blood pressure you had an ultrasound of
your heart which showed no major abnormalities.
Please take your medications as prescribed and follow up with
the appointments listed below. You will need to follow up with
the infectious disease service. An ultrasound has been scheduled
for ___ to evaluate your liver abscess.
The following changes were made to your medications:
STOPPED lisinopril
INCREASED Lantus (insulin glargine) to 12 units at bedtime
STARTED colace for constipation
STARTED senna for constipation | ___ with a PMH of ESRD on HD, benign duodenal tumor s/p Whipple
procedure and recent segment IV hepatic abscess s/p ___ drainage
presented with hypotension/fever/AMS despite ongoing antibiotic
therapy.
# Hypotension/fever/confusion: The patient presented after
hemodialysis with confusion and altered mental status. She
subsequently spiked a fever in the emergency department. This
presentation was similar to that several weeks prior at which
time she was diagnosed with a liver abscess. Her presenting
altered mental status each time was likely due to an acute
infectious process, presumably the liver abscess. On her last
admission the liver abscess was drained with an ___ placed
pigtail catheter. She was discharged on ceftazidime 1g QHD and
metronidazole 500mg TID. Blood cultures grew Bacteroides
fragilis. Abscess cultures grew pan-sensitive E.coli and
Klebsiella. A CXR done in the emergency department this
admission did not reveal an infectious infiltrate. The patient
is anuric, therefore no urine was sent. An ultrasound was
performed and showed: a 2.4-cm complex collection within hepatic
segment IVb slightly larger than ___. The patient
went for CT guided abscess aspiration on ___. No aspirate
could be obtained. The abscess cavity was washed out and
cultures sent. The abscess was felt to have matured into a
phlegmon. The infectious disease service was consulted and
recommended continued therapy with ceftazidime and metronidazole
until ___. The transplant surgery service was also contacted
and recommended no further imaging or surgical intervention. The
patient's ongoing, relative hypotension is likely due to volume
removed at dialysis, ACEi therapy and her infectious process.
The patient's ACEi was discontinued. An echocardiogram was
ordered to rule out a cardiac etiology of the hypotension, the
report was similar to prior obtained from OSH.
# ESRD on HD: The patient initiated HD within the past year. She
had a left upper extremity placed at ___ in ___. The patient
received dialysis on ___ while hospitalized. She was given a
TID phosphate binder and nephrocaps. All medications were
renally dosed. No gross derangments in electrolytes or volume
status were encountered.
# Anemia: The patient's anemia is not new per her nephrologist
and is most likely due to end stage renal diseease. Her dose of
epo was recently increased. As an outpatient she had several
negative guaiacs. She denies symptoms of GI bleed. Her
hematocrit was monitored while she was hospitalized.
# Hypertension: The patient's requirement for anti-hypertensives
has been decreasing over the last 6 months. Labetalol was
discontinued during her last admission. Lisinopril was
discontinued this admission. The patient was borderline
hypotensive this admission potentially due to her acute
infection. Fluid removal at dialysis should be judicious.
# Leg Pain: Secondary to spinal stenosis. The patient takes
gabapentin at home. Gabapentin was initially held in the setting
of AMS, but reinitiated when her mental status cleared.
#DMII: The patient's most recent A1C was 6.4. Obtained during
her last admission. She was initiated on QHS insulin glargine 10
units. This was increased to 12 units QHS at discharge. Her
recent hyperglycemia is likely infection related.
TRANSITIONAL ISSUES
*******************
1. Ceftazidime 1g QHD/metronidazole 500mg TID until ___ or
as specified by the ___ infectious disease service
2. F/u abscess washout cultures
3. Dialysis ___
4. Qweek safety labs (CBC w/diff, Chem7, LFTs) while on
ceftazidime
5. Monitor fingersticks as outpatient for titration of insulin | 140 | 538 |
13999829-DS-48 | 25,678,530 | You were admitted due to low oxygen levels and nausea. Your
oxygen levels are at a safe level using your home oxygen. You
were able to tolerate a diet with vomiting. You were found to
have a small blood clot in the lung which has likely been
present for several weeks. | # PE- small, subsegmental. This is likely chronic, present since
DVT was diagnosed several weeks ago. On Lovenox for DVT. Factor
Xa level therapeutic. ___ without DVT, no need to consider IVC
filter.
# Nausea/vomiting/diarrhea- none since presentation, making
active viral gastroenteritis unlikely. Ongoing alcohol use
could certainly cause some gastritis. continued PPI and H2
blocker therapy.
# Stage IV NSCLC- recently reversed full hospice care, and was
discharged last week with ___. He will need to re-establish
care with his primary oncologist after discharge (Drs. ___
___. He is doing well from a symptomatic standpoint- pain is
well controlled, and he has suggestion of anxiety or depression,
with good family support. Will continue nebs and supplemental
O2 therapy. | 51 | 123 |
11363444-DS-5 | 23,415,388 | Dear ___,
___ were admitted to the ___
for seizures. We monitored ___ on EEG to look at the electrical
activity within your brain, and it showed numerous seizures. We
performed extensive evaluation for the cause of your seizures
including an MRI which showed possible congenital abnormality of
one part of your brain, which, in addition to your very high
blood sugars due to diabetes, we believe may be the cause of
your seizures. We started ___ on medications which prevent
seizures in the future, which ___ should daily take as
prescribed.
Your sugars were high on admission so your diabetes medications
were changed - Metformin was stopped and ___ were started on
Humalog (short acting) insulin. Your Lantus dose was changed to
20 units at night at bedtime.
___ should also take your other medications, especially for high
blood pressure, and go to your appointments as scheduled.
It was a pleasure taking care of ___,
Your ___ Care Team | ___ is a ___ year old woman with vascular risk
factors (HTN, HLD,
uncotrolled DM) who presents with a few days of posterior
headache, then acutely with vertigo and a first-time seizure.
She had been noncompliant with home medications for the better
part of a month. On the day prior to admission woke up more
lethargic then usual, woke up around 7:30 AM, was unsteady on
her feet and complained of vertigo. Went to OSH where she had
an event with L gaze, L head turn, LUE convulsions progressing
to brief generalized convulsions, 2 minutes total per report and
drowsy afterward. CT head at OSH showed no acute pathology and
she was loaded with keppra 1000mg and transferred to ___.
# Neurology
Initial suspicion was for partial seizure with secondary
generalization, keppra was continued 1g BID and she was ordered
for MRI. Her exam on arrival showed visual neglect (L
hemianopsia) and a likely left ___ paralysis. Labs showed ___
and hyperglycemia to 350. The MRI done ___ was
motion-degraded, with microvascular changes but no acute
pathology and no clear seizure focus, though this was
non-contrast due to her ___. It was felt that hyperglycemia may
have led to lower seizure threshold. ___ obtained routine EEG
with ___ brief generalized seizures (1 minute) with rhythmic
theta slowing that correlated with staring and one event with
her leftward head turn. Continuous EEG was started and she was
revealed to have numerous electrographic seizures that lasted up
to few minutes; overnight she was loaded with phenytoin, then
subsequently with lacosamide the following morning and
levetiracetam was increased to 1500mg BID. Her EEG was quiet for
24 hours afterwards and they were discontinued. LP was performed
and CSF appeared unremarkable, sent for paraneoplastic
autoantibody panel. Her ___ improved after fluids and she
underwent repeat high resolution MRI with and without contrast,
which did not show acute infarct or mass but was noted to have
hypotropia of right inferior parietal lobe which may be
congenital. Levetiracetam was weaned down to simplify her
regimen and she was discharged with phenytoin and lacosamide.
# Renal
Initially presented with ___, Cr to 1.9, which was thought due
to dehydration and possible hyperglycemic hyperosmolarity. She
was resuscitated with IVF and Cr improved to 1.1.
# Endocrine
Initial blood sugars were 350 on arrival here, no ketonuria, but
it was thought she may have had some non-ketotic hyperglycemic
crisis due to not taking insulin/hypoglycemic agents for past
week which may have lowered her seizure threshold. ___ was
consulted who assisted with insulin recommendations while
holding her home metformin. Upon discharge they recommended
reducing her home glargine to 20u qhs due to reduced
requirements inpatient and suspicion of noncompliance with her
previous Rx of 50u. They also recommended stopping Metformin as
it did not seem to be effective as her pre-meal finger sticks
had been in the 200s at home. As her sugars had been within good
range in the hospital, the endocrinologist advised sending her
out of a Humalog sliding scale. The patient was instructed to
check her blood sugars before meals and give herself Humalog
based on the sliding scale. She has been using her Lantus so she
was familiar with giving herself SC insulin. She was offered
nutrition consultation which she declined. BG on discharge
100-199.
Her sliding scale was as follows: Administer 6 units for FSG of
120-159, 7 units for 160-199, etc, going up 1 unit of insulin
for every increase of 40 in blood sugar.
# Social
SW was consulted to explore her medication noncompliance.
Revealed that she is able to afford her medications but had
misunderstanding with her pharmacy re: calling for refills. She
was given health education and scripts for her home meds to
refill with clear instructions to follow up with her primary
provider for future refills. | 157 | 632 |
15613908-DS-7 | 20,839,852 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were admitted because of altered mental
status. You were evaluated by the psychiatry team who felt that
you should be admitted to an inpatient psychiatric unit. You
were observed on the medical floor briefly before being
transferred to the psychiatric unit. You are now medically
cleared to continue your care in an inpatient psychiatric
facility. We wish you all the best in your continued recovery.
Sincerely,
Your ___ Team | ___ hx paranoid schizophrenia, COPD, osteomyelitis, HTN presents
from nursing home with AMS, craling on floor, becomming fearful
of staff.
# AMS-the patient underwent a full workup including urinalysis,
chest x-ray, laboratory studies and psychiatric evaluation to
determine the cause of her altered mental status. The workup was
negative and per psychiatry she should be treated at an
inpatient psychiatric unit for an exacerbation of her chronic
paranoid schizophrenia. Her home medication of perphenazine was
continued for her paranoid schizophrenia, but her mirtazipine
was held to minimize sedating agents. There was some question of
consolidation on her chest x-ray but on repeat imaging there was
no concerning consolidation and the patient is therefore
medically cleared for further psychiatric treatment. Continued
workup for her altered mental status included negative RPR,
normal TSH, and normal B12 level. The patient tolerated regular
food with soft consistency during the hospitalization. She
required increasing physical and chemical restraints while
hospitalized due to severe agitation. 2.5 mg IV haldol was
initially used which was not sucessful. Increasing doses up to
5mg IV haldol were not sucessful. 1mg IV ativan was found to be
most effective but was used sparingly in light of the negative
effects of benzodiazepine treatment in the elderly and out of
concern of worsening her delirium. She tried to climb out of her
bed several times desbite 1:1 sitter and was eventually upgraded
to a full body posey restraint which she also wiggled out of.
She was finally put in a full bed mesh posey restraint to
prevent her from falling and injuring herself. Prior to
initiating the full bed mesh posey she had a fall from bed and
injured her wrist. She had imaging of the wrist which revealed
chronic degnerative changes but no fractures. Her pain was
controlled with acetominophen as needed. Seroquel was started at
bedtime to assist with insomnia and agitation overnight.
Psychiatry continued to follow and she was started on depakote
as well as daily routine activity modficatios and she improved
dramtically; she was transitioned to a lo-boy bed. Her mental
status improved and stabilized back to baseline.
# COPD-The patient's resting oxygen saturation on room air
varied between 90 and 94% throughout hospitalization. She did
not complain of shortness of breath or showed symptoms of
wheezing. Her chest x-ray showed some interstitial changes but
it is not clear how long these have been present. ___
___ was contacted several times but no records were able to
be obtained from her hospitalization there. She had no evidence
of COPD exacerbation while here.
# Transient oxygen requirement: Had one 24 hour episode of
supplemental oxygen requirement (2L to maintain SaO2 >90%).
Chest radiograph without evidence of infection or atelectasis,
and ABG unremarkable. She has long-standing untreated COPD but
at baseline does not require oxygen. Most likely she had an
acute aspiration given her significant saliva, secretions,
resulting in aspiration pneumonitis. She was without respiratory
distress, fever, cough. She had mild improvement with nebs.
Oxygen weaned off within 24 hours. On ___ patient vomited and
complained of chest pain, SBP 190, received 10 mg IV
hydralazine. EKG obtained and showed no changes, troponin
returned 0.07. Pt then desaturated to mid ___ on room air and
required 3L NC. CXR was obtained and appeared to show infiltrate
(final read pending). Labs were drawn and notable for a
leukocytosis of 13.4. The patient's infiltrate and new hypoxia
was likely secondary to an aspiration event and she completed a
course of empiric vanc/meropenem for presumed HCAP x7 days.
# # Rash: Resolved. Noted to develop new erythematous rash
notably in the lower extremities which is concerning for drug
rash given recent exposure to antibiotics in the setting of
treatment for aspiration pneumonia. Non-pruritic. Antibiotics
were discontinued and her rash improved with observation.
-------------------- | 82 | 629 |
15838432-DS-6 | 21,932,557 | Dear Mr. ___,
You were admitted to the hospital for abdominal pain and nausea.
This was likely a result of either food poisoning from something
you ate or a viral infection of your GI tract. It improved with
some fluids and medication to help with the nausea. Please get
plenty of rest and adequate fluid intake. Please also establish
with a primary care doctor and follow with them. It was a
pleasure taking care of you, best of luck.
Your ___ medical team | Summary:
___ year old with ESRD on HD secondary to PKD presenting with
nausea, vomiting and abdominal pain. He improved with
symptomatic treatment and was discharged in good condition. | 82 | 29 |
12576254-DS-20 | 22,616,004 | Dear Mr. ___,
You were recently hospitalized at ___ because you were
experiencing nausea, vomiting, and diarrhea. You had a CT scan
of your abdomen and an abdominal ultrasound which showed
gallstones in your bladder but no evidence of gallbladder
infection. You also had a nuclear scan which did not show any
gallbladder infection. Your vomiting and diarrhea may be from a
viral illness.
Please call your primary care doctor at your earliest
convenience to schedule a follow-up appointment.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Team | ___ year old male with PMH of prostate cancer, PTSD, and
depression who presents with N/V/D and abdominal pain found to
have cholelithiasis and homicidal ideation.
# N/V/D & Abdominal Pain: The patient presented with several
weeks of watery diarrhea (intermittant, up to 7 episodes per
day) as well as NBNB emesis. He also reported a "full" feeling
in his RUQ with some tenderness to palpation. There was no
radiation of abdominal pain to his shoulder. On admission he was
afebrile with a mild leukocytosis of 13.7. A RUQUS was obtained
which showed cholelithiasis with no evidence of cholecystitis,
with negative sonographic ___ sign and liver findings
consistent with steatosis. A CT of the abdomen with contrast
showed a distended gallbladder with cholelithiasis adjacent to
the gallbladder neck, with no pericholecystic fluid, stranding,
or gallbladder wall thickening. The patient received 2L IVF in
the ED and was given ondansetron for management of nausea.
Surgery was consulted in the ED and recommended a HIDA scan. By
the following morning, the patient's leukocytosis had improved
to 12.6. HIDA scan showed no acute cholecystitis. Evaluation of
gallbladder ejection fraction was not performed. As the patient
remained afebrile, with normal lipase and LFTs, his symptoms
were most likely secondary to viral gastroenteritis. Other
diagnoses on the differential include biliary colic or
inflammatory bowel disease. The patient denied any further
nausea or vomiting, but reported having several bowel movements.
He was able to tolerate a regular diet without any nausea or
vomiting. He was able to be discharged with instructions to
follow up with his PCP.
# ___: On admission, the patient's creatinine was 1.3 which
improved to 1.0 after IVF. The most likely etiology of his ___
was pre-renal azotemia given his poor PO intake for past ___s vomiting and diarrhea.
# Homicidal Ideation: On initial evaluation, the patient
demonstrated pressured speech and spent a long time discussing
his Native ___ ancestry and reported he was "out for blood"
with respect to people in ___ who dug up his mother's grave.
He stated that he had a plan to cross the border with a war
party. He denied homicidal ideation while in the hospital.
Because of these remarks, he was put on ___ from his ED
evaluation and throughout hospitalization had a 1:1 sitter.
Psychiatry was consulted and evaluated the patient, and found
him to have aspects of narcissistic/histrionic personality
disorders. He was not deemed to be undergoing a manic or
psychotic episode and it was determined that the patient was not
posing a true violent threat (please refer to OMR notes). The
patient was thus cleared for discharge from a psychiatric
perspective. He does not take any psychiatric medications.
# Prostate Cancer: The patient has a history ___ grade 6
prostate cancer. He is not currently undergoing treatment, which
is the patient's own choice. He believes that chemotherapy will
cause prostate cancer metastasis. This was not an active issue
during this hospitalization.
# Chronic sinusitis: The patient takes pseudoephedrine at home
for symptomatic management of chronic sinusitis. He reported
taking two tablets the day prior to admission. Urine tox screen
on admission was positive for amphetamines. The patient has no
history of amphetamine abuse. Pseudoephedrine was held during
hospital stay. | 92 | 539 |
11900721-DS-25 | 24,711,015 | Dear Ms. ___,
It was a pleasure caring for you during your admission to the
___. You came in because of
pressure and discomfort in your abdomen.
You had a paracentesis that was negative for infection. You also
had a CT scan that showed severe constipation. Most likely, the
constipation is causing your pain.
Before discharge today, you had a paracentesis of 2.5L to
relieve pressure in your belly. Please continue your outpatient
paracentesis schedule. You preferred to keep your appointment
this ___ in case fluid has reaccumulated.
Please continue your MiraLax to treat your constipation. Please
also continue the increased dose of lactulose.
Once again, it was a pleasure caring for you and we wish you the
best.
Sincerely,
Your Medical Team | Ms. ___ is a ___ yo female with cryptogenic cirrhosis
requiring frequent large volume paracenteses and suspected
sarcoidosis who presented with two days of abdominal pressure
following outpatient para.
# Abdominal Pressure: Most likely differential includes
hemoperitoneum from traumatic paracentesis on ___ or
increased fecal burden/constipation (seen on CT. Could also
potentially be gas/dyspepsia. Unlikely to be peritoneal
infection (dx tap without neutrophilia or organisms on spin),
colitis (no diarrhea, CT not consistent). CT showed increased
fecal load and non-hemmorhagic ascites. Bowel regimen was
icreased on discharge to minimize effect of constipation on her
abdominal pressure and encephalopathy.
# HEPATIC ENCEPHALOPATHY: On presentation was A&Ox3 with only
minimal asterixis. Had infectious work up as above for her
abdominal pain, which was unrevealing (NG on blood cultures,
negative UA, negative CXR). Lactulose was increased, rifaximin
was continued.
# VARICES: history of grade 1 esophageal varices, last EGD was
___.
Omperazole 20mg daily was continued.
# ASCITES: Now requiring weekly paracentesis of ___ at a time.
No SBP on diagnostic tap from ER, although there were numerous
red cells, H&H was stable after ED diagnsotic tap. Therapeutic
tap on day of discharge revealed 2.5L of serosanguinous fluid,
no immediate complications. No abdominal pain after tap. Plan
was to continue as scheduled with ___ outpatient para
evaluations with radiology.
# ___ on CKD: Slight ___ on presentation with Cr 1.5 from
baseline of 1.2-1.3 which has now resolved after holding
diuretics. Likely prerenal due to decreased PO intake with
abdominal discomfort. Diuretics were restarted on discharge.
# Cirrhosis, compensated: Cryptogenic, diagnosed on liver biopsy
in ___. She is not a transplant candidate. Her meld on
presentation was 18, and 17 on discharge.
# Diet controlled DM: Was maintained on an insulin sliding
scale.
#CODE: Full
#CONTACT: Patient, Brother ___ ___
TRANSITIONAL ISSUES
- Please check CBC, chem-10, LFT's, ___ on ___,
___ and fax results to ___, attn: Dr. ___. F:
___.
- Trend Cr given ___ on presentation. Discharge Cr was at recent
baseline, 1.3
- Continue scheduled paracenteses
- Follow-up pending fluid cultures. Consider further work-up for
high RBC count in ascitic fluid
- Follow-up CT final read | 123 | 369 |
11463165-DS-23 | 28,678,796 | You were admitted to the hospital after a fall. You sustained a
laceration to your right arm. During your hospital stay, you
were evaluated by the Cardiac service to see if there was a
cardiac event which led to your fall. Your cardiac medication
was changed to a longer lasting agents. You were evaluated by
physical therapy prior to your discharge. Your vital signs have
been stable and you are preparing for discharge home under the
care of your family. You are being discharged with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Please follow-up in the Hand clinic on ___, and schedule an
appointment with your primary care provider ___ 24 hours, so you
can be seen in 2 weeks.
Please schedule an appointment with your cardiologist in 24
hours so that you can be seen in 1 week. | ___ year old female who was admitted to the hospital after a fall
resulting in an injury to her right arm. The mechanism of the
fall was unknown. Upon admission to the hospital, the patient
was made NPO, given intravenous fluids, and underwent imaging of
the head, neck, chest, abdomen, right arm and right knee. No
fractures were identified. The patient was reported to have a
small right frontal scalp hematoma. The Hand service was
consulted for management of the right arm open wound. The wound
was irrigated and a DSD was applied and the patient was
scheduled for an appointment for follow-up with the Hand
service.
During the ___ hospital stay, she underwent a cardiac
evaluation to help to determine the cause of her fall.
Cardiology was consulted for interrogation of her pacemaker.(
see report on findings). She also underwent carotid studies and
an echocardiogram. Carotid studies showed mild atherosclerosis
in the right internal carotid artery, otherwise a normal carotid
ultrasound. Findings from the echocardiogram showed atrial
fibrillation with a rapid ventricular rate, and a left
ventricular ejection fraction of 50%. The ___ cardiac
medications were changed to long acting agents. A one week
follow-up appointment with her cardiologist was recommended to
her family.
In preparation for discharge, the patient was evaluated by
physical therapy and recommendations were made for discharge to
a rehabilitation facility. The family opted for discharge to
the ___ assisted living quarters with 24 hour care. At
the time of discharge, the ___ vital signs were stable and
she was afebrile. She was tolerating a regular diet with
assistance during mealtime. She was ambulatory with the
assistance of a walker. She required frequent orientation to
her surroundings, which was reported to be her baseline mental
status.
The need for follow-up appointments with the Hand surgeon, PCP,
and cardiologist were discussed with the ___ daughters.
The medication change was reviewed and the pharmacy which
supplies the medications to the facility was contacted. The
___ daughters were instructed to schedule an appointment
with the ___ cardiologist this week.
On HD #5, the patient was discharged with her daughters to the
assisted living facility with preparations made for 24 hour
care. A copy of the discharge instructions was provided to her
daughters. | 285 | 398 |
10674875-DS-2 | 28,088,193 | Dear Ms ___,
You were hospitalized due to symptoms of weakness and sensory
loss resulting from transient ischemic attack, a condition where
a blood vessel providing oxygen and nutrients to the brain is
transiently decreased. The brain is the part of your body that
controls and directs all the other parts of your body, so
decreased blood supply to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Transient ischemic attack 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 attacks, we plan to
modify those risk factors. Your risk factors are:
PFO
diabetes
high cholesterol
New medication: atorvastatin 40mg daily for your high
cholesterol.
Please continue your home dose of warfarin starting ___
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below. PLease have your PCP check your INR ___
PLease work with physical therapy and occupational therapy.
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. | ___ is a ___ year old woman with fibromuscular
dysplasia, 2 prior CVAs in ___ and ___, PFO on warfarin (INR
3.5) who presents with acute neurological symptoms concerning
for
new ischemic lesion versus TIA. In the ED she had onset
right-sided hemiparesis/sensation loss and facial droop, LUE
weakness, dysarathria and nonfluent aphasia. CT shows no
obvious new infarct. CTA shows no vessel cutoff. MR head showed
a small restricted diffusion in the right occipital region which
we think is artifactual. Given her risk factors, her
presentation is concerning for TIA. For risk factor assessment:
LDL 123, a1c 6.2%. She was started on atorvastatin. To evaluate
for thromboembolic source in the setting of her known PFO, a
lower extremitiy u/s was done and showed no evidence of DVT.
___ evaluated her and cleared her to be discharged with home
___.
# Transitional issues:
- follow up with neurology (Neurologist in ___ or Dr. ___
based on ___ preference)
- follow up with PCP. Next INR check by ___
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (x) Yes (LDL = 123 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) 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 followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 319 | 364 |
11653727-DS-23 | 24,562,745 | Mr ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ after a fall at home and found to have
significant acute renal failure. You were mildly dehydrated an
received IV fluids. Unfortunately you then developed heart
failure due to the fluids and valvular disease in your heart.
After diuretics to make you urinate more you improved and are
being dsicharged to rehab to improve your strength and
functional status. | ___ M history of prostate cancer s/p XRT complicated by
radiation proctitis and recurrent admissions for BRBPR, COPD on
home O2, severe MR with pulmonary hypertension who presented to
the ED for possible syncopal event and admitted to the ___ for
significantly elevated lactate likely dehydration related,
resolved with IVFs course complicated by acute dCHF exacerbation
and acute metabolic encephalopathy both now resolved.
# SIRS without evidence of infection
# Lactic Acidosis
Patient presented with tachycardia and elevated lactate to 7.8.
Workup did not demonstrate focal evidence of infection. Patient
was thought to be dehydrated in setting of poor PO intake,
diarrhea, and continued use of diuretic and ACE-I despite it
being discontinued after recent admission. No evidence of
infectious process during admission and never had a fever or
positive cultures. Lactate resolved with IVFs and withholding
diuretic / ACE-I
# Mitral Regurgitation
# Acute on Chronic Respiratory Failure
# Acute on Chronic Heart Failure with preserved Ejection
Fraction: LVEF 50-55% with pulmonary hypertension related to
severe mitral regurgitation and LVH. Acute CHF exacerbation
iatrogenic related to aggressive IVFs in the FICU for elevated
lactate. Medications were titrated. IV diuresed with Lasix
during admit and transitioned to PO Torsemide 40mg daily prior
tod ischarge which maintained euvolumia. Continued Metopolol
Succinate but discontinued hydralazine and ACE-I given
predominant right sided failure so no need for aggressive BP
control but rather leaving room for diuresis. DC weight: 65.6kg,
appeared euvolumic.
# Acute Renal Failure
# CKD Stage IV - Cr peaked at 3.3 (baseline ___ etiology
remained unclear; did not improve with fluid resuscitation,
remained stable during hospitalization. Suspect this is new
chronic baseline. Continued Calcitriol. Per outpatient
discussions (See Dr ___ recent note) patient is opposed
to HD. If Cr continues to worsen readdressing goals of care
should be primary focus.
# NSTEMI: Presented to the ___ with elevated troponin to 0.18
in setting of dehydration and renal failure; CK-MB was flat, no
clear evidence of ongoing ischemia. EKG without acute changes.
Likely demand in setting of hypotension as well as acute on
chronic renal failure.
# Anemia of Chronic Blood Loss and anemia of chronic disease /
Chronic Kidney Disease. Chronic blood loss from chronic
radiation proctitis related GI bleeding. Hgb during this
admission nadired at 7.0, prompting 1 unit of pRBCs ___ with
appropriate increase in Hct which remained stable overnight.
# Atrial Fibrillation: Not on coumadin due to recurrent LGIB.
His aspirin and metoprolol were reportedly held on last
admission. Held metoprolol in setting of hypotension initially
but restarted as above for CHF. Discharged on low dose
Metoprolol succinate for rate control and CHF
# HTN: Held antihypertensives for hypotension initially on
admission. Medications titrated during admission and discharged
only on Torsemide and Metoprolol. No need for Hydralazine and
ACE-I, BPs well controlled / slightly hypotensive during
admission.
# GOC: Began to have ___ discussion with patient though he was
not ready to discuss code status or long term care goals. See
Dr. ___ note for additional
discussion about advanced care planning. Remained FC in house.
CHRONIC
# COPD: Remote 30 pack year smoking hx. On supplemental O2 at
home. Continued Tiotropium and albuterol nebs
# Dyslipidemia: hx of 2 prior CVA's and s/p endarterectomy.
Residual L sided weakness. Continued simvastatin 40 mg daily
# Hypothyroidism: continued levothyroxine 25 mcg daily
# Gout: no recent flares, continued allopurinol | 76 | 593 |
19397036-DS-26 | 29,260,108 | Dear Ms. ___,
You were admitted due to increasing abdominal pain. After
careful evaluation, we felt this was likely related to
constipation-predominant irritable bowel syndrome, likely
exacerbated by prolonged opioid use. It improved with laxatives
and increased number of bowel movements. Given that you had
some dark stools, we prepped your colon and you had a
colonoscopy done that showed a small lesion at the connection
between your large and small intestine that we biopsied. You
also reported some chest pain, but after further testing, we
concluded it was unrelated to your heart. We have started you on
a new medication called amitiza to help with your IBS and
underlying constipation. We also recommend that you decrease the
amount of opioids you are using to further help with intestinal
motility. Please follow-up with your PCP and with liver clinic.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___ | ___ year old female w/ hepatitis C-induced liver cirrhosis,
status post DCD liver in ___ c/b biliary strictures
admitted due to worsening abdominal pain with rising LFTs and
___.
# Diarrhea: Pt. reported one episode of dark loose stools during
this admission. The following day, stools were noted to be brown
and guaiac negative. Her hematocrit remained stable. Of note,
she also had reported several episodes of black loose stools
prior to admission for which she had been scheduled for an
outpatient colonoscopy. Last EGD in ___ demonstrated normal
mucosa in the esophagus, mild gastritis, and normal mucosa in
the duodenum. After several days of bowel prep (initial attempt
at colonoscopy revealed too much stool), a colonoscopy was
performed ___ that demonstrated now active bleeding. A
polyp, however, ws biopsied. The patient's aspirin and plavix,
which were initially held in anticipation of colonoscopy per her
outpatient GI's recomendations, were restarted at time of
discharge.
#Abdominal Pain: On admission, the patient reports 3 weeks of
increased abdominal pain accompanied by vomiting and diarrhea.
Pt. with chronic abdominal pain requiring significant opioids at
baseline. A liver biopsy in ___ which showed recurrent
chronic viral hepatitis C with Grade 2 inflammation and Stage 3
fibrosis. Pelvic U/S from prior hospitalization shows peritoneal
cysts on the left side, though patient's pain is on the right.
RUQ U/S this admission showed patent hepatic vasculature. Ab
ultrasound demonstrated minimal, non-tappable ascites. This
abomdinal pain is likely multifactorial in origin. Given
difficulties with bowel prep due to significant amounts of hard
stool, abdominal pain may represent constipation predominant
IBS. Chronic high dose opioid use suggests additional component
of narcotic bowel syndrome. Pt. was discharged on lubiprostone
for constipation predominant IBS as well as with recommendations
to titrate down opioid use. Pt. reported significant
improvement in pain by time of discharge.
#Rising LFTs: LFTs appear to have been rising over past several
months and then actually downtrended during this admission
without intervention. Liver biopsy ___ showed evidence of
chronic viral hepatitis C with Grade 2 inflammation and Stage 3
fibrosis. HCV viral load at that time was also high (2 million),
further supporting diagnosis of recurrent hepatitis.
Unfortunately, pt has history of suicidality on interferon and
so is currently awaiting new treatment options. RUQ U/S this
visit showed patent hepatic vasculature without tappable
ascites. No signs or symptoms of infection. Rising LFTs,
therefore, are most likely related to slow HCV progression.
# HCV cirrhosis s/p DCD liver transplant in ___. Multiple
complications including biliary strictures requiring stents (now
removed) and hepatic artery stenosis requiring stents (still in
place, on aspirin and plavix). Pt. was continued on ___
tacrolimus with monitoring of levels. Her aspirin and plavix
were initially held for colonoscopy and were restarted on
discharge. She was continued on atovaquone
#Acute Kidney Disease: Cr elevated to 1.7 on admission,
increased from baseline Cr of 1.4. FENA 2.54% on ___ did not
support prerenal, however Creatinine improved with intravenous
fluids and albumin challenge. UA with LG leuks, 74 WBCs, Pos
Nit, and few bacteria, but as UCX with no growth did not treat.
