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18156112-DS-9 | 21,916,187 | Dear Ms ___,
You were admitted to ___ after an episode of confusion with
some numbness and tingling of your tongue. EEG was performed
which showed no seizure activity. You had a CT of your head
which showed a normal brain but a nodule in your thyroid. Follow
up thyroid ultrasound also showed a nodule. It was recommended
that you proceed with a fine needle aspiration. This is a
procedure that can be performed as an outpatient. In addition,
the CT of your chest showed a small 4mm nodule in your lungs.
You will need to follow this up with additional imaging in the
future. During your admission, your blood pressure was found to
be low at times and you had a condition known as orthostatic
hypotension. You show include more salt in your diet and drink
sports drinks to keep enough fluid in your vessels to prevent
low blood pressure in the future. You have been scheduled with a
primary care physician in our system. Please attend the
appointment in order to set up the procedure for your thyroid,
to develop a plan to follow the nodule in your lung, and to
manage your blood pressure.
During your admission, MRI was performed which showed that the
bottom of your brain, the area called the cerebellum, is
slightly lower than the average individual. Although this is an
incidental finding in the majority of people, it may be
associated with some complications in certain individuals. You
have be scheduled for a follow up appointment in the ___
neurology clinic to monitor for any complications of this
finding and to treat your seizure disorder. It was a pleasure
caring for you during your stay. | TRANSITIONAL ISSUES:
1) CT showed 1.0 cm heterogeneously enhancing right thyroid
nodule. Thyroid U/S showed 1.5 cm nodule in the mid right gland
for which FNA was recommended.
2) CT showed left upper lobe 4 mm pulmonary nodule. Will need
routine surveillance as outpatient.
3) Orthostatic hypotension during admission. Recommended
increase PO fluids and dietary salt. Will need follow up as an
outpatient.
4) MRI showed cerebellar tonsils extending 5 mm below the
foramen magnum with effacement of CSF in the foramen magnum.
Patient currently asymptomatic. Will need routine surveillance
as an outpatient.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mrs. ___ is a ___ year old woman with past medical history of
depression and seizure disorder who presented as a code stroke
for acute onset of dizziness associated with confusion with some
numbness and tingling of her tongue. Neurologic examination was
notable for inattention, nystagmus in primary gaze and in all
directions, and possible dysmetria bilaterally. EEG was
performed which showed no seizure activity. NCHCT and CTA
head/neck were negative for acute stroke or vascular occlusion.
MRI showed low laying cerebellar tonsils extending 5 mm below
the foramen magnum with effacement of CSF in the foramen magnum
(this was the first episode of confusion and the patient was
otherwise asymptomatic so no further work up was indicated to
work up this finding during admission). Her lamotrigin level was
within therapeutic range (13.4). During her admission, she was
found to be orthostatic. She was instructed to include more salt
in her diet and to increased PO fluid intake (sports drinks).
Overall her presentation was most consistent with a metabolic
etiology (intoxication) vs orthostatic hypotension given the
inattentiveness and cerebellar signs. Seizure was less likely.
Prior to discharge, her blood pressure had normalized and she
was back to her baseline mental status.
Of note, CTA head/neck during admission did reveal a thyroid
nodule and a 4mm lung nodule. Follow up thyroid ultrasound also
showed a nodule and fine needle aspiration was recommended. She
was scheduled with close follow up with a PCP at ___ to
schedule a FNA, monitor the lung nodule, and to manage her blood
pressure. She was also scheduled with a neurology appointment at
___ to follow her seizure disorder, the Chiari malformation,
and to monitor for any additional episodes of
dizziness/confusion. | 284 | 375 |
12963637-DS-19 | 28,709,383 | 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:
- No baths or swimming for at least 4 weeks.- Any stitches or
staples that need to be removed will be taken out at your 2-week
follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
Non weight bearing Right upper extremity. Keep arm elevated to
reduce swelling.
Physical Therapy:
NWB RUE. Keep splint on until 2 week follow up. Do not get wet.
___ use sling for comfort. Pendulum swings for shoulder. Elevate
arm whenever possible<br>
Treatments Frequency:
Do not get splint wet | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right distal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF Right Distal Humerus Fx,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to a facility was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the right
upper extremity, and will be discharged without 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. | 181 | 237 |
17905041-DS-10 | 22,457,077 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right calf pain and was admitted to the orthopedic
surgery service for further compartment checks. On repeat
checks, the patient was found not to have compartment syndrome
by clinical exam and ___ pressure monitoring was deferred.
The rheumatology service was consulted and recommended
outpatient follow-up with ___ or equivalent service. Their
suspicion for rheumatological disease was low and no outpatient
follow-up was deemed necessary. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medication and the patient was voiding/moving bowels
spontaneously. The patient is NVI distally in the bilateral
lower extremity. The patient will follow up with ___ Physiatry
per routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 43 | 184 |
16287038-DS-18 | 23,755,466 | Dear Ms. ___,
You were admitted for concerns of difficulty walking, weakness
in your arms, and difficulty speaking. You were admitted to the
___ Neurology stroke service for further work up. MRI brain
was negative for any acute or subacute strokes which is very
reassuring. You likely have been under significant amounts of
stress and anxiety which can manifest as a variety of different
neurologic symptoms. We recommend that you continue outpatient
talk therapy for mental health, as well as continuing physical
therapy. In conjunction with your case manager at ___, we
recommend that you see a speech therapist at ___ or in the
community; we have provided you with a referral/prescription to
facilitate this.
We truly wish you the best and hope for a speedy recovery so you
can return to school. Please continue to take your home
medications as prescribed. | ___ is a ___ year old woman with history of anxiety
and a cryptogenic left middle cerebellar peduncle infarct s/p
tPA 1 month ago (seen at ___ who was admitted from the ED after
presenting with difficulty moving all extremities (left>right)
and speech difficulties including stuttering/halting speech
after taking a 40 minute walk home from school. Physical exam
findings do not localize to a particular vascular region or
region of the nervous system and were noted to change during the
course of the day and from day to day. In the ED, non-contrast
___ CT revealed no acute intracranial process, chest x-ray
demonstrated no acute cardiopulmonary process, and telemetry has
been normal sinus rhythm since admission. MR brain and ___
were normal with no signs of acute, subacute, or chronic
processes, and the likelihood of prior stroke for which she was
given TPA is questionable. Imaging from ___ has been sent to
___ but has not yet arrived by time of discharge. On hospital
day 2, ___ appeared more withdrawn with significant
psychomotor retardation. She reported that she has been feeling
low mood for the last month and "off" since before college began
(she is a sophomore). Due to concern for possible functional
overlay of her symptoms, we consulted psychiatry for diagnostic
clarification and management recommendations. Patient denied any
SI and stated that she was feeling overwhelmed with the demands
of schooling and a need to be a perfectionist. She felt much
better when she was re-assured that she did not have a stroke
and that she likely was manifesting her stress through physical
symptoms. She was restarted on her sertraline and psychiatry was
going to reach out to her outpatient therapist.
Patient recovered significantly during hospitalization and
returned to her baseline function. Her mental status was
slightly altered however as she was quite child-like in her
speech and actions, however she was able to comply with a full
neurologic examination and demonstrated excellent strength on
confrontational testing.
In concert with her case manager at ___, case management at
___ recommended that ___ see a speech therapist and
occupational therapist at ___ or in the community. She was
provided with a referral/prescription for these therapies.
Her medications were not adjusted and she was discharged home
with the same meds as prior. She will follow up with the Stroke
Neurologist in a few months and the images from ___
___ will be reviewed during this time. If suspicion that
she had a stroke in the first place is low (after outside
hospital imaging is reviewed), her medications (aspirin and
statin) may be adjusted.
TRANSITIONS OF CARE ISSUES:
1. Patient to follow up with stroke neurologist on scheduled
date and medication adjustements will be decided at this time
2. Patient to follow up with PCP ___ ___ weeks
3. Patient to continue seeing her outpatient therapist and
continue sertraline
4. Patient to continue ___ / and speech therapy | 142 | 487 |
14630468-DS-23 | 22,720,957 | Ms. ___,
You were admitted to ___ with shortness of breath and
secretions. You were treated for pneumonia with IV antibiotics.
You required suctioning multiple times per shift, but overall
your symptoms improved.
You will need to complete 10 days of antibiotics. | ___ yo F with laryngeal CA s/p resection, chemo/XRT who is s/p
trach and PEG who presents with increased suctioning needs. Pt
with recent admission for PNA, concern for tracheobronchitis vs
PNA resulting in her thick, copious secretions.
1. HCAP Pneumonia vs Tracheobronchitis: She has thick clear
secretions. No purulence, fever, or chills. Elevation in her WBC
count initially, though improved with treatment. Initially
treated with Vancomycin and Zosyn, narrowed to Zosyn only with
negative cultures. Plan for treatment for 10 day course. She
has no inner cannula because it makes it feel difficult to
breath for her, which makes her pre-disposed to
plugging/secretions. She required suctioning multiple times per
shift. She was treated supportively with expectorants, nebs,
trach mask oxygen supplementation, and antibiotics.
2. Anemia: Stable at 25 throughout admission.
3. Acute renal failure with creatinine 1.2: Resolved with
hydration and treatment of her infection to 0.8.
4. Crohn's disease: No signs of active disease. No diarrhea, no
melena, no hematochezia.
5. Schizoaffective disorder: Continued on olanzapine 6.25 daily
and trazodone bid.
6. CAD: continued ASA, statin, atenolol. | 42 | 182 |
10203235-DS-21 | 28,960,005 | Dear ___,
WHY DID YOU COME TO THE HOSPITAL?
- You came to the hospital because you were experiencing chest
pain.
WHAT HAPPENED IN THE HOSPITAL?
- We gave you medication to help treat your chest pain
- We performed a percutaneous intervention (PCI) (a procedure
when we look for any blockages in the vessels in your heart and
treat them). We saw a blockage in the right coronary artery (one
of the main blood vessels that provides blood to your heart) and
we opened the vessel with a stent.
- We monitored you after the procedure. You had some chest pain
right after the procedure, but this resolved.
- We felt you were safe to go home with close follow up with
your outpatient providers.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 2 lbs in 1 day or 3 lbs in 1 week.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team | Ms. ___ is a ___ with CAD s/p CABG (LIMA-LAD, SVG-OM1,
SVG-D1, SVG-PDA) ___ with subsequent occlusions of all SVGs;
S/P multiple DES to mid LAD (___), ostial LMCA (___), LCx/OM
(___), RCA/RPL ___ and ___ and type 2 diabetes mellitus
presenting with chest pain and admitted for an NSTEMI. On
arrival, EKG demonstrated new diffuse ST depression. She was
placed on heparin and nitroglycerin infusions. Patient was
continued on home metoprolol 100 mg total daily, isosorbide
dinitrate 10 mg TID, aspirin 81 mg daily, clopidogrel 75 mg and
ranolazine. Patient received additional clopidogrel 300 mg
re-load on hospital day 2. Patient's valsartan and furosemide
were held in preparation for contrast angiography given CKD. She
was hypertensive on arrival which was thought secondary to pain
as it resolved with initiation of nitroglycerin drip. Peak CK-MB
31, peak troponin-T 0.71. Echocardiographic LVEF 59% with focal
basal inferior hypokinesis (unchanged from ___. She
underwent coronary angiography which showed 95% in-stent
restenosis of the ostial RCA and 100% in-stent restenosis of the
LAD with LIMA-LAD graft patent. IVUS-guided re-stenting of the
ostial RCA was performed. Post-PCI course was complicated by
transient chest pain requiring reinitiation of nitrolycerin
infusion. Pain resolved without additional intervention. Given
no ST elevations on EKG (but persistent ST depressions) and
resolution of pain without additional intervention, low concern
for stent thrombosis. Patient was monitored for 24 hours post
PCI and remained stable. She was discharged without chest pain
with plan for follow up in clinic. Patient was reinitiated on
valsartan and furosemide with metoprolol tartrate transitioned
to metoprolol succinate prior to discharge. Given presentation
with NSTEMI and now 2 layers of drug-eluting stents in the
ostium of the RCA, prolonged and preferably lifelong dual
anti-platelet therapy was recommended. | 228 | 289 |
13317548-DS-4 | 22,892,694 | Dear ___,
___ was a pleasure taking care of you at ___
___ in ___.
You were admitted for abdominal pain and nausea, which was
treated with medication. Laboratory studies and imaging were all
normal and the GI team was consulted to further evaluate the
reason for your symptoms. The endoscopic ultrasound showed
evidence of stomach inflammation. You have been diagnosed with
gastritis, but this does not fully explain the severity of your
abdominal pain. As your abdominal pain and nausea have improved,
you have been discharged with pain, nausea, and gastritis
medication and outpatient PCP ___ ___ at
10:40am) to further investigate the cause of your symptoms.
Medication changes:
-Tramadol 50 mg every 6 hours as needed for pain
-Ondansetron 4 mg orally every 8 hours as needed for nausea
-Omeprazole 40 MG orally twice a day
-Prochlorperazine 10mg PO up to four times a day
-Polyethylene Glycol 17 grams orally as needed for constipation
-Ranitidine 75 mg twice a day (over the counter) - you can take
this medication until you improve and then stop it. | Patient is a ___ with a h/o gallstone pancreatitis s/p
cholecystectomy and ERCP with sphincterotomy (___), who
presents with ongoing abdominal pain and nausea. Patient was
recently admitted from ___ to ___ where an extensive work-up was
done for her abdominal pain including CT, H. pylori serology,
vaginal ultrasound and GYN consultation. Ultimately her oral
contraceptive pill was changed to continuous per GYN
recommendations. The team was unable to find an etiology for her
abdominal pain. When she was discharged, the patient reported
that she continued to have pain. On the night prior to
admission, her pain worsened, which became intolerable. Denies
any precipitating cause. Given her symptoms, she presented to
the ED for evaluation. In the ED, triage vitals were 98.2 88
124/63 20 100% RA. Evaluation notable for lipase of 67, all
other labs CBC with diff, Chem 10, LFTs all unremarkable, hcG
negative. RUQ ultrasound was unremarkable. KUB unremarkable and
not notable for a partial SBO. On admission to the floor,
patient's pain and nausea were controlled with analgesics,
antiemetics, and she was given IVF and made NPO. Her home
omeprazole was increased to 40 MG PO BID. GI was consulted and
an endoscopic ultrasound was notable for gastritis, though per
GI this does not adequately explain her severe pain requiring
hospitalization. No signs of pancreatic inflammation or biliary
pathology. Work-up for celiac, immunoglobulin deficiency, and
hypertriglyceridemia were unremarkable. After a continued
extensive work-up, the etiology of the patient's abdominal pain
remains unclear and GI recommended no further in-patient
evaluation. As her pain and nausea have abated and are
well-controlled with oral medications, she has been discharged
home with medications (tramadol for pain, omeprazole and
ranitidine for gastritis) and outpatient ___ to see her GI
physician for ongoing investigation to her abdominal pain. | 171 | 296 |
14576985-DS-12 | 24,448,032 | Ms ___,
You were admitted to ___ after fall from ___ bed. Your
injuried included a small right posterior bleed in yuor head and
a right humerus fracture. You were seen by the Neurosurgery
doctors and had a repeat head CT scan and an MRI which showed
the head bleed was stable, and your neurological exam was also
normal. The Orthopedic doctors ___ your ___ fracture
and determined it did not need surgery and that it would heal on
its own. You should wear the sling until your follow-up in 4
weeks. You were seen the by Physical therapists who felt you
were functioning below your baseline and would benefit from a
short stay at rehab to regain your strength. You are now ready
for discharge; please note the following instructions:
ACTIVITY:
Right upper extremity: Weight-bearing as tolerated in right
upper extremity, keep in sling for comfort.