Renal ultrasound demonstarted no obstruction or other
abnormalities. Cryoglobulins were negative. Her creatinine on
discharge was 1.5.
#Chest Pain: Patient reported substernal chest pain during this
admission. Resting echo, stress echo and EKG without evidence of
ischemia. Troponins negative. Despite cardiac risk factors
(age, long tobacco abuse history and chronic inflammation), ACS
was considered unlikely. She was continued on her beta blocker
as well as aspririn and plavix for her hepatic artery stents at
discharge. A statin was deffered given liver transplant.
#?Vaginal Bleeding: Pt. reported one isolated episode of minimal
vaginal bleeding. Post-menopausal bleeding is obviously
concerning, though unclear if this is true vaginal bleeding or
perhaps rectal bleed. Pt. does have normal PAP documented
___. Ultrasound from prior admission showed unremarkable
uterus/adnexae. Work-up was deferred to outpatient. | 160 | 656 |
19362199-DS-6 | 22,399,786 | You were admitted with abdominal pain and found to have
gallstones. You were seen by the GI service and felt to most
likely have passed a gallstone. Your MRCP did not show any
stones in the common bile duct or any inflammation of the
gallbladder or pancreas, however gallstones were seen in your
gallbladder.
Although you may have passsed a gallstone, it is still not
completely clear. Therefore, it is very important that you make
an appointment with a Gastroenterologist to discuss your
abdominal pain further as you may require either refferal to a
surgeon or another form of therapy.
Please call your doctor if you experience recurrence of your
severe abdominal pain or if you develop significant nausea,
vomiting, or fevers. | ___ yo F 6 weeks postpartum admitted with RUQ abdominal pain,
transaminitis, and mildly dilated common bile duct from
baseline.
#Cholelithiasis/Probable transient choledocholithiasis with
biliary obstruction:
Patient presented intially with acute RUQ abdominal pain,
nausea, and elevated aminotransferase levels without
hyperbilirubinemia. An ultrasound should gallstones without
choledocholithiasis and slightly enlarged common bile duct. Her
symptoms improved with conservative therapy and MRCP on hospital
day two showed gallstones but no evidence of choledocholithiasis
or intra or extra hepatic biliary dilatation. Given her acute
onset of pain, history of post prandial abdominal pain,
particularly with fatty foods, and abrupt improvement in pain
with resultant downtrending of LFTs, it was felt that the
patient most likely passed a gallstone. She was able to tolerate
a regular low fat diet prior to discharge and was discharged
home to follow up in GI clinic for further evaluation of her
abdominal pain and for further consideration of cholecystectomy
should she continue to have post-prandial abdominal pain without
other cause.
# Code: full
# Disposition: Patient was discharged home with GI and potential
surgical follow up. | 120 | 177 |
11000065-DS-19 | 21,454,253 | Dear Mr. ___,
You were admitted to the hospital because of imbalance/concern
you were having a stroke and hematemesis (vomiting blood). You
had a number of imaging studies that showed that you did not
have a stroke. Neurology was consulted and they evaluated you.
They agree that you did not have a stroke. You had an EGD by the
gastroenterologists which shows that the lining of your
esophagus is inflamed. There is some concern that the cells
lining your esophagus are changing in response to chronic
inflammation, which can be a precancerous condition (called
___ esophagus). The gastroenterologists took biopsies of
the lining of your esophagus and took biopsies of a polyp in
your stomach. They will follow up with you re: the results of
those biopsies and let you know if you need future endoscopies
for surveillance.
The best thing you can do for your help is quit drinking
alcohol. The social worker will give you resources for
abstinence programs before you leave.
It will be important that you take all the medications listed
below and follow up with your primary care doctor.
Best of luck with your continued healing.
Take care,
Your ___ Care Team | Mr. ___ is a ___ year old man with a history of HTN, EtOH
use disorder, erosive esophagitis, and
prior TIA who presents after an acute episode of dysequilibrium
and instability on ___ ___s repeated episodes of
hematemesis.
# Dysequilibrium
# Active alcohol intoxication
# Alcohol withdrawal
# H/o TIA
He described an acute episode of dysequilibrium and instability
the morning of ___ which resolved after 5 minutes. However,
during the hospital stay he still felt unsteady on his feet.
This resolved with time, and was most likely due to alcohol
intoxication.
Neurology was consulted in the ED. They commented that the head
CT from ___ showed either a small IPH or
calcification (there was some concern for a globus pallidus
lesion). This lesion was not visualized on subsequent brain
imaging.. Neurosurgery was also consulted in the
ED. They said that no neurosurgical intervention was indicated
and no AEDs were indicated.
Workup was remarkable for CT head without evidence of an acute
bleed, CTA head and neck without evidence of significant
vascular stenosis, MRI brain WWO contrast without evidence of
infarct/hemorrhage, and telemetry without significant events.
Lipid panel, Hgb A1c, and TSH were within acceptable ranges.
His presentation was complicated by acute alcohol intoxication
as well as withdrawal and hematemesis with a mild blood loss
anemia.
# Alcohol withdrawal
# Hypomagnesemia
# Hypophosphatemia
# Hypocalcemia
He presented to the ED actively intoxicated and then entered
withdrawal. He has a history of alcohol withdrawal last year
after quitting alcohol cold ___. No history of DTs or
seizures. He has never been hospitalized for alcohol withdrawal
in the past. He completed a diazepam taper and is was CIWA with
lorazepam available per protocol. At the time of discharge, he
was no longer withdrawing and not receiving benzodiazepines for
withdrawal. He was treated with thiamine, MV, and folate
supplementation. Social work was consulted and he was given
resources for alcohol cessation programs and help lines.
# Hematemesis
# Acute blood loss anemia
# Esophagitis
# Possible ___ esophagus
He described ___ episodes of hematemesis the day prior to
admission. He had no further hematemesis inpatient. He has been
hospitalized at ___ in ___, and ___ for
hematemesis and was found to have severe erosive esophagitis by
EGD in ___. At that time he was started on a PPI, which he
continues to take. He is not known to have a history of
cirrhosis/varices.
H/H has trended down: 16.1/44.8 -> 14.2/40.4 -> ___. He
remained hemodynamically stable. GI was consulted. They
completed an EGD on ___. The gross appearance of the esophagus
was consistent with ___ esophagus. Biospies were taken of
the esophagus. He had mild esophagitis. A polyp in the gastric
antrum was biopsied. He was continued on omeprazole 40 mg PO
BID. GI will follow up with him re: the results of the biopsies
and possible need for future surveillance EGDs.
# High risk for aspiration
CTA neck showed that the upper thoracic esophagus is distended
with air-fluid levels placing him at high risk for aspiration.
CXR was clear. He had no signs/symptoms of aspiration. He was
evaluated by ___ and did not show evidence of aspiration on
their swallow exam.
# Essential HTN, poorly controlled
Likely with some contribution from alcohol withdrawal. He was
continued on his home amlodipine and clonidine
# AG Metabolic acidosis (resolved)
Likely d/t EtOH ingestion and lactic acidosis (resolved).
# Leukocytosis (resolved)
Likely stress response in the setting of alcohol withdrawal and
possible TIA. No fever. Tachycardia is likely related to
withdrawal. No localizing signs/symptoms of infection. CXR
wasclear. BCx have no growth to date.
Mr. ___ is clinically stable. The total time spent today on
discharge planning, counseling and coordination of care was
greater than 30 minutes. | 193 | 595 |
16677287-DS-10 | 26,910,017 | You were admitted after your MRI ___ showed an new stroke in
the right side in the area called the basal ganglia. This is
likely caused by high blood pressure, cholesterol and diabetes.
- You should stop taking aspirin and Plavix.
- Instead, start taking Aggrenox (which contains aspirin and
another medication called dypyridamole) which helps prevent
strokes.
- Start simvastatin, a medication for cholesterol that also
helps prevent strokes. | Patient was admitted to the stroke service after she was found
to have an
incidental acute ischemic infarct on a surveillance brain MRI
scan. On questioning, she acknowledges having generalized
headaches a ___ days ago and noted minor gait unsteadiness. At
this time, she is symptom free. Exam is normal.
Brain MRI: Acute, small left globus pallidus infarction seen on
2
cuts. No intracranial or extracranial stenosis seen. Exam with
no residual deficits. Likely secondary to small vessel disease.
She is in sinus rhythm. Telemetry showed no atrial fibrillation.
An outpatient TTE was ordered but will likely be low yield. For
now, she was switched from asa/plavix to aggrenox and started on
low dose statin. Keppra was continued at previous doses. | 69 | 115 |
19388963-DS-10 | 26,680,862 | 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:
- WBAT LLE, transfers as tolerated
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 ASA 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.
Physical Therapy:
WBAT, transfers as tolerated
Treatments Frequency:
___ shower with dressing in place. Remove dressing if saturated
or falling off. ___ replace if wound still oozing, otherwise
may leave open to air. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Right femoral shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R femur cephalomedullary 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
WBAT in the RLE extremity, and will be discharged on ASA 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. | 214 | 252 |
14972430-DS-20 | 25,771,370 | Ms. ___,
.
You were admitted to the hospital because you were found to have
a slow heart rate. You had a pacemaker placed. Proper
functioning of your pacemaker was confirmed.
.
During your admission, you were found to have worsening kidney
function. The worsening kidney function was likely due to your
slow heart rate, as it improved when your pacemaker was placed.
We restarted you on your home lasix. Please follow up for a
blood test to check your electrolytes and kidney function on
___.
.
MEDICATIONS CHANGED THIS ADMISSION:
START lasix 40 mg by mouth daily
START seroquel 12.5 mg by mouth twice a day (discuss stopping
this medication with your primary care physician upon discharge
from rehabilitation) | ___ woman with a history of DM, CKD, HTN who was
discharged ___ after being admitted for a fall and pneumonia
admitted with fatigue; found to be in complete heart block with
bradycardia to 30.
.
# RHYTHM: Patient was admitted with complete heart block with
heart rate to the ___. On admission, she remained asymptomatic.
She underwent pacemaker placement without immediate
complication. The pacemaker was interrogated and shown to have
proper functioning, CXR with proper lead placement. The patient
received 48 hrs of vancomycin for prophylaxis. The patient
should follow up in device clinic in one week.
.
# Acute on chronic kidney injury: The patient was admitted with
acute kidney injury to 2.2 (creatinine at discharge 1.8;
previous known baseline 1.5). Creatinine improved to 1.8 with
pacemaker placement; making etiology of acute kidney injury
likely secondary to poor renal perfusion from bradycardia. The
patient's lisinopril was held until improvement in renal
function. She was resumed on home lasix 40 mg PO daily. The
patient was discharged on lasix and lisinopril. The patient
should have her potassium, BUN and creatinine checked on
___. She should also follow up with her primary care
physician regarding her creatinine upon discharge from
rehabilitation.
.
# Delirium: Patient became delirious during her admission.
Likely baseline in setting of slow cognitive decline.
Infectious sources of delirium were not identified. Urine
culture negative. Patient was recently treated for pneumonia,
but no residual evidence of pulmonary infection during this
admission. After the patient received her pacemaker, she was
started on Seroquel 12.5 mg BID per geriatric recommendations
during previous admission. The patient should follow up with
her primary care physician upon discharge from rehabilitation to
discuss seroquel discontinuation.
.
#CORONARIES: no evidence of ACS or CAD. The patient was
monitored on telemetry throughout admission.
.
# PUMP: The patient does not carry a diagnosis of CHF. Last
echo in ___ with grade 2 diastolic dysfunction. She was
continued on lasix 40 mg PO daily.
.
#Hypertension: The patient remained normotensive throughout
admission. Lisinopril was held for acute kidney injury during
admission, but resumed at discharge.
.
#Type II diabetes mellitus: diet controlled. The patient was
maintained on a diabetic diet with insulin sliding scale
throughout admission.
.
#Low back pain: Chronic. On admission, the patient did have
mild low back pain. Pain was controlled with tylenol as needed
throughout admission.
.
#Pseudogout: Chronic. No evidence of flare throughout
admission. Allopurinol was held during admission for acute
kidney injury. It was resumed prior to discharge.
.
#Anemia: Chronic. The patient remained at baseline hematocrit.
Throughout admission.
.
CODE: confirmed full (with HCP ___
.
EMERGENCY CONTACT: 2 goddaughters are HCP ___ h
___, c: ___ ___ (___)
=============================================================
TRANSITIONAL ISSUES
#The patient needs to follow up in device clinic in one week.
Call ___ for an appointment.
#Please check sodium, potassium, BUN, creatinine on ___.
Fax results to Dr. ___ (___)
#The patient should follow up with her primary care physician
upon discharge from rehabilitation to discuss seroquel
discontinuation. | 131 | 559 |
14448804-DS-13 | 24,439,761 | You were admitted to ___ following evaluation for a possible
left ulnar artery occlusion. You were started on an IV
anticoagulant and transitioned to xaralto, and oral
anticoagulant. You were also seen by the ___ cardiology
service whom recommended adding isosorbide mononitrate 30mg
daily. You will need to follow up with your primary cardiologist
next week. Please continue to take xarelto for 3 months. At that
time, after you follow up with your cardiologist, they may stop
this medication if the see fit. However, if they have any
questions, you may call Dr. ___ office to schedule an
appointment in 3 months.
You will need to continue you home medications except
amlodipine, which was increased to 10mg once a day
You will need to continue to take aspirin 81mg once a day
You may continue to take a regular diet. | Mr. ___ was admitted to ___ following evaluation at ___,
He was started on a heparin drip for his left hand pallor and
parasthesia. While in route Mr. ___ hand began to improve.
Upon examination in the ER he was found to have a dopplerable
ulnar pulse, but no radial pulse. It was later discovered that
he had a previous CABG with a left radial artery graft. A CTA of
his upper extremity was performed which did not show any obvious
occlusion. On HD 1 he was evaluated by cardiology for the
possibility of atrial fibrillation. Although he had a previous
heart history there was not sufficient evidence for an embolic
event secondary to a-fib. While inpatient he also had an ECHO,
which did not show any clots, and an Carotid duplex which showed
<40% stenosis. He was transitioned to xarelto on HD 1 and is
scheduled to follow up with his cardiologist next week. At the
time of discharge he was ambulating, tolerating PO, had no left
hand symptoms, and was doing well. | 140 | 178 |
16728825-DS-8 | 24,534,893 | Dear Ms. ___,
It was a pleasure caring for your at the ___
___! You were admitted for anemia related to your
diagnosis of Gastric Antral Vascular Ectasia (GAVE). Your
hemoglobin was 9.0 when you presented to the Emergency
Department and subsequently dropped to 7.8 the following
morning. You received 1 unit of packed red blood cells, and your
hemoglobin increased appropriately. You were seen by the
Gastroenterology team and had an endoscopy on ___. You
tolerated this procedure well and your hemoglobin upon discharge
was 9.2. The Gastroenterologists recommend that your continue to
take your pantoprazole 40mg TWICE a day. You will also be
started on ferrous sulfate 325mg (iron supplementation) TWICE a
day. You will be scheduled to follow-up with the
Gastroenterologists in two months for a repeat endoscopy.
Of note, you also had left scapular pain and a right-sided
headache. For your chest pain, we performed an ECG and labs
which were reassuring and did not show signs of cardiac
ischemia. You also received Tylenol to manage the pain. Your
headache pains resolved after blood transfusion. If your
continue to experience pain or notice that the pain has changed
in quality, please see your primary care doctor.
Thank you for letting us take part in your care,
Your ___ Care Team | Ms. ___ is an ___ year-old woman with a history of GAVE and
severe aortic stenosis who presented with a one week history of
fatigue, weakness, melanotic stools, left scapular pain, and
headache now s/p 1U pRBC and endoscopy on ___.
# Iron Deficiency / Blood loss Anemia: Patient had a hemoglobin
of 9.0 on admission which subsequently decreased to 7.8 the
following morning. She received 1U pRBC with an appropriate bump
in the hemoglobin. She was seen by the Gastroenterology team and
had an endoscopy on ___. She tolerated the procedure and had a
hemoglobin of 9.2 on discharge. Endoscopy demonstrated normal
mucosa in the esophagus and duodenum, with numerous non-bleeding
angioectasias in the antrum (in a watermelon stomach pattern)
and otherwise normal EGD to the third part of the duodenum. She
had successful APC to these lesions and tolerated the procedure
well. She will continue to take her pantoprazole 40mg BID and
will be started on ferrous sulfate 325mg BID upon discharge.
# Left scapular pain: Given her history of severe aortic
stenosis, she had a work-up for cardiac ischemia including an
ECG showing normal sinus rhythm without ST changes and negative
troponins x2. The left scapular pain resolved on hospital day 1.
# Headache: She endorses right-sided, dull headache with no
associated vision changes. She states that the headache started
after she scratched her eye earlier this week while gardening,
for which she has been applying topical erythromycin at home.
This also coincides with the time she started feeling other
symptoms of anemia. She was given Tylenol and caffeine with no
effect. Her headache resolved after 1U pRBC.
# Hyperlipidemia. She was continued on her home atorvastatin. | 216 | 280 |
15928453-DS-19 | 21,038,991 | Ms. ___,
You were admitted to the General Medicine Service at the ___
because you had a seizure. You were seen by Neurology, who
recommended taking your phenobarbital at night with dinner and
also increased your dose. You were also experiencing abdominal
pain and chronic diarrhea. CT scan of the abdomen showed
inflammation of the colon and a new ovarian mass, confirmed by
an ultrasound of your abdomen. Stool culture was positive for
C. diff. Infectious Disease recommended a prolonged course of
vancomycin, with close follow-up with a gastroenterologist. You
were also seen by OB/GYN, who determined that the mass is
unlikely to be an infection. They recommended outpatient
follow-up with a gynecologist. We had to adjust your warfarin
dose because your INR fluctuated rapidly. You were seen by
Hematology, who recommended a medication called apixaban.
However after discussion with you, it was determined you would
stay on warfarin for now. Because your warfarin level (INR was)
low, you will need to take lovenox until your level is within an
appropriate range. You should take 7.5 mg of warfarin tonight,
further doses of warfarin should not be taken until you check
your INR tomrrow (___) and discuss an appropriate dose with Dr.
___. You also developed inflammation of your right arm due
to you IV. Please keep your arm elevated and place warm/moist
towels or compresses on it during the day. Also, please avoid
any heavy lifting with your right arm until the inflammation has
subsided. If you notice any purulence or drainage, or increased
redness or warmth, please seek medical attention at your PCP's
office or at the nearest emergency department.
Please take your medications as prescribed. Regarding your oral
vancomycin specifically, you should take 125 mg 4 times per day
until ___, then 125 mg three times per day from ___ through
___, then 125 mg twice per day from ___ through ___, then
125 mg once per day from ___ through ___, then 125 mg every
other day from ___ through ___, then stop. You will be
given enough vancomycin for 30 days. You will need to discuss
obtaining a prior authorization for the remainder of your
regimen with your primary care physician (Dr. ___.
We have arranged follow up appointments for you with your
primary care physician, OB/GYN, gastroenterology, and neurology.
We also recommend you discuss seeing a hematologist as an
outpatient to assist with managing your anticoagulation. Please
keep your follow up appointments as scheduled.
We hope you continue to feel better.
- Your ___ Team | ___ with Wegeners, chronic abdominal pain and diarrhea,
recurrent C. diff colitis, history of multiple DVT/PEs on
warfarin s/p IVC filter, and epilepsy on phenobarbital p/w a
seizure in the setting of fevers, chills, and colitis, now found
to have a complex ovarian mass and C. diff colitis.
# Seizure: Patient with a history of epilepsy on phenobarbital
100 mg BID initially presented to ___ after her
neighbor witnessed a grand mal seizure. There was no tongue
biting or loss of bowel/bladder function. She was then
immediately taken to the ___. She underwent head CT at ___
___ which was negative. Phenobarbital level was therapeutic
at 21.2 and she had been taking her antiepileptic as prescribed.
Unclear precipitant for the seizure, although patient reported
fever to 102, chills, and rigors for the last 24 hours. Patient
was in a post-ictal state in the 24 hours afterwards, and
continued to improve during her hospital stay. Blood cultures x
2 were negative. She remained afebrile. She was seen by
Neurology, who suspected that she has poor phenobarbital
absorption secondary to warfarin interaction and chronic
diarrhea. She likely requires a higher dose of phenobarbital to
maintain a therapeutic level in the blood. Per Neurology
recommendations, she was maintained on 250 mg phenobarbital at
night with dinner, and scheduled for outpatient Neurology
follow-up with eventual change to a different anticonvulsant.
Outpatient Neurology follow-up was scheduled with Dr.
___.
# Ovarian mass: CT scan of the abdomen at ___
incidentally found a complex ovarian mass in the right adnexa.
RUQ U/S confirmed this finding. GYN was consulted, who did not
think the mass was concerning for infection. She was scheduled
for outpatient GYN follow-up with Dr. ___ in 6 weeks.
# Colitis - Patient presented with ___ days of worsening
abdominal pain and diarrhea. CT scan at ___ showed
pancolitis that was particularly prominent in the R ascending
colon. Blood cultures were positive for C. difficile, and
negative for salmonella, shigella, and campylobacter. Given
history of recurrent C. diff colitis, and failure to clear
infection with vancomycin and fidoxomicin, ID was consulted, and
recommended a prolonged 70-day vancomycin taper. She was
discharged with only a 30-day supply of vancomycin due to
insurance difficulties. Her PCP is ___. She will follow-up
with her PCP to obtain prior authorization for the remaining
40-day supply of vancomycin. She was also scheduled for
follow-up with Dr. ___ at ___. She
will need repeat C. diff testing if she has a recurrence of her
symptoms in the future.
# Superficial thrombophlebitis: Had US-guided peripheral IV
placed in the R antecubital fossa due to difficult access. She
developed edema, erythema, tenderness and warmth at the site of
peripheral IV. Right upper extremity US showed minimal chronic
nonocclusive thrombus seen in the right internal jugular vein,
the medial portion of the right subclavian vein and and one of
the two right brachial veins. The IV was removed, and the skin
was treated with warm compresses and elevation. The rash
improved without antibiotics. Infectious disease team evaluated
arm along with primary team. Given improvement without
antibiotics, thought was this was unlikely to be
infectious/cellulitis and did not need antibiotic treatment.
Patient was advised to seek medical care should her arm become
more erythematous, warm or painful or if she should develop
fevers.
# H/o DVT/PE: Patient takes high doses of warfarin for DVT/PE
prophylaxis. Her INR was difficult to maintain within the
therapeutic window of ___. Her INR became subtherapeutic within
one day of holding warfarin, and required bridging with 1 mg/kg
BID lovenox. Per prior heme-onc notes, she is likely a fast
metabolizer and would benefit from alternative forms of
anticoagulation. Heme/Onc was consulted, adn recommended
Apixiban 2.5 mg BID for DVT/PE anticoagulation given patient's
rapid metabolism. Options were discussed with patient - she
prefers warfarin with INR monitoring for now, but will consider
Apixiban at a later date. She was discharged with 40 mg lovenox
SC and warfarin 7.5 mg, and was instructed to monitor her INR at
home and follow-up with her PCP regarding adjustments in dosing.
She will follow-up with heme/onc at ___ for further
assistance in managing her anticoagulation. | 443 | 694 |
19699040-DS-6 | 20,421,854 | Dear ___,
You were admitted to ___ and
underwent ultrasound guided drainage of a pelvic fluid
collection. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | ___ 2.5mo s/p panniculectomy at OSH with sudden onset LLQ pain 5
days prior to presentation. No constitutional symptoms
consistent with obstruction, no change in bowel habits. At time
of consultation, pt AFVSS with well healing panniculectomy
incisional scar with focal LLQ tenderness with rebound.
Otherwise benign abdominal exam. WBC 9.6. CTAP notable for well
circumscribed 7.5x5.5cm mesenteric fluid collection with
___ units 20, low-normal for hematoma. Her large
mesenteric fluid collection was concerning for infected
hematoma, and she was admitted with IV antibiotics and a consult
for interventional radiology drainage under image guidance.
During the ___ procedure on ___, limited grayscale and
color Doppler ultrasound imaging of the left lower quadrant
demonstrated a 7.3 x 4.8 cm loculated fluid collection,
corresponding to the fluid collection seen on CT ___. A
5 ___ catheter was advanced into fluid collection and 80 mL
of clear serous fluid was removed. No drainage catheter was
left in place. A sample was sent for microbiology.
The fluid showed no growth, with no microorganisms seen.
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.
ID: The patient's white blood cell counts 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.
On ___, IV antibiotics were discontinued, and patient was
advanced from NPO to a regular diet as tolerated.
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. | 252 | 336 |
15116755-DS-19 | 26,777,954 | Dear ___ was a pleasure taking care of you on the neurology team.
You were admitted to us because of a history of worsening of
your bilateral leg weakness over the last ___ months. There was
a concern about your safety at home as it was really difficult
for you to ambulate, and you reached a point where you were
unable to complete your activity of daily living without
assistance.
We starte you on a steroid course, which can help with your
worsening symptoms of multiple sclerosis. We have not changed
any of your other medications.
You were also seen by our physical therapy team, and it was
recommended that you get transferred to an acute rehabilitation
program. | Mrs. ___ was placed on a steroid course, starting with 1g
of IV solumedrol daily for 3 days, with a plan to decrease to
500mg for 3 days, then to 250mg for 3 days.
She was seen by physical therapy in order to evaluate her
weakness and the need for acute rehabilitation which she was
found to require.
She had no complications during her stay. WE continued to check
her dextrose which was found to be within normal range and she
did not require insulin. | 115 | 83 |
13669949-DS-14 | 22,566,722 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- No weight bearing in the right leg
- Range of motion at the right knee as tolerated, in an unlocked
___ brace
Physical Therapy:
RLE NWB
ROMAT in unlocked ___
Treatments Frequency:
Patient may come out ___ in bed. Please check that straps
are not too tight and do not cause skin breakdown.
Dressings may be changed as needed for drainage. No dressings
needed if wounds are clean and dry.
Staples will be removed in ___ weeks in clinic at Ortho ___
follow up. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. On POD#2, the
patient developed a fever, leukocytosis, abdominal pain, and
diarrhea. Stool assay was positive for Clostridium difficile.
Medicine service was consulted who recommended starting PO
vancomycin. The patient's fever and leukocytosis improved and
she was cleared for discharge by the Medicine service. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 197 | 282 |
19195851-DS-22 | 22,810,377 | WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
· You should get up out of bed every day and gradually
increase your activity each day
· Increase your activities as you can tolerate- do not do
too much right away!
2. It is normal to have swelling of the leg you were operated
on:
· Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
· Avoid prolonged periods of standing or sitting without
your legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
· You will probably lose your taste for food and lose some
weight
· Eat small frequent meals
· It is important to eat nutritious food options (high
fiber, lean meats, vegetables/fruits, low fat, low cholesterol)
to maintain your strength and assist in wound healing
· To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
· Take aspirin as instructed
· Follow your discharge medication instructions
ACTIVITIES:
· No driving until post-op visit and you are no longer
taking pain medications
· You should get up every day, get dressed and walk
· You should gradually increase your activity
· You may up and down stairs, go outside and/or ride in a
car
· Increase your activities as you can tolerate- do not do
too much right away!
· No heavy lifting, pushing or pulling (greater than 5
pounds) until your post op visit
· You may shower (unless you have stitches or foot
incisions) no direct spray on incision, let the soapy water run
over incision, rinse and pat dry
· Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
· Redness that extends away from your incision
· A sudden increase in pain that is not controlled with pain
medication
· A sudden change in the ability to move or use your leg or
the ability to feel your leg
· Temperature greater than 100.5F for 24 hours
· Bleeding, new or increased drainage from incision or
white, yellow or green drainage from incisions | The patient was admitted to the Vascular Surgery Service for
evaluation and treatment. The patient was admitted ___ to the
floor and was monitored overnight. On ___, the patient
underwent evacuation of left groin hematoma, which went well
without complication (reader referred to the Operative Note for
details). Following this procedure, the patient had a brief
period of hypotension in the PACU requiring IV fluid
resuscitation and transfusion of 1u PRBC. Her urine output was
adequate through this and she continued to mentate. She was kept
in the PACU overnight for observation. The patient arrived on IV
fluids and antibiotics, with a foley catheter, and oxycodone for
pain control. The patient was hemodynamically stable.
Neuro: The patient received oxycodone and tylenol following the
OR with good effect. The patient experienced delirium
postoperatively. Infectious workup demonstrated UTI and
following treatment for this her mental status gradually
improved. She was continued on home antipsychotic medication.
CV: Following arrival on the floor the patient remained stable
from a cardiovascular standpoint; vital signs were routinely
monitored. She was continued on home antihypertensive agents.
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: Post-operatively, the patient was placed on clear
liquids with IV fluids. Diet was advanced when appropriate,
which was well tolerated. Patient's intake and output were
closely monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary. Foley catheter was placed on admission. The patient
was found to have self-removed the catheter early morning ___.
It was replaced but again found to have been self-removed on the
afternoon of ___. It was left removed given the findings of UTI
and the patient voided subsequently without issue.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient was noted to
be febrile prior to the operating room evacuation of hematoma.
There was overlying erythema of the area of hematoma in the left
groin and the patient was placed on broad spectrum IV
antibiotics. These were stopped on ___ as the erythema had
significantly resided and the patient was transitioned to
bactrim for empiric skin coverage and urinary coverage as urine
culures obtained ___ demonstrated E coli UTI. As noted
prior,the patient was receiving bactrim and the planned course
is 1 week.
Endocrine: The patient received stress dose steriods
___ and home oral steroids were continued for her
Addison's disease. Home thyroid replacement was also continued.
Hematology: The patient's complete blood count was examined
routinely. Postoperatively due to hypotension and downtrending
Hct the patient received 1u PRBC. Thereafter her Hct was stable.
Aspirin and coumadin were restarted postoperatively. Her INR was
3.3 at the time of discharge. She received 1 mg of coumadin
___.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
Drains: The patient had a JP drain placed in the operating room
and this was removed on ___ without issue.
Therapy: The patient was evaluated by the physical therapy
service. They recommended the patient be discharged to a
rehabilitation facility post discharge. This was arranged.
At the time of discharge to an extended care facility, the
patient was afebrile with stable vital signs. The patient was
tolerating a regular diet, voiding without assistance, and pain
was well controlled. The patient and family received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 465 | 590 |
17513349-DS-14 | 21,992,512 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for back pain and fevers. You were
found to have a pneumonia which was treated with antibiotics.
You were also found to have an elevated Creatine Kinase, which
indicated evidence of muscle breakdown. This is possibly from
your fall. It improved with fluids and you should not have any
long term side effects. You also had an MRI of your back which
did not show any concerning findings other than chronic spinal
disc bulges which are managed conservatively.
You also had an episode of chest pain during your stay. We
performed an EKG which did not show acute changes but did show
possible evidence of an old cardiac event such as a heart
attack. You had a cardiac ECHO which is an ultrasound to look at
your heart function. The good news is this was normal. You
should be sure to talk to your primary care doctor about this. | ___ year old male with pmhx of Hep C who presented with fevers
and back pain, found to have aspiration pneumonia and rhabdo in
setting of being down for period of time after fall.
ACTIVE MEDICAL ISSUES:
# Aspiration Pneumonia: Pt presented with fevers for several
days as well as back pain. Pt mets SIRS criteria with fevers and
tachycardia in ED and was also noted to by hypoxic to 89% on RA.
CXR at ___ on ___ showed no acute processes but CT abd/pelvis
showed scattered left lower lobe peribronchiolar opacities and
pt started on CTX and azithromycin for presumed CAP. UA
unremarkable and blood cx was no growth. After the first
hospital day, he remained on room air and his cough improved.