Neurosurgery:
¨ Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
¨ If you were on a medication such as Coumadin (Warfarin),
or Plavix (clopidogrel), or Aspirin prior to your injury, you
may safely resume taking this after 2 weeks from day of
discharge.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion, lethargy or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ New onset of the loss of function, or decrease of function
on one whole side of your body.
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. | The patient presented to Emergency Department on ___.
Patient was transferred from ___ following a fall from
bed. She was initially evaluated with R Shuolder X-rays, CT
head, C-spine, CT Abd/Pelvis head, Hip were performed which were
notable for Displaced fracture through the right humeral
head without evidence of overt intra-articular extension
and a right intraparenchymal hemmorhage within posterior right
parietal lobe. Patient was transfered to ___ for further care.
She was evaluated by Orthopedic surgery who recommended
non-operative/conservative management of her humerus fracture
with a sling for comfort with outpatient orthopedic followup.
Neurosurgery evaluated the patient and recommended further
imaging with repeat Non-contrast head Ct and MRI with contrast
for further evaluation of the hemmhorage along with holding the
patient's anticoagulation with coumadin and aspirin. Upon
reviewing further imaging, this suggested unchanged right
parietal intraparenchymal hematoma without associated underlying
nodular enhancement potentially on the basis of amyloid
angiopathy. Neurosurgery recommended restarting her coumadin/ASA
two weeks after hospitalization with followup with Neurosurgery
after repeat imaging in 4 weeks for further evaluation and
management. Her warfarin is currently managed at her assisted
living facility with ___ services.
Neuro: She remained stable neurologically throughout her
hospital course with frequent reevalaution by nursing and
medical staff throughout hospitalization; pain was initially
managed with oral pain medication.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Her coumadin
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO for possible
operative intervation and was then advanced to a regular diet.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
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. | 508 | 364 |
17356318-DS-35 | 28,257,046 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
WHY WAS I HOSPITALIZED?
- You were admitted to the hospital because you had an injury to
your kidneys, as well as some cramping in your arms and legs.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given albumin to improve your kidney function.
- We started you on a muscle relaxant, Flexeril, to treat your
muscle cramps.
- We found a clot in the vein behind your left knee. We
discussed this case with the blood doctor, ___ the
___. Overall, it is uncertain whether this blood clot
was new or it was the same one that you've had in the past.
- You were initially on a blood thinner called heparin. We
switched you back to your Lovenox and increased the dosage to
80mg twice daily.
- Your hemoglobin level dropped, for which you received a blood
transfusion and iron.
- There was concern that you were having active bleeding from
your upper GI tract. You underwent an endoscopy which thankfully
did not show any areas of active bleeding in your esophagus,
stomach, and first part of the intestine.
WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL?
- Please take your medicines as prescribed and attend your
doctor's appointments below.
- Please stick to a low salt diet and monitor fluid intake, and
weigh yourself regularly as you had been doing at home. Call
your doctor if you notice a weight gain of 3 or more pounds in
one day. This might mean you need more Torsemide.
- Continue to work on your nutrition!
- You will need to have blood work done on ___, at
your usual location.
We wish you all the best!
Your ___ Care Team | ====================
PATIENT SUMMARY
====================
___ with h/o with cirrhosis secondary to hepatitis C and
hemochromatosis complicated by ascites, lower extremity edema,
esophageal varices and hepatic encephalopathy, CAD s/p PCI
(___), mesenteric ischemia from SMA thrombosis s/p small
bowel resection, protein C vs. ATIII deficiency with multiple
DVTs and PE including while on warfarin (currently on Lovenox),
who presented with cramping of b/l hands and b/l legs. He was
found to have acute vs. chronic left popliteal nonocclusive DVT
for which he was initially on heparin gtt then transitioned back
to Lovenox, uptitrated 80mg BID based on anti-Xa level per
discussion with primary hematologist Dr. ___. Additionally
found to have pre-renal ___ and hyponatremia that resolved with
albumin and holding diuretics. Cramping improved with initiation
of low-dose Flexeril which the patient tolerated well. Course
c/b acute on chronic anemia which was c/f slow upper GI bleed,
and patient underwent EGD which did not show any areas of active
bleeding. He received IV Iron for chronic iron deficiency. He
was discharged home after remaining stable on his new Lovenox
regimen.
====================
ACTIVE ISSUES
====================
# Acute vs. chronic left popliteal nonocclusive DVT
# History of recurrent DVTs and PE
On admission found to have small left popliteal DVT which was
confirmed on repeat ultrasound. Patient had known left popliteal
DVT dating back to ___, though not apparent on
ultrasound in ___. Patient had been adherent to Lovenox
70mg BID. Discussed with primary hematologist, Dr. ___
did not feel this to be a failure of Lovenox as ~25% of DVTs do
not resolve and given the small size of DVT, it may not have
been visualized on the ___ ultrasound. Initially on
heparin gtt, then restarted Lovenox 70mg BID (1mg/kg). Anti-Xa
level after 3rd dose at 0.58, and Lovenox was titrated up to
80mg BID. Anti-Xa level after 3rd dose therapeutic at 0.78.
# Acute on chronic macrocytic anemia
# Iron-deficiency anemia
# Chronic GI bleed ___ GAVE
H/H dropped after being on heparin gtt to 6.8, initially
concerning for slow upper GI bleed given patient's known upper
GI vascular pathologies. Briefly switched from oral daily PPI to
IV BID PPI. Underwent EGD which showed 3 cords of grade II
varices in the distal esophagus; 1 cord of grade II varices in
the mid esophagus; GAVE; portal hypertensive gastropathy;
duodenal portal enteropathy; and a possible gastric varix. No
signs of active bleeding. Received 1u pRBC with appropriate rise
in H/H. H/H remained stable on Lovenox per above. Received 1g
iron dextran.
# Cramping
Acute on chronic. Trigger likely from hypovolemia. Electrolytes
unremarkable. CK normal. Kept on home oral magnesium oxide BID.
Repleted electrolytes for K>4, Mg>2. Trialed on 5mg
cyclobenzaprine QHS which significantly improved cramping and
was well tolerated. He was discharged with short course to be
continued until PCP ___.
# Acute kidney injury
# Hyponatremia
Cr rose to 1.3 from baseline ~0.9-1.1, presumed secondary to
pre-renal etiology iso poor PO intake and diuretics. Resolved
with albumin. Diuretics held initially then restarted.
Discharged on 80mg torsemide, 150mg spironolactone daily. Dry
weight: 160.5 lbs.
# Severe protein calorie malnutrition
History of malnutrition. Nutrition consult placed, recommended
uptitration of glucerna to 6x per day and 2g sodium / carb
consistent diet.
==================== | 291 | 517 |
15346117-DS-24 | 24,083,628 | Dear Mr. ___,
It was a pleasure taking ___ of you during your stay at ___.
You were admitted with an infection of your right foot. You went
to the operating room to have your foot washed out and a sample
of the bone taken. You were treated with antibiotics and your
condition improved. You were sent home to complete a course of
antibiotics and to follow up with your infectious disease
doctors.
___,
Your ___ Team | ___ with DMI c/b nephropathy, retinopathy, and recurrent
neuropathic foot ulcers with recent admissions for osteomyelitis
and subsequent R ___ toe phalengectomy presenting for evaluation
of ? continued right toe infection.
# Right toe/tibial osteomyelitis: The patient was first
diagnosed with OM during hospitalization ___ and had
phalangectomy at that time, discharged on a 10 day course of
Augmentin and bactrim. He was readmitted ___ for
worsening right toe OM and was discharged on a 6 week course of
cefazolin, which was changed to zosyn at OPAT follow up ___.