His pneumonia was thought to be likely from an aspiration event
in setting of being down after mechanical fall. He was continued
on CTX and azithromycin which was switched to cefpodoxime and
azithromycine for discharge for pt to complete 5 day regimen.
# Back Pain: Pt presented with radiating lumbar back pain after
mechanical fall on concrete steps. MRI did not show evidence of
cord compression but did show spinal disc bulges and
degenerative disc disease at the mid thoracic spine. He did not
have continued fevers after his first hospital stay so there was
a low suspicion for abscess. His pain improved with low dose
oxycodone (2.5mg) and tylenol. He was ambulating well by
discharge and was cleared by ___ for home.
#Hypotension: Pt had brief episode of hypotension after arriving
to the floor with blood pressure of 82/60. He was assymptomatic
and afebrile although he was sating 89% on room air. Given his
hypoxia and chest pain (see below), a CTA was performed which
was negative. His hypotension was most likely in setting of
recently taking clonidine and oxycodone. His clonidine was held
and later restarted at a lower dose. He remained normotensive
for remainder of hospital stay.
#Rhabdo:Pt was noted to have an elevated AST which prompted CK
to be checked. It was found to be elevated to ___. Pt then
admitted to period of time surrounding the fall that he does not
remember. It is likely that he was down during this time. He was
given continuous fluids with a goal urine output of >100 cc/hr.
His CK was trended to below 5000 and fluids were stopped. He did
not have any evidence of kidney injury.
#CP: Pt with episode of chest pain on ___ in the setting of
hypotension and hypoxia. EKG with no acute ST changes but with Q
waves in III and AVF as well as poor R wave progression. CTA
negative for PE. He did not have recurrence of pain the
remainder of the hospital stay. Pt denied known cardiac history.
Repeat EKG when pt was not in pain was stable. Pt had an ECHO
which was normal. He does not need follow up with cardiology. | 168 | 485 |
15692523-DS-7 | 20,025,975 | Dear Ms. ___,
You were admitted to the neurology service at ___ after you
were found to have a hemorrhagic stroke. Your hemorrhagic stroke
likely occured because of a condition called amyloid angiopathy,
which makes the blood vessels in your brain very fragile. You
were also treated for a urinary tract infection. You were
evaluated by physical therapy who thought you would benefit from
acute rehab.
We did not make any changes to your medications.
It was a pleasure taking care of you during this hospital stay.
Please follow up with your primary care provider and Dr. ___
in neurology clinic as below. | Ms. ___ was admitted to the stroke neurology service. The
etiology of her IPH is likely amyloid angiopathy. A urinalysis
was repeated and showed large leukocyte esterase and 28 WBCs.
She was started on ceftriaxone empirically, however a urine
culture was eventually negative and the antibiotics were
stopped.
Her mental status remained relatively consistent while admitted,
with the patient oriented to self and hospital, and interacting
appropriately. Her vision made minor improvements during her
stay and at the time of discharge she was able to count fingers.
Her blood pressure should be monitored closely with a goal
systolic blood pressure of 100-140. She did have a brief episode
of hypotension previously for which her atenolol was held.
She was seen by physical therapy who recommeded discharge to
acute rehab. | 99 | 126 |
18005279-DS-6 | 25,452,270 | You were admitted to the acute care surgery for pain control
after sustaining a xiphoid fracture and a Left calcaneal
fracture. You will remain non weight bearing to your Left lower
extremity until you have Orthopedic followup.
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
wheeze.
*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 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 concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician. | She was admitted to the Acute Care Surgery team for management
of her xiphoid process fracture. She was placed on nasal oxygen
and given medications for pain control. She was evaluated by
orthopedics for the left calcaneal fracture which was managed
non-operatively. A bulky ___ dressing was applied and she was
instructed to remain non weight bearing to her left lower
extremity. She will follow up in 2 weeks with Orthopedics as an
outpatient.
Her pain was well controlled with the oral pain regimen and she
was able to work with Physical therapy who have recommended
rehab after her acute hospital stay.
Her home medications were confirmed with her pharmacy and PCP's
office. The pharmacy reported that patient had last filled some
of her medications in ___ and ___ of this year and some as
far back as ___. After reviewing the medication with patient
and her Goddaughter who was present it was disclosed by patient
that she had stopped taking all of her medications month ago
without her PCP's knowledge. She was agreeable to having them
restarted while in the hospital.
She was discharged to rehab on HD# 4 with an appointment
scheduled for her to follow up with Orthopedics. | 287 | 201 |
13094848-DS-21 | 24,422,532 | Dear Mr. ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
You came in with a left foot infection as a result of your
diabetes.
WHAT DID WE DO FOR YOU IN THE HOSPITAL?
You went to the operating room, and the foot doctors removed
___ of the bone of your left foot. You were also found to have
a bacterial infection in your blood. You were treated with IV
antibiotics.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-You should continue your antibiotics as prescribed through your
PICC line.
-___ clinic will call you to schedule a follow-up
appointment.
-You should continue to avoid putting your full weight on your
foot.
-You will need your wound vac changed 3 times per week.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with a history of AML s/p
chemotherapy (in remission), type II diabetes mellitus c/b
peripheral neuropathy, coronary artery disease s/p 4 vessel
CABG, and hypertension, who presented with 5 days of left foot
pain, found to have infected diabetic foot ulcer probing to
bone, concerning for osteomyelitis, and strep viridans
bacteremia. | 115 | 60 |
19538920-DS-46 | 23,354,893 | Dear Ms. ___,
You were admitted with abdominal pain, nausea and diarrhea. Your
tests showed that your liver and pancreas were inflamed. Taking
too much tylenol can cause very serious liver damage, so we were
cautious and started you on a medicine to help that while we
continued with your workup. Unfortunately that medication
(N-acetylcysteine, or "NAC") can cause itching, which happened
to you. We treated it with benadryl which helped to make it
tolerable.
Ultimately you were diagnosed with having had a gallstone get
stuck temporarily, causing pain and bile to back up into your
liver and pancreas. The blockage resolved on its own; however,
in order to reduce the chance of it happening again, you were
taken for an ERCP procedure by our gastroenterology team. They
made the hole the stones go through bigger. This is not
guaranteed to keep it from happening again, but should make it
significantly less likely.
You also received dialysis ___ and ___.
Please follow up with your primary care doctor and the ___
clinic as below.
It has been a pleasure taking care of you,
Your ___ Care Team | ___ woman w/PMHx including ESRD on HD, CAD s/p CABG w/PVD, DM
admitted with mild gallstone pancreatitis, w s/p ERCP with
treatment of choledocholithiasis.
# Mild gallstone pancreatitis ___ choledocholithiasis s/p ERCP
with sphincterotomy: Patient presented with elevated LFTs and
lipase and an HPI consistent with gallstone pancreatitis.
Imaging was positive for cholelithiasis but not cholecystitis.
Given her multiple comorbidities and high surgical risk which
precluded more definitive treatment (cholecystectomy), ERCP team
agreed to perform an ERCP and sphincterotomy on ___, which
was uneventful. At discharge patient was tolerating a diet and
labs were stable. Patient was not discharged on antibiotics as
she does not fall into an immunocompromised group for purposes
of post-procedure prophylaxis.
---F/U with ___ clinic ___
# CAD s/p CABG w/PVD: Home amlodipine, ___, carvedilol
continued. Pravastatin held in setting of transaminitis.
---Can restart pravastatin once LFTs normalize as outpatient
#ESRD on HD: Received dialysis on ___ and ___ as
inpatient. | 181 | 150 |
16921511-DS-14 | 29,474,098 | Dear Ms ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for a
malfunctioning gastrostostomy-jejunostomy (GJ) feeding tube,
which was replaced during your admission here. However, your
urine labs showed some abnormalities that were concerning for a
urinary tract infection. These labs included elevated white
blood cells, presence of white blood cells as well as bacteria
in your urine.
For your GJ-tube dislodgement, we removed the old one while you
were in the emergency room and then after you were admitted to
the floor, the interventional radiology team replaced it with a
new one on ___.
Following the replacement, we restarted you on the same tube
feeds that you had been getting at the nursing home. It is
important that you continue the tube feeds to maintain a good
caloric input.
For your urinary tract infection which required antibotics, we
started treating you with intravenous ceftriaxone at a dose of
1gm per day before switching you to oral antiobiotics which you
will need to continue taking at home.
Given that you use a foley catheter to urinate, it will be
important for you to finish the full course of the antibiotics.
Please follow-up with your primary care provider to make sure
that the urinary infection is resolved.
Since you are on ciprofloxacin, please do not take your
trazadone while taking the ciprofloxacin. This can lead to drug
interactions. Please discuss with your primary care physician
prior to ___ the trazadone.
Thank you for letting us take part in your care!
Sincerely,
Your ___ Team | Ms. ___ is a ___ old woman with a h/o MDD, HTN, FTT ___
cognitive impairement s/p G tube placement in ___ c/b colonic
perforation and sepsis, s/p GJ-tube replacement in ___, who
presented from a nursing facility with GJ-tube dislodgement and
was also found to have a catheter-associated UTI. She has an
assigned legal guardian.
# GJ Tube malfunction: Multiple unsuccessul attempts to replace
the GJ-tube had been made at the ___ facility, which
prompted her to present to the ED. During her hospital course, a
tube study was confirmed and ___ replaced the GJ-tube ___
without any complications. Following the procedure, her tube
feeds of Osmo 1.5 @ 70cc/hr x 16hrs/day were restarted and she
tolerated them well. He rtube feeds should be re-started at her
facility.
# Urinary Tract Infection: Patient was noted to have a WBC of 10
in the serum and positive nitrites and leukocytes on urinalysis.
She has chronic foley catheter. Catheter was removed and
replaced. While in the hospital, she was treated with 1gm IV
Ceftriaxone Q24H and, even though her urine culture grew mixed
flora concerning for feculent contamination, she was dischared
on oral ciprofloxacin for total antibiotic course of 10 days
(end date ___ given chronic foley and initial
presentation. She was noted to have adequate urinary output and
her foley was in place prior to discharge.
# Failure to Thrive: Patient was previously admitted to the
psychiatry unit in ___ for FTT which was thought to be
secondary to cognitive impairement. Her admission lasted 4
months (___) with a course complicated by lung
abscess and misplaced PEG tube c/b colonic perforation and
sepsis s/p transverse colectomy and colostomy G-tube
re-placement in ___. Since her discharge in ___, she had
been on chronic tube feeds until she presented for this current
hospitalization. She was initially NPO after admission and we
re-started her home tube-feeds following the ___ procedure.
# Major Depressive Disorder: At baseline, the patient appears to
have mild dementia although she is oriented x3. During this
hospital course, she maintained a guarded affect despite
describing her mood as "good". We continued her home
Mirtazipine 7.5 mg qhs during the hospital course.
# CT Abdomen and Pelvis: CT abdomen and pelvis showed "either a
fluid filled rectum with a stool ball, versus peritoneal
enhancement of a collection of intrapelvic ascites with few
locules of air through which the distal colon transverses."
Recommended clinical correlation with rectal exam. Rectal exam
performed and showed no stool. Acute care surgery evaluated
patient who believed may be retained fecolith. They did not want
to do any intervention as patient was hemodynamically stable
with no further signs of infection. THey did not recommend
intervention given that is consistent with prior (no surgical
intervention needed). ___ consider enema to remove ?fecolith in
rectum if patient develops symptoms.
TRANSITIONAL ISSUES
===================
# Patient should continue with her tube tubes.
# Ciprofloxacin 500 PO Q12H with end date ___.
# She should discontinue trazadone while on the ciprofloxacin to
prevent QTc prolonging effects. Consider ___ trazadone
after stopping ciprofloxacin.
# CODE STATUS: Full (per Molst)
# CONTACT: ___ (Professional Guardian)
___ (c) ___ | 260 | 521 |
16081861-DS-5 | 23,989,401 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and found to have an infection in your
appendix. You were taken to the operating room and had your
appendix removed laparoscopically. You are now doing better,
tolerating a regular diet, and ready to be discharged to home to
continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mr. ___ is a ___ yo M who presented to the Acute Care
Surgery Service on ___ with abdominal pain and found to
have an infection in his appendix. Informed consent was obtained
and the patient was taken to the operating room and underwent
laparoscopic appendectomy. Please see operative report for
details. He was extubated and taken to the PACU in stable
condition then transferred to the floor.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. Initially
post op the patient had nausea that spontaneously resolved with
time. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without
services.The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 736 | 194 |
12382423-DS-10 | 27,175,130 | Dear Ms. ___,
You were hospitalized at ___.
Why did you come to the hospital?
=========================
- You came to the hospital because you were having worsening
pain and weakness in your left leg.
What did we do for you?
==================
- We repeated an MRI of your lumbar spine, which showed the
L5/S1 disc herniation.
- You were evaluated by the Neurosurgery team, who decided that
you did not need emergency surgery.
- We gave you medication to help control your pain.
- We gave you IV steroids to help decrease inflammation of your
spinal cord
What do you need to do?
==================
- It is very important that you follow-up with the Neurosurgery
team for your spine surgery.
- Please follow-up with your primary care doctor ___
information below).
- We faxed your prescriptions for your pain medicines to the ___
pharmacy that you go to.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team | ___ yo F with history notable for L5-S1 disc herniation who
presented with progressive L lower extremity and lumbar back
pain admitted for pain control. Repeat MRI showed L5-S1 disc
herniation. The patient was evaluated by neurosurgery, who
determined that there was no acute surgical intervention needed.
The patient was given IV steroids, and lidocaine patch,
tizanidine, and ketorolac for pain control. She was discharged
home with neurosurgery follow-up.
# L5/S1 disc herniation
Patient has had many years of back pain with 8 weeks of
worsening pain. Imaging consistent with some of the neurological
findings seen on physical exam. Evaluated by neurosurgery who
recommended admission to medicine for pain control and
dexamethasone taper. She completed a dexamethasone taper over 4
days. MRI L spine showed known L5-S1 disc herniation. MRI T
spine showed no acute process. Elective surgery offered for
___.
#Pain control
- standing Tylenol 1g TID
- Lidocaine patches (3) on left lower extremity.
- PO Oxycodone 5mg Q6 hour PRN (patient only required oxycodone
one time).
- Tizanidine 4mg Q6 hours PRN
- Clonazepam 1mg BID PRN
- standing bowel regimen
#Seasonal affective disorder
Continued home Seroquel 100mg Qhs. Continue home Trintellix 5mg
daily.
TRANSITIONAL ISSUES
=================
- Patient should follow-up with ___ Neurosurgery for lumbar
decompression surgery.
- Please ensure adequate pain control.
- Repeat MRI T-spine in 3 months for 5mm abnormal signal in T5
# CONTACT: ___ (husband) ___ | 154 | 222 |
17810291-DS-19 | 25,586,025 | You were admitted with shortness of breath from volume overload
and have been treated with diuretics for a heart failure
exacerbation with improvement in your symptoms. You were noted
to have a very elevated WBC count and have undergone an
extensive work up that has been unrevealing. You were seen by
gastroenterology for your diarrhea and the infectious work up
has remained negative. You underwent an endoscopy and
colonoscopy that did not reveal any explanation for the
diarrhea. You were seen by infectious disease who recommended a
few additional tests that are currently pending. I will contact
you and Dr. ___ any of these tests return positive.
It is important that you keep the follow up appointment with Dr.
___ and discuss the enlarged lymph nodes on your
recent CT torso. Please return for urgent evaluation if you
develop any fevers or new symptoms concerning to you. If you
have any questions after returning home this week, you can call
___ and ask them to page Dr. ___. We have
given you a few tablets of Ativan to help with sleep, please
only use one half tablet immediately before bed and avoid any
alcohol while taking it.
Best wishes from your team at ___ | ___ y/o with PMhx of tobacco abuse, COPD, HTN and metastatic lung
cancer with brain metastases s/p resection and
SRS who p/w acute SOB with BLE edema in setting of ___ weeks of
diarrhea and impressive leukocytosis. Acute on chronic diastolic
CHF resolved with aggressive diuresis. Extensive infectious
work up has been negative to date and WBC remained elevated
without clear source.
# Acute Hypoxic Respiratory Failure: resolved today
# Acute on chronic diastolic CHF:
# Right Pleural Effusion (small)
Dyspnea was felt most likely due to fluid overload with ___ edema
and elevated JVP. Right pleural effusion was evaluated by IP and
was too small to aspirate. Mediastinal adenopathy had increased
and stable anterior mass noted on CTA chest without PE. Limited
TTE was essentially unchanged with preserved LVEF and presumed
RV dysfunction. Pt did well with diuresis and volume symptoms
resolved. He returned to dry weight of 150-152lbs and was
continued on home regimen of Lasix 40mg and Spironolactone daily
with Metolazone as needed weekly.
# ___ weeks of Diarrhea: Pt/family reported multifactorial
weight loss and pt was noted have a very high WBC that appeared
reactive on smear reviewed by hem/onc. Diarrhea has been present
for many weeks now and sounds secretory by history. Cdiff
negative x 2 and all stool infectious w/u has been negative to
date. GI was consulted and pt underwent ___ without
significant findings (final biopsy results pending at
discharge). Pt was initially treated with empiric antibiotics
that did not really affect diarrhea and were discontinued. Pt
remained afebrile and tolerating po well without any antibiotics
for > 24hrs prior to discharge.
# Leukocytosis/Leukomoid Reaction: Pt underwent a broad
infectious work-up that returned negative and CT torso did not
reveal any clear source. There was not enough ascites on CT
torso for safe aspiration and IP did not find enough pleural
fluid to aspirate. Peripheral blood smear shows reactive cells
per heme and the only localizing symptom was diarrhea (See
above). Blood and Urine Cx negative, HIV negative, Hep C
negative and CRP 7.5. Given lack of clear infectious source,
antibiotics were stopped and ID was consulted. ID recommended
Strongyloides and Entameoba Histolytica serologies that were
pending at the time of discharge but there were felt unlikely to
be the source of leukocytosis. Ultimately the source of
leukocytosis remains unclear and verbal handoff was provided to
PCP. Pt will be following up with his primary oncologist soon
after discharge.
# Chronic Hep B: pt endorsed history of hep B exposure and labs
reviewed positive hepB Viral load with serologies consistent
with true exposure. Pt will need outpt follow up to determine
a treatment plan and preferred to discuss with his PCP after
discharge.
# Metastatic Lung Adenocarcinoma:
# Secondary Neoplasm of Brain: He is s/p radiation to his chest
and SRS for brain mets. Pt never received chemotherapy. CT
imaging on admission showed enlarging mediastinal LNs and
anterior mediastinal mass.
Close follow up scheduled with primary oncologist and pt/family
notified of imaging findings.
# Hypertension: Pt was continued on Atenolol 50mg and Amlodipine
10mg daily. Losartan was restarted on discharge.
# Depression/Bipolar Disorder: continued lexapro
# COPD: resumed home Anoro and albuterol. No evidence for COPD
exacerbation.
# BPH: No voiding issues while inpt, continued finasteride and
Tamsulosin. | 211 | 557 |
13854391-DS-12 | 25,869,039 | Dear Mr. ___,
It was a pleasure taking part in your care. You were admitted to
the hospital following a fall at home. You fractured your C7
vertebrae and lost consciousness. You also had 2 seizures on the
way to the hospital. We found that you did not have a bleed in
the head, and there were no abnormalities when we looked at your
heart valves. The seizures were likely from not taking
lorazepam, and this is a medication you should take as
prescribed.
Please do not make any changes to your medications, but take as
prescribed. You may discontinue the zolpidem.
You will need to keep the neck collar on for ___ weeks. You
will also need to follow up with the ___ in 6 weeks.
You should follow up with your PCP ___ ___ days for suture
removal.
Please keep all ___ appointments.
Please avoid taking medications with NSAIDs such as naproxen,
ibuprofen, and aspirin. You may take up to 2gm of acetaminophen
daily for pain, but no more for risk of liver damage.
Please make a ___ appointment with your gastroenterologist
within 2 weeks of discharge. | PRIMARY REASON FOR HOSPITALIZATION: Patient is a ___ yo man with
HIV on HAART therapy (last CD4 377 and VL neg on ___, DMII,
and early cirrhosis (thought EtOH) who was admitted to ___
after he slipped on a dog pillow at home and was found to have
C7 fracture. On transfer from OSH, patient had 2 seizures in the
ambulance ride over. These were felt to possibly be
post-traumatic vs. benzodiazepine withdrawal seizures and no
further episodes occurred. In house, his head was imaged with CT
showing no acute bleed, and neck CTA confirmed C7 fracture and
no vascular injury. He was discharged with instructions to wear
a ___ J-Collar and ___ in 6 weeks at the ___.
. | 183 | 122 |
16095232-DS-8 | 23,582,303 | Dear ___,
___ was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had difficulty
breathing.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a buildup of fluid in your lungs, which may have been
caused by your blood pressure being too high.
- You were given medications to remove fluid from you lungs, and
you improved.
- We talked about how it is important for your health to stop
smoking
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs in 2 days or 5lbs in 1 week.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 171 lbs. You should use this as your
baseline after you leave the hospital.
BACK PAIN:
============
Your side/back pain appears to be due to a pulled muscle in your
back. This should go away over time, but can be treated with
heat packs, Tylenol (check with pharmacist for dosing since you
also take Vicodin which has Tylenol), and ensuring that you do
not lay in bed for prolonged periods of time. You should follow
up with your primary care doctor if this does not improve. | =============================
BRIEF SUMMARY
=============================
___ year old female with a complicated medical history notable
for heart failure with borderline EF in the setting of coronary
artery disease (managed medically after concerns for medication
compliance and need for long stents when ___ cath showed
co-dominant system with 40% left main, 60-80% left circumflex,
100% OM2, 60% RCA), hypertension, hyperlipidemia, diabetes, and
active tobacco/alcohol use. She also has a history of aortitis
of a penetrating ulcer in the setting of H flu bacteremia s/p
___ with subsequent type B aortic dissection s/p
repeat ___ ___ (followed by ID on suppressive
azithromycin) and painful, erosive rheumatoid arthritis on
Humira.
She presented from home with a 1 day history of respiratory
distress found to be in hypoxemic respiratory failure in the
setting of severe hypertension, which quickly responded to BiPAP
and diuresis. Per the patient she had been having no issues
since her discharge in ___ up until this point. The exact
trigger is unclear, but she was ruled out for ACS and there was
some thought that subacute heart failure with volume overload
and perhaps some non compliance with her home anti-hypertensives
may have been contributing. We ultimately discharged her to home
without services (patient declined) and no medication changes
after an ECHO showed no change in her LV function.
During her hospital stay, it was clear there were numerous
issues that have prevented her from following up with all of her
medical providers. She noted issues with coordinating The Ride
service to attend appointment, having a husband at home with his
own health issues, and generally be "tired" of all her medical
appointments. We felt like connecting her with complex case
management as an outpatient would be best to help navigate these
difficult compliance issues in this high risk patient.
============================
TRANSITIONAL ISSUES
============================
[] Refer to complex case management at ___. Pt expressed
issues with abundance of healthcare appointments and feeling
overwhelmed with attending all of them; relys on The Ride which
can be troubling; would benefit from consolidation of her
appointments as well as reminder calls.
[] Smoking cessation
[] For PCP: given results of RUQ U/S showing steatosis but not
able to exclude fibrosis, please consider outpatient referral to
hepatologist for fibroscan
[] Seen in ___ clinic (Dr ___ - who reached out and
discussed restarting chronic ___ for suppression given
hx of H influenza aortitis. Restarted on discharge.
[] Patient does not have a cardiologist, had seen Dr. ___ in
the past, please make sure this appointment is scheduled as it
was pending at the time of discharge
[] Patient does not have any follow up with vascular surgery or
CTA scheduled, per ___ OMR note: "Discussed with patient
need to follow up with vascular surgeon. She expressed
resistance as she has so many comorbidities she does was
hesitant with following with vascular surgery. Will plan for
follow up CTA and appointment."
[] Discharge weight: 77.6 kg (171.08 lb)
==============================
PROBLEM-BASED SUMMARY
==============================
#PULMONARY EDEMA:
#HYPERTENSIVE URGENCY:
#ACUTE DECOMPENSATED HEART FAILURE:
Blood pressure elevated >190 systolic upon arrival to the ED,
and
with sudden onset symptoms the patient likely flashed at home.
___ have had medication and dietary indiscretions at home
recently causing gradual fluid accumulation over past few
months,
with hypertensive urgency tipping her over into flash pulm
edema.
173 lb (appears approximately 12 lbs up from ___. Her
clinical status improved after diuresis and she is now on
room air. Tropes <0.01 x 2 with no ischemic EKG changes.
Given 2 days of IV Lasix with good UOP and weaned off O2, before
transitioning back to home dose of PO Lasix. Continued
Carvedilol, lisinopril.
She was seen by Social work for med compliance as well as
nutrition for dietary
counseling. Given that her symptoms resolved after diuresis, she
remained chest pain
free, and she was ruled out for ACS, there is no indication for
exercise
stress test at this time.
#ETOH USE DISORDER:
Patient is still drinking ___ nips/day and has hepatic steatosis
on her most RUQUS. We had multiple extensive discussions
regarding this
at admission, and she was seen by Social work to offer
resources. She expressed
that she would stop drinking given that her recent RUQUS showed
steatosis and knowing
that alcohol will do more damage to her liver. She did
not want additional resources on discharge.
#Steatosis
RUQUS ___ showing Echogenic liver consistent with steatosis.
Other forms of liver disease and more advanced liver disease
including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Counseled on EtoH cessation and seen by SW as well as nutrition.
___ benefit from follow up with outpatient hepatology for
possible
fibroscan.
#Elevated Lactate
Lactate intermittently elevated to 5.1 with unclear etiology.
Remained hemodynamically stable, warm and well perfused on
exam with no suspicion for shock. Given episode of flash
pulmonary edema with tachypnea/tachycardia, elevated
lactate have resulted from intense respiratory muscle use with
decreased clearance from possibly cirrhotic liver.
#Back pain
Patient endorsed paraspinal back pain in her mid right back with
tenderness to palpation. Appears most consistent with
musculoskeletal pain
Counseled that this was likely muscular pain that will go away
with time,
can manage with Tylenol, hot packs, and to remain active and not
lay in bed
for prolonged periods of time. Denies any urinary symptoms, no
CVA tenderness.
#Hx aortitis s/p ___ x 2
Pt follows with ID as outpatient. Takes azithro 250 daily for H
influenza suppression however did not wish to take this int he
hospital due to diarrhea. Started upon discharge and will follow
up with Dr. ___.
#Psychosocial issues
Had discussions with patient and social work regarding how
overwhelming the multiple health appointments she has are. Would
benefit from complex case management at ___ and
consolidation of as many appts as possible on the same day to
minimize burden on patient.
#CAD: Continue home atorvastatin, aspirin
#RHEUMATOID ARTHRITIS: Just took her Humira on ___
#DIABETES MELLITUS:
Continued home glargine + SS with novalog given latex allergy.
Held home glipize and metformin in house. | 251 | 954 |
14214341-DS-46 | 27,004,507 | Dear Mr. ___,
It was a pleasure being involved in your care.
- You were admitted to the hospital with worsening back pain as
well as abdominal pain.
- Your back pain is most likely from a musculoskeletal cause
such as a muscle spasm.
- Your bloating is likely from pancreatic insufficiency, which
is a condition in which the pancreas does not produce enough
enzymes to digest food. You were given a pancreatic enzyme
supplement (Creon) to help you.
- Please take all of your medications as described below. Take
1000 mg acetaminophen 3 times per day to prevent back pain. You
may take a muscle relaxant we are prescribing called tizanidine
three times a day as well. This may make you sleepy, so take the
medication before bed initially. Do not drive after taking this
medication.
- Please attend all of your follow-up appointments.
We wish you the best!
Your ___ Team | ___ man with a history of ESRD secondary to diabetic
nephropathy status post DDRT x2, calciphylaxis and peripheral
vascular disease status post left BKA who presents with acute on
chronic back pain as well as chronic abdominal pain/bloating. | 152 | 38 |
11676070-DS-16 | 22,866,997 | A hematoma is a collection of blood. A bruise is a type of
hematoma. A hematoma may form in a muscle or in the tissues just
under the skin. A hematoma that forms under the skin will feel
like a bump or hard mass. Your body may break down and absorb a
mild hematoma on its own. A more serious hematoma may need
treatment.
Return to the emergency department if:
You have new or worsening pain, or pain that does not get
better with medicine.
You have a fever.
You have trouble moving the body part that has the hematoma.
Contact your healthcare provider ___:
You have questions or concerns about your condition or care.
Follow up with your healthcare provider as directed:
You may need to have surgery if your hematoma is severe. You may
also need other tests to make sure there is no other damage that
needs to be treated. Write down your questions so you remember
to ask them during your visits.
Self-care:
Rest the area. Rest will help your body heal and will also help
prevent more damage.
Apply ice as directed. Ice helps reduce swelling. Ice may also
help prevent tissue damage. Use an ice pack, or put crushed ice
in a bag. Cover it with a towel. Place it on your hematoma for
20 minutes every hour, or as directed. Ask how many times each
day to apply ice, and for how many days.
Gradually the blood in the hematoma is absorbed back into the
body. The swelling and pain of the hematoma will go away. This
takes from 1 to 4 weeks, depending on the size of the hematoma.
The skin over the hematoma may turn bluish then brown and yellow
as the blood is dissolved and absorbed.
Keep the hematoma covered with a bandage. This will help
protect the area while it heals.
Do not take NSAIDs, aspirin, or your oral anticoagulant
(___) until ___, or unless directed by your
cardiologist or surgeon.
**If the hematoma is enlarging, you have difficulty breathing or
swallowing, feel short of breath, or the wound site is draining,
please return to the Emergency Department. The most serious
complication from a neck hematoma is airway compromise
(inability) to breathe, and may require an emergency surgical
intervention if there is active bleeding. | he recently underwent a total thyroidectomy with Dr. ___
___ at ___ on ___, and was discharged the following
day, with a stable, small right-sided hematoma noted
post-operatively. He was subsequently discharged on ___.
On ___, he was instructed to restart his oral
anticoagulant, ___ 5mg BID, as previously prescribed. Over
the weekend, Mr. ___ noticed interval increase swelling and
some serosanguinous drainage to the area over 3 days' duration.
On ___, he noted the site to be about twice the size it had
been previously, prompting him to call Dr. ___ clinic in
the afternoon. We advised him to seek further evaluation
yesterday afternoon (___) in our emergency department,
with the understanding he would be promptly evaluated by our
surgery team. He was admitted to our surgical ICU for
airway/continuous O2 monitoring, with no issues to report at the
time of writing.
Since the swelling has started, he denies any change in
swallowing, dysphagia, difficulty breathing, or other symptoms
concerning for tracheal deviation, only complaining of a mild
headache, resolved with Tylenol. however physical exam was
notable for significant ecchymosis and grossly visible swelling,
consistent with post-operative hematoma at the surgical site. On
palpation, the hematoma was soft, not fluctuant, and no oozing
at the site was noted at time of evaluation. His labs have
remained stable, with no concern for blood loss or significant
arterial bleed at this time. This morning, the swelling has
decreased, with ecchymosis around the area less pronounced. On
palpation, the hematoma is firmer, no tenderness to palpation.
We feel that the area is stable and is now forming a clot. The
area was demarcated on arrival to the floor, and has not evolved
beyond the margins, with estimated size ~14x5cm. We have no
concern for cellulitis or STSI at this time. His other home
medications have been continued while inpatient, remaining
asymptomatic, with no aberrations in oxygen saturation or blood
pressure to note.
He has had no complications during his brief hospital course and
will resume his ___ on ___, per Dr. ___
___ Dr. ___. Additionally, he has an outpatient endocrinology
appointment this afternoon with Dr. ___ as well.
Unfortunately, he was unable to be transferred to the floor to a
standard medical-surgical unit due to unavailability and
remained in the ICU during his stay, with no issues to note. | 372 | 397 |
15849338-DS-5 | 29,116,714 | INSTRUCTIONS AFTER SURGERY:
- You were in the hospital for 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:
-Remain touch down weight bearing to the Left leg. Ok to use for
transfers. Try to minimize activity for the next few weeks until
instructed by your Doctor that you may begin to increase
activity.
-Left Leg elevated
MEDICATIONS:
- You were restarted on your Coumadin with Lovenox until you are
therapeutic. Your INR will need to be checked daily with changes
made to your dose depending on your INR level.
- 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 Coumadin as prescribed. Lovenox to be taken until
therapeutic.
- Check INR daily - adjust Coumadin level as needed.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks. The
surgical site should remain clean, dry and intact.
- Any stitches or staples that need to be removed will be taken
out at a determined time by your surgeon.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
-Drains x 2 will remain in place. The drains should be stripped
every two hours. A log of the output should be recorded and
brought to all follow up appointments. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left leg wound dehiscence and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for an irrigation and debridement and
partial closure by plastic surgery, 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 was taken back to the operating room on ___ for
L leg wound washout and primary closure. Drains were placed as
well as an incisional wound VAC. 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 transferred from the
orthopedic service to plastics service following this surgery.
The patient is on Coumadin and was taken off this and placed on
a heparin gtt. Cardiology was consulted in regards to his
anticoagulation and recommended that it was ok to stop the
heparin gtt around the time of surgery on ___. The heparin
gtt was stopped 6 hours prior to surgery and restarted after
surgery. Cardiology recommended that the patient remain on hep
gtt or lovenox until Coumadin restarted and INR at therapeutic
level (2.5-3.5). He was switched from hep gtt to lovenox on
___. He was restarted on normal Coumadin dose of 10mg Daily on
___. Labs were checked by for evaluation of ___, INR for
monitoring of coagulation status. On day of discharge his INR
was 1.3.
The patient worked with ___ who determined that discharge to
rehab was appropriate.
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
NWB in the left lower extremity, and will be discharged on
Coumadin with lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ 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. | 302 | 458 |
17475607-DS-16 | 21,835,950 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___. As you know, you were admitted with shortness of
breath, cough, and wheezing thought to be an exacerbation of
your COPD likely from continued smoking and possible a viral
infection. Your chest X-ray in the hospital did not show any
pneumonia. You were treated with nebulizers, steroids, and an
antibiotic called Azithromycin. Your symptoms and breathing
improved with these treatments. You will need to continue to
take the steroids and antibiotic at home for the next three
days. If you feel shortness of breath, please take your home
inhalers as previously instructed. We highly encourage you to
quit smoking as it can worsen your COPD. Please take your
medications as instructed. Please followup with your primary
care physician and lung doctor. If you develop worsening cough,
shortness of breath, chest pain, lower leg swelling, or fevers,
please seek medical help urgently.
Sincerely,
Your ___ Care Team | ___ y.o. M with history of COPD Gold Stage II, CAD with ___
___ in ___, Systolic Heart Failure (EF of 40-45%
___, CKD, seasonal allergies, presenting with several days
of shortness of breath, cough, wheezing.
# COPD Exacerbation: On admission, exam was most notable for
diffuse expiratory polyphonic wheezes, but patient was otherwise
breathing comfortably without use of accessory muscles. There
was no associated JVD, inspiratory crackles, ___ edema. CXR
was notable for hyperinflation, but no evidence of pneumonia.
CBC and Chem 7 were otherwise within normal limits. The
patient's presentation was attributed to a COPD exacerbation
likely in the setting of continued smoking as well as possible
viral infection. The patient was given Prednisone 60 mg in the
ED and continued on 40 mg. He was also managed with Azithromycin
(500 mg x1, followed by 250 mg PO QDaily) x 5 days and
Albuterol/Ipratropium nebulizers Q6H. The patient was continued
on his home ___. At the time of discharge, the patient's
wheezing had resolved and his dyspnea had improved. His
ambulatory O2 sat was 98% RA at discharge. He was discharged on
Prednisone and Azithromycin to complete a five day course. The
patient will have close followup with his pulmonologist and PCP
at discharge.
CHRONIC ISSUES
# Systolic Congestive Heart Failure (CHF): Last ECHO notable for
LVEF 40-45%. On admission, the patient was not grossly volume
overloaded (no JVD, no inspiratory crackles, no ___ edema). The
patient was continued on his home Furosemide 10 mg PO QDaily,
Lisinopril 20 mg PO QDaily, and Metoprolol Succinate 75 mg PO
QDaily.
# CAD: s/p LAD stent ___. The patient was previously on
Simvastatin 20 mg PO QDaily and appeared to have discontinued in
___ in the setting of CPK 1000s attributed to viral
myositis. CPK ___ was 487, although elevated was within
normal limits for ___ men (upper limit CPK 800s).
The patient was continued on his home Aspirin 81 mg PO QDaily,
Clopidogrel 75 mg PO QDaily, and Metoprolol Succinate 75 mg PO
QDaily. The patient's Simvastatin 20 mg PO QDaily was restarted
during this hospitalization.
# Chronic Kidney Disease (CKD): On admission Cr 1.9 (near
baseline Cr 1.6-1.9). Nephrotoxic agents were avoided and the
patient's medications were renally dosed.
# Paranoid delusions: The patient had a history of paranoid
delusions. On admission, the patient had no apparent mood
disturbances and had no obvious active delusions or
hallucinations. He was continued on his home Perphenazine 4 mg
PO QHS.
# Hypertension: The patient's blood pressures were
well-controlled during her hospitalization. The patient was
continued on her home Lisinopril 20 mg PO QDaily.
# Chronic back pain: The patient has chronic pain from
underlying spinal stenosis and followed by the ___ Pain
Clinic. The patient was continued on his home oxycodone and
Gabapentin 100 mg PO QHS. | 158 | 473 |
12330994-DS-25 | 27,763,216 | Dear Mr. ___,
WHY WAS I ADMITTED?
You were admitted because you were having diarrhea.
WHAT WAS DONE WHILE I WAS HERE?
We tested your stool for different infections, which you did not
have.
We continued your dialysis.
We gave you fluids so that you did not become dehydrated.
We gave you a medicine to slow down your diarrhea ("loperamide,"
or "Imodium") - which helped.
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
We wish you the best!
-Your ___ Care Team | ___ year old male with alcoholic cirrhosis s/p DDLT ___ ___s deceased donor renal transplant ___, with delayed
graft function, HD ___ who presented with watery diarrhea
for 1 week.
#Diarrhea
#Hypovolemia
Patient with increased stools, up to 7 times per day, for the
past week. Stools are liquid and brown/yellow. No fevers or
leukocytosis
but the patient is on immunosuppression. His C diff, CMV,
norovirus, fecal culture, salmonella, shigella, campylobacter,
vibrio, yersinia, and E coli 0157:H7 were negative. Ova and
parasites and cryptosporidium/giardia were pending at time of
discharge. Other viral causes also possible especially since
diarrhea improved without intervention. We gave him IV fluids
and loperimide once c diff negative, to improvement of his
symptoms.
# ESRD s/p DDRT after OLT, complicated by DGF
Per patient, he initially had decreased urine output on
admission. It was likely pre-renal due to his
diarrhea/hypovolemia. His urine output improved over his
admission with fluids as above. We continued his HD ___
and continued midodrine 5mg prior to HD session.
#Immunosuppression
We continued home Myfortic 360 PO BID and prednisone 5mg daily.
His next belatacept as outpatient was due ___.
#Prophylaxis
We continued oral valgancyclovir 450 mg twice weekly and
atovquone 1500mg daily.
#Pyuria
He was ___ ceftriaxone in the ED for pyuria. His urine culture
grew >100,000 CFU of enterococcus. ___ that the patient was
asymptomatic, we did not treat with antibiotics as it was felt
to be asymptomatic bacteriuria. He has a history of VRE in the
past, but did not have any symptoms/other labs concerning for
urinary infection or sepsis from urinary source.
# History of seizure
We continues home keppra 1000mg daily, with additional 500mg
after HD
#Latent TB infection
The patient has just finished his 9 month course of isoniazid.
He finished his 2 week course of pyridoxine on ___.
# Depression:
We continued home Sertraline 50mg & Mirtazapine 15mg | 83 | 295 |
11684108-DS-5 | 20,174,788 | Mrs. ___,
___ was a pleasure taking care of you here at ___
___. You were admitted to the hospital with
nausea, vomiting and back pain which we found was secondary to a
right subclavian artery aneurysm with clot into the aorta. Once
your BP was controlled with IV medications, your pain improved
but did not completely resolve. We then took you to the
operating room for repair. During the operation we also treated
blockages in the left kidney and leg arteries. You tolerated the
procedure well. However, your postoperative course was
complicated by multiple problems including micro-embolism to the
fingers in your right hand, as well as an adverse reaction to
the medication we used to treat this complication. Also, we
found you have severe blockage in one of your main arteries in
your right leg, but no intervention was needed at this point, as
well as a leak from your thoracic duct that caused you
respiratory problems and now requires a special diet, and a
thrombus in one of the veins in the left side of your neck.
You were treated appropriately for all of these complications
and responded well to our interventions. You are now ready to be
discharged to a rehabilitation facility, where you shall
continue with your ongoing recovery. Instructions have been
given to the medical personnel that will be taking care of you
once discharged from our hospital. | This is a ___ year-old female with no prior surgical history who
developed acute onset mid-scapular back pain this evening while
at a family event. This was reportedly accompanied by
lightheadedness. CT scan done at OSH demonstrated irregularities
of the aortic arch consistent with thrombosed dissection versus
atherosclerotic disease as well as a retropharyngeal right
subclavian with proximal aneurysmal dilation. The patient was
transferred to ___ for further evaluation and management.
Despite BP management with IV labetalol, she continued to have
chest and back pain. After cardiac clearance, she was taken to
the operating room and underwent a median sternotomy,
debranching of the left and right subclavian arteries, an 8 mm
aorto to right subclavian artery bypass using a Hemashield and a
7 mm Hemashield Y grafted to the left subclavian artery, left
renal artery stent, left iliac artery stent, and a thoracic
endovascular stent graft from left common carotid to the mid
chest using a venous TX2 device (please see Operative Note for
further details). Her post-operative course was complicated by:
Acute right hand ischemia: On POD#1, distal petechiae and
ischemic changes were noted on right hand fingers, likely an
atheroembolic phenomenon. Arterial duplex ultrasound showed
patent brachial, radial, ulnar and palmar arch arteries.
Unfortunately, management is limited to observation of the
cyanotic digits, awaiting for these to self-demarcate and
progress until amputation, and therapeutic anticoagulation to
maximize potential for digit survival. Hand surgery was
consulted on POD#6 given development of right hand contractures.
Recommendations included working with Occupational Therapy for
passive and active ROM, and wearing of a wrist-based splint
device to avoid contractures while at rest.
HIT: Upon starting anticoagulation with heparin, platelet count
dropped below forty thousand. The diagnosis of heparin-induced
thrombocytopenia was made when labs returned positive for
heparin dependent-antibodies. Anticoagulation regimen was thus
changed and patient started on an argatroban drip. Platelet
counts were serially monitored and returned to normal levels
after a few days.
Chylothorax, pleural effusions: On POD#5, JP drain output
changed in appearance and was noted to be of murky consistency
and increased output, highly suspicious for a chyle leak from
injured thoracic duct. Patient was thus started on octreotide
and put on non-fat TPN. At this point, her white blood cell
count started to rise. A CT of the torso put in evidence
bilateral pleural effusions. Intravenous antibiotics were
started (vancomycin and zosyn from ___ until ___. Started on
oral bactrim for a 7 day course on the day of discharge). JP
drainage cultures were sent and later found to be negative.
Decision was made to perform a left thoracentesis, upon which
approximately 500 cc of chylous output was evacuated and sent
for analysis. On POD#13, patient's diet was advanced (non-fat,
medium-chain triglyceride diet) and well-tolerated. TPN was
cycled and then discontinued. IV antibiotics were discontinue
upon discharge and transition to oral antibiotics was done
(Bactrim).
Right common femoral and external iliac occlusion: Incidentally,
CTA torso done to evaluate the leukocytosis and fever previously
mentioned, found the right external iliac and common femoral
arteries to be thrombosed, a finding that was new since prior
imaging done a couple of weeks back. Non-invasive studies were
done and showed an occluded right CFA with reconstitution SFA
and patent popliteal, DP and ___. No intervention was indicated
at this point.
Left internal jugular thrombus: On POD#14, patient was noted to
have left upper extremity swelling. A left upper extremity
Duplex ultrasound showed thrombosis of the left internal jugular
vein. As patient was already anticoagulated, no further
interventions were undertaken other than ACE wrapping the
extremity. INR levels were serially monitored and on POD#19 was
noted to be supratherapeutic, for which purpose the argatroban
drip was discontinued and coumadin dose held.
After screening with case management, patient was found an
appropriate rehab facility to be discharged to. At this time she
was tolerating the non-fat diet, ambulating and voiding without
assistance and pain was under control. She received teaching and
follow-up instructions with verbalized agreement and
understanding with the discharge plan. | 235 | 663 |
12268300-DS-20 | 26,657,103 | Dear Mr. ___,
It was a pleasure taking care of you during your recent
admission to ___.
You were admitted because of worsening kidney function. Based
on your symptoms over the last several weeks, you likely have a
viral infection which has made you feel ill, have a decreased
appetite, and not drink fluids. This has made you extremely
dehydrated, causing decreased kidney function, difficulty with
balance, and low blood pressure. You were given IV fluids to
help replete your fluids, and your kidney's returned to their
baseline.
In addition, you had difficulty urinating with symptoms of
urgency and increased frequency. This is likely due to
enlargement of your prostate. We have started you on two
medications to make it easier for you to urinate. If you feel
like you are retaining urine, please catheterize yourself as
necessary.
The following changes were made to your medication regimen:
- START finasteride once daily
- CONTINUE tamsulosin once daily
Please continue the rest of your medications as prescribed prior
to admission
___ Pharmacy in ___ carries straight catheter kits with
all of the equipment you will need. Please bring your
prescription for them to dispense the kits to you.
___ Pharmacy is located at:
___ in ___
___ | ___ yo M with h/o Crohn's disease, CKD, chronic pain syndrome,
presenting with acute on chronic renal failure and leukocytosis.
.
# Acute on chronic renal failure- Creatinine on admission was
2.1, up from baseline Cr 1.4-1.8. Patient was fluid
resuscitated and creatinine returned to baseline. AOCRF
therefore most likely due to poor oral intake. Creatinine
remained at baseline for the remainder of admission.
.
# Urinary retention- Patient had a foley placed in the ED
initially. Foley was removed on HD 2 and patient had difficulty
urinating. On exam, his prostate was enlarged diffusely without
tenderness, consistent with prior exams and diagnosis of benign
prostatic hypertrophy. His home tamsulosin was restarted and in
addition he was started on finasteride. Foley was replaced for
an additional 24 hours and then removed. At that time, patient
was able to urinate on his own, however had continued retention.
Following discussion with outpatient urologist, patient was
taught intermittent self-catheterization, and was discharged on
tamsulosin/finasteride, with plans to intermittently
self-catheterize as necessary until the medications took full
effect. Patient will schedule ___ with urology on his
own, per urologist's request. Patient was comfortable with
process of self-catheterization at the time of discharge and was
given a prescription for kits.
.
# Back pain- Pain appeared to be related to overall myalgias
exacerbating underlying chronic low back pain. MRI prior to
admission ruled out compression or stenosis. Patient was
continued on outpatient methadone for pain control.
.
# Increased ALT and alkaline phosphatase- Evidence of gallstones
on RUQ ultrasound without signs of cholecystitis, biliary or
common bile duct obstruction. Increase likely related to viral
illness and trended down during admission.
.
# Leukocytosis- WBC 15 at PCP's office, downtrended without
antibiotics on admission. CXR clear at PCP ___. U/A also
negative for signs of infection. Bump is likely related to
chronic steroid use and also viral illness.
.
# Hypothyroidism- continued home levothyroxine 175mcg po daily
.
# Transitional issues-
- Patient discharged on finasteride and tamsulosin. Requiring
intermittent self-catheterization for benign prostatic
hypertrophy leading to urinary retention. Will need outpatient
___ with urology.
- PCP and nephrology ___ appointments scheduled | 207 | 372 |
11265558-DS-3 | 27,818,125 | Dear Ms ___.
You have been admitted here after you developed lightheadedness
and loss of your balance during walking.
We perform Head CT to evaluate your brain for new lesion. It did
not show any new lesion concerning for stroke.
Worsening of your symptom was because of dehydration that you
had. It could be because of Hydrochlorthiazide that you take for
blood pressure. You need to drink at list 8 glass of water to
prevent dehydration.
We performed Blood test and found that your kidney is not
working well because of dehydration,after you recieved fluid
your kidney started to work well again.
Your headache could be because of migraine or dehydration that
you had. As your son has migraine and your headache is
throbbing, this is possible that your headache is migraine type
headache.
We prescribe Fioricet every 6 h as needed for headache
We did not change your preadmission medication and you should
take them per instructed.
It was our pleasure to be involved in your care. | ___ year-old woman with recent Ischemic infarction in the setting
of HTN, with memory deficit, mild right pronator drift and left
Horner syndrome:(mild left ptosis, smaller pupil), came with
dizziness, light headedness and feeling unsteady during walking.
she also has a throbbing ___ headache in her vertex, without
photophobia, phonophobia or nausea.She also reported a transient
double vision while going down the stairs. It was transient and
never happened again.
In exam:
VS: BP;120-140/60-80, not orthostatic, HR: 60-86, RR:14
HEENT: not pale, dry mucus membrane.
Lungs are clear, HR is sinus, abdomen is soft. No edema in ext.
MS: awake, alert and oriented x3, digit span : 5, speech is
fluent with intact repetition and comprehension.
CN: EOM: full, pupils: L:3-->2, R: 5--->3, mild left eyelid
ptosis,face is symmetric.
Mild right pronator drift. No sensory or motor deficit,
Cerebellar exam: no dysmetria, coordination is intact.
In gait exam: she became light headed when she stood up. she
felt unsteady.
Labs:
138 104 29
-------------< 107 AGap=13
3.6 25 1.1
Ca: 8.9 Mg: 1.8 P: 2.9
11.9
4.7 >----< 194
35.7
Imaging:
Brain CT : No acute new lesion in brain. there is the old
lacunar infarction in L internal capsule
******************
1. Neurology : light headedness and unsteadiness ___
dehydration, after receiving 1 lit of IVF she her light
headedness after standing was improved.
CT of the head did not show any new lesion, no new focal finding
were detected in neuro exam. we thimk the worsening of her
symptom is recrudescence of her previous symptom because of
dehydration
2. Hemodynamic: Dehydration secondary to HCTZ? stabilized after
1 lit of IVF.
3. Renal:
Prerenal ___: improved after hydration
4. Hem: HCT drop: seems to be dilutional, she did not have any
gross blood loss.
Her HCT was checked again and remain stable
5. ID: No fever, U/A did not show finding in favor of infection.
She has been afebrile since she came.
6. Disposition: Will be home, she will start working with ___
next week.
7. Code status: Full
___
PGY2, ___ | 162 | 364 |
12365873-DS-19 | 20,250,471 | Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Sutures/staples will be removed at your first post-operative
visit.
Activity:
-Continue to be full weight bearing on your left leg.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity as tolerated
Left lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Remove staples 14 days from date of surgery. | Mr. ___ was admitted to the Orthopedic service on ___ for
a left femur fracture. On the same day of admission he
underwent open reduction internal fixation of the left femur
without complication. Post operatively he was placed on Lovenox
for DVT/VTE prevention. He worked with physical therapy and had
difficulty with ambulation. On ___ he was given 2 liters of
normal saline for fluid volume deficit with good response.
During physical therapy ___ and ___ the pt felt light-headed
and flush, with BP decrease (although maintaining adequate blood
pressures). On ___, the patient did very well with physical
therapy, who determined that he was safe for discharge home with
plans for outpatient physical therapy. The remainder of his
hospital course was otherwise uneventful and he is being
discharged home with lovenox for DVT prophylaxis, PO dilaudid
for pain, and outpatient ___ prescription, with clear
instructions to follow-up in ___ trauma clinic. All his
questions were answered adequately prior to discharge. | 238 | 165 |
12256511-DS-21 | 20,846,928 | Dear Mr. ___,
It was a pleasure taking care of you at ___! You were admitted
for difficulty swallowing, confusion and worsening kidney
function. You were found to have bladder obstruction, so a foley
catheter was placed to drain out the urine and your kidney
function improved. We have held your home furosemide (lasix)
pending further improvement in your kidney function. In
addition, you were found to have very high blood pressure, which
improved on your home lisinopril.
You were evaluated by physical therapy in the hospital, who
recommended that you get further physical therapy at home.
You also had an episode of decreased mental status, for which
the neurology team was consulted and a CT scan of your head was
performed, which was normal. You should follow up with your
neurologist and PCP to have this evaluated further.
Your urinalysis showed possible urinary tract infection, so we
have prescribed an antibiotic called ciprofloxacin which you
should continue for the next 6 days. | # Metabolic encephalopathy: At 4:30 pm ___, patient was found by
the nurse to be very somnolent. He was difficult to arouse with
verbal and painful stimuli. No recent med changes. Vitals were:
T 97.9, BP 167/65, HR 63 RR 18, O2 98%RA. FSG 134. Neuro exam
showed no focal deficits. EKG showed no acute changes. STAT labs
were drawn (CBC, Chem10, Troponin, coags, ABG), which were all
stable. He had a CXR that showed no acute changes. Foley was
placed, which drained 500cc urine, but led to no changes in MS.
___ was consulted, and they recommended a head CT, which
showed no significant abnormalities. EEG was obtained and was
pending at time of discharge. The episode resolved within ~2
hours. The etiology was felt to be related to hospital delirium
and/or sleep-wake cycle disturbance in the context of
___ disease. He was noted to be somewhat confused
afternoon of discharge, but mental status spontaneously returned
to baseline within ___ hours. Per family, patient does
experience "good days and bad days" in terms of his mental
status, and felt that mild intermittent confusion was consistent
with baseline. He will need follow-up with his neurologist, Dr.
___.
___ on CKD: Mr. ___ presented with a Cr 3.5, BUN 66. At the
time, of presentation, his baseline was unknown. Given his
history of BPH, the etiology was felt to be post-renal
obstruction. A foley catheter was placed, and he put out 900cc
of urine. Upon further investigation, his baseline creatinine
was determined to be between 2.5 and 3.0. His Cr trended down
the following day to 3.1 and stabilized.
#Urinary retention: Patient has a history of BPH and on
presentation was felt to be acutely retaining urine. A foley
catheter was placed that drained 900cc of fluid. On hospital day
2, the foley was removed and he was given a trial to void, which
he passed. Tamsulosin was continued. Avodart was not available
at this hospital and substituted with finasteride. During his
episode of somnolence, foley was replaced and drained 500cc
urine w/o immediate improvement of MS. ___ patient pulled it out
the next day (balloon up). However, urinary function remained
stable without signs of significant urethral damage. He will
need follow up with his urologist, Dr. ___.
#HTN: On the day of admission, he was found to have a systolic
blood pressure in the 200s. His Lisinopril and Lasix were held
given concern for ___. However, he was given his home nifedipine
and also given hydralazine to control his pressures. After his
creatinine stabilized, he was restarted on his home Lisinopril.
His Lasix was held pending PCP follow up to ensure stable Cr.
#Unsteady gait: Patient was noted to have unsteady gait by RN
likely related to age and baseline ___ disease. His home
Sinemet was continued. A physical therapy consult was placed,
and they recommended home physical therapy.
#Dysphagia: Patient originally presented with difficulty
swallowing both liquids and solids. He had a chest xray and an
xray of the soft tissues of the neck that showed no evidence of
obstruction. His dysphagia returned to baseline spontaneously.
He was maintained on a thickened liquid diet with no nuts or
cereals.
#Pyuria: He was found on admission to have a urinalysis
significant for >100 WBCs, 50 RBCs and few bacteria. Urine
cultures were taken and he was given 1g of IV ceftriaxone for
concerns of UTI. Pyuria was felt to be secondary to bladder
distension in the setting of acute urinary retention and urine
cultures grew skin flora contaminants. However, given his mental
status change, he was started on a 7 day course of
ciprofloxacin, renally dosed 250mg daily(___- ___) for empiric
UTI coverage on discharge.
#Anemia: Patient has chronic anemia secondary to renal
dysfunction. His HCT remained at baseline.
#Hypothyroid: continued Synthroid
#Thrombocytopenia: Chronic thrombocytopenia. Platelets were
stable. | 161 | 631 |
11699379-DS-6 | 28,483,421 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month and while taking narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | The patient was admitted through the emergency room after
developing sternal drainage following AVR/CABG. ___ had a CT scan
that showed sternal dehiscence and was taken to the OR on
___ with Dr. ___ underwent exploration of the
sternum and mediastinum and sternal debridement and washout.
There was no evidence of infection or purulent fluid
collections. Cultures from the sternum were sent for culture and
are no growth to date. There was evidence of sternal fractures
and ___ was transferred from the operating room to the ICU
paralyzed and sedated until definitive closure. The plastic
surgery team was consulted and ___ underwent open reduction and
internal fixation with plating system (Synthes) and ZIPFIX
closure, closure with bilateral pectoralis major
musculocutaneous flaps on ___. ___ was transferred back to the
ICU and paralytics were stopped. The patient was initially
hypoxic and required additional PEEP to correct de-recruitment.
___ was extubated on ___ and weaned to nasal cannula. ___ was
given cough suppressants for a persistent cough. ___ was followed
by the plastic surgery team. All OR cultures remained negative.
___ was transferred to the floor on ___. ___ was seen by our
social worker due to difficulty dealing with his surgical
dehissence/repair. ___ was evaluated by ___ for sternal precaution
teaching. ___ was deemed appropriate for discharge home and was
discharged on ___ with visiting nurses. ___ will have follow up
with Plastic Surgery in 1 week and with Dr. ___ on ___. | 107 | 243 |
13607306-DS-19 | 27,698,874 | Dear Ms. ___,
It has been a pleasure taking part in your care during your
recent hospitalization to ___.
You were admitted with a left breast wound and painful left
upper extremity swelling. You underwent physical exams,
laboratory testing, imaging, and a biopsy, which showed a breast
cancer, which had spread to your brain, spine, liver, and lung.
When you initially presented to the hospital, you were noted to
have significant liver damage. You were started on chemotherapy,
which appears to have improved your liver function. You were
noted to have low blood counts as well. You developed a blood
clot in your left upper extremity which was causing swelling in
your arm. Please continue to take the injection medication
(lovenox) to help prevent further clots.
During the admission, you underwent radiation therapy to treat
the cancer that was found in your brain. You received steroids
to help prevent swelling.
You were seen by the endocrine doctors because ___ thyroid
levels and low cortisol, a stress hormone. You were started on a
medication, prednisone, to replace this hormone. Please have
your blood drawn on ___ when you visit your
primary care doctor at the appointment below (bring the
prescription with you). Do not take the medication prednisone
prior to having the labs drawn on that day.
Please continue to follow up with the appointments as listed
below. Please continue to take the medications attached.
- Your ___ care team | ___ with a PMHx of EtOH and tobacco abuse, who presented to BI
___ with breast ulceration, L arm swelling and jaundice; was
diagnosed with Her2+ metastatic breast cancer, LUE DVT, hepatic
failure, and was transferred to OMED for further management.
Breast cancer was determined to be stage IV Her2+ with
metastasis to brain, spine, liver, lung. She had MRCP which
shows numerous metastatic lesions with subsegmental biliary
dilatation. Given the number and location of metastatic lesions,
no ERCP or ___ interventions were thought to be helpful.
Patient was initially on dexamethasone for cerebellar met, which
was tapered to prednisone 7.5mg daily after cyberknife on ___.
Given liver failure, patient was placed on combination herceptin
q3weeks/navelbene q1week ___ - further doses of navelbene
have been held due to thrombocytopenia). Patient's liver failure
markedly improved on herceptin (Tbili from ___ to ___ with
improvement in jaundice). R sided femoral port was placed on
___. Patient's left upper extremity DVT was treated with
lovenox 1mg/kg dosing. Patient with anemia and thrombocytopenia
during admission, likely ___ chemotherapy, liver failure
(anemia, thrombocytopenia), anemia of chronic disease and marrow
infiltration (NRBCs and toxic granulations on smear). Patient
required RBC transfusions as well as platelet transfusions
through course of hospitalization. Central endocrine dysfunction
was noted with central hypothyroidism and adrenal insufficiency.
Patient d/c on 7.5mg prednisone daily. plan to follow up with
endocrine in ___ weeks. | 236 | 230 |
12175593-DS-22 | 27,030,343 | Dear Mr ___,
It was a pleasure having you here at the ___
___. You were admitted here after results of an ECHO
done in the outpatient setting, showed some possible vegetations
on you heart valves. A repeat trans-esophageal ECHO showed us
better images and that what were seeing were pieces of fibrin
structures and likely non-infectious. We also increased your
home dose lasix to 40mg daily and added on a medication called
losartan for your heart. Your aspirin was discontinued.
Please weigh yourself every morning and if you weigh more than
3lbs, please call your outpatient provider.
Please keep your follow up appointments below
We wish you the very best,
Your ___ medical team | ___ with significant cardiac history including afib on warfarin,
AVR, MVR, sCHF presenting with vegatations on outpatient ECHO.
# MITRAL VALVE VEGETATIONS: Lack of fevers or other stigmata of
endocarditis, weight loss, symptoms of acute heart failure make
this diagnosis difficult without additional information.
Cardiology attending reviewed imaging and thought they were more
indicative of loose sutures. ESR/CRP not elevated. TEE show
unlikely vegetations, likely fibrin on mitral valve. Aortic
valve clear. No growth in blood cultures while in-house.
# Acute on chronic systolic heart failure: Appears to be volume
up with some vague history that may be attributable to heart
failure. Patient also has widening of Left bundle on EKG and
going in atrial tach. Has evidence of RV pacing which can also
contribute to new decompensation. EP interrogation showed
pacemaker response to atrial tachycardia. Patient was diuresed
with IV lasix 40mg and eventually switched to PO lasix 40mg
daily on day of discharge. Losartan 25mg was also added to his
regimen. Metoprolol succinate dose was increased to 75mg daily.
Patient was discharged with close PCP and cardiology follow up.
# Afib: Rate controlled currently, on warfarin. Will have INR
check this week at ___.
# Retinal swelling/glaucoma:
- continue Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
- continue Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
# CAD: no acute process
- continue Simvastatin 20 mg PO DAILY
- continue Aspirin 81 mg PO DAILY
- continue metoprolol as above
# BPH:
- Finasteride 5 mg PO DAILY
- Tamsulosin 0.4 mg PO HS
# Code: DNR/DNI | 114 | 284 |
13333479-DS-21 | 26,338,259 | Dear Mr. ___,
It was a pleasure taking part in you care. You were admitted for
diarrhea. When we checked your blood, we found that you had
elevated creatinine, which shows some injury to your kidneys. We
believe this was due to dehydration from your nausea and
vomitting. We gave you fluids and your kidneys recovered nicely.
We do not believe this to be related to a transplant rejection.
We tested your stool and found that you had an infection with
salmonella. We started you on the antibiotic Cipro. Please
finish a 14 day course of this antibiotic to end on ___. Some
other lab studies for the cause of your diarrhea are still
pending, but we believe you are well enough to go home. Please
follow up these results at you next appointment with Dr. ___.
Please have blood work drawn on ___. The results will be sent
to Dr. ___ Dr. ___.
Please be sure to wash your hands thoroughly after handling
poultry.
We have made a few changes to your medicines.
Please START Ciprofloxacin HCl 500 mg by mouth every 12 hours
until ___ to complete a 14 day course
We have STOPPED mycophenolate mofetil. You will start
azathioprine instead, as we suspect MMF may have contributed to
your diarrhea.