Presented from ___ clinic ___ with concern for worsening
infection and drug rash. Seen by vascular surgery, podiatry, ID
in ED. Pt w/ PICC in place, continued on vancomycin, and started
cipro/flagyl. Debrided in OR under local anesthesia on ___,
bone sample taken in OR grew mold. Pt started on PO
voriconazole, and cipro and flagyl discontinued. The culture of
the bone sample speciated to trichosporon, which was felt to be
a contaminant and not a true pathogen, and so voriconazole was
stopped. As the patient underwent surgical debridement of the
infected area of his foot, he was transitioned to oral
antibiotics (levofloxacin 750mg pO Q24h and clindamycin 600mg PO
Q8h) for 6 weeks.
w
# Macular rash: Patient presented with itchy erythematous
macules over trunk and extensor arms. The distribution and time
course consistent with drug rash. Zosyn, torsemide, omeprazole
were discontinued as possible culprits. Rash with new ___ was
initially concerning for DRESS. However, he had no
transaminitis, elevated cr thought most likely manifestation of
baseline CKD, rash resolving, and eos downtrending; DRESS less
likely per derm. Pt given sarna, benadryl, triamcinolone PRN
itch. Torsemide was restarted as this was an old medication for
Mr ___ and unlikely to cause his rash and AIN. Omeprazole
was switched to an H2RA.
#Acute interstitial nephritis
Creatinine elevated on admission 1.7, recent baseline appeared
to be 0.9 - 1.2. Initially interpreted this as acute-on-chronic
kidney injury (CKD III). Pt was not responsive to fluid trial
overnight ___. AIN, DRESS initially thought possible given
many recent drug exposures, rash, ___ and eosinophilia on CBC.
Nephrology was consulted, and urine sediment demonstrated pyuria
and WBC casts, consistent with acute interstitial nephritis, due
to either cefazolin or zosyn. Eosinophilia was decreasing by
time of discharge, and creatinine decreased to 1.3
# Hypertension: SBPs up to 210s in the ED in the presence of 600
protein on UA. Patient follows with nephrology who recently dc'd
home amlodipine and added torsemide 40mg daily. Initially
torsemide and lisinopril held given presumed ___. Torsemide was
restarted at 20mg daily, and once AIN was diagnosed, lisinopril
was also restarted. Labetalol was also started due to persistent
markedly elevated blood pressure on the floor.
# Anemia, chronic: The patient presented with an H/H of
7.5/22.3, just below recent baseline. The patient has a history
of iron deficiency anemia, recently investigated in ___ with
colonoscopy and EGD notable for gastritis. The patient was
started on iron supplementation and omeprazole at that time.
Anemia also likely due to ESRD/ low epo production as well as
anemia of inflammation. He remained hemodynamically stable with
guaiac negative stool and no evidence of bleeding. In
preparation for OR, pt was transfused one unit PRBCs on ___ w/
appropriate hct bump.
# IDDM. Continue home glargine and ISS; pt had episodes of
hypoglycemia to ___, likely owing to lower carb diet in the
hospital; glargine reduced to 20 BID in-house, to be restarted
at home level on discharge. He continued to have overnight
episodes of hypoglycemia, and occasionally reported symptoms of
vision changes, headache, and diaphoresis. Glargine was reduced
to 12U BID, which patient states he had been taking at home.
Continued home gabapentin for neuropathy
# Hyperlipidemia: Continued home pravastatin.
# Peripheral Vascular Disease: Continued home aspirin.
# Hx of gastritis: Discontinued home omeprazole owing to concern
for drug reaction. Switched to ranitidine
TRANSITIONAL ISSUES:
-Pt's HTN difficult to control as inpatient. Labetalol added
with good effect. Pt also restarted on home lisinopril after
brief course of amlodipine. Pt needs close renal f/u to manage
his HTN as well as his CKD.
-Acute interstitial nephritis: likely causative agent Zosyn vs
Cefazolin. Both medications added to patient's allergy list
-Pt should follow up in ___ clinic, scheduled for ___.
-Antibiotics course:
- po clindamycin 600 mg q 8 H
- po levofloxacine 750 mg q 24 h
Start Date: ___
Projected End Date: Tentative plan ___ w or until ___ | 76 | 738 |
18630328-DS-3 | 29,914,518 | Mr. ___,
You have been hospitalized at ___
___ due to symptoms of difficulty swallowing, difficulty
speaking, double vision, and difficulty breathing which resulted
from a neurologic condition called MYASTHENIA ___. You were
also found to have PNEUMONIA which we treated with antibiotics
and was likely caused by aspirating from your difficulty
swallowing. Your condition has fortunately improved with
PLASMAPHERESIS, a treatment that removes the culprit antibodies
from your blood. You will need to take a number of medications
to help the myasthenia go into remission (e.g. to calm down the
immune system which currently is hyperactive), including
Prednisone which your Neurologist will gradually increase. Your
Neurologist may also start you on a medication called
Cellcept/mycophenolate mofetil which may be able to help prevent
future flares of your myasthenia ___.
Additionally, you should see a Pulmonary physician to address
your lung issues. Dr. ___ has agreed to follow you in ___
___, but he needs a referral first from a primary care physician
at the ___. Please go see Dr. ___ in the clinic
to help manage your general medical issues and have him make a
referral to Dr. ___ in Pulmonary ___. Also have Dr.
___ you to a ___ a sleep study as you
likely have OBSTRUCTIVE SLEEP APNEA which can cause a number of
problems including high blood pressure, daytime drowsiness, and
increased risk of heart attack and stroke.
To help prevent further symptoms and recurrence, we are changing
your medications in the following manner:
1. We would like you to take PREDNISONE at 30 mg each day. Your
Neurologist may increase this slowly after seeing you in ___
clinic.
2. We would like you to take Calcium and Vitamin D as Prednisone
can predipose you to bone degradation and osteoporosis.
3. We would like you to take FAMOTIDINE 20 MG twice daily to
prevent the formation of stomach or intestinal ulcers while
taking Prednisone.
4. Please take CLINDAMYCIN 600 MG three times daily for the next
two days to complete treatment for your pneumonia.
5. After completing the two days of Clindamycin, please take
BACTRIM DS 1 tablet each day for prevention of infection while
taking Prednisone.
6. You may take PYRIDOSTIGMINE up to three times daily as needed
for symptoms of myasthenia ___ such as weakness, double
vision, and difficulty swallowing (or as otherwise directed by
Dr. ___.
You may take your other medications as previously prescribed.
We would like you to followup with Dr. ___ as listed
below.
If you experience any of the following symptoms, please seek
medical attention.
It was a pleasure providing you with medical care during this
hospitalization. | ___ h/o suspected NPH s/p VPS, depression/anxiety and new dx
myasthenia ___ recently started on Prednisone (20mg) with
subsequent worsening of bulbar symptoms (dysphagia, dysarthria)
concerning for myasthenic flare.
[] Myasthenia ___ - The patient was consented for and treated
with plasmapheresis for five days (alternating). A ___
temporary pheresis catheter was placed and subsequently removed
for use with this treatment. His dysphagia, dysarthria, and
dyspnea quickly improved after the first treatment. His proximal
muscle weakness also improved gradually including neck flexion
and neck extension. His pyridostigmine was held. His Prednisone
was restarted at 20 mg and increased to 30 mg on ___, and he
was discharged at this dose with the aim to increase when he
sees Dr. ___. He may also benefit from initiation of a
___ agent as an outpatient.
[] Aspiration pneumonia - His CXR had bilateral infiltrates. In
the setting of dysphagia with myasthenia, this was interpreted
as aspiration pneumonia. He was treated with ceftriaxone for 12
days and clindamycin for 14 days (the last two days as an
outpatient).