We have STOPPED your LISINOPRIL for now as it can exacerbate
kidney injury in acute situations. Please follow up whether or
not to restart it with Dr. ___ Dr. ___. | HOSPITAL COURSE
___ with h/o ___ Lindau c/w B/L RCC s/p living related
kidney transplant in ___ sent in by PCP for diarrhea x1
week. Found to have elevated creatinine to 4.8 from baseline of
2.4 with phos elevated to 4.8 with a gap acidosis. Renal
ultrasound found no vascular changes. Urine sodium consistent
with prerenal etiology. Infectious diarrhea workup sent along
with stool osmolality and fecal fat (given patient's pancreatic
insufficiency). ___ LEVEL ON ___ INACCURATE DUE TO DRAW
TECHNIQUE, PLEASE DISREGARD. Patient was fluid resuscitated and
creatinine trended down to baseline. Found on ___ to have had
Salmonella growing in stool so started on Ciprofloxacin q12
hours until ___ to complete a 14 day course. MMF was dose
decreased from 500mg BID to ___ BID initially due to side
effect of diarrhea. Eventually it was switched entirely on ___
to Azathioprine.
ACTIVE ISSUES
# AOCKD: Responded well to fluid resuscitation with creatinine
down from 4.5 to 1.7 with fluid resuscitation with D5W with
NaHCO3. Sodium from 135 to 141. This was likely due to fluid
loss from diarrhea and not intrinsic renal dysfunction from
rejection. Renal transplant U/S showed no evidence of
hydronephrosis and normal vascularity within the kidney.
# Diarrhea: Has loose stools at baseline due to pancreatic
insufficiency, but diarrhea this time more watery. Previously
has had MRI abdomen as workup of pheochromycytoma or other NET
as cause for diarrhea. Colonoscopy in ___ showed normal
mucosa with normal biopsies. TTG was normal. On this admission
was found to have salmonella growing from stool. Started on
Ciprofloxacin q12 hours on ___ until ___ to complete a 14
day course.
# KIDNEY TX: RLQ graft s/p b/l nephroectomies. Baseline
allograft function in 2.2-2.4 range. Complicated by renal
osteodystrophy. Admitted on the following:
Mycophenolate Mofetil 500 mg PO BID, Sirolimus 2 mg PO DAILY,
Prednisone 3mg daily. Cellcept (MMF) was initially titrated down
to 250mg BID due to diarrhea. After Salmonella was found it was
switched entirely to Azathioprine 50mg on discharge.
# HTN: held home lisinopril
INACTIVE ISSUES
# VHL: Has been followed at ___ over years by Dr. ___. Likely
cause of the RCC for which he got transplanted. Has multiple
hemangiomas in brain. Octreoscan in ___ showed possible NET
in left adrenal gland.
# Bone Disease: His BMD done on ___ showed some
osteoporosis. He is currently on hectorol and fosamax for his
Renal osteodystrophy. Last PTH was ___ in ___ and
vitamin D level was 26 in ___.
- Cont Doxercalciferol
- Cont Alendronate Sodium 70 mg PO QSAT
# Hyperlipidemia: Continued gemfibrozil.
TRANSITIONAL ISSUES
# ___ LEVEL ON ___ INACCURATE DUE TO DRAW TECHNIQUE, PLEASE
DISREGARD
# f/u speciation of Salmonella
# Stool fecal fat, osm had insufficient sample to run
# Lisinopril was held this admission. Can consider restarting it
given normalizing kidney function.
# Octreoscan in ___ showed possible NET in left adrenal
gland. Previously had unremarkable workup with Dr. ___ in
GI | 235 | 482 |
16462650-DS-9 | 22,258,573 | You were admitted with presumed pneumonia. Your oxygen level and
breathing have been stable. You also had some hypotension in the
emergency department, but your vital signs have also been stable
since admission. You will be discharged on a course of
antibiotics for your presumed pneumonia. Your diltiazem was
increased because your heart rate was slightly elevated; this
should be monitored by your doctors. | ___ M with history of MDS, A. Fib, admitted to the MICU with
fever, cough, and hypotension concerning for sepsis
# Leukocytosis. Patient initially met ___ SIRS criteria with
leukocytosis and fever. However WBCs normalized with fluids, so
was likely hemoconcentrated. While PNA was possible given
increased productive cough, CXR appeared unchanged from prior.
UA negative. BCx pending. Patient wihtout GI complains. Other
potentional sources of infection includes sinusitis and c. diff
considered, but no history to suggest. Initially treated with
vancomycin and zosyn, but these were stopped as initial culture
data was negative and leukocytosis was more likely due to
hemoconcentration. He was transferred to floor, and his daughter
thought that his respiratory status was worse than baseline. So
he was started on an 8-day course of antibiotics. Initially this
was levofloxacin, but was changed to cefpodoxime given his
prolonged QTc at 470 (which appears prolonged since ___. He
was afebrile and had good O2 saturation on RA while
hospitalized.
# Cough: Patient clarified his story, stating that his cough was
actually a baseline chronic cough, which contributed to decision
to hold further antibiotics. However he was noted to be coughing
more during rounds on day of callout from ICU. Expectorating
well. Afebrile without leukocytosis, so held Abx, with
recommendation to have low threshold for CXR and Abx if
unstable.
# Hypotension. Patient has known orthostatic hypotension.
Initially concerned for potential septic shock, but patient
responded to fluids and restarting his Midodrine that was held
in the ED. Maintained mentation. Continued Midodrine and
fludrocortisone. Trended mentation, maintain MAP > 60, and goal
urine output goal > 0.5cc/kg/hr.
# Coagulopathy. Given low haptoglobin without other evidence of
hemolysis and labs not consistent with fulminant DIC, though
possibly low grade. More likely related to poor nutrition.
# MDS. ___ transfused 1 unit pRBC last admission. Hct trended
down to ___ range after fluids. No evidence of acute blood
loss or high grade hemolysis, so trended. Darbepoetin alfa is
non-formulary and given ___ hold for now
# A. fib. Currently in sinus rhythm. CHADS2 of 2. Not
anticoagulated likely due to frequent falls. Continued
Amiodarone and once hypotension back to baseline, restarted dilt
at short acting 30mg QID. He tolerated this well, although his
heart rate was still slightly elevated in the 100s. His
diltiazem was increased to 60 mg QID, and he will be discharged
on 180 mg daily sustained release. This should continue to be
titrated.
# CKD. Cr of 1.2 now at baseline of 1.2-1.3
# Chronic Hyponatremia. Na 131 appears to be baseline.
# Hypothyroidism- cont. Levothyroxine 25mcg daily
# GERD. - cont. omperazole daily
TRANSITIONAL ISSUES
1) Consider ASA or anticoagulation for his atrial fibrillation
with CHADS2 of 2
2) Complete 8-day course of antibiotics (cefpodoxime)
3) Monitor HR and BP on increased dose of diltiazem | 64 | 457 |
14233331-DS-23 | 28,149,985 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were admitted: back pain
What we did while you were here:
- Our spine specialists evaluated you and reviewed your MRI from
___
- You had a biopsy to test for infection
- Our infectious disease (ID) specialists evaluated you and
recommended against antibiotics since we do not think you have a
new infection
Instructions for when you leave the hospital:
- Follow up with your primary care doctor (___) next
___ at 1:45pm.
- Return to the hospital if you have worsening pain, fever,
chills, weakness, numbness, incontinence, or any new symptoms
concerning to you.
We wish you all the best!
Sincerely,
Your ___ Care Team | ___ with h/o L3/L4 osteomyelitis in ___ c/b epidural and psoas
abscess s/p extended IV antibiotics, L4/L5 spinal stenosis,
lupus-like syndrome on hydroxychloroquine, transferred from
___ for acute on chronic lower back pain with MRI
concerning for recurrent L3/L4 discitis. She was treated in ED
with one dose of vancomycin/ceftriaxone, discontinued on
admission. CT-guided L4 biopsy was performed and sent for
culture; preliminary Gram stain was negative. ID was consulted
and recommended against antibiotics given low suspicion for new
infection (afebrile, no leukocytosis, CRP only 15, pain
spontaneously improved off abx). Patient remained afebrile with
no neurologic deficits, and was discharged at baseline
functional status with good pain control on oral agents and
lidocaine patch.
As of ___ there is no growth on tissue culture
ACTIVE ISSUES
====================
# Acute on chronic low back pain:
See above.
# Vaginitis:
Treated empirically with topical miconazole. UA/UCx negative.
# Lupus-like syndrome:
Outside rheumatology records unavailable. Per patient, symptoms
include fatigue, diffuse arthralgias, facial rash. No known
leukopenia, anemia, or serositis. Last flare 4 months PTA. On
hydroxychloroquine. Condition and treatment may predispose
patient to infection. However, given lack of fever,
leukocytosis, or other infectious signs/symptoms, continued
hydroxychloroquine this admission.
# Lower extremity venous stasis:
No evidence for acute cellulitis, but possible portal of entry
for infection. Continued home furosemide 40mg daily
CHRONIC ISSUES
====================
# HTN: continued home losartan, metoprolol
# OSA: continued home CPAP
TRANSITIONAL ISSUES
====================
-L4 biopsy cultures negative to date as of ___ (final for
bacteria, pending for mycobacteria/fungal culture) at discharge.
Low suspicion for infection but if positive, inpatient team will
call patient to advise readmission for IV abx.
-Pain: Well controlled on standing APAP and occasional 2.5mg
oxycodone. Please refill if need be.
#Contact: husband ___ ___
#Code: Full (confirmed) | 111 | 276 |
19260901-DS-18 | 28,278,022 | Dear ___,
___ was a pleasure caring for you at ___. You were admitted to
the hospital for an abnormal heart rhythm called atrial
fibrillation and for congestive heart failure. You started a
blood thinning medication called warfarin to reduce the risk of
strokes. You will need to have the blood thinner level, called
INR, checked frequently. They will check it before your
appointment with your primary care physician later this week.
The cardiologists tried to put your heart in a normal rhythm by
giving an electric shock called cardioversion, but your heart
returned to the irregular rhythm. Because of this, you will
need to take metoprolol to control your heart rate. Because
your red blood cell levels dropped when you started the blood
thinner, we checked for a bacteria called H. pylori that can
cause ulcers in the stomach. The test was positive, so you will
need to take omeprazole to reduce stomach acid and amoxicillin
and clarithromycin, which are antibiotics to kill the bacteria.
Your kidney function also got worse during this admission, but
it returned to baseline by the time you were discharged. You
will need to follow up with Dr. ___ to further manage your
kidney disease.
Medication changes:
start metoprolol 75 mg by mouth twice daily
start warfarin 2.5 mg by mouth daily
start amoxicillin 1 g by mouth daily for one week
start clarithromycin 500 mg by mouth twice daily for one week
decrease glyburide to 2.5 mg by mouth daily
stop aspirin until discussed with your primary care physician
stop metformin
stop nifedipine
stop enalapril
stop furosemide | ATRIAL FIBRILLATION: The patient presented in atrial
fibrillation. She was started on heparin and bridged to
warfarin due to her stroke risk. After an attempt at rate
control with metoprolol, cardiology recommended DC
cardioversion, which was performed after a TEE confirmed no
there was no atrial thrombus. She initially was in sinus
rhythm, which then became a combination of atrial bigeminy and
wandering atrial pacemaker. An attempt was made to stabilize
her in sinus rhythm with amiodarone, but the patient reverted to
atrial fibrillation and amiodarone was stopped. The metoprolol
was increased and she was rate-controlled in the ___ at
discharge.
.
ACUTE SYSTOLIC CONGESTIVE HEART FAILURE: The patient had
progressively increasing dyspnea during the week leading up to
admission and also had increased salt intake. She had a BNP of
3800 and TTE showed an LVEF of 45%. She was also in rapid
atrial fibrillation with a ventricular rate in the 130s on first
presentation. As her rate was controlled and she was diuresed,
her oxygen was weaned off and her lower extremity edema mostly
resolved.
.
URINARY TRACT INFECTION: The patient's urinalysis on admission
suggested an infection, and her culture grew out a pan-sensitive
E. coli. She completed seven days of ciprofloxacin.
.
ANEMIA DUE TO ACUTE BLOOD LOSS: As the patient was being
bridged from heparin to warfarin, her hematocrit began to trend
down. Her stool was weakly guiac-positive, so her aspirin was
held and H. pylori serologies were sent. She was also started
on omeprazole and sucralfate. Her hematocrit stabilized and
actually was trending up slightly at discharge. The H. pylori
antibodies returned positive, so she was discharged on a week of
amoxicillin and clarithromycin, along with standing omeprazole.
.
DIFFICULTY SWALLOWING: The patient's family was concerned that
she appeared to be having some difficulty swallowing at home.
She was evaluated by speech therapy with a bedside and video
swallowing studies, and they felt that she was safe for an
unrestricted diet provided she used a chin tuck with thin
liquids.
.
ACUTE ON CHRONIC (STAGE IV) KIDNEY DISEASE: The patient's
baseline creatinine is around 2.5. On admission, her creatinine
was 2.7 then rose to a peak of 3.8 in the setting of diuresis
before falling to 2.9 at discharge. Nephrology was consulted,
who recommended stopping her ACEI until outpatient evaluation.
Although she did not need dialysis as an inpatient, the
possibility was discussed with her family, and they thought it
was unlikely that they would pursue dialysis in the future.
.
PERIPHERAL VASCULAR DISEASE: The patient was started on
atorvastatin. Aspirin was held in the setting of GI blood loss,
with a plan to consider restarting this as an outpatient once H.
pylori treatment is complete.
.
HYPERTENSION: Enalapril was held given concern for the
patient's worsening renal function, but metoprolol was increased
and she had good blood pressure control while an inpatient.
.
DIABETES MELLITUS: Her home oral hypoglycemics were held and
she was placed on an insulin sliding scale. At discharge, she
was usually only requiring about 2 units of insulin daily with
sugars in the high 100s, so she was discharged on one half of
her prior home dose of glipizide. | 263 | 548 |
19612651-DS-7 | 26,802,085 | Mr. ___,
You were admitted to ___ because of septic shock causing low
blood pressure.
WHILE YOU WERE HERE:
- We did studies, but we were unable to find the exact source of
your infection
- We observed you carefully, watching for signs of infection
- Your blood pressure and fever stabilized
- We drained the fluid causing you discomfort from your abdomen
WHEN YOU GO HOME:
- Please continue all medications as directed
- Please follow-up with your primary doctor and ___ hepatologist
- For any fevers, diarrhea, vomiting or any other concerning
symptoms, please call your doctor or return to the emergency
department immediately
We wish you the best,
Your ___ Care Team | ___ with hx of HCV cirrhosis, remote MI s/p stent, L4-S1 spinal
fusion c/b infection, presents with 5 weeks of abdominal pain,
distension, emesis, diarrhea, cough, and fevers, who was
admitted to ICU with septic shock.
# SEPTIC SHOCK OF UNKNOWN SOURCE:
Patient presented hypotensive requiring levophed with unclear
etiology of infection. He had no meningismus or CNS symptoms to
suggest meningitis and had a clear urinalysis. Diagnostic
paracentesis was negative for SBP. Patient was started on broad
spectrum antibiotics and weaned off pressors. Given his back
pain and known hardware, MRI was ordered to evaluate for
epidural abscess and showed no evidence of infection. TTE showed
no vegetation. He continued to spike fevers, and was put on
vancomycin, flagyl, and ceftriaxone. He was stabilized and
transferred to the floor. His cultures from ___
were negative, along with a negative MRSA swab. He was switched
to flagyl and cefpodoxime for an 8 day total course (END: ___
for CAP vs. SBP. Suspicion was not strong enough for SBP to
recommend future prophylaxis, but this could be considered.
#Elevated Alk Phos: Unclear etiology as patient was improving
clinically and no new medications that seemed to be the culprit.
Rest of LFTs increasing but still within normal range. Some
suggestion of obstruction on prior CT. Spoke to hepatology who
suggest repeating in the morning. RUQ U/S w/o evidence of
obstruction. Was seen to be falling on repeat and will have this
rechecked with ___ hepatology f/u.
# HEPATITIS C CIRRHOSIS:
Patient was diagnosed within the past year. Of note, was found
to be Mitochondrial M2 antibody positive. He was found on
admission to have ascites and had a diagnostic and therapeutic
tap. MELD-Na on admission 19, but improved throughout his stay.
He had a negative ___, AMA, and anti-smooth muscle antibody.
Also found to be HIV negative, with a positive HCV (viral load =
5.8). His spironolactone was initially held, but continued on
discharge. His IgG, IgA, and IgM were all within normal limits.
He will require outpatient hepatology follow-up and endoscopy.
# Chronic back pain:
Patient's PCP recently weaned him off of opioids. His pain was
managed on oxycodone in the hospital. An MRI of the back was
done and showed no evidence of epidural abscess or discitis. He
should follow-up for appropriate pain control.
# CORONARY ARTERY DISEASE: Continued aspirin. Restarted his
statin.
# HYPERTENSION: Held atenolol while admitted, continued upon
discharge.
TRANSITIONAL ISSUES
=====================
[] Continue flagyl and cefpodoxime for an 8 day total course
(END: ___ for CAP vs. SBP. Suspicion was not strong enough for
SBP to recommend future prophylaxis, but this could be
considered.
[] Follow-up for appropriate pain control for chronic back pain
[] Needs HAV and HBV vaccination per serology
[] Will have outpatient hepatology follow-up and EGD w/ Dr.
___ at ___
[] Blood cultures were pending and should be followed-up in
clinic
# Communication: HCP: ___ ___
# Code: Full Code, confirmed | 106 | 483 |
10602639-DS-13 | 21,232,717 | Dear Mr. ___,
You came to ___ because you had a pneumothorax after your
thoracentesis. You had a chest tube placed by the interventional
pulmonary team. The pneumothorax improved and your chest tube
was removed. You should follow up with the interventional
pulmonary team in one month.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ year old man with history of COPD (Home O2
2L), active tobacco use, LLL lung adenocarcinoma s/p
chemoradiation, who presented after outpatient thoracentesis for
new pleural effusion, c/b PTX s/p chest tube placement now with
improving pneumothorax and s/p chest tube removal with
resolution of pneumothorax. | 69 | 52 |
14217968-DS-20 | 20,772,558 | Dear Ms. ___,
You presented with abdominal pain and were found to have
perforated diverticulitis. You were admitted for bowel rest and
IV antibiotics. Once your pain improved, your diet was advanced
and then your antibiotics were changed to oral. You are now
ready for discharge home to continue your recovery. You will be
given a prescription to complete a 2-week course of antibiotics.
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 | Ms. ___ is a ___ yo F admitted to the Acute Care Surgery
Service on ___ with abdominal pain. She initially presented
to her gastroenterologist who obtained a CT scan demonstrated
heterogeneous thickening and inflammation of the sigmoid colon
with multiple diverticula primarily located within the distal
sigmoid colon. There is a small perisigmoid fluid collection
which was felt to be representative of an early developing
abscess. Therefore she was referred to the emergency department.
The patient was hemodynamically stable, made NPO, given IV
fluids and IV antibiotics.
On HD2 her abdominal pain improved and therefore her diet was
advanced to regular which she tolerated well. On HD3 she
continued to tolerate a regular diet without abdominal pain and
therefore antibiotics were transitioned to oral. The patient
remained stable from a cardiovascular standpoint; vital signs
were routinely monitored. Intake and output were monitored
closely. The patient's fever curves were closely watched for
signs of infection, of which there were none. 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.
On HD3 the patient was discharged to home, 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. Follow up appointments were
made with her gastroenterologist Dr. ___. | 263 | 240 |
16525795-DS-10 | 29,259,975 | Dear Ms. ___,
You were admitted with pancreatitis. you underwent an MRCP to
look for the cause but no gallstones were seen. We are not sure
what caused your pancreatitis but it may have been related to
either alcohol intake or gallstones.
We recommend you abstain from any alcohol. Dr. ___
recommends to follow up with Dr. ___, a bariatric
surgeon to discuss having your gallbladder taken out, this
should be arranged for you but if you do not hear anything from
their office by next week, then call Dr. ___ for
instructions.
Your magnesium levels were low and you were repleted with
intravenous magnesium and should continue taking your oral
magnesium pills as an outpatient.
Your kidneys were not working well when you were first admitted,
which was likely due to dehydration which is now resolved.
Your platelet count was also low which may indicate some degree
of underlying fatty liver disease which was suggested on prior
imaging studies as well. This is another reason why you should
not drink any alcohol. Your platelet count improved before you
were discharge. Your B12 and folate levels were normal. | Ms. ___ is a ___ woman with history of chronic diarrhea (?
due to ?collagenous colitis or pancreatic insufficiency,
followed by ___ and previous episode of pancreatitis ___
thought due to hypertriglyceridemia), with known pancreatic mass
(s/p EUS x 2 by Dr. ___ most recently EUS by Dr. ___
___ with FNA biopsy showing benign lymph tissue) who was
recently admitted to ___ diagnosed with
acute pancreatitis (lipse 7,___ on ___ and CT ab (wo contrast)
showing mild (7mm) CBD ductal dil and ? gallstones (although u/s
later at our hospital showed no stones) who left AMA (wasn't
happy with her care there) and represented to ___ on ___ with
ongoing (but improved) ab pain. ERCP team was consulted. Also
found to have progressive acute renal failure (Cr ___ up from
1.4 at OSH, unknown b/l) which later resolved with IV fluids.
The ERCP team recommended MRCP that was done on ___ which
showed no stones, no cholelithiasis, no ductal dil, and only a
7mm pancreatic cyst which was known about from prior EUS exams.
She was managed supportively with IV fluids, analgesia and her
diet was advanced which she tolerated well. The etiology of her
pancreatitis was felt either to be due to alcohol intake,
gallstones, or perhaps both. Course also complicated by
anemia/thrombocytopenia which improved, possibly ETOH-related as
well. She continued to have chronic diarrhea throughout her
hospital course that is a chronic issue for her and unchanged.
She required multiple repletions of her magnesium and potassium
while her PO intake was poor, however they have normalized on
teh day of discharge. Rest of her hospital course/plan are
outlined below by issue:
#Acute pancreatitis: lipase > 7,000 as OSH. Also followed by
___ here at ___. RUQ ultrasound without clear evidence of
gallstones and previous pancreatitis was reportedly due to
triglycerides however triglycerides at OSH were <200 which were
normal here as well. I feel the most likely etiology for her
pancreatitis is alcohol (given liver disease as apparent by AST
2x> ALT on LFTs at OSH which later normalized, fatty liver
infiltration seen on RUQ u/s, and unexplained macrocytic
anemia). She did admit to drinking moderately, perhaps 2 drinks
per day but I'm wondering if she had been drinking more than
this to result in her pancreatitis and hematologic
abnormalities.
-counseled on alcohol and smoking cessation
-pain control with IV morphine PRN
#Acute renal failure. ? baseline CKD: Last labs in our system
were from ___ at which time Creatinine was 1.1 (not normal for
female to have Cr >1.0 so likely at least mild CKD at baseline).
-most likely prerenal azotemia due to volume shifs with
pancreatitis, improved with fluids
-Note: it does not appear she had IV contrast with her CT scan
at OSH
-creatinine improved to 0.9 on the day of discharge. encouraged
PO fluid intake.
#Diarrhea: Per history, diarrhea since ___ during a visit in
___, colonoscopy with Dr ___ in ___ were normal and
biopsies were taken from SB (normal) and cecum (collagenous
colitis), was on cholestyramine for ___ years, EGD ___ ___ duodenal biopsies were normal, ___ acute
pancreatitis(due to hypertriglyceridemia?), in ___ iron
deficiency anemia, EGD normal with biopsy showing IEL suggestive
for celiac disease (anti-TTG and anti-CPG were negative), repeat
___ ___ was negative for collagenous colitis, in ___ was
positive for elevated levels of chromogranin, vip, gastrin, and
stool elastase levels were low. Repeat EGD and colonoscopy in
___ ___ small antral ulcer and IEL in
duodenal biopsy, normal colonoscopy. Most recent ___ by
___ ___ s/p biopsies from which were
unremarkable and showed ?LN in uncinate process of pancreas
(biopsy was benign).
-Unclear picture ddx including ?microscopic colitis vs
pancreatic insufficiency. Cdiff testing was negative. Regardless
this is not new. Appears to be continuing of her usual chronic
diarrhea.
-continued her PRN immodium
#Anemia/Thrombocytopenia: plts at OSH on ___ were 134--> 111
--->98 ---> 90 (on ___ upon arrival at ___ improved --> 98
--> 106 --> 119 --> 148 on the day of discharge.
Thrombocytopenia feel is most likely related to alcohol use
(ETOH induced marrow suppression +/- also possible underlying
liver disease (CT scan showed e/o fatty liver). there was no
splenomegaly.
-Anemia workup: note she has had recent EGD and colonoscopy in
___, both unremarkable. Fe studies nremarkable, normal
iron level, normal ferritin. Given high MCV 102 however, so
B12/folate were checked and were normal.
#Periodontal disease: takes doxycycline chronically, which was
continued
#Hypothyroid: Continued Levoxyl
#Depression/Anxiety:
- Continued citalopram, trazodone
#hyperlipidemia
- continue simvastatin
#Transitional:
-7 mm cyst in the head of the pancreas (7:33) requires followup
MRCP
in ___ year (patient and husband were made aware verbally, letter
sent), Dr. ___ is aware as well.
-pending stool ova and parasites to be follow up by Dr. ___
at follow up appointment.
#Consults: ERCP
#Communication:
-plan was discussed with Dr. ___ fellow on ___ who
spoke with Dr. ___ recommended outpatient GI surgery
referral with Dr. ___ as outpatient. Dr. ___
agreed to contact Dr. ___ office to make sure that the
appointment was arranged next week as it is a ___.
-I reviewed the full plan with the patient with her husband at
bedside on the day of discharge and answered all questions.
#Code: FULL (confirmed)
#HCP: Husband ___ ___ (cell)
#DISPO: she will go home with her husband where she lives
independently.
>30 minutes spent seeing the patient and organizing discharge.
___
___ | 189 | 891 |
19578341-DS-17 | 28,488,346 | Ms. ___,
You were admitted to the hospital with dizziness. Your
neurologic examination looked good when you came into the
hospital, but we wanted to get an MRI of your brain given that
you are at high risk for strokes. We did the MRI of your brain,
which fortunately did NOT reveal any new strokes.
We did further testing, which revealed signs that the dizziness
may be due to the inner ear. You may have something called
Benign paroxysmal positional vertigo (BPPV), which we will give
you exercises for.
We noticed that your INR level for the Coumadin was a little bit
low. After discussion with our pharmacists, we will increase
your dose from 6mg to 7mg for tonight and tentatively for
tomorrow. However, please call the ___ clinic in the
morning on ___ to confirm what dose you should take.
It was a pleasure taking | Ms. ___ is a ___ woman with history of HTN, diabetes,
UC in remission, and prior left parietal ischemic stroke in the
setting of nonischemic cardiomyopathy with a left ventricle
thrombus who is on coumadin presenting with lightheadedness,
vertigo, and gait instability.
By the time of evaluation in the ED, symptoms had resolved apart
from mild gait unsteadiness. Her exam was notable for having a
positive head impulse test to the left with a corrective saccade
(suggestive of peripheral vestibulopathy), normal mental status,
normal cranial nerves, mild left arm parietal drift (likely
related to her prior infarct) and a mild left arm sensory
ataxia.
Her workup was notable for CT head which revealed no acute
process, and hypodensities related to old infarcts in the right
parietal lobe and left occipital lobe. She had a CTA head/neck
which revealed no large vessel occlusion. She had an MRI head
which revealed no infarct; there were chronic infarcts involving
the left occipital lobe and right centrum semiovale.
Given the negative workup and reassuring exam, etiology felt
consistent with peripheral vestibulopathy.
#Dizziness: Likely secondary to peripheral vestibulopathy, with
component of vestibular neuritis vs BPPV.
- Given instructions for Epley maneuver to be done at home
- Follow up with PCP ___ ___ as scheduled
#Subtherapeutic INR: Noted to have subtherapeutic INR and did
miss one dose of ___ on ___ while in ED. Home regimen is
6mg daily except for ___ where it is 4mg. In past, when
INR has run low she has increased dose to 8mg. After discussion
with pharmacy, will recommend 7mg tonight (___) and discussion
with ___ clinic tomorrow.
- Coumadin 7mg tonight (___)
- Please call ___ clinic in AM (closed today for holiday)
to ask for recommendations for further dosing. Otherwise, would
recommend Coumadin 7mg tomorrow (___) and then resuming to
previous regimen.
- Follow up with PCP ___ ___ as scheduled | 143 | 311 |
16283409-DS-8 | 29,399,613 | Dear Mr. ___,
You were admitted to the ___
for weakness in the setting of a urinary tract infection. While
you were here we gave you IV fluids to help with dehydration and
antibiotics to continue treating your infection. It is important
that you complete your antibiotics course as prescribed, and
that you continue to drink enough fluids to stay hydrated.
Best Wishes! | # UTI: Pt was admitted with confirmed enterococcal UTI from ___
culture, sensitive to macrobid and on d3 of macrobid therapy
with worsening functional status (weakness, unable to ambulate).
Given ___ and worsening clinical status, pt was changed from
macrobid to IV antibiotic therapy with ampicillin during
inpatient stay that was transitoned to augmentin by discharge
(course to end ___. He never articulated any urinary symptoms
to team during stay.
# ___: Creatinine was 1.9 on admission (compared to baseline
~1.0). This was thought to be prerenal given pt baseline
dementia and recent malaise, although per family report has be
hydrating well PO. FeNa of 0.3% argued for this also, and Cr
improved to near baseline (1.3) with IVF repletion, further
supporting prerenal etiology. Bladder scan on admission revealed
220ml arguing against obstruction, and pt was able to void into
urinal during his stay. Pyelonephritis was unlikely given no CVA
tenderness, afebrile, and no white count. Lisinopril was held
until near resolution ___ by creatinine measurement, but
reinstated by discharge, and home tamsulosin was continued.
# Weakness: Strength intact throughout on exam and unchanged
during stay. His continued weakness was thought likely ___
deconditioning surrounding persistent infection and/or
dehydration, with limited improvement in mobility during short
inpatient stay. He has no other evidence of acute medical
process (no evidence of other infection, cardiopulmonary process
or neuro deficit) to account for his instability. At discharge
he was unable to stand or transfer without assist, and
functioning significantly below baseline per ___ evaluation.
# Dementia: Maintained at baseline per family description. By
day 2 pt was oriented to person +/- place and communicated
pleasantly. We continued his home donepezil, memantine, and
discontinued home trazadone, quetiapine, and cetirizine in order
to limit altering medications in this geriatric patient with
dementia.
# Hypertension: Home lisinopril was held until resolution of
___, and restarted at home dose 5mg on day of discharge, SBPs
ranged in the 130-150's. It would be appropriate to recheck
basic metabolic panel upon transfer in order to confirm
continued resolution of Cr (<1.4) and may consider d/c'ing if
elevated and unresponsive to IVF repletion.
# Aspiration Risk: Although kept on regular heart healthy diet
for most of stay, on day of discharge nursing raised concern for
aspiration risk. Pt was transitioned to nectar liquids and soft
solids and should have formal swallow evaluation within first
day after transfer to rehabilitation. | 62 | 402 |
13727775-DS-8 | 25,987,395 | Please call Dr. ___ ___ if you have any of
the following: fever, chills, malfunction of PD catheter,
abdominal pain or ineffective PD | Patient came to ED with clogged PD catheter. It was unable to be
unclogged in the ED and so she was admitted to have ___ attempt
wire clearance of tubing. On ___ she had this procedure
performed and was then trialed on PD that night. She was able to
infuse over 2L and remove it without issue. She was therefore
discharged home. | 23 | 62 |
16579365-DS-19 | 27,218,959 | You were admitted with a fall. You had a head CT which showed no
significant changes and a CT neck which showed no broken bones.
You were found to be increasingly confused in the ED. You had an
EEG which revealed signs concerning for seizure. Your seizure
medication was increased. Your diabetes remained under poor
control and you were seen by ___ who adjusted your insulin.
Dr. ___ you to physically recuperate after the fall
and follow up with him in clinic in 2 weeks. His office will
call you for a follow up. Right now it is tentatively booked for
___ at 2pm. | Dr ___ is a ___ w/ GBM which has increased on recent
imaging (awaiting completion of SRT) who presented after a
mechanical fall c/b severe concussion followed by confusion, now
s/p ___ sessions of CK to the inf and superior lesions. ___ was
found to have epileptiform activity on EEG but not c/w seizure,
but his antiepileptic was increased in dose with some
improvement of his MS but with persistent confusion. Being
discharged to rehab.
# Altered Mental Status:
Patient with fall + significant head strike which resulted in
likely severe concussion as evidenced by altered mental status
following event. Repeat head CT confirmed a delayed bleed had
not occurred. No infectious signs and symptoms. Could also have
hospital associated delirium being in the ED for several days.
Fortunately patient now slowly improving but remains off
baseline. Has a diathesis for confusion in light of progressive
GBM based off MRI from ___ ___s the XRT. EEG revealed
epileptiform activity but not organized enough to be a seizure.
Lacosamide increased from home dose of 100 mg BID to ___ mg BID
w/o significant improvement of his mental status. Of note, his
mental status is much improved in the morning, able to
articulate his research on V1. ___ has ___ PhD in neuroscience
- cont lacosamide, now ___ mg bid
- cont delirium precautions, frequent reorientation
- cont ___
- cont wound care to his elbow post fall
# GBM
# Hx of seizures
Patient was due for a radiation appointment which ___ missed
while
in the ED. Edema demonstrated on ___. No need for steroids per
neuro-oncology. Completed his five sessions of cyberknife
inpatient ___ to the R frontal superior and inferior GBM
lesions. Unfortunately his options for treatment are extremely
limited. Dr ___ neuro-oncologist, wants him to
rehabilitate and in two weeks, will see him in clinic to discuss
goals of care.
- Continue home lacosamide, increased to 150 mg BID
- f/u with Dr ___
# HTN
# CAD:
No concerning signs for ACS based on history. ECG
re-demonstrates
prior LBBB
- cont home ASA
- cont home statin
# DM2:
On multiple oral agents at home. Here has been poorly
controlled. ___ was seen by the ___ inpatient consult service
with persistnetly poorly controlled diabetes.
- increased home glipizide xl to 20 daily
- resumed home metformin 1000 mg bid
- resume linagliptin 5 mg on d/c (non-form here)
- continue insulin while in rehab but pt does NOT want to resume
on discharge to home in light of his goals of care
# seborrheic dermatitis:
Started ketoconazole shampoo for beard and cream for the face on
___. Continue for 7 days.
# CKD III: Cr at baseline 1.7
# Hypothyroidism: Continue home levothyroxine (check lvl here)
# Psoriatic arthritis: Continue home sulfasalazine
FEN: Regular diet
DVT PROPH: HSC while inpatient
ACCESS: PIV
CODE STATUS: FC (presumed)
DISPO: ___ in ___
BILLING: >30 min spent coordinating care for discharge.
______________
___, D.O.
Heme/___ Hospitalist
___ | 104 | 478 |
19334308-DS-21 | 21,759,986 | Dear ___,
___ was a pleasure taking care of you.
Why you were admitted?
-You were admitted because you were having abdominal pain and a
CT scan revealed a large pelvic mass likely originating from the
ovary.
What we did for you?
-The gynecology oncologist evaluated you. They felt like you
were otherwise stable and could return next week for surgery to
further surgical workup of this pelvic mass.
What should you do when you leave the hospital?
-Please take all your medications as prescribed and attend your
follow up appointments.
-If you have any severe abdominal pain, fevers, chills, please
call the gynecology clinic at ___.
We wish you the best,
Your ___ team | ___ yo female with hypothyroidism, IBS, depression presents for
abdominal pain found to have large pelvic mass on CT scan. A
10x14cm mass was found in the pelvis with transvaginal
ultrasound concerning for an ovarian origin. CA-125 of 49. She
was evaluated by the gyn-onc who recommended that she be
discharged and return outpatient for diagnostic laparoscopy with
bilateral salpingo-oophorectomy with intraoperative frozen
section to determine if further surgical staging with total
hysterectomy, omentectomy, and pelvic and periaortic
lymphadenectomy is necessary. She understood the plan and was
discharged.
#Pelvic Mass
#Abdominal Pain
Large heterogenous mass found on CT with transvaginal ultrasound
and elevated CA-125 concerning for ovarian malignancy. Other
tumor markers wnl. Her severe abdominal may have been due to
intermittent ovarian torsion. She was given IV ketorolac in the
ED and only required intermittent tylenol for pain control. She
was evaluated by the gyn-onc who recommended that she be
discharged and return outpatient for diagnostic laparoscopy with
bilateral salpingo-oophorectomy with intraoperative frozen
section to determine if further surgical staging with total
hysterectomy, omentectomy, and pelvic and periaortic
lymphadenectomy is necessary. Plan for outpatient gyn surgery on
___.
#Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES
========================
[]Patient to follow up with gyn-onc for surgery. Will follow up
with atrius oncology post-operatively
[]Gynecology clinic phone number: ___
#Code Status: Full (confirmed)
#Emergency Contact: ___ (husband) ___ (h),
___ (c) | 106 | 217 |
14745859-DS-9 | 29,515,992 | Dear Ms. ___,
You came to the hospital because you were having nausea,
vomiting, and dizziness.
While you were here:
-You had a CT scan (a special x-ray) of your ___ and of your
lungs, which showed you had a mass in your lung that had spread
to your brain.
-You had a biopsy done which did show you have a type of lung
cancer call Non-small cell lung cancer.
-You had a lumbar puncture to look for cancer cells in the
fluid around your spine.
- You were seen by a radiation oncologist, who helped to plan
your radiation care.
-You were also set up with an appointment to see an oncologist
near your home in ___.
- You were started on a steroid (dexamethasone) to help
decrease the swelling in your brain and 2 medications
(famotidine and Bactrim) to help prevent complications of the
steroids
-You were also found to have high blood pressure and were
started on a medication lisinopril.
-You were given an antibiotic for your tooth abscess.
When you leave the hospital, it is important you take all of
your medications as you are prescribed. It is also important you
follow-up with your radiation oncologist, oncologist, and your
dentist for your dental care.
If you have any worsening shortness of breath, dizziness, or
seizures, it is important you come to the ER right away.
It was our pleasure to care for you, and we wish you the best!
Your ___ Care Team | Ms. ___ is a ___ female with history of tobacco
abuse and recent dental abscess who initially presented with
nausea/vomiting to ___ and found to have left
cerebellar mass and frontoparietal mass. She was transferred and
initially admitted to Neurosurgery service subsequently found to
have LLL mass on CT chest concerning for primary lung malignancy
with brain metastasis. ___ guided lung biopsy showed NSCLC and
staging with bone scan and LP was done. LP cytology pending at
time of discharge. Radiation planning for Cyberknife therapy and
outpatient oncology follow-up was arranged, and pt was
discharged home with close outpatient follow-up
# Brain Lesions:
# Nausea/Vomiting:
Patient initially presented with nausea, vomiting, and a several
week history of dizziness. Patient was found to have cerebellar
and left frontoparietal lesions with adjacent edema on CT ___.
The patient was started on dexamethasone 4mg BID and Keppra with
good response and improved nausea/vomting. Because she improved
with medication, neurosurgery signed off without the need for
surgical intervention. A CT chest was done and a new large LLL
mass (~7cm) was found on CT chest. This was suspected to be the
primary lesion, so an ___ guided biopsy of the LLL was done. The
pathology revealed NSCLC. Radiation oncology was consulted, who
recommended CyberKnife therapy to the brain metastasis and
mapping was complete. Neuro-oncology also followed the patient
and recommended an LP to check for leptomeningeal spread. This
was done and cytology was pending at discharge. Outpatient
oncology follow-up with Dr. ___ at ___ was
arranged. The pt was tapered down to dexamethasone 4mg QAM and
2mg ___, but had reoccurrence of morning ___ ache, so was
resumed on 4mg BID. Was also started on famotidine and Bactrim
for GI and PCP prophylaxis, respectively, in the setting of
___ term steroids.
# Left Lower Lobe Lung Mass: Found on chest CT with associated
lymphadenopathy which was found to be NSCLC. Pt did not have any
hypoxia and remained on room air. Care was organized as above.
# Dental Abscess: Patient reportedly had a tooth abscess for
which she was taking oral abx at home (penicillin) prior to
admission. However, she discontinued this in setting of
nausea/vomiting. She was seen by a dentist in house and a
Panorex x-ray was done which revealed retained roots that were
recommended to be removed and for the patient to complete a 7
day course of antibiotics. OMFS was contacted, who recommended
pulling teeth #2,3,12,26,30 as an infection risk, however the
patient wished to defer to her outpatient dentist and endodonist
for secondary opinion. Per radiation oncology, these procedures
do not have to be completed prior to radiation, as dental
exposure with ___ radiation is minimal. Will need close dental
follow-up for further procedures. She completed a 7 day course
of antibiotics, first penicillin then amoxicillin (___)
while in house.
# Hypertension:
Pt has no history of hypertension, but found to have elevated
BPs throughout hospital stay requiring PRN hydralazine. Because
it persisted, the patient was started on captopril 6.25mg BID
with good response, then transitioned to lisinopril (___). The
pt had a chem 7 checked prior to discharge for reference.
#Bacturia
Pt had a urine culture positive for E.coli at 10,000-100,000
CFU. In the setting of no symptoms, this was not treated. The
patient remained asymptomatic.
TRANSITIONAL ISSUES
==============
- New medications- Dexamethasone, bacterium, lisinopril,
famotidine
- LP pending at time of discharge. If cytology is positive for
leptomeningeal disease, she should get whole brain radiation,
rather than CyberKnife.
- ___ wants to see Dr. ___ in ___
- Outpatient oncologist will need to check PDL1, EGFR, ALK, ROS1
- Pt on dexamethasone 4mg BID, should have bone density
screenings, and encourage vitamin D and calcium intake
- Please check lytes & BP on lisinopril. Adjust dose as needed
- Will need follow up with dentist and endodontics for further
treatment of poor dentition
CODE: Full
EMERGENCY CONTACT HCP: ___ ___ | 252 | 642 |
12153312-DS-9 | 27,380,695 | ***You staples should be removed at rehab on ___
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with sutures. You may wash your hair
only after sutures and/or staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this only after follow up with Dr.
___ his approval.
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to. | Pt was admitted to the neurosurgery service and was kept NPO in
preparation for surgical evacuation. On ___ he underwent a R
sided burr hole craniotomy for evacuation of ___. He tolerated
the procedure well. Post operatively he was transferred to the
ICU for close monitoring. On Post op exam it was noted that he
had a new facial and some difficulties with speech. A CT was
performed immediately which showed new intraparynchymal
hemorrhages in the right frotal and parietal lobe. Patient
remained in the ICU, a repeat CT the following day showed slight
expansion of the hematomas.
Patient then underwent a R hemicraniectomy on ___ and was
transferred back to the ICU for continued care. Mannitol 25mg
q6h was started postoperatively and diet was advanced. The pt
recieved a helmet and dressing changes demonstrated a well
healing incision. On ___, q2h neurochecks and tube feeds were
started w/ goal of 50/hr. Chemical DVT prophylaxis with SubQ
heparin was begun as well. On ___, mannitol was decreased to
25g Q8H for 2 doses. His exam improved, he was now following
commands on the R side and w/d on the L side to noxious stimuli.
He was transferred to the SDU. Speech and swallow was consulted
to advance his diet and ___ for evaluation. He was found to
have a UTI and was started on cipro.
His diet was advanced. He began tolerating soft POs without
complication.
On ___ patient was transfused 1unit platelets for acute
neurosurgical postoperative concern for continued
thrombocytopenia. The platelets increased as expected. The
incision was clean and dry upon discharge. The patient was
discharged the following day with no acute issues. He will
require extensive rehabilitation and will follow-up in 4 weeks
for evaluation if his craniectomy with a CT-head. | 225 | 295 |
13786130-DS-21 | 21,106,734 | You presented to the hospital with ongoing diarrhea, found to
have recurrent C. diff infection with septic shock. Due to your
persistently low blood pressure, you required admission to the
ICU for medications to improve your blood pressure called
"pressors." Your diarrheal infection responded well to
antibiotics. However, due to the IVF's you required in the ICU
and holding of your home diuretic (Lasix), you developed
significant lower extremity edema / volume overload. You
required adjustment of your diuretic regimen and the
cardiologists were consulted to aide in management.
.
You will follow up with your cardiologist, Dr. ___ will
be calling to arrange for follow up in ___.
.
Your weight on discharge is 155.76 lbs or 70.8kg.
Weigh yourself daily | ___ y/o woman with a PMH of severe AS s/p St ___ valve
placement on ___, acute cholecystitis s/p Percutaneous drain
and recent treatment for C. diff with PO Vancomycin, who p/w
recurrent diarrhea, c/w recurrent C. diff with septic shock.
#Septic shock: Given recent h/o c.diff treated from ___
and lack of other localizing signs of infection, c.diff was
initially most likely source of sepsis. The patient was
hypotensive and tachycardic on arrival to the ED with a
leukocytosis to 16.4. Ms. ___ experienced resolution of
diarrhea until ___ when she started having 3 episodes of watery
diarrhea per day. Another potential source for sepsis would be
her perc chole drain, but cholangiogram did not show any issues
with the drain and GNR's in bile were thought to be
colonization. Her perc chole tube was monitored for evidence of
erythema or prurulent drainage PO vancomycin was restarted. She
was on pressors for about a day in the ICU, and these were
weaned; her baseline BP's run very low with SBP's in the 90's.
Her cdiff was positive and she was treated with PO vanc and IV
flagyl. She was transitioned to oral regimens of vanc and
Flagyl. Plan was to treat for 14-day course (day 1: ___ for
first recurrence of Cdiff. The patient was called out to the
floor on ___ with hemodynamics stable. She remained stable on
the floor and completed her 14 day course of therapy while
inpatient.
# Atrial fibrillation with h/o TIA
Currently in Afib, though rates are acceptable. Continued
amiodarone, beta-blocker. Continued coumadin and dosed daily per
INR. Pt received 1mg on ___ and ___. Would continue to
monitor INR upon discharge and adjust warfarin dosing prn. Pt
was given 1mg daily during admission and will discharge on this
regimen. Would monitor INR every 2 days and increase warfarin
dosing prn.
.
# CAD, s/p CABG, AS, s/p AVR, sys CHF, acute on chronic (volume
overload), severe MR. ___ asa, statin, bb. Held ACEI
during admission and upon discharge given borderline blood
pressures of 90's to low 100's. Attempted to have pt wear
compression stalkings.Continued coumadin for duration post
bioprostetic AVR as well as for atrial fibrillation. Cardiology
was consulted to assist with management and pt's lasix was dc'd
and torsemide started to promote diuresis in the setting of gut
edema. Per report outpt dry weight is 145-147lbs. Pt is 70.8kg,
155 lbs on ___, on discharge. Was 73.5kg ___ and 74.1kg ___.
Plan is to continue torsemide 30mg daily until pt reaches her
goal weight. Then, would dc torsemide and resume lasix at home
regimen of 40mg daily. The patient will be following up with her
cardiologist Dr. ___ in the next week. The office will be
calling to arrange for follow up.
**Please assess daily weights.
** pt has a foley for I/o monitoring. You may discontinue upon
arrival to rehab and perform voiding trial.
.
___: Patient had a Cr of 1.8 and appears to have a baseline of
0.6-1.0. This was likely ___ volume depletion/hypotension in the
setting of ongoing diarrhea and septic shock. Her creatinine
returned to 1.1 on callout to floor and 1.0 on day of discharge.
# Hyponatremia
Most likely due to hypervolemic hyponatremia from CHF flare.
Improved/normalized.
.
# Cholecystitis, s/p drain
No RUQ pain, fever to suggest infection. LFT check earlier on
admission was WNL. Drain was capped. Pt will be following up
with ACS upon discharge to discuss CCY vs drain pull.
# Depression. Started SSRI per pt daugther request. Pt will need
to be monitored and dose adjusted prn. Can monitor QTC on
upcoming cardiology follow up.
#HLD: continued home atorvastatin
#Osteoporosis: continued home alendronate
.
Transitional care
1.continue diuresis, goal weight 145-147 lbs. Transition back to
home lasix dose when at goal weight
___ outpt surgery
___ outpt cardiology
4.monitor INR
5. daily weights
6.DC foley and provide voiding trial | 121 | 632 |
12986118-DS-5 | 27,196,416 | 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 weight bearing right lower extremity in ___
brace
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 30mg 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.
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Encourage turn, cough and deep breathe q2h when awake<br>TDWB
with unlocked ___ (immobilizer for now)
Treatments Frequency:
Sutures/staples removed. Dressing changes daily. Elevation as
tolerated. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right distal femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge back to SNF 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
NVI distally in the right lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
ANTIBIOTICS / ID: Ceftriaxone for UTI
TRANSFUSIONS: She received 1 unit of pRBC in the PACU for HCT
23.1 and 2u pRBC yesterday for HCT 20.6 with appropriate reponse
to HCT 27 on discharge. | 218 | 284 |
11906499-DS-18 | 22,876,554 | Dear Mr. ___,
You were admitted to the hospital with symptoms concerning for a
biliary infection and obstruction. You had an ERCP which showed
narrowing of the distal part of the common bile duct and a stent
was placed. You also had a CT done to better visualize this
area.
The ERCP team will see you in follow up, and they will also
discuss the case and imaging with the surgeons to evaluate
whether there may be any role for surgery.
Please follow up with all scheduled appointments and take the
antibiotics for three more days.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | Pleasant ___ yo M retired OB/GYN with hx gallstone pancreatitis,
CCY, hx of bile duct stricture, s/p ERCP with stent, who
presented to the ED today with shaking chills,
fevers to 102 and now elevated bilirubin of 3.8 concerning for
cholangitis.
# Possible cholangitis
# Distal CBD narrowing
Initially with signs/symptoms of infection concerning for
cholangitis, but once on floor, pt stable, no abd pain,
non-toxic, VSS. Of note, prior bx were non-diagnostic,
neoplastic/ dysplastic lesion could not be excluded. ERCP done
on ___ showed distal CBD narrowing, large amounts of thick
sludge material and stones were removed, brushings were
obtained. Biopsies of the ampulla were obtained. ___ 6 cm stent
was placed. ERCP recommended CTA abdomen/pel, which was done on
___, read pending. Discussed with ERCP; also want surgery to
evaluate, and they will call patient to set up outpatient
appointment. Patient will also be discussed in upcoming
multidisciplinary rounds. Started antibiotics on admission for
possible cholangitis. Will continue with cipro/flagyl for 3 more
days on discharge.
# Anemia: mild, unclear ___, no e/o active bleeding
# Dysuria/frequency: c/f UTI, but urine culture with no growth.
# HTN
# CAD
-cont home antihypertensive, lasix unclear why pt not on asa,
transitional issue for PCP
# HLD: cont home statin
# anxiety/depression: cont home meds | 103 | 205 |
13993571-DS-12 | 23,051,393 | You were admitted with recurrent bacteremia (bacteria in the
blood), likely related to recurrent cholangitis (infection in
the liver), which is likely from a benign stricture in on of the
bile ducts (a narrowing that leads to problems with drainage of
bile from the liver). With antibiotics you improved, you were
seen by the Infectious Disease and Hepatology consult services
who recommended finishing a course of oral antibiotics and
following up as an outpatient. Your case will be discussed at
an interdisciplinary team meeting of experts on ___, and
the results of that meeting will be discussed with you when you
follow-up, including whether there are any options to try and
prevent future episodes.
Please weigh yourself every morning, call your doctor MD if your
weight goes up more than 3 lbs, as that may be a sign of heart
failure. | ___ man with a past medical history of recurrent
gram-negative rod bacteremia from an unclear source but thought
to be gastrointestinal, now presenting with E. Coli and
Klebsiella pneumonia bacteremia thought to be of biliary
etiology, possibly from current cholangitis from a benign left
sided bile duct stricture.
During the hospitalization the patient was evaluated by
infectious disease and hepatology. He improved rapidly with
antibiotics and will follow up as an outpatient as noted below
on the day of discharge, he was feeling well, we reviewed his
situation, his medications, the plan of care, and he was looking
forward to going home.
#Sepsis (___) from E. coli and Klebsiella pneumoniae
bacteremia thought to be of biliary etiology, possibly from
current cholangitis from a benign left sided bile duct
stricture.
-This is approximately his third admission this year for
gram-negative sepsis
his blood cultures from ___ to pan susceptible E. coli,
and Klebsiella pneumonia resistant only to ampicillin
Infectious disease consulted, he was initially on cefepime,
narrowed to ceftriaxone, and then changed to oral ciprofloxacin
at the time of discharge, to complete a 14 day course from the
first negative culture which was ___
He was also seen by Hepatology who requested an MRCP which was
done showing a benign stricture in the left side of the liver
leading to chronic biliary dilation there, and likely the cause
of recurrent cholangitis and his recurrent gram-negative rod
bacteremia
Testing for autoimmune hepatitis, or other etiologies of
strictures was negative, as was testing for hepatitis B and C
His case will be discussed at an interdisciplinary meeting on
___, and the results will be conveyed to him at follow-up
appointments as delineated below -- there is the chance that
there could be a procedure to dilate the stricture
-He will continue ursodiol
#Diabetes II on insulin with ?neuropathy, nephropathy
-Patient was treated with sliding scale insulin during his
admission and his sugars were adequately controlled
#Stage IV CKD, baseline GFR ___
-The patient was at his baseline
#HTN, HL
#Chronic Systolic CHF - LVEF 30%
#s/p CABG in 1990s
-We continued aspirin, atorvastatin, metoprolol XL, nifedipine
XR
#Moderate megaloblastic anemia, stable
#Thrombocytopenia, stable
-we suspected these were related to sepsis and CKD
-his reticulocyte count was inappropriately low, no signs of
hemolysis, no signs of vitamin
B12 or iron deficiency
#s/p CCY in ___
#Pulmonary fibrosis
#Hypothryoid - levothyroxine
#Other - omeprazole
[x] The patient is safe to discharge today, and I spent [ ]
<30min; [x] >30min in discharge day management services.
___, MD
___
Pager ___ | 142 | 396 |
17199034-DS-15 | 24,445,564 | Dear Mr. ___,
You were admitted to ___ from ___.
WHY WAS I ADMITTED?
===================
- You passed out and hit your head.
- You were seen at ___, where they were concerned
that you may have broken a bone in your neck. You were then
transferred to ___ for further care.
WHAT HAPPENED WHILE I WAS HOSPITALIZED?
=====================================
- You were seen by our spine and trauma surgeons, who did not
feel that your neck needed surgery.
- We performed stool studies and identified an infection call C
diff was causing your diarrhea. We treated you with antibiotics.
- You had a CT scan of your abdomen that showed some
inflammation and a possible mass, which will need to be followed
up as an outpatient.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
========================================
- Take all of your medications as prescribed.
- Follow up with your doctors as listed in this packet.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | Outpatient Providers: ___ man with CAD, pneumothorax,
cerebral aneurysm, and multiple cervical spine fusions presented
as a transfer from ___ after sustaining a
syncopal episode in the setting of several weeks of diarrhea
that has worsened over the last several days. Imaging showed
possible C4 fracture and colonic thickening concerning for
infection vs. malignancy. During his hospitalization he was
found to be C diff positive.
TRANSITIONAL ISSUES
===================
[ ] Colorectal cancer screening - CT abdomen at ___
___ showed inflammation in the colon and a question of a
colonic mass. Per the patient, he has never had a colonoscopy or
other forms of colorectal cancer screening. This should be
pursued on an outpatient basis.
[ ] Headaches, nausea - Being worked up as an outpatient by Dr.
___ neurosurgery given known cerebral aneurysm.
This evaluation should continue as planned.
[ ] C-collar - to remain in place for 6 weeks or until cleared
by our ___ in follow up.
[ ] C diff - to complete a 10 day course of PO vancomycin (D1 =
___, D10 = ___
[ ] Tamsulosin - held (as below), but can be restarted on an
outpatient basis
ACUTE ISSUES:
===============
# C diff
Patient presented with complaint of diarrhea that had acutely
worsened over the week prior to presentation. A CT abdomen at
the OSH showed inflammation in the colon concerning for
infection vs. malignancy. He was started on ciprofloxacin and
flagyl and stool studies were sent. C diff was positive, so his
antibiotics were changed to PO vancomycin, which he will take
for a total of 10 days. His symptoms improved while on
antibiotics. Of note, there was a question of possible mass seen
on the OSH CT abdomen, which will need further evaluation as
above. The patient, per his report, has never undergone
colorectal cancer screening.
# Possible C4 fracture
Imaging studies from both OSH and ___ were consistent with a
possible C4 fracture. Spine surgery and trauma surgery were
consulted and did not feel as though it was an unstable fracture
or required surgical management. They recommended a C-collar for
6 weeks with close outpatient follow up. Activity as tolerated,
no lifting, twisting or bending.
# Syncope
Patient presented to OSH after a syncopal episode. Based on
history, it was suspected that this may have been a vasovagal
episode in the setting of significant nausea, abdominal
cramping, and headaches. Orthostasis is also possible in the
setting of significant liquid diarrhea for the week and even day
prior to presentation. Based on history, there was a low
suspicion for cardiac etiologies and seizures. His diarrhea was
treated as above.
# Headaches, nausea
Constellation of symptoms that have plagued the patient for
several years and have improved after ___ surgery in the
past. Most recently, patient reports that his outpatient
neurosurgeon suspected that this was caused by his known
cerebral aneurysm and was planning to perform an MRI. He should
continue this outpatient evaluation as planned.
CHRONIC ISSUES:
===============
# Depression
- Continued citalopram 20mg daily
# BPH
- Holding tamsulosin as patient has not taken for the last week
and wanted to avoid medications that may lower BP. This can be
restarted on an outpatient basis as BPs allow. He was continued
on Finasteride.
# Full Code (presumed)
# HCP
Name of health care proxy: ___
___: Friend
Phone number: ___ | 150 | 542 |
15156662-DS-9 | 26,927,873 | You were admitted with shortness of breath. This may be due to
asthma. You were treated with steroids and inhalers. With this
your breathing improved.
You should see a primary care physician who can help diagnose
and treat your possible asthma. | Assessment and plan: ___ with presumed asthma who presents with
reactive airways disease.
# Suspected asthma exacerbation:
# Reactive airway disease:
He improved with steroids, nebs. Given his recent failure of a
short course of steroids we treated with a longer course of
steroids (10 days). In addition, he had inhaler teaching. He had
no evidence of infection and no antibiotics were given. He was
also given a prescription for Flovent to start after his
prednisone burst is complete.
He will follow up with a primary care physician for further
evaluation and treatment. | 41 | 89 |
18937426-DS-11 | 21,691,753 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain. We did
an endoscopy to look for a source of the pain. There was no
ulcer found, but there was gastritis and duodenitis, i.e.
inflammation of the stomach and the first part of the
intestines. This could be related to your known H. pylori
infection, for which you will need to take 3 medications called
PrevPAC.
Your gastroenterologist, however, thinks the pain is more likely
due to your Crohn's disease. We recommended you stay to be
treated with budesonide and Remicaid, but you elected to leave.
You should still take budesonide, and you should contact Dr.
___ to find out when you will get your next Remicaid dose.
It was a pleasure caring for you here at ___. | Mr. ___ is ___ with h/o Crohn's disease s/p jejunal and partial
ileal resection in setting of SBO in ___, currently maintained
on Remicade and ___, newly diagnosed H.pylori prescribed
PrevPAC (but not yet taking) who is presenting with abdominal
pain.
1. Abdominal pain: Given NML CRP and ESR, that he's been on ___
and Remicade, and no active inflammation on CT, initially seemed
unlikely that IBD was the cause of the abdominal pain. He
underwent EGD which revealed gastritis and duodenitis with no
visible ulcers. We initially treated for IBD flare with cipro
and Flagyl per GI recommendations but these were disconinued
prior to discharge, and budesonide was initiated per GI. We
recommended that patient stay in house for a Remicade infusion,
but he refused as he wanted to get home to be with his young
children. He will have to get next Remicade infusion as an
outpatient. ___ was continued. Omeprazole was given in house,
but was replaced by PrevPAC (lansoprazole, clarithromycin,
amoxicillin) on discharge for continued treatment of known H.
pylori. | 134 | 175 |
11539573-DS-17 | 24,101,580 | You were admitted because of a seizure caused by not taking your
anti-seizure medication. It is important that you take this
medication. You have a wonderful support staff to help you at
home; please continue to work with them on your housing issues
and medication usage. | TRANSITIONAL ISSUES:
- given new seizure activity, very important to impress upon
patient the need for antiepileptic; decreased valproate to
1000mg EC daily, as there is less risk of seizure if med is
withdrawn
- continue supportive care of patient living in community,
though may ultimately prove unable to tolerate independent
living; continue to assess
#Seizure: Hx of seizure disorder and a question of etoh
withdrawal seizures, though pt does not appear to be drinking at
present. BCA of 0 at CHA. Valproic acid level of 0; further
history gathering reveals that pt had stopped allowing med
administration so the Rx was DC'd. In ED pt was loaded with
valproic acid as well as phenobarb. CIWA were unremarkable on
floor, no clinical signs of withdrawal. No seizure activity.
Neuro on, rec 1000mg Valproic acid EC on DC.
#Schizoaffective d/o
#outbursts: Patient requiring security in ED and restraints,
then had multiple code purples on the floor. Pt with very labile
mood, going from calm to combative and physically
confrontational without clear provocation. Security sitter was
DC'd after first day on ___ floor and patient quickly had a code
purple, threatening nurses. At times requiring IM olanzapine
10mg and sometimes being easily redirectable with offering of a
drink or snack. Extensive coordation with outpatient team at
___, which is very involved. Contact there was ___,
___. See separate documentation from ___ attending
note ___ and SW ___ for further details on patients
current outpatient situation. On day of DC, safe discharge
planned with ___ team for patient to be seen at home upon ___.
Patient sent in chair car accompanied by clinical psychiatrist
to ensure pt calm through return home.
>30 minutes spent on planning on day of discharge including
talking to outpatient team and multiples trips into room to talk
to patient regarding DC | 46 | 300 |
14462563-DS-19 | 27,768,343 | Dear Mr. ___,
You were seen at ___ for
several issues:
- Weakness
- Bacteria in your blood caused by infection of an area of skin
and bones in your foot
- High blood sugars
- Poor blood flow in your left leg
Here is what we did about each problem:
We found that you had an infection in your blood, which we are
treating with IV antibiotics. You had a PICC line placed so that
you can get these IV medications at home and do not need to stay
in a hospital. This infection most likely came from your right
foot, which had a wound that may have infected your bone. You
saw a podiatrist (foot doctor) and infectious disease specialist
to help guide your primary team. You had a surgery to remove
infected bone. You should follow up in clinic with podiatry and
with infectious disease.
We think this infection is partially causing your weakness. We
checked an MRI of your spine and brain, which did not show any
concerning infection or abnormality. You saw a neurology
specialist, who felt that some of your weakness may be due to
your diabetes and the effect that this can have on your muscle.
They would like to see you in clinic in 1 month to evaluate for
any further muscle weakness. First, you will do a test called an
EMG that will help guide them in their evaluation. The
appointment for this is already arranged.
You also had very high blood sugars when you came in, and this
is why you were sent to the ICU. These were controlled, and you
were seen by our diabetes experts who helped to manage your
insulin while you were in the hospital.