[] Oxygen requirement - While being treated for aspiration
pneumonia and myasthenia ___, the patient was noted to have
an oxygen requirement ___ NC). An ABG was attempted but
returned with venous blood; the blood gas was nonetheless
reassuring from a pCO2 and pH standpoint. His CXR showed signs
of diaphragmatic flattening consistent with possible
COPD/emphysematous features; he has a ___ pack year history of
tobacco use (remote, stopped ___ years ago). He was treated with
albuterol + ipratropium nebulizer treatments to assist with
bronchodilation. Pulmonlogy was consulted and recommended aiming
for a lower SaO2 goal of ___ (as the threshold for O2
supplementation) during the day with 3L of O2 at night given his
nocturnal desaturations and signs suggestive of obstructive
sleep apnea (snoring, apneic episodes at night at home per his
wife). The oxygen may not be required in the ___ but
Pulmonology thought he might need this for several weeks. They
recommended gentle diuresis with Furosemide and extension of his
antibiotic treatment with clindamycin to 14 days. Dr. ___
plans to followup with the patient in ___, but he requires
a PCP referral first; he named ___ as a good candidate
to followup the patient and provide the appropriate referrals. | 425 | 375 |
16589694-DS-11 | 26,285,610 | INSTRUCTIONS AFTER ORTHOPAEDIC admission:
- You were in the hospital for a broken right proximal humerus
fracture treated nonoperatively.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right upper extremity in sling
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- None
WOUND CARE:
- None
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Persistent or increasing numbness, tingling, or loss of
sensation
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
___ weeks:
Pendulums
PROM
sling in public only/no sling use at home
Focus on maintaining ROM of elbow/shoulder to shoulder level
___ weeks:
PROM above shoulders
AAROM/AROM gently without resistance, PROM above shoulders
wean from sling as able
___ weeks:
AROM as able
start gentle resisted exercises
12 weeks and on:
ROM and Strength as able
From week ___ and on ___ should be outpatient and 2 days a week
with Home Exercise Program
**This is typical and may be altered based on fracture, xrays
and physical exams
Treatment Frequency:
None | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a The patient presented to the emergency department and
was evaluated by the orthopedic surgery team. The patient was
found to have a right proximal humerus fracture and was admitted
to the orthopedic surgery service. The patient was treated
nonoperatively in a sling and worked with physical therapy who
determined that discharge to rehab was appropriate. The patient
was given anticoagulation per routine, and the patient's home
medications were continued throughout this hospitalization. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the right
upper extremity, and will not be discharged on any
anticoagulation for DVT prophylaxis since no orthopedic
intervention was performed. 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. | 538 | 208 |
17306012-DS-10 | 28,060,523 | You presented to the hospital with persistent fevers, cough, and
weight loss. Further work-up for your symptoms included a CT
scan, which showed new masses in your liver and abdomen. A
biopsy of one of your liver masses showed adenocarcinoma. Other
potential causes of fever were ruled out - such as tuberculosis
(TB), tick-borne illnesses, urinary tract infection.
Your CT scan also showed a potential pneumonia, for which you
were treated with antiobiotics. You should continue with the
antibiotic for an additional 3 days.
Please refer to the attached medication list for any changes to
your medications. It was a pleasure taking part in your medical
care. | ___ y/o F with PMHx significant for stage IIIC primary peritoneal
cancer diagnosed in ___ s/p total abdominal hysterectomy,
bilateral salpingo-oophorectomy, omentectomy, resection and
ablation of peritoneal tumor, mobilization of right liver,
diaphragm resection, diaphragm ablation of tumor as well as
chemotherapy (last chemo ___. Also with PMHx of endometrial
CA diagnosed at the time of surgery that was noted to be
contained to a polyp, multinodular goiter s/p total
thyroidectomy, GERD, HTN, who presented to outpatient clinic
with ___ months of persistent non-productive cough, LOA, weight
loss, as well as ___ weeks of fevers.
#) Mesenteric Mass / Liver Lesions: ms. ___ was admitted
with fever and was found on abd CT to have numerous new
hypodense lesions throughout the liver with the largest
conglomerate located in the inferior right lobe of the liver
involving
segments V and VI and measuring 4.4 x 5.9 cm. New soft density
in the root of the mesentery concerning for disease recurrence,
appearing to encase branch vessels of the SMV but no occlusion.
No discrete measurable adenopathy. CA-125 added onto admission
labs and was elevated at 41 (from 11 before). To further eval
these masses, she underwent ultrasound guided biopsy on ___
which eventual revealed poorly differentiated adeno CA with
lymphovascular invasion. (Discussions with ___, led to the
conclusion that the mesenteric mass was not a candidate for bx
given location and likely low yield).
These findings were discussed with Ms. ___ oncologist
(Dr. ___ about final path and the decision
was to initiate chemotherapy (___) next
week once the antibiotics for the pneumonia was complete. Dr.
___ PCP) was also notified.
Attempts were made to place a Port on the day of discharge,
but was not possible given that the patient had already started
lunch. This will be done as an outpt and will likely be placed
after the first chemo regimen.
#) ? RML PNA: Seen on CT scan. She was admitted with
leukocytosis with WBC 12 and quickly normalized on the second
day of hospitalization. She was treated with CTX monotherapy and
transitioned to PO levofloxacin on the day of discharge. While
PNA could explain fevers and cough, persistent nature and long
course of patient's symptoms do not seem consistent. Location in
the anterior RML abutting the pleura also raises the possibility
of malignancy as an etiology. (will not include azithro, as
patient has already completed a 5 day course of this). A repeat
Chest CT was done on the last day of hospitalization to follow
up and assess whether the RML infiltrate had responded to abx
(and whether it was due cancer). She was placed on benzonatate,
tessalon perles, guaifenesin/dextromethorphan for symptomatic
treatment of the cough.
Also with h/o positive PPD in the very remote past, she was
ruled out for TB with 3 induced sputum.
#) Fever: Ms. ___ continued to be febrile despite
receiving antibiotics. Temperature went as high as 102 which
was relieved by ibuprofen. Likely attributed to cancer
recurrence. Has reports of multiple tick bytes. Lyme and Babesia
serologies were negative. There was a single blood cx on ___
positive for CoNS. This was considered a contaminant since
multiple blood cx were negative since then. She was treated
with vancomycin initially, which was subsequently discontinued.
#) HTN
- On toprol, HCTZ
#) Recent Eye Surgery: On home eye drop regimen
#) Hypothyroidism, Mutinodular Goiter - cont synthroid
#) Hypokalemia/hypomagnesium - replete lytes PRN
.
# OTHER ISSUES AS OUTLINED.
.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: []heparin sc []SCDs [X] Ambulation
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: [] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#CONTACT: Husband Home: ___ Cell phone: ___
#CONSULTS: Oncology, Gyn Onc aware
#CODE STATUS: [X]full code []DNR/DNI | 110 | 666 |
11642399-DS-20 | 29,960,137 | Dear ___
___ were admitted to the gynecologic oncology service after
undergoing the procedures listed below. ___ have recovered well
after your operation, and the team feels that ___ are safe to be
discharged home. Please follow these instructions:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex) for 3
months
* No heavy lifting of objects >10lbs for 6 weeks.
* ___ may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms ___ was admitted on ___ from an OSH with a vaginal cuff
dehiscence. In the ED small bowel was visualized in the vagina,
was easily reduced at which point a foley was placed and vagina
was packed. Patient was then taken to the OR and underwent
vaginal cuff repair. For full detail see operative note. Ms
___ recovered well in the PACU and was transferred to the floor
in stable condition. Ms ___ WBC count on admission was
elevated at 19.6. On POD 1 Ms ___ was tolerating PO, pain well
controlled and tolerating regular diet. Her white count dropped
to 11.7. She received 24 hours of Levo/flagyl. On POD 2 Ms
___ had met all post operative mile stones, her WBC count
dropped to 7.7 and she was discharged in stable condition with
follow up appointment scheduled with Dr. ___. | 143 | 149 |
13864297-DS-23 | 21,860,164 | Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Ms. ___ was admitted to the Vascular Surgery service with
HPI as stated above. She was started on an argatroban drip
because of her known history of HIT, and drip was titrated to
goal PTTs of 60-80. She was planned for non-invasives and
duplex of the right lower extremity in the morning.
On HD#2, ___, her argatroban drip was continued. CPK was
41. LENIs demonstrated no evidence of DVT, and NIAS
demonstrated R ABI 0.9-1.1, L ABI 0.68-1.13. She also underwent
CTA of the abdomen and pelvis with lower extremity runoff, which
demonstrated a focus of a nearly occlusive thrombus in the right
external iliac artery, yet with good flow distal to this region.
Because there was a chance she might go for angiography, she
was kept NPO and her normal home meds of hydrochlorothiazide and
lisinopril were held; blood pressure was controlled with IV
hydralazine PRN. When it became clear that the schedule would
not allow her to go for angio that day, she was permitted to eat
and she received her home HCTZ and Losartan. She continued on
the argatroban drip.
On HD#3, ___ she was prepared to go the the OR the
following day. She was made NPO at midnight and HCTZ and
Losartan were discontined in preparation for angiography. PTTs
were therapeutic on the argatroban drip.
On ___, she went to the operating room for angiography.
For full details please see the dictated operative report; in
brief, left common iliac artery stent was patent, and right
external iliac artery had area of high-grade stenosis which was
stented with good effect. The patient tolerated the procedure
well and returned to the floor in good condition.
On the following day she complained of continued pain not
alleviated by the procedure and was evaluated by the team; it
was determined that her pain was likely chronic and not related
to vascular issues. Follow-up with chronic pain was considered
but patient stated that she has an appointment with orthopaedic
surgery for evaluation and possible steroid injection of the
right hip, and she will follow up with ortho for further
management of pain.
Creatinine on ___ was 0.9, she tolerated a regular diet,
the IV fluids were discontinued, and she ambulated
independently. It was decided that she was appropriate for home
with limited prescription for pain meds. She is discharged to
home without services on ___ with appropriate information,
warnings, prescriptions, and plans to follow up. | 323 | 427 |
10225567-DS-6 | 20,746,341 | Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital because you had bloody bowel
movements.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your blood counts were monitored closely.
- You received 2 blood transfusions to help keep your blood
counts normal.
- You received an angiogram, which did not find a source of
active bleeding.
- You received a colonoscopy, which did not find a source of
active bleeding but found multiple diverticulosis, which leads
us to suspect that your bleeding was due to a diverticular
bleed.
- You received a heart ultrasound (transthoracic echo), which
showed some mild valvular changes in your heart that can be
monitored by your PCP.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with
your doctor
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | TRANSITIONAL ISSUES:
====================
[ ]The GI team recommended a follow-up outpatient colonoscopy in
___ year after discharge, to be arranged by the patient's PCP.
Since colonoscopy screening is not recommended for patients ___
years old, the patient can choose to undergo this colonoscopy in
___ year if it is within his goals of care.
[ ]The patient's LGIB is likely due to diverticular bleed. It is
important for the patient to maintain a ___ diet and
continue with his bowel regimen to reduce risk of constipation.
[ ]His home losartan was held in setting of LGIB. The patient
should follow up with his PCP prior to restarting losartan.
[ ]The patient's TTE showed normal EF with mild aortic stenosis
and mild aortic regurgitation. This can be followed up by his
PCP and monitored outpatient with TTEs every ___ years.
ACUTE/ACTIVE PROBLEMS:
======================
#. Lower GIB
Presented with BPBPR and was found to have gross bright red
blood in the rectal vault on exam. Had an episode of large
volume hematochezia in the ED and received 1u pRBC. Hgb bumped
appropriately to 7.5 from 6.8. CT angio abd/pelv showed findings
compatible with active arterial bleeding in the descending
colon. ___ was consulted and patient was taken for an ___
embolization; however, the mesenteric angiogram was negative for
lower GI bleed so embolization was not performed. His H/H were
monitored with CBCs twice daily, with transfusion threshold for
Hgb <7. His losartan was held in the setting of bleeding. He had
no further episodes of bleeding but Hgb on ___ was 6.9 so he
received a ___ pack of RBCs. During his admission, the patient
was not symptomatic, denying chest pain, shortness of breath or
extertional dyspnea, lightheadedness, abdominal pain. GI
performed a colonoscopy on ___, which did not visualize active
bleeding. Colonoscopy visualized L-sided diverticulosis, which
is likely the etiology of the patient's presenting complaint.
Recommended outpatient colonoscopy in ___ year with PCP and
___ diet. On discharge, patient remains asymptomatic and
Hgb is 7.9, Hct 26.1.
#. Systolic murmur
Physical exam was notable for a ___ systolic murmur, most
prominent in left-upper sternal border. Neither the patient nor
the patient's son were aware of the murmur. The patient denied
symptoms of chest pain or palpitations, exertional dyspnea,
lightheadedness, presyncope/syncope. Outside records were not
available. TTE was performed and showed normal EF and mild
aortic stenosis, mild aortic regurgitation. This can be followed
outpatient with echos every ___ years.
#. Elevated creatinine
Creatinine on admission was 1.6. Patient's baseline creatinine
was unknown; one discharge summary from ___ from ___
mentioned that the patient has a history CKD stage 3 and his
creatinine on ___ was 1.3. During this admission, he did not
have symptoms of dysuria, hematuria, oliguria, or polyuria.
Patient's PCP confirmed that patient does have CKD and baseline
creatinine is 1.5. On discharge, the patient's creatinine is
1.5. | 215 | 472 |
13338150-DS-4 | 23,449,259 | You came to ___ with abnormal liver labs. You had a procedure
to see if the bile duct was blocked, but it looked fine and no
intervention was needed for this. The blockage in bile flow is
likely in a number of small branches of the bile duct due to the
cancer going to the liver. Getting chemo as planned should
decrease the amount of small blockages within the liver and
improve this.
You had minimally-invasive biopsies of the pancreatic cancer
while you were here. The biopsy results are not back, but will
hopefully be available when you see your oncologist on ___
to start treatment.
After your procedure, you had acute urinary retention and needed
a urinary catheter. This is a common problem in older guys and
is usually related to having an enlarged prostate. Please take
the new medications tamsulosin and finasteride to help decrease
the obstruction from the prostate and follow up with a
urologist. If you don't urinate for a day despite trying, this
could mean you are retaining again and you should seek medical
attention.
We also found that you have syndrome of inappropriate
anti-diuretic hormone secretion (SIADH). This is a hormonal
disorder common in patients with cancer. It will make your body
hold onto water. Please make sure you maintain a reasonable salt
intake and don't drink excessive amounts of water.
We stopped three medications: lisinopril (which can be dangerous
for the kidneys in people at risk for getting dehydrated), your
atorvastatin (which can be hard on the liver), and your Tylenol
___ (which might make it more difficult to urinate). | ___ w/ presumed stage IV pancreatic cancer with hep;atic mets
admitted for hyperbilirubinemia. Bile duct was normal on ERCP,
so no stent was placed. Underwent EUS-guided biopsies and has
follow up with oncology (Dr. ___ at ___ in 5 days to
start treatment. His post-procedure course was complicated by
acute urinary retention.
# Hyperbilirubinemia
# Pancreatic cancer
Patient with hyperbilirubinemia and transaminitis that was
concerning for biliary obstruction in the setting of presumed
pancreatic cancer. Patient underwent ERCP evaluation with EUS
with FNB of his pancreatic mass and liver lesions. Bile duct
was patent, so per Dr. ___ hyperbilirubinemia is likely
___ infiltrating metastatic disease in the peripheral liver and
main bile duct and CHD are decompressed. Per the ERCP team,
there is no role for further ERCP intervention and there is no
great target for PTC as well. They anticipate that with
palliative chemo, his bilirubin will stabilize/improve. He will
follow up with ___ oncology on ___ to start
treatment.
#ACUTE URINARY RETENTION
Patient had acute urinary retention after his procedure. Given
the patient's age and the use of anesthetics, cause is presumed
to be medication effect on presumed underlying BPH. A foley was
placed and he was started on tamsulosin and finasteride. He
passed a spontaneous void trial two-days after his procedure He
was told to limit meds that will worsen urinary retention: he
will use opiate analgesics sparingly and stop using Tylenol ___.
# ___.
Cr mildly elevated to 1.4 from baseline 1.1-1.2. Resolved to
1.0 with 3L IVF. His blood pressure was consistently <140/90 on
this admission and he is at risk for poor PO intake and
resultant pre-renal ___ going forward, so his lisinopril was
stopped.