Lastly, we did a study to look at your arteries. This showed
that your left leg arteries do not carry blood as well as they
should. This is called "Arterial insufficiency" and it happens
with peripheral vascular disease. We started you on aspirin for
this. We also arranged a follow-up appointment with our vascular
surgery colleagues. They can discuss the severity of your
arterial insufficiency and discuss management options with you.
Finally, our kidney transplant team also evaluated you and your
kidney transplant looks good.
You were also seen by our physical therapists, who worked with
you while you were in the hospital.
It was a pleasure taking care of you at ___
___. Please take all of your medications as
prescribed. Please follow up with the appointments we have
arranged for you.
Sincerely,
Your ___ Care Team | ___ with h/o IDDM, HTN, ESRD s/p transplant with subsequent CKD,
AF on Coumadin, presenting with R sided weakness and fatigue.
Patient found to have hyperglycemia without ketones concerning
for hyperosmolar hyperglycemic syndrome with infectious source
as precipitant, found to have MSSA bacetermia due to right toe
osteomyelitis.
#Right toe osteomyelitis with MSSA Bacteremia. MRI of the spine,
MRI/MRA brain negative for intracranial or epidural abscess.
Urine cultures negative, CXR negative. TTE showed no vegetations
or valvular disease but was followed with TEE, which was also
negative. Patient was started on vancomycin and cefepime
empirically ___ then narrowed to nafcillin from ___
once speciation returned. Changed to cefazolin on ___ given
transaminitis. Patient had PICC placed ___ for completion of
antibiotic therapy. Course of therapy will be ___ weeks pending
final cultures from debridement (see below). Patient will follow
up with ___ clinic for total course of antibiotics. Of note,
patient's MRI spine showed disciitis, which may affect
antibiotic course. Patient had stage 2 ulcer in quarter diameter
with minimal purulent drainage. Patient evaluated by podiatry
and initially given minimal drainage was not felt to be
concerning for osteomyelitis. Initial XR of foot showing no
osteomyelitis of the first metatarsal. However, given some
concern for osteomyelitis, MRI was pursued, which showed
osteomyelitis of the distal portion of the second toe proximal
phalanx. Patient went to the OR on ___ for amputation of the
second toe and debridement by podiatry. ID was consulted and
guided antibiotic therapy and course. As above, patient will
follow up with ___ clinic.
# Diabetic Amyotrophy: etiology of generalized weakness most
likely due to diabetic amytrophy per neuro consult given history
of other complications of diabetes, including neuropathy,
retinopathy, and ESRD. MRI spine and MRI/MRA of head negative
for any intracranial or epidural or spinal cord process. CRP and
ESR were elevated, but this was in the setting of infection. TSH
was normal as was HIV. Neurology was consulted given his
weakness, and felt it was due to diabetic amyotrophy. He will
follow up in clinic with neurology and have EMG studies prior to
office visit. Patient was also seen by physical therapy.
#Hyperosmolar hyperglycemia syndrome: upon initial presentation,
patient noted to be hyperglycemic to >500 with an acidosis
although no ketonuria. He was initially admitted to the MICU for
insulin drip management of his HHS. He was weaned down to SQ
insulin and transferred to the floor. He was followed by ___
who managed his insulin dosing.
#Peripheral arterial disease: ABIs showing left lower extremity
arterial insufficiency with ___ of 0.83. As such, patient was
started on aspirin 81 mg with plan for possible plavix and/or
discussion of bypass options as an outpatient. He was set up for
a vascular surgery appointment after discharge.
#Acute renal failure on CKD s/p renal transplant: Cr 3.1 on
admission from bl 2.5-2.9 from At___ records. This was felt to
be due to an osmolar diuresis in setting of HHS, and his
creatinine improved to baseline by the time of discharge with
light IVF hydration transitioning to po intake. He remained on
his home tacrolimus with trough goals of ___, continued
prednisone 5 mg daily and bactrim PCP ___. MMF was held
given concern for sepsis initially but was resumed during his
hospital course.
# Afib: (___-3) Continued home metoprolol and diltiazem. His
coumadin was held initially due to concern for epidural abscess
but then restarted after negative MRI.
#HLD: Continued home statin | 417 | 574 |
15057889-DS-20 | 22,093,410 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of shortness of breath
WHAT HAPPENED IN THE HOSPITAL?
==============================
- When you were first admitted, you had a lot of extra fluid in
your body, so we gave you medications to help you urinate more
to pull the fluid out of your lungs
- An ultrasound of your heart showed a significant amount of
backward flow at the mitral valve, next to where your last clip
was placed.
- You were taken to the procedure room for placement of another
clip.
- You tolerated the procedure well and your mitral valve
function was noted to be significantly improved after the clip
was placed.
- You were evaluated by the physical therapists who recommend
that you go to a rehab facility to work on your strength
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You should continue taking your medications as prescribed.
- You should attend the appointments listed below.
- Your weight at discharge is 151lbs. Please weigh yourself
today at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ___ with hx HFpEF, MR ___ mitral clip, COPD, HTN, HLD, PVD who
was transferred to ___ from ___ after being found to
have
a heart failure exacerbation and severe MR, now ___ second
mitral clip and aggressive diuresis.
#Acute on chronic HFpEF:
Given history of mitral clip placement in ___ with
interval worsening of mitral regurgitation on TTE in ___, there was a high level of concern that the patient's acute
heart failure and resulting pulmonary edema were due to acute
worsening of his MR. ___ was diuresed initially with Lasix
boluses, but did not respond well, so was eventually started on
a continuous infusion. This was later stopped due to rising
creatinine, resulting in an acute kidney injury. A repeat TTE
this hospital stay confirmed worsening of his MR with severe
flail noted at the A3/P3 leaflets, resulting in severe MR. ___
patient was evaluated by the structural heart team who felt ___
was likely to benefit from another mitral clip. The procedure
was performed on ___ and ___ tolerated the procedure well.
Intraoperative pressure tracings indicated significant
improvement in the severity of the MR immediately after the clip
was placed, as did intraoperative TEE. After the procedure, the
patient was noted to have a quieter murmur. After clipping, his
creatinine came back down to baseline, likely related to his
increased cardiac output, and ___ was once again able to tolerate
diuresis. His home torsemide was restarted but at a higher dose
of 20mg daily. His peripheral edema improved significantly and
___ was titrated off supplemental O2 prior to discharge.
Physical therapy was consulted and recommended discharge to a
rehab facility.
#Altered mental status, resolved:
While hospitalized, the patient had one episode of nighttime
altered mental status. At the time, ___ exhibited no focal
neurologic symptoms. Given his decreased renal function at
baseline with an acute worsening, his gabapentin dosing was
decreased to 300mg twice daily. It was felt that this episode
was most likely delirium either related to polypharmacy or being
in the hospital. ___ had no recurrence of his AMS.
#Chronic kidney disease:
Baseline creatinine appears to be between 2.3 and 2.7. During
aggressive diuresis, the creatinine rose to a peak of 3.4, but
then improved and came back to baseline with a diuretic holiday
and placement of the mitral clip, which likely led to
significant improvement in cardiac output and renal perfusion.
The patient was not started on an ACE inhibitor while
hospitalized, but this can be readdressed as an outpatient.
Discharge Cr 3.2.
#Constipation
While hospitalized, the patient reported that ___ felt
constipated despite having many bowel movements per day. ___
stated that although ___ was having many bowel movements, they
were small, and ___ was constipated. ___ was given a bowel
regimen consisting of Colace, senna, and Miralax PRN, reduced at
discharge. ___ was also given standing psyllium.
TRANSITIONAL ISSUES:
===================
[]Recheck Cr ___ prior to dosing torsemide and hold if climbing
from discharge of 3.2 (baseline appears to be 2.5 to 2.7) as pt
appears dry on day of discharge
[]careful monitoring of volume status and adjustment of diuretic
with goal net even daily (stool output also a factor as pt
requesting increase bowel regimen despite multiple stools daily)
[]Daily weight: discharge wt 67.7kg | 248 | 556 |
18754359-DS-30 | 26,661,169 | Mr. ___,
You were admitted to the hospital with dizziness, which was felt
to be due to dehydration related to a urinary tract infection.
We gave you antibiotics and fluids and your condition improved
MEDICATION CHANGES
Please START cipro 500mg twice daily for five additional days
Please HOLD bowel medications until stools are no longer loose,
then restart colace and miralax PRN | ___ y/o F with hx of Bipolar Affective Disorder, DM, HTN, HCL who
presents with dizziness and found to have a UTI
.
# UTI
Urinalysis was consistent with a UTI, and cultures grew E. coli.
Started on cipro in the ED, which required renal adjustment. She
was discharged on a 7 day course of cipro 500mg BID. Longer
course of treatment due to diabetes.
.
# Acute on Chronic Kidney Injury
Creatinine elevated to 2.4 on admission, felt to be related to
dehydration from UTI. She was given 3L of IV fluids in the ED
with resolution of hypotension. Creatinine improved to 1.9
(baseline ~1.7) the following day and remained stable.
.
# Diarrhea
Had incontinence of stool initially. C. diff toxin was sent and
was negative. This may have been related to an increased amount
of bowel medications. These were stopped, and should be
continued as an outpatient only when she is constipated.
.
# DM
Last 8.8% on ___. Rechecked and found to be 7.6%. Continued
lantus and ISS. Glyburide was a listed medication, but this had
been stopped a while ago due to kidney function.
.
# HCL: Continue home Zocor 20 mg QHS
.
# HTN:
Amlodipine continued. Losartan was held in the setting of acute
kidney injury, then restarted the day prior to discharge. Blood
pressure was high in th 160s while off losartan. Continued as
outpatient. Blood pressure in the 130s on discharge.
.
# GERD: continued Prilosec 20 mg QHS
.
# Bipolar Affective Disorder: continued perphenazine 32mg qHS.
She has not been on Giodon for a while per ___. | 59 | 267 |
19444470-DS-18 | 20,469,934 | You were admitted with pancreatitis after ERCP done for a
biliary leak after your recent cholecystectomy, as we discussed
at length with you and your wife ___. | This is a ___ y/o man with a history of HTN and HCL who on the
day prior to ___, developed ruq abdominal pain, chills,
nausea, and severe malaise. He was brought to ___
by his wife ___, where he was found to have gangrenous
cholecystitis. He underwent an open cholecystectomy by Dr.
___ there on ___. The surgery was complicated,
and Dr. ___ reported that he could not remove the entire GB
- to do so and expose the field, he would have had to remove his
rt. colon and place a colostomy. He removed what he could,
leaving part of the infendibulum and placing a JP drain in the
fossa for expected bilary leak. Pt. was sent home, and elective
ERCP for stenting for leak planned here at ___ on ___. This
done and pt. sent home. Unfortunately, pt. immediately
developed pain, and was sent back to the ___ and admitted for
post-ercp pancreatitis.
.
JP drain output was noted to be very high, however (565 cc on
day of admission and 300 cc the following day) concerning for
continued leak and possible biloma. Pt. also had marked
leukocytosis. I consulted surgery here as well as (re)
consulting ERCP team to re-evaluate. Pt. underwent another
CTAP. Fortunately, his CT revealed only expected post surgical
findings as well as evidence of known pancreatitis. Surgery and
ERCP did not recommend further intervention at that time. Pt.
was placed emperically on unasyn IV while the above being
answered, then transitioned to oral augmentin both for ? mild
ongoing leak and leukocytosis and pain as well as lt UE
superficial thrombophlebitis (see below) which subsequently
developed. A bile drain culture was obtained, however, this
appears to be contaminated and largely uninterpretable.
.
Pts drain output slowly improved (down to 30 cc morning of
___. Given this, the biliary stent is believed to be
working, and the leak improving. The patient was discharged with
a plan to follow-up with his surgery 2 days post-discharge.
.
Pt. incidentally developed a small area of induration and
erythema and pain at the lt upper arm/biceps at a site of
attempted phlebotomy, consistent with a superficial
thromboplebitis. This was improving with hot packs and
continuation of oral augmentin as of ___. | 27 | 387 |
13152426-DS-19 | 29,240,458 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital for confusion. You were found
to be sick from a urinary tract infection. You were given
antibiotics and your symptoms improved. You were seen by
physical therapy who recommended rehab. We wish you the best | The patient is a ___ year-old woman with a history of
schizophrenia, parkinsonism, h/o frequent UTI assoc. w/ AMS who
presents w/ lethargy and AMS, found to be in SIRS with grossly
dirty UA. | 57 | 36 |
19877618-DS-4 | 20,429,194 | Dear Dr. ___,
___ was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for evaluation of fevers, nausea, vomiting, and rapid
heart rate following screening colonoscopy. Given that your
symptoms developed soon after colonoscopy, it is likely that
they were due to movement of bacteria out of the gut in the
setting of the procedure. There was no evidence of new infection
on CT scan. Your symptoms improved with antibiotics, intravenous
fluids, and initial bowel rest, and your were tolerating an oral
diet by the time of discharge, though you continued to
experience fevers.
In discussion with your gastroenterologist Dr. ___ are
now discharged on a broad-spectrum oral antibiotic regimen,
including ciprofloxacin, Bactrim, and metronidazole (Flagyl),
which you should continue for 10 days unless directed otherwise
by your Dr. ___ please be in touch with Dr. ___
(___) within the week to confirm the duration of your
broad-spectrum antibiotic course, after which point you likely
will return to your typical regimen of levofloxacin and Bactrim
alternating with metronidazole.
In addition, your kidney function was found to be decreased
slightly from baseline, likely reflecting fluid losses from
colonoscopy preparation and vomiting.
It is important that you follow up with primary care doctor and
gastroenterologist to ensure continued resolution of your
symptoms. Please return to the emergency department in the event
of worsening or unimproving symptoms in the interim. | Dr. ___ is a ___ with history of ileocolonic/perianal Crohn's
disease complicated by left upper ischiorectal fossa abscess in
___, right gluteal abscess in ___, and persistent perianal
fistula status post multiple intestinal resections last in ___
who presented with nausea/vomiting, rigors, and fever following
routine colonoscopy on the day of admission. | 234 | 53 |
16257001-DS-21 | 29,976,391 | Dear Mr. ___,
You were admitted after experiencing bleeding in your brain due
to rupture of a blood vessel. You underwent a procedure to close
the blood vessel using a coil of wire, you will need to take
aspirin 325mg daily following this procedure.
We placed a tube in your brain to drain excess fluid that had
built up as a result of inflammation and bleeding. The tube
became infected and you were treated with antibiotics. You
suffered a gastrointestinal bleed related to an ulcer in the
small intestine. The ulcer was clipped to stop bleeding and you
were given blood to replace the losses.
Lastly, you were treated for injury to your kidneys, an excess
of fluid, and a lung infection that led to difficulty breathing.
You were discharged to a skilled nursing facility for further
rehabilitation after your recent injury.
Please follow up with your neurosurgeon, Dr. ___, in 4 weeks
for further evaluation and management of your recent
subarachnoid hemorrhage. You will need to undergo an MRI/MRA
___ protocol prior to your visit.
MEDICATION CHANGES
START ACETAMINOPHEN 650 MG PO Q6H PRN PAIN/FEVER
START ASPIRIN 325 MG PO/NG DAILY
START LABETALOL 300 mg PO BID
START AMLODIPINE 5 MG PO BID
START SARNA LOTION 1 APPL TP TID PRN PRURITIC RASH
START PANTOPRAZOLE 40 MG PO DAILY
STOP ATENOLOL 50 MG PO DAILY
Angiogram with Embolization and/or Stent placement
Medications:
**Take Aspirin 325mg (enteric coated) once daily. | Mr. ___ is a ___ year old male with a history of hypertension
who was treated for a subarachnoid hemorrhage with coiling of a
right ___ aneurysm and placement of an external ventricular
drain. He developed a Staph epidermidis infection of the drain,
for which he was treated with IV vancomycin and removal of the
drain. He had a precipitous drop in hematocrit due to a bleeding
duodenal ulcer that was treated with an ulcer clipping, blood
transfusions, pantoprazole, and sucralfate. Due to hypotension,
initiation of lisinopril, and supra-therapeutic levels of
vancomycin, he developed acute kidney injury/acute tubular
necrosis, which improved over the course of his stay. He then
developed hypoxemia, from a combination of fluid overload in the
setting of acute kidney injury and pneumonia. He was treated
with careful fluid management and vancomycin and cefepime with
resolution in his hypoxemia. His course was notable for a waxing
and waning level of consciousness, related to injury sustained
during his subarachnoid hemorrhage. He was discharged to a
skilled nursing facility for further rehabilitation.
# Subarachnoid hemorrhage: Head CT imaging revealed a diffuse,
extensive subarachnoid hemorrhage along with hydrocephalus.
Further imaging revealed a right posterior inferior cerebellar
artery aneurysm, that was treated with coiling. An external
ventricular drain was placed to decreased intraventricular
pressure. Repeat head CT imaging after drain removal did not
reveal progression of his hydrocephalus or significant continued
bleeding. While hospitalized, the patient's mental status waxed
and waned, with periods of increased alertness and orientation
and periods of somnolence, related to injuries sustained from
his subarachnoid hemorrhage. Concurrent medical complications
detailed below also contributed to his wavering mental status.
# Pneumonia: After the patient developed low grade fevers and
new hypoxemia, chest x-ray revealed right lung opacities
consistent with an aspiration pneumonia. The patient was treated
with vancomycin and cefepime for 8 days out of concern for a
hospital-acquired pneumonia. The patient was afebrile after
treatment and was weaned off of supplemental oxygen.
# Acute kidney injury with acute tubular necrosis: This was due
to hypotension, lisinopril, and supra-therapeutic levels of
vancomycin. The patient was treated with careful fluid
management, including Lasix diuresis, and discontinuation of
lisinopril and additional vancomycin. His creatinine peaked at
4.5 (baseline 0.5), before trending downwards to 2.8 at
discharge. Creatinine and electrolytes should be checked every 7
days to ensure continued improvment.
# Drug rash: The patient developed a macular, erythematous rash
on his trunk and bilateral lower extremities from cefepime while
hospitalized. There was no evidence of mucosal involvment, no
lesions on the palms or soles. He was treated with Sarna lotion
and Benadryl. The rash remained on the day of dishcarge.
# Gastrointestinal bleed: The patient experienced an acute drop
in hematocrit to 20.5 with black, tarry stools while
hospitalized. He was treated with blood transfusions. An upper
endoscopy revealed 2 duodenal ulcers, of which 1 bleeding ulcer
was clipped. He was further treated with pantoprazole and
sucralfate. His morning gastrin level, sent for further
evaluation of duodenal ulcers, was pending at discharge.
# EVD infection: The patient developed a Staph epidermidis
infection of his external ventricular drain. He was treated with
intravenous vancomycin and removal of his drain, with resolution
of his fevers.
# Dysphagia: After evaluation by the hospital speech and swallow
team, the patient was made NPO due to his aspiration risk. A PEG
tube was placed, through which the patient received nutrition. A
follow up evaluation later in the ___ hospital course
placed him at lower aspiration risk, permitting the patient's
transition to ground solids and thin liquids by mouth with
cycled tube feeds through his PEG at discharge.
# Sinus tachycardia: The patient's heart rate ranged from the
___ to 110s. Electrocardiograms and echocardiography did not
reveal a cause. He was without pain or anxiety. Hematocrit had
trended down following gastrointestinal bleedinig and he was
again transfused 2 units PRBc however there was no change in
tachycardia. He did not appear hypovolemic. Bilateral lower
extremity ultrasound was negative for DVT and echocardiography
did not show evidence of right ventricular strain (suggesting
against a hemodynamically significant pulmonary embolism). Sinus
tachycardia was attributed to his recent brain injury. The
patient received metoprolol, which was later changed to
labetalol for additional treatment of hypertension. On the day
of discharge, heart rate remained in the range of 80-110.
# Hypertension: The patient's systolic blood pressures were
often above 160, while his diastolic blood pressure ranged from
the ___ to 110s. The patient was treated with metoprolol
initially, which was later changed to labetalol and amlodipine.
On the day of discharge, patient was hypotensive with physical
therapy and amoldipine downtitrated from 10mg daily to 5mg
daily. As renal failure resolves, he will require further
titration of amlodipine and labetalol to maintain SBP <160.
TRANSITIONAL ISSUES
===================
- Mr. ___ will need to follow up with his neurosurgeon, Dr.
___, in 4 weeks. He will require an MRI/MRA with the ___
protocol prior to his appointment. An appointment is currently
being made.
- The patient's creatinine has been downtrending since
developing acute renal failure. Please continue to trend his
serum creatinine and electrolytes with measurements
approximately every 7 days.
- The patient's goal systolic blood pressure is less than 160
mmHg. His amlodipine was decreased from 10 mg to 5 mg daily on
___. Please monitor his blood pressure, as further
titration of his labetalol and amlodipine may be required.
- The patient has a morning serum gastrin ordered as part of an
evaluation of duodenal ulcers and recent bleeding, the results
were pending at the time of discharge
- The patient is currently receiving tube feeds. As his need for
supplemental nutrition decreases, please consider slowing or
stopping his tube feeds. | 231 | 945 |
14860771-DS-7 | 20,833,168 | You were admitted because of symptoms of spasms and
lightheadedness. Because you have a prior diagnosis of multiple
sclerosis, we were concerned about a possible exacerbation of
this disease, we obtained an MRI of your brain that did not show
any new lesions. However, we did discover that you have a
urinary tract infection, and started you on a course of
antibiotics for this. We also increased your dose of baclofen to
help with your symptoms of spasticity.
We discussed your case with your outpatient neurologist, Dr.
___. You should follow up in her clinic. | Ms. ___ was admitted because of symptoms of spasms and
lightheadedness. Due to her prior diagnosis of multiple
sclerosis, we were concerned about a possible exacerbation of
this disease. Thus, we obtained an MRI brain to look for any
evidence of new lesions. The MRI did not show evidence of an MS
flare. However, we did discover that the patient had an urinary
tract infection. We started her on ceftriaxone IV for this and
transitioned to nitrofurantoin, for a total course of 1 week on
antibiotic therapy. In addition, we also increased her dose of
baclofen to help improve her symptoms of spasticity. During her
admission, we discussed her case with her outpatient
neurologist, Dr. ___. She will be following up with Dr. ___
in her clinic. | 94 | 128 |
18178553-DS-3 | 28,369,514 | Dear Ms. ___,
You were admitted to ___ for
low blood counts due to a bleed from an ulcer in your stomach.
For this, we've started you on medications to decrease the
stomach acid and help the lesion heal if it is just an ulcer. We
also gave you blood to keep your blood levels up.
We conducted blood tests and a CT scan of your abdomen to figure
out why you developed an ulcer. You do not have an infection,
but the CT scan was concerning for potential gastric cancer. You
desired to follow-up with a Surgical Oncologist to discuss the
risks/benefits of surgery and further treatment - your
appointment is scheduled for ___.
You should follow up with your doctors as ___ and continue
taking all of your medicaitons. | Ms. ___ is a ___ year old woman with a history of CVA on
plavix and recent GI bleed ___ bleeding ulcer) transferred
from ___ for anemia to Hct 17.
# ANEMIA: Patient was transfused 2u pRBCS with appropriate
response and underwent EGD that showed a large gastic antrum
ulcer ~30mm. H. pylori Ab testing negative, but CT abdomen had
findings conerning for gastric cancer ("thickening of gastric
antrum and enlarged lymph nodes"). During a family meeting on
___, the patient confirmed that she desires to be FULL
CODE, and desired surgical oncology follow-up to discuss
risks/benefits of surgery. ___ Surgical Oncology follow-up is
scheduled on ___.
# ACUTE KIDNEY INJURY: Patient with peak Cr 1.9 at OSH prior to
transfer. Cr improved to 1.0 with IV hydration suggestive of
prerenal azotemia. Her Cr transiently worsened to Cr 1.4 in the
setting of contrast CT. Cr at the time of discharge was 1.3.
# DELERIUM: Post-EGD, the patient developed waxing/waning
attention deficit consistent with delerium. This improved with
frequent reorientation. The patient was back to baseline mental
status at the time of discharge.
# CORONARY ARTERY DISEASE: The patient's Imdur and Metoprolol
were held in the setting of GI bleed. Atorvastatin was
continued without complications.
# H/O CVA: This is now the pt's second admission for GI bleed,
both requiring blood transfusions. The patient was started on
plavix three months ago for CVA. In light of the EGD findings of
a non-healing ulcer and two admissions for large GI bleeds, the
risks of Plavix outweight the benefits and we thus recommend
stopping Plavix.
# HYPERTENSION: Hold Imdur, metoprolol, and furosemide was held
in the setting of GI bleed. Amlodipine was continued without
complications.
# HYPOTHYROIDISM: Continued levothyroxine without complications.
****TRANSITIONAL ISSUES****
1. This is now the pt's second admission for GI bleed, both
requiring blood transfusions. The patient was started on plavix
three months ago for CVA. In light of the EGD findings of a
non-healing ulcer and two admissions for large GI bleeds, the
risks of Plavix outweight the benefits and we thus recommend
stopping Plavix.
2. Based on family disucssions and results of the CT scan: the
patient will have follow-up with ___ Surgical Oncology on
___ to discuss the risks/benefits of surgery.
3. Metoprolol, furosemide, and Imdur stopped in the setting of
GI bleed. Could consider restarting as outpatient if BP control
and volume control is needed.
4. The patient's CBC should be trended 2x/week with pRBC
transfusion for Hb<7 or hemodynamic instability. | 130 | 417 |
10414738-DS-9 | 26,922,052 | Discharge instructions with or without URETERAL STENT
PLACEMENT:
You have an indwelling ureteral stent that MUST be removed
and/or exchanged in the next few weeks time. Please follow-up as
advised.
You may experience some pain associated with spasm of your
ureter especially while there is an INDWELLING URETERAL STENT.
This is normal
-Resume all of your pre-admission/ home medications, unless
otherwise noted. Please avoid Aspirin unless otherwise advised.
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequency over the next month.
-You may have already passed your kidney stones OR they may
still be in the process of passing.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take IBUPROFEN as directed and take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower and bathe normally.
-Do not drive or drink alcohol while taking narcotics or operate
dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, severe abdominal pain,
or inability to urinate, call your doctor or go to the nearest
emergency room.
Call your urologists office for follow-up AND if you have any
questions. | Mr. ___ was admitted to Dr. ___ service
from the ED for overnight observation, pain control, and IV
fluids and IV antibiotics. He was monitored for fever, nausea
and vomiting and prepared for ureteral stent placement on
hospital day one. He underwent LEFT uretersopy and ureteral
stent placement. No concerning intra-operative events occurred;
please see dictated operative note for full details. The
patient received ___ antibiotic prophylaxis. At the
end of the procedure the patient was extubated and transported
to the PACU for further recovery before being transferred to the
floor. He was transferred from the PACU in stable condition to
the general surgical floor. On POD1 he had his Foley removed and
voided without difficulty. At discharge Mr. ___ had
pain that was well controlled with oral pain medications, he
was tolerating a regular diet and he was ambulating without
assistance and voiding without difficulty. He was given explicit
instructions to follow-up with Dr. ___ definitive stone
management and ureteral stent removal/exchange. | 280 | 169 |
14265172-DS-12 | 23,481,058 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
- You initially came to ___ with shortness of breath and
cough, you were found to have a blood clot in your lungs and
signs of a pneumonia
- You were intubated and placed on a ventilator in order to help
your breathing
- You were initially given antibiotics for a possible pneumonia
- You were determined to have a type of pneumonia caused by an
allergic reaction to your Taxol or Herceptin used to treat your
breast cancer
- You were started on steroids in order to help treat your
pneumonia
- You were also started on a blood thinner in order to treat
your blood clot
What should you do when you leave the hospital?
- Continue to take all your medications as prescribed. The
details for your prednisone taper are listed below.
- Please start taking your lovenox shots on ___. You will
start taking 5 mg of warfarin (5 tablets) on ___.
Please have your labs checked on ___. The results should be
faxed to Dr. ___ your primary care doctor.
- See information regarding your doctor ___ listed
below.
Sincerely,
Your ___ Care Team
PREDNISONE TAPER:
prednisone 50 mg (___), prednisone 40 mg (___),
prednisone 30 mg (___), prednisone 20 mg (___),
prednisone 10 mg (___) | Ms. ___ is a ___ year old female with history of breast CA
s/p surgery/radiation on adjuvant chemotherapy (C10 of Taxol,
Herceptin scheduled on ___, hypertension, hyperlipidemia,
depression, and anemia, who initially presented to ___
with one-week history of shortness of breath and cough, found to
be hypoxic with CTA remarkable for small right lower lobe
segmental PE and bilateral infiltrates, started empirically on
cefepime and Lovenox, was transferred to ___ MICU on ___
with acute hypoxemic respiratory failure requiring intubation,
underwent bronchoscopy with BAL notable for eosinophilic
pneumonia likely secondary to Taxol versus Herceptin, with
improved respiratory status after IV diuresis and steroids
subsequently extubated and treated on the medical floor.
# Eosinophilic pneumonia
# Acute hypoxic respiratory failure -
Patient initially presented one week of dyspnea and cough, found
on CTA at outside hospital to have a small right lower lobe
segmental PE in addition to bilateral interstitial infiltrates.
Was empirically started on cefepime and Lovenox. She was
transferred to ___. She subsequently had acute hypoxic
respiratory failure requiring intubation, underwent bronchoscopy
with BAL showing 35% eosinophils, suggestive of eosinophilic
pneumonia, which was thought to be the primary etiology of her
respiratory failure, although there ___ have had some
contribution from her small segmental PE. Per her outpatient
oncologist Dr. ___, eosinophilic pneumonia can be a
consequence of either Taxol versus Herceptin, the latter of
which she received more recently. She received 48 hours of
broad-spectrum antibiotics, which were subsequently
discontinued. Also received 3 days of IV methylprednisolone,
which was subsequently transitioned to p.o. prednisone 60 mg
daily followed by taper. Plan to continue prednisone 60 mg for 1
week (___), and to taper down 10 mg each week. She was
also intermittently diuresed with Lasix boluses. She was started
on calcium, vitamin D, and PCP prophylaxis with bactrim. Also on
H2 blocker. PFTs and chest CT were obtained prior to discharge.
Chest CT demonstrated improvement in infiltrates. Plan to
follow-up with pulmonary and repeat PFTs and chest CT in 6 weeks
to assess for interval resolution and infiltrates.
# Segmental PE -
Was noted to have small segmental right lower lobe PE on CTA
from ___ on ___. This was provoked in the setting of
malignancy. She was initially started on Lovenox 1 mg/kg BID and
as per conversation with outpatient oncologist and was then
transitioned to rivaroxaban. Unfortunately, rivaroxaban was not
covered by her insurance and apixaban was over $300.00 per
month. After discussion with her PCP and oncologist, we re
initiated lovenox 60 mg SUBQ BID to be bridged with warfarin.
She will continue lovenox and start warfarin 5 mg daily on
___. We have asked the patient to have labs checked-
CBC, CHEM 10, and INR on ___. This is important given
that her Cr was 1.3 upon discharge.
#Acute kidney injury -
Pt with baseline Cr < 1.0. Peak Cr of 1.4 on ___. Etiology
thought to be pre renal ___ diuresis. Cr downtrended to 1.3 on
day of discharge. This ___ have been exacerbated by initiation
of Bactrim for PCP ___.
# HTN
# Hypertensive urgency -
Patient has a history of hypertension, is maintained on
hydrochlorothiazide 25mg daily, losartan 50 mg daily, and
amlodipine 5 mg at home. On transfer to the general medicine
floor, patient was noted to have hypertensive urgency with BP
200/100. Amlodipine was increased to 10 mg daily, losartan was
increased to 75 mg daily, and she received intermittent
labetalol.
# Breast Cancer -
History of breast Ca s/p surgery/radiation on adjuvant
chemotherapy
(C10 of Taxol, Herceptin scheduled for ___. Per outpatient
oncologist Dr. ___, eosinophilic pneumonia is likely
related to Taxol versus Herceptin, the latter of which she
received most recently. Plan is to not continue with Taxol and
for outpatient referral for allergy for consideration of
possible Herceptin. Anastrozole was held while inpatient per
outpatient oncologist.