# SIADH
The patient was given aggressive fluids (despite appearing
euvolemic) to help him make urine for a spontaneous voiding
trial; after this, Na dropped to 129. Given underlying cancer,
this is presumed to represent SIADH. He was recommended to avoid
excessive free water intake, although a rigid fluid restriction
was not initiated since he will be at risk for poor PO intake
generally.
# HLD.
Atorvastatin was stopped in the setting of transaminitis.
#CODE: Full (confirmed)
#CONTACT: ___ (patient's son) ___
#CONSULTS: ERCP
#DISPO: Medicine for now
******************* | 269 | 367 |
18715578-DS-38 | 22,629,280 | Dear Ms. ___,
You were admitted to ___ for
abdominal pain, nausea and vomiting. We were concerned about an
infection in your abdomen and put you on antibiotics. While
here, we obtained a CT scan and MRI, both types of pictures of
your abdomen. Both pictures showed that you had a blood
collection near the bone you previously fractured. The
radiologists and vascular surgeons were not concerned for an
active bleed, and the blood collection should resolve on its
own. After seeing the pictures, there was no more concern for
infection and we stopped the antibiotics. Follow up appointments
and information about your medications can be seen below.
It was a pleasure taking part in your care!
Your ___ Team | Ms ___ is a ___ year old woman with a history of
HCV/EtOH cirrhosis c/b ascites, HE, EV, HCC s/p TACE, DM2,
depression presenting with abdominal pain and vomiting.
ACTIVE ISSUES
#Abdominal pain, nausea, vomiting
Patient presents with 3 days of right upper quadrant and diffuse
pain, anorexia, and nausea/vomiting. Vitals were notable for
tachycardia on arrival but no fevers. She received 2 L NS and
tachycardia resolved. Labs showed leukopenia, stable Hgb/Hct and
thrombocytopenia, normalized lactate after fluid administration,
and no evidence of pancreatitis, hepatitis, or
UTI/pyelonephritis. Ucx was negative and blood cultures were
pending at discharge, but patient's HR remained stable and she
was afebrile while in house. CT demonstrated fluid collection
that was hematoma vs infectoin and she was empirically started
on vanc/zosyn. Follow up read of CT and further investigation
with MRI showed that the fluid collection was most likely a
hematoma from her previously fractured ramus. There was also a
pseudoaneurysm noted near the hematoma. ___ did not think there
was an abscess to drain and vascular believed that the
hematoma/pseudoaneurysm would resolve on its own and no
intervention was necessary. Vanc/zosyn was discontinued on ___
and patient remained afebrile.
Supportive care and pain control was provided with PO dilaudid,
nausea control with Zofran. She was also given albumin to
support lower blood pressures, and her BP responded
appropriately, and was at baseline at discharge.
#Cirrhosis ___ EtOH and HCV: Patient's cirrhosis is ___ to EtOH
and HCV complicated by ___ s/p TACE x 2. In the past her
cirrhosis has been complicated by hepatic encephalopathy,
ascites, esophageal varices (2 cords of small varices were seen
in the distal esophagus ___. Not on transplant list due to
recent EtOH use. Currently appears well compensated without
evidence of worsening ascites, active bleeding, or
encephalopathy. Recent CT scan does show new lesions c/w HCC.
She was continued on home lactulose, rifaximin and
spironolactone. She was also continued on thiamine and folate
given history of ETOH abuse.
# Pancytopenia: Noted on prior hospitalization, unclear
etiology. Could be related to underlying cirrhosis, ?MDS.
___ of counts at time of discharge may be ___ to albumin
administration and/or abx administration. We continued
cyanocobalamin, and folate supplement.
#GERD: We continued her home omeprazole
#PSYCH: We continued her home doses of quetiapine, trazodone,
fluoxetine, and pramipexole
Transitional Issues
====================
[ ] Patient's counts were slightly below baseline at discharge.
She's ordered for labs to follow up her counts.
[ ] CT scan shows evidence of ___ recurrence. Not currently a
transplant candidate for ongoing EtOH use. Consider continueing
___ evaluation as an outpatient. | 117 | 437 |
14544923-DS-19 | 29,323,024 | Dear Mr. ___,
It was a pleasure taking care of you.
You were admitted because you were having difficulty breathing.
We suspect you had a pneumonia from aspirating. You were given
antibiotics with improvement.
Please get your INR checked on ___ or ___.
We wish you the best,
Your ___ team | ___ history of CAD s/p remote CABG, combined
systolic and diastolic HF (LVEF 40-50% up from 25%), AFib on
Coumadin, HTN, HLD, COPD and pulmonary fibrosis (home ___ NC
intermittently), OSA not on CPAP and primary hyperparathyroidism
with lung mass noted in ___ which family and patient opted
against workup up for after ___ discussions, Parkinsonism (not
on
therapy), aneurysm in L supraclinoid ICA under surveillance,
progressive cognitive impairment and functional decline, who
presents with dyspnea, hypoxia, suspect aspiration pneumonia
#pneumonia, likely aspiration
#hypoxic respiratory failure
#HF, combined reduced EF with diastolic
#severe COPD:
#ILD:
Patient presented with new O2 requirement (3LNC at rest) over
baseline ___ while ambulating). Suspect aspiration on top of
severe underlying lung disease and likely some component of
volume overload. Patient given CTX/azithromycin (___) as
well as a couple doses of IV Lasix on admission with
improvement. Discussed with family about patient's diet, they
accept risk of aspiration acknowledging that this would likely
lead to further hospitalizations, but they report that the pt
loves to eat. Pt is DNR/DNI. They will modify patient's diet to
decrease risk of aspirating. Pt was seen by SLP to assist with
tips to help lower risk of aspiration. On discharge, pt was on
RA satting 88-93%, which is his baseline. Pt already with
portable home O2.
#Afib: on warfarin. RVR in ED though pt now rate controlled. INR
supratherapeutic at 3.7 on admission, held doses of warfarin and
restarted on discharge at 1mg (previous regimen he was taking).
Discharge INR of 2.1 | 47 | 241 |
17557436-DS-14 | 22,108,170 | Dear Mr. ___,
Thank you for coming to ___!
Why were you admitted?
- You were admitted for pain in your right arm, and you were
found to have a deep vein thrombosis (DVT) related to your prior
___ line
What happened while you were in the hospital?
- You were started on a heparin drip (blood thinner)
- There was no evidence of infection.
- We did not think further blood tests (to evaluate for
coagulation or clotting disorders) were warranted
- You were transitioned to an oral blood thinner
What should you do when you leave the hospital?
- You have one new medication (rivaroxaban): You should take
15mg tablet twice daily for 21 days. Then transition to the 20mg
tablet once daily. You should continue this until for a total of
___ months. You should follow up with your PCP for this.
- You do not need to take aspirin while you are on this blood
thinner.
- Your antibiotic was changed from minocycline to clindamycin
after discussion with Dr. ___. She will call you to
schedule a follow-up.
- If you have worsening pain, then you should call your doctor
or come back.
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team | ___ with a history of osteoarthritis s/p bilateral hip
replacements in ___ and recent left hip prosthetic joint
infection due to coagulase negative staphylococcus being treated
with vancomycin via who presents with right upper extremity DVT. | 200 | 37 |
11258138-DS-15 | 24,067,968 | Dear ___
___ were admitted to the neurology service after presenting to
the emergency department for evaluation of vertigo. Given your
history and physical finding on neurological exam we were
concerned about the possibility of a stroke. During your
admission, ___ were started on aspirin and ___ had a brain MRI
done which showed no acute stroke or hemorrhage. On the day of
your discharge, ___ reported feeling much better and that the
vertigo had resolved. At this time, the most likely cause of
your symptoms is a migraine. For this reason we recommended to
continue your home medications and follow up with neurology as
scheduled with Dr. ___ (___). | ___ female with HTN on progesterone for heavy menstrual
bleeding presents with six days of intermittent vertigo,
nausea/vomiting, and recent onset diplopia.
#Vertigo: The patient was found on exam to have left beating
nystagmus though head impulse testing was negative. Given lack
of consistent peripheral signs of vertigo and suspicion for a
central event, she was started on ASA 81mg. In addition, her
stroke risk factors were assessed, and she was found to have LDL
140 and HbA1c 5.7%. A CT head and CTA head and neck were both
negative for an acute intracranial process. An MRI head was done
to further assess for evidence of stroke, which showed no
evidence of stroke or hemorrhage
Patient was discharged home to continue on her home medications.
Also, recommended to follow up with PCP for evaluation of
elevated LDL. She will follow up with neurology as scheduled.
Prescription for meclizine was provided to use as needed for
vertigo. | 114 | 159 |
16164016-DS-7 | 22,454,843 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on a seven day course of Keppra
(Levetiracetam). This medication helps to prevent seizures.
Please continue this medication for seven days total from the
time it was started (___). It is important that you take
this medication consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | On ___, the patient was admitted from the Emergency
Department to the Neurosurgery service for observation and
treatment of the patient's subdural hematoma in the setting of
home anticoagulation.
On ___, the patient remained neurologically intact and his
epeat NCHCT was stable. His INR normalized to 1.1, and he was
evaluated by Physical Therapy. The ___ service recommended
strongly that the patient be discharged to acute rehab due to
imbalance, unsteady gait. | 417 | 73 |
13557963-DS-8 | 24,479,054 | Dear Ms. ___,
It was a pleasure to ___ for you at the ___
___.
Why did you come to the hospital?
- You were found with a wound on your neck that required urgent
treatment.
What did you receive in the hospital?
- We provided you with pain medication and antibiotics to
prevent infection.
- You underwent a procedure upon arrival to help clean the
wound and promote healing.
- Because your wound began showing signs of an infection, you
underwent a repeat procedure to clean it, and we placed a
special dressing in place that promotes healing.
- The dressing we placed allowed for adequate healing, and on
___ you no longer required it.
- We continued to monitor your lab values and vital signs for
signs of infection.
- Psychiatry has been working with you to address any mental
health needs you have, and we have arranged for you to
eventually receive further ___ at an inpatient psychiatric
facility.
What should you do once you leave the hospital?
- Please attend all follow up appointments as listed below, and
adhere to the following recommendations.
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.
We wish you the best!
Your ___ ___ Team | Patient was taken to the operating room for a neck exploration,
wash out, JP placement, closure on ___ after presenting to
the trauma bay (see the op report for full details). She was
taken to the TSICU intubated and sedated and off pressors, where
she remained stable. a unit of blood was transfused for Hb<7 and
she was later extubated sequentially to room air. she was taken
to the surgical floor with a 1:1 sitter. In the morning of POD2
she was noted to be withdrawn and agitated, and was taken back
to the TSICU for sedation and further monitoring. A CT head did
not reveal any acute intracranial process. She remained stable
after sedation, and was transferred back to the surgical floor
on POD3 in stable conditions. | 384 | 130 |
15332125-DS-12 | 25,451,201 | OK to shower and clean area daily
Take antibiotics as prescribed
Daily packing changes to right breast
Take oxycodone only for severe pain not relieved by Tylenol
and/or ibuprofen | ___ previous BBR for macromastia, recent breast abscess s/p I&D
bedside represented with reaccumulated abscess. It drained
spontaneously at home. When she arrived in the ED, her WBC was
16 with small 2cm collection on US that continued to drain. She
was kept on ancef and her WBC normalized on ___. She is now
stable and ready for discharge with cefadroxil and pain
medication and ___ for dressing changes. | 26 | 69 |
11673731-DS-16 | 22,734,471 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for a urinary tract
infection. We treated your infection with antibiotics and you
improved. You were also noted to have a high sodium level in
your blood. This was due to poor intake of fluids during your
hospitalization. Your sodium level returned to normal with IV
and oral fluids. You should try to drink ___ liters of water a
day to keep your sodium at an appropriate level. You are being
discharged with an antibiotic called cefpodoxime to continue to
treat your urinary tract infection at home. You will complete
your antibiotic course on ___.
It is very important that you complete the entire antibiotic
course and that you do not skip doses. Your course should end on
___ and you should have no more pills after the ___.
You should continue to take your other medications as
prescribed.
You have a follow-up appointments scheduled. This appointment
information is included in your discharge paperwork.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ team | ___ with past medical history of IDDM, hypertension, and CKD
Stage III who presents with cough and lethargy, found to have
___, UTI, and hyperglycemia. | 183 | 27 |
13988233-DS-20 | 20,205,615 | Dear Ms. ___,
You were admitted to the ___
with worsening chest pain going to your back. Imaging revealed a
new penetrating aortic ulcer below your prior stent. Your blood
pressure was carefully monitored. The decision was made not to
proceed with operative intervention. You are now ready to be
discharged home. Please continue to monitor you blood pressure
and make sure it is within goal (systolic less than 120). Please
call your doctor with any questions or concerns. If you have
have new worsening back or chest pain, please call your doctor
or go to the emergency department. Also be on the look out for
dizziness, nausea, vomiting, loose stools or other signs of
dehydration. Call us if you have new worsening belly pain or
weird sensations in your legs. It is very important that you
continue taking your medications as indicated in your discharge
medication reconciliation.
Please call your doctor or nurse practitioner if you experience
the following:
You experience new chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised. | Ms. ___ is an ___ year old woman with a history of a thoracic
aortic aneurysm who had a TEVAR and placement of right vertebral
drug eluting stent done in ___ for a penetrating
aortic ulcer. She had worsening midsternal and epigastric chest
pain that radiated to her back and CTA torso completed at
___ revealed an enlarging distal penetrating
atherosclerotic ulceration with focal dissection superior to the
patent celiac. With these findings, she was transferred to ___
on an esmolol drip. She was admitted to our intensive care unit.
While in the intensive care unit the systolic blood pressure was
eventually controlled on an oral regimen and she was weaned off
the esmolol drip. We initiated lisinopril 10mg qd, and
restarted her carvedilol. Her CTA showed a stable dissection
without evidence of an endoleak at the previously placed aortic
arch stent. Once her pain resolved and she was tolerating a
regular diet she was transferred to the vascular surgery floor
where she remained throughout the rest of the hospitalization.
She was seen by the physical therapist who recommended rehab for
deconditioning. However, after discussion with her son and
involving her and our case managers the decision was made to
send her home per the family's request. She will need close
follow up with her PCP and is discharged home with ___ services
for blood pressure monitoring.
On discharge, she was able to tolerate a regular diet, get out
of bed and ambulate without assistance, void without issues,
pain was controlled on oral medications alone and she was given
the appropriate discharge and follow-up instructions.
She will require a CTA of the abdomen and a follow up with with
Dr. ___ in 3 months. | 383 | 285 |
12542450-DS-26 | 22,556,392 | Dear Mr. ___,
It was a pleasure taking care of you! You were admitted with
fever, and we found that your blood counts were low. We treated
you with antibiotics and performed laboratory tests and imaging
studies to determine the cause of your fever. During your
hospitalization, we had many discussions with you and your
family, during which you decided that you wanted your care to
focus on comfort. In accordance with your wishes, we are
discharging you to hospice, where your care may focus on
comfort.
We wish you the best!
Your ___ Oncology Care Team | Mr. ___ is a ___ year-old gentleman with relapsed FLT3+ AML
s/p URD alloSCT (___) now on sorafenib /decitabine who
presents with fever this hospital stay for whom we are treating
and workup up for neutropenic fever.
He was recently admitted to ___ for neutropenic fever, rectal
abscess and initiation of new chemotherapy regimen ___.
In between these admission he had discussion with Dr. ___ relating that he was considering options such as
hospice, but was willing to continue chemotherapy as of ___.
He has since been admitted for febrile neutropenia ___. Since
admission patient and his wife have started to express desire to
consider switch to hospice care if patient failed to have a
short term hospital course.
At this time patient has required daily pRBC and plt
transfusions, and
is on IV vancomycin and cefepime for febrile neutropenia. On
discussions with both him and his wife on ___ and ___, he
reports that he feels he is at a juncture where he wants to
decline taking futher pills