# Anemia -
Patient was observed to have acute hemoglobin drop 5.8 from 8.0
earlier in admission. She required 1 unit PRBC with appropriate
posttransfusion hemoglobin. There was no evidence of hemolysis
or obvious source of bleeding. Reticulocyte index of 0.8
suggested hyperproliferation. Can consider iron supplementation
in the outpatient setting..
# GERD - Endorsed symptoms of GERD, was started on ranitidine
150 mg PO BID
# Depression - Continued on home fluoxetine 20mg daily
# HLD - Continued home simvastatin 10mg QPM
TRANSITIONAL ISSUES
[ ] New/Changed/held Medications:
- Amlodipine 5 mg increased to 10 mg daily
- Losartan increased from 50 mg to 75 mg daily
- Started prednisone 60 mg daily x 1 week (through ___
followed by taper 10mg weekly
-- prednisone 50 mg (___), prednisone 40 mg (___),
prednisone 30 mg (___), prednisone 20 mg (___),
prednisone 10 mg (___)
- Started lovenox 60 mg subq BID
- Started warfarin 5 mg daily (to start on ___
- Started calcium carbonate 1000mg daily
- Started vitamin D 800 units daily
- Started bactrim SS 1 tab daily
- Anastrozole 1mg daily held at discharge
-PNEUMONITIS
[ ] Plan for repeat outpatient PFT and interval CT chest at
outpatient pulmonary follow-up. This appointment has been
scheduled.
[ ] Plan for outpatient allergy referral by outpatient
oncologist for consideration of additional herceptin
[ ] Please check finger sticks and monitor BG given steroid use
-PULMONARY EMBOLI
[ ] Started on lovenox and warfarin upon discharge
[ ] Plan for patient to have CBC, CHEM 10, INR on ___. Will
have results faxed to PCP and oncologist.
-___
[ ] Please evaluate renal function. Lovenox ___ need to be re
dosed based on renal function. Please consider decreasing
losartan is Cr remains elevated. Could switch from Bactrim to
atovaquone for PCP prophylaxis if renal function has not
normalized.
-OTHER
[ ] Consider up-titration and/or additional anti-hypertensive
medications as indicated by PCP
[ ] Consider Fe supplementation
# Communication:
Name of health care proxy: ___
Relationship: Sister
Phone number: ___
# Code: Full, confirmed | 218 | 955 |
11978595-DS-20 | 25,773,226 | You have undergone the following operation: POSTERIOR Lumbar and
Thoracic Decompression
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 brace. This brace is to be worn
for comfort 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
___ 2. 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: Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please inspect the incisions daily | Mr. ___ was first seen in the ___ ED on ___ with ___
weakness, worse on the left, and bilateral pain sensation loss
to T12 sensory level. In the ED he was evaluated by Ortho Spine
and his outside L-spine MRI was assess and showed no emergent
need for surgery, but would be follow with continued assessment
of the need for surgery. On ___ the Medicine and Spine teams
became concerned that his symptoms could not be explained by
L-spine disk disease and a Neurology consult was called in the
afternoon. CRP and ESR came back and were elevated but not
extremely high and along with MRI findings appeared to r/o
epidural abscess. On ___ a T-spine MRI was performed and
showed cord compression and myelomalacia at the level of T8-9,
T9-10 and T10-11. In the AM on ___ both Neurology and Spine
recommended surgery to relieve T-spine cord compression. A
C-spine MRI was performed which showed disc disease but no cord
compression. A decision was made to correct both the L-spine and
T-spine cord impingement and compression.
Mr. ___ underwent a successful T7-11 laminectomy in addition
to a L3-5 laminectomy. Post-operatively he was given pain
medication and antibiotics. His lower extremity strength
improved. He developed a post-operative ileus which slowly
resolved.
He was discharged on a regular diet and in good condition. He
will follow up with Dr. ___ in 10 days. | 368 | 236 |
17848638-DS-19 | 28,202,188 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with a small bowel obstruction. You were given IV fluids and
bowel rest. Your bowel function returned with this management.
Your diet was progressively advanced as tolerated. You are now
tolerating a regular diet, having bowel function, and ready to
be discharged to home 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. | Ms. ___ is a ___ yo F with a history of multiple abdominal
surgeries and small bowel obstructions who presented to the
emergency department on ___ with abdominal pain for ___
hours and no flatus. She had a CT scan concerning for a small
bowel obstruction with a transition point in the right middle
abdomen. She was admitted to the Acute Care Surgery Service for
further management.
On HD1 she was made NPO and given IV fluids. She remained
afebrile and hemodynamically stable with a white blood cell
count of 12.5.
On HD2 her abdominal pain was improved and she was started on a
clear liquid diet which she tolerated well.
On HD3 she had return of bowel function. Her diet was advanced
to regular which she tolerated well without abdominal pain,
nausea, or emesis. After tolerating a regular diet, she was
discharged to home.
The patient remained alert and oriented throughout this
hospitalization. Her baseline chronic pain was well controlled.
She remained stable from a cardiac and pulmonary standpoint. The
patient voided without problem. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
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. | 244 | 233 |
16233087-DS-18 | 22,806,688 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Mr. ___ was admitted on ___ with a one day history of
shortness of breath, hypervolemia on exam, elevated BNP
consistent with congestive heart failure exacerbation, likely
secondary to severe mitral regurgitation. He was given IV Lasix
with improvement in his symptoms. He underwent routine
preoperative testing and evaluation. Coumadin was discontinued
in preparation for surgery and he was started on a Heparin
bridge. He was taken to the operating room on ___ and
underwent an attempted mitral valve repair with a 30 mm Physio
II ring and then a subsequent mitral valve replacement with a
___ tissue valve. Please see operative note for full
details. He tolerated the procedure well and was transferred to
the CVICU in stable condition for recovery and invasive
monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 2 due to hemodynamic instability with vent
weaning on POD 1. He was slowly weaned from inotropic and
vasopressor support. Beta blocker was initiated and he was
diuresed toward his preoperative weight. He remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. On postop day 4 he he developed
acute onset of paresthesias and pain of the left lower
extremity. These neurologic changes actually resolved on a
short course of intravenous heparin. Lower extremity ultrasound
was consistent with a cardiac embolus lodged at the femoral
bifurcation. On ___ he underwent a left lower extremity
embolectomy via groin incision. He was restarted on Heparin and
Coumadin for thrombus and chronic atrial fibrillation (goal INR
2.5-3.5 given clot/Afib/tiss MVR). Rehab is being asked continue
IV heparin until INR 2 or >. Goal PTT for IV heparin is 50-70
given recent hematuria. Post op course also complicated by
acute kidney injury. Peak creatinine 2.9 on ___. Creatinine
had decreased to likely new baseline of 2.0 at the time of
discharge. Rehab is being asked to repeat BMP on ___,
___ to trend creatinine level. His preop lasix dose has been
increased from 20mg daily to 40mg BID x 2 weeks, then decrease
to 40mg daily continuous. His left groin staples are intact and
should be removed in 3 weeks. If he leaves rehab before this
time, they can be removed at cardiac surgery office visit. He
does not need vascular surgery office follow up visit. He was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 9, he was
ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. He was discharged to ___
___ in good condition with appropriate follow
up instructions. | 101 | 445 |
15883038-DS-21 | 26,158,509 | Ms. ___,
You were admitted to the ___
for management of your peripheral vascular disease. You
underwent an amputation of your left leg during your stay. You
tolerated this procedure well and are ready to be discharged to
rehab to continue your recovery. Please see the following
instructions regarding your discharge.
WHAT TO EXPECT:
1. It is normal to feel tired. This might last for ___ weeks.
You should get up out of bed every day and gradually increase
your activity each day. Remember that many patients who undergo
amputation fall once they get home. Be very careful when
standing, transferring from one position to another or walking!
Increase your activities as you can tolerate. Do not do too
much right away!
2. It is normal to have some swelling surrounding the incision.
Elevate your leg above the level of your heart every ___ hours
throughout the day. Avoid prolonged periods of standing or
sitting without your legs elevated. You should wear an ACE
bandage over your bandage. It is very important that you
practice your range of motion exercises on your left knee.
3. It is normal to have a decreased appetite. Your appetite
should return with time. You might lose your taste for food and
lose some weight. Eat small, frequent meals. It is important
to eat nutritious food options (high fiber, lean meats,
vegetables/fruits, low fat, low cholesterol) to maintain your
strength and assist in wound healing.
To avoid constipation, eat a high fiber diet and use stool
softener while taking pain medication.
MEDICATION:
Follow your discharge medication instructions below. These have
been carefully reviewed by your providers.
You can use Tylenol ___ every 8 hours. Be aware that there
are some over-the-counter and prescription medications that
contain Tylenol (also known as Acetaminophen). Be sure never to
consume more than 3000mg of Tylenol(Acetaminophen) in one day.
You have been taking a prescription pain killer called
oxycodone. Continue to use narcotic pain medication sparingly.
You should require smaller amounts and doses less often as time
goes on. NEVER DRIVE OR OPERATE MACHINERY WHILE ON NARCOTIC
PAIN MEDICATION. If you are taking narcotics, keep in mind that
you may become constipated. You can take over-the-counter stool
softeners or laxatives to prevent or treat this.
ACTIVITIES:
No driving until post-op visit and you are no longer taking pain
medications.
Do not bear weight on your stump or lean on your stump.
You may shower. Do not directly spray the incision. Let the
soapy water run over incision, rinse and pat dry.
CALL THE OFFICE at ___ FOR:
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Any questions or concerns
Good Luck | Ms. ___ was admitted to the Vascular Surgery Service at the
___ after evaluation of her left toe gangrene. On prior
arteriography, she was noted to have substantial peripheral
arterial occlusive disease with no meaningful opportunities to
improve her circulation. Her home Warfarin was held and she was
started on a Heparin Drip. Shortly after admission, she
underwent non-invasive US studies which confirmed our prior
plans for amputation. After obtaining consent and discussing the
situation with the patient and her family, she underwent an
uncomplicated Left Below-Knee Amputation on ___. For
further information on this procedure, please refer to the
operative note in the OMR.
After an uneventful stay in the PACU, the patient was
transferred to the floor where she remained for the duration of
her stay. While on the floor, her pain was well controlled and
we started her on a Heparin bridge to her home Coumadin. She was
noted to have a mild ___ and ___ in her Creatinine
post-operatively to 1.3, which trended back to her baseline of
0.8 prior to her departure. For her first 3 post-operative days,
Ms. ___ was noted to be less active than prior, while she was
still A&O x4. On ___, she was noted to have some difficulty
with word finding during morning rounds and she was send for a
NCHCT, which was negative for acute intracranial processes. She
also experienced substantial nausea and had multiple bouts of
non-bilious emesis prompting a KUB which demonstrated dilated
loops of small bowel consistent with an early SBO. However,
after being given an aggressive bowel regimen, she passed a
large BM and her symptoms improved substantially.
Of note, Ms. ___ was started on Metoprolol ER 25 mg daily during
her last admission in ___. Throughout her admission, she
had multiple episodes of AFib with RVR which responded well to
increasing doses of PO Metoprolol. She remained hemodynamically
appropriate otherwise throughout her stay and was discharged on
Metoprolol 50 PO QID for rate control per cardiology
recommendations.
Prior to her discharge, she was tolerating a regular diet,
having bowel movements and voiding without difficulty. She was
sent to rehab with the appropriate instructions and discharge
appointments. | 498 | 361 |
17654074-DS-24 | 28,653,262 | Dear Ms. ___,
You were admitted to ___ due to your symptoms of infection and
low blood and platelet counts. This was most likely due to a
viral illness that you have now mostly recovered from, as you
are feeling much better. On an ultrasound we noticed a small
lesion on your liver that hadn't been seen previously. You will
get an MRI of your liver as an outpatient and will follow up
with your liver doctor about this.
The MRI has been scheduled for ___ at 8:15pm. Please arrive
at 7:30pm on ___ ___ floor radiology at ___
in ___ (same building as Dr. ___. You will need
to not eat or drink for 4 hours beforehand. Dr. ___ will
discuss these results with you either by phone, letter or at
your next clinic appointment.
It was a pleasure taking care of you!
Your ___ Liver Team | Ms. ___ is a ___ with history of alcoholic cirrhosis
complicated by ascites and portal hypertension who presented
with fever which quickly resolved, and was found to have anemia
and thrombocytopenia concerning for viral infection. Labs not
c/w hemolytic anemia. She was found to be flu negative, blood
cultures and urine cultures pending. Only a small amount of
ascites seen on RUQ U/S, though a hyperechoic liver lesion found
that will be worked up as an outpatient.
ACTIVE
=====
#Fever:
Patient reported fevers with associated rhinorrhea, cough,
vomiting, and body aches. Her rapid flu was negative and CXR was
without evidence of pneumonia. Her UAs were repeatedly
contaminated and only a small amount of ascites with a patent
portal vein was seen on U/S and patient without abdominal pain.
She had no leukocytosis and was afebrile in the ED, where she
quickly improved and was asymptomatic on admission to the floor.
Her symptoms and infection time course were most consistent with
an acute viral illness and the patient never received
antibiotics. Blood and urine cultures were pending on patient's
discharge.
#Anemia/Thrombocytopenia:
The patient had previous macrocytic anemia with a baseline Hb of
___ and presented with normocytic anemia with Hb of 8.3.
Additionally, the patient has new onset thrombocytopenia with
normal-high previous platelets (despite cirrhosis) of 421 in
___ now with platelets of 85. There was no significant
splenomegaly on U/S to suggest splenic sequestration and no
evidence of portal vein thrombosis on doppler. Hemolysis labs
were wnl, smear and diff were wnl, negative guaiac stools, and
no new medications since previous admission. Presentation most
consistent with suppression from viral illness.
#Rt lobe liver nodule:
The patient had a new finding on RUQ U/S not seen on previous
Ultrasounds most recent on ___, hyperechoic lesion read as
consistent with hemangioma but also concerning for
hepatocellular carcinoma in a cirrhotic patient. Radiology
recommended triphasic CT vs MRI Liver to further evaluate.
Chronic
=====
#Cirrhosis: Due to alcohol. Childs class B. MELD 9. Previously
complicated by hepatic encephalopathy, ascites, portal
hypertensive gastropathy. We continued lactulose 30mL QID,
lasix 20mg PO daily, spironolactone 50mg PO daily
#History of Alcohol Abuse:
No current signs of withdrawal. Last drink ___ per
patient. continued daily folic acid, thiamine, multivitamin
# GERD. Continued omeprazole 40 mg PO BID
****TRANSITIONAL ISSUES****
-New hyperechoic Rt liver lesion seen on RUQ U/S, possibly c/w
hemangioma, will need MRI Abdomen, being performed ___.
Pending prior authorization at time of discharge.
-Patient needs repeat CBC at next clinic appointment to ensure
recovery from her anemia/thrombocytopenia
-Pt not currently on iron, appears to be iron deficient, may
benefit from PO Iron
-Pt's first Urine Culture grew staph aureus after she was
discharged, original report in error stated GNR, pt ordered
Cipro 500mg BID x3d. Will f/u BCx results and second UCx and
contact patient if any changes in plan are needed
# CODE Status: Full Code Confirmed
# CONTACT: Mother, ___ ___ Father, ___
(___) | 147 | 503 |
16925477-DS-20 | 24,113,491 | Dear Ms. ___,
It was a pleasure being involved in your care.
Why was I admitted to the hospital:
===================================
- You had an infection in the skin of the right arm, known as
cellulitis.
What happened in the hospital:
==============================
- You were evaluated by several specialists who determined that
you did not have an infection in your elbow joint.
- You were given IV antibiotics.
What you should do when you leave the hospital:
===============================================
- Take all of your medications as described below. Take your
antibiotics until ___ (14 days total).
- Attend all of your follow-up appointments.
We wish you the best!
Your ___ Team | Ms. ___ is a ___ year old woman with a history of aortic
stenosis s/p mechanical AVR, prothrombin gene mutation,
recurrent DVTs on Coumadin, ESRD s/p renal transplant,
pancreatic transplantation in ___ and repeat in ___ on
immunosuppression, DM 1, HTN, CAD s/p CABG and AVR in ___ and
LCx PCI in ___, COPD who presents with right arm erythema and
pain found to have
cellulitis with an elevated INR and ___.
ACUTE/ACTIVE PROBLEMS:
======================
# Right upper extremity cellulitis
She presented with 5 days of worsening redness, swelling, and
elbow pain with pain on range of motion. X-rays were negative
for effusion at ___ on ___ but x-rays at ___ on ___
show evidence of effusion raising the concern for a septic joint
effusion in the setting of inadequately treated infection with
an ESR at ___ of 120. S/p two days of PO Keflex and two
doses of doxycylcine without improvement. She presented to ___
where she was evaluated by orthopedic surgery who felt that her
presentation was not concerning for septic arthritis. ID agreed
that her presentation was consistent with cellulitis. She was
given IV vancomycin with great improvement and discharged on PO
cephalexin and doxycycline to complete a 14 day course on ___.
# ___ on CKD
# H/O of ESRD ___ DM2
# s/p renal and pancreas transplant:
Likely pre-renal in the setting of active infection. She denies
diarrhea and reports adequate PO intake. Improved with IVF. Her
home losartan and furosemide were held and should be restarted
by her PCP when seen.
# Elevated INR
# Prothrombin Gene Mutation
# H/O DVT
Likely reflects changes related to infection and antibiotics. No
evidence of active bleeding. Her warfarin was held and her INR
was tracked daily. After discharge, she should have her INR
monitored daily until <3 and then warfarin should be restarted
at home dosing. She should have this checked daily until stable
and she will call her PCP to confirm what dose of warfarin dose
to take.
# Diarrhea
C. diff test not finalized at time of discharge. Most likely
antibiotic associated diarrhea, but given concern for degree of
morbidity with C. diff in this transplant patient she was given
empiric PO vancomycin to continue for some time off of
antibiotics. | 100 | 370 |
12067814-DS-18 | 21,770,138 | Ms. ___, it was a pleasure taking care of you here at
___. You were admitted to the hospital because your heart was
going very fast. This is due to a condition you have called
atrial fibrillation. This caused you to feel palpitations and
dizziness as well. Shortly after your arrival your heart went
back into a normal rhythm and your symptoms improved.
You will need to follow-up with your cardiologist to discuss
further treatment options for your atrial fibrillation. | Ms ___ is a ___ yo female with history of CHF and
pacemaker placement in ___ who presented with palpitations
and dizziness and found to have afib with rvr.
.
#) Atrial fibrillation with RVR: Patient presented in afib with
RVR with rates up to the 160s on ___. Per outside hospital
medical records, she has had chronic afib in the past. While in
the ED She spontaneously converted back to sinus rhythm and
remained in sinus rhythm throughout her hospital stay. The
trigger for the RVR is most likely dehydration from diarrhea
and/or vomiting. Since the pt's atrial fibrillation is not new,
it is unknown why the pt has not had anticoagulation in the
past. While hospitalized patient did experience some atrial
pacing for skipped p waves noted on telemetry. Her Metoprolol
succinate was kept on 75mg PO daily since her heart rate
remained controlled in sinus rhythm with rates in the ___-60s.
.
Pt's pacemaker was interrogated and it was found that the
pacemaker was working appropriately with stable lead parameters.
There was frequent mode switching for atrial tach/AF. Increased
AVI to improve intrinsic conduction; if PR is too prolonged
(i.e.,concern for diastolic MR), can decrease with more
V-pacing.
See printout in chart for details.
.
Patient had an admission to ___ recently where
she had a very similar presentation with palpitations, nausea,
vomiting, and dizziness. During that admission metoprolol
succinate was increased from 50mg to 75mg. She had atrial
sensing with ventricular pseudofusion. Pacer was interrogated
and AV delay was increased to 200ms and mode switch rate
decreased to 150bpm.
.
#) C diff colitis: pt was admitted, already taking PO Vancomycin
from a previous hospitalization. Pt reported that diarrhea
subsided. She did not have another episode and continued PO
Vancomycin for the planned duration.
.
#) Chronic Diastolic CHF (EF >70%): patient appeared euvolemic,
with daily weights, strict I/Os monitored during stay.
. | 80 | 310 |
12855734-DS-5 | 29,326,881 | Dear Mr. ___,
You were recently admitted to the hospital after you presented
with headaches, nausea, vomiting, and chest tightness. On
evaluation, you were found to have high blood sugar and some
elevated kidney labs which indicated to us you may be deydrated.
You were given fluids in the ED and when you were transferred
up to the floor and your symptoms and labs both improved. Your
blood sugar levels were high so you were also given insulin.
Going forward it is important to stay compliant on the insulin
and metformin regimen in order to prevent complications of
diabetes. In addition, it is also important to decrease your
Motrin or Advil use because it can affect the lining of your
stomach. We have given you a card where you can make an
appointment with your PCP for regular follow up.
We really enjoyed taking care of you!
Sincerely,
Your ___ care team | Mr. ___ is a ___ y/o M w/ uncontrolled T2-IDDM presents with
a one day history of HA, lightheadedness, and nausea as well as
2x NBNB vomiting, notably without diarrhea or abdominal pain.
#Acute kidney injury: BUN/Cr ratio on admission was 40/3.0 =
13.3. Both his BUN and Cr improved with ___ fluid to 21 and
1.2. NSAIDs, metformin, and lisinopril held. Urine lytes and
CK wnl. Patient received 3L fluid in ED and maintenance on
floor.
-- Discharge Cr 1.2, no prior baseline in our system
#Nausea/vomiting: Does have h/o GERD. Takes Ranitidine at home.
Most likely gastroenteritis given h/o eating various foods that
were not well maintained. No fever, no blood, no wbc, no abd
pain. Peptic ulcer disease given his history of NSAID use is
possible but less likely given no abdominal pain/blood. Zofran
was not required after admission. Serum tox negative.
#Normocytic anemia with prior h/o gastritis +H.pylori (partially
treated) - DRE Hemeoccult negative. Iron studies wnl. Retic
normal, but inappropriate for anemia.
-- H Pylori Ab NEGATIVE
-- Omeprazole started
-- Needs EGD in future
#Lactic Elevated without acidosis: combination of systemic
hypoperfusion (poor PO, emesis, responsive to fluid repletion
decreasing lactate already) and possibly due to metformin use in
___. Metformin held.
# ID-T2DM: as an outpatient supposed to take Insulin and
Metformin though endorsed poor adherence to Insulin, only used
Metformin. FSBG on arrival ~350s. Fingersticks overnight in
200s. Metformin held due to ___.
-- A1c was = 11.1
-- Lantus 25U with breakfast + sliding scale
-- encouraged very close PCP follow up and glargine with sliding
scale
# Chest "tightness": Chronic though present in last few days as
well. Infectious etiology not likely given no fevers and normal
CXR. Atypical angina is possible but low likelihood given lack
of any other CV sypmtoms. Although smoking history is prominent
no wheezing to suggest COPD no sputum production along with a
clear lung exam. GERD is most likely etiology. Continued home
ranitidine.
-- may consider stress test as o/p given risk factors
(cigarettes, DM2, HTN)
# Active Smoker
-- declined nicotine patch
#Hypertension: current SBPs 130-140s. Held lisinopril in setting
of ___.
# Hyperlipidemia: Continued home simvastatin.
# Emergency Contact: ___, roommate, ___ | 154 | 368 |
14394070-DS-5 | 21,384,514 | 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 until
___ . On ___ resume your ASA 81 mg daily. Do not
resume your Plavix until ___. On ___ resume taking
your Plavix 75 mg daily.
***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.
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 | On ___ Mrs ___ was admitted to the neurosurgical service
after transfer from
OSH with SDH. Upon admission she was neurologically
intact,received 1 pack platelets and the maxilo-facial scan was
negative for fracture.
She was monitored overnight on the neuro surgical unit.
On ___ she remained stable and a repeat head CT demonstrated
no change. Oncology service at ___ was contacted and
follow chemotherapy will resume on ___. She
remained neurologically intact,denied headache and ambulated
without difficulty. | 430 | 76 |
12108342-DS-7 | 22,792,955 | Dear Ms ___,
You were admitted to the hospital because you were experiencing
fevers. We did not find evidence of a bacterial infection in
your blood, urine, or lungs. A CT scan of your lungs did not
demonstrate any sign of blood clots, pneumonia, and it
demonstrated that the fibrosis in your lungs is unchanged from
before. We suspect that your symptoms were from a viral
infection.
You were evaluated by our rheumatologists who did not think your
symptoms were related to your lupus. They did strongly
recommend, however, that you speak to your rheumatologist about
starting lupus medications because we do have evidence that the
lupus continues to be active.
After you are discharged, please call your PCP about setting up
an appointment soon after discharge.
Please reschedule your rheumatologist appointment that you
missed last ___.
Lastly, you should establish care with a pulmonologist (a lung
doctor). If you do not have a lung doctor, you should call the
___ pulmonary department at ___ to schedule an
appointment, or ask your PCP for ___ referral.
No medication changes were made this admission.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team | Ms ___ is a ___ year old woman with a history of SLE
(not on DMARDS), ILD who was admitted with fever, cough,
malaise.
# Fever
# Cough, Malaise: Patient admitted with fevers without
localizing symptoms other than cough and morning sinus/nasal
congestion. CXR and CTA in the ED demonstrated no pneumonia or
effusions, no PE, and unchanged ILD/fibrosis. Flu negative.
Urine cultures negative and blood culture no growth after 48
hours. CRP 30 on admission, but decreased to 15, and then 7. She
had no localizing symptoms on exam and fevers revolved after
admission and did not return. Antibiotics withheld throughout
admission. Rheumatology consulted (below) and felt that fevers
were not not related to SLE/CTD. Cough improved throughout
admission (presently mostly in mornings). Patient had no fevers
in the 48 hours prior to discharge. By day of discharge patient
was ambulating independently, tolerating diet, voiding and
stooling normally. She was discharged with intent to PCP
___ this week. Warning signs to seek medical attention
discussed with patient and patient education provided.
# SLE: Rheumatology consulted inpatient and did not believe her
presenting fevers were related. She did, however, show evidence
of active disease, with stable leukopenia, low compliment
levels. No joint/muscle involvement. Rheumatology strongly
recommended ___ with outpatient rheumatology to pursue
medical therapy.
# Dyspnea
# Interstitial lung disease: Patient had experienced mild
dyspnea in 2 weeks prior to admission. CXR and CTA in the ED
demonstrated no pneumonia or effusions, no PE, and unchanged
ILD/fibrosis. Flu negative. She remained on RA throughout
admission. On day of discharge, patient ambulating independently
in halls with normal ambulatory oxygen saturation. Her dyspnea
symptoms were improving, but not entirely resolved, by time of
discharge. Note that on prior testing she had elevated PASP
(although she did not appear volume overload presenty) but
deferred right heart cath. She was strongly recommended by
medicine and rheumatology consult service to have ___ with
rheumatology, PCP, and establish care with a pulmonologist.
Warning signs were discussed with patient.
# Anemia: CBC stable from outpatient priors. Hemolysis labs were
normal.
Time spent coordinating discharge > 30 minutes. | 240 | 347 |
17966058-DS-21 | 25,498,749 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were having uncontrolled
nausea, vomiting, and abdominal pain that was concerning for an
ulcerative colitis flare
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given pain and nausea medications
- You were given antibiotics for your fever
- You underwent an EGD and flexible sigmoidoscopy which was
consistent with an ulcerative colitis flare. After discussion
about options, you opted for surgery on ___.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Patient initially presented with nausea, vomiting, poor po
intolerance, and was operated on by Dr. ___ on ___. She
received a total abdominal colectomy with an end ileostomy for
an Ulcerative Colitis flare. Patient's post-op course
complicated by a fever/tachycardia/mouth pain (secondary to
recurrent candidiasis and HSV gingivostomatitis). Assessed by ID
and placed on a 14 day course of fluconazole, 7 day course of
valacyclovir, and a nystatin swish and swallow. On DC patient
continued steroid taper ( week 1 20 AM, 20 ___ & week 2 15 AM, 20
___ & week 3 15 AM & 15 ___ & week 4 10 AM & 15 ___ & week 5 10 AM
& 10 ___, week 6 5 AM & 10 ___, week7 5AM & 5PM), a 30 day course
of lovenox injections, nystatin swish, wafers, and pain
medication. She was also informed of the incidental breast mass
found on imaging that will need to be followed by her PCP. | 130 | 161 |
16139392-DS-14 | 27,254,295 | Discharge Instructions
Brain Tumor
Surgery
- You underwent a biopsy. A sample of tissue from the lesion in
your brain was sent to pathology for testing. The final results
of this testing can take 7 days or longer to finalize.
- Please keep your incision dry until your sutures/staples are
removed.
- You may shower at this time but keep your incision dry.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection such as
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.
This includes Indomethacin.
- 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 have also been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- You may take Oxycodone for moderate-severe pain as directed.
Do not drive or drink alcohol while taking this medication.
- You have been prescribed Decadron, which is a steroid to help
prevent brain swelling in the days surrounding surgery. Please
take this as prescribed. You should take Pepcid while taking
steroids to prevent GI upset.
What You ___ Experience:
- You may experience headaches and incisional pain.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason | ___ year old male with h/o ETOH abuse presenting with altered
mental status, likely ETOH withdrawal, and findings concerning
for meningoencephalitis. Given temporal lobe hypodensity there
is concern for herpes encephalitis, or acute infarct or
neoplasm.
# AMS: Thought to be due to a combination of ETOH withdrawal and
CNS infection at first especially since outside head CT showed
hypodensity in the left temporal lobe. Head MRI showed a
gyriform cortical FLAIR hyperintensity and thickening involving
the left hippocampus, parahippocampal cortex, anterior temporal
cortex, and insular
cortex with underlying nodular enhancement at left anterior
parahippocampal
and temporal cortex. Pt was started on empiric therapy with
vanc/ceftriaxone/ampicillin and acyclovir. However, LP was not
impressive for infection and HSV PCR was negative. CXR and UA
were not concerning for infection. TSH, B12, syphilis were
negative/within normal limits. The pt had an EEG that showed
concerning epileptiform discharges and he was started on
fosphenytoin and keppra after his waveforms failed to improve.
He did not receive a formal diagnosis of seizure. On phenytoin
and keppra, his mental status improved and returned to baseline.
His phenytoin dose was increased to obtain a higher level during
this admission.
.
Neurosurgery was consulted as upon further review of radiologic
images, the lesion was consistent with mass. Neuroncology also
was consulted to co-manage this patient. The patient underwent
stereotactic brain biopsy on ___ which was preliminarily
consistent with Glioblastoma Multiforme.
.
# ETOH withdrawal: Pt's last drink was likely ___. He was
started on the MICU phenobarbital protocol with tapered down
doses for 7 days. This was discontinued after two days because
the pt was extremely agitated, and he was started on IV Ativan.
He was noted to be very delirious and inappropriate. He was also
given IV thiamine x3 days/folate/MVI. He had an NGT placed for
PO med administration, which he removed himself after a day.
CHRONIC ISSUES
# Rheumatoid arthritis:
- pt does not have regular medications
# ETOH abuse:
- treat withdrawal as above
- once more clinically stable, SW consult
***TRANSITIONAL ISSUES***
HCP: Sister (___) ___, cell phone ___
****************
On ___, he proceeded to the OR for a stereotactic biopsy of
the lesion without complication. He was extubated shortly after
the
On ___ the patient was taken for a functional MRI and a CTA
head for pre-operative planning. The patient remained
neurlogically intact and was ambulating independently.
On ___ the patient was alert and oriented and was moving all of
his extremities with full strength. The patients incision was
well approximated with sutures which were clean dry and intact.
He was ambulating independently and tolerating an oral diet. The
patient was discharged home with prescriptions that will be
filled through the hospital's free care service, and he was
given discharge instructions with follow up information. | 610 | 457 |
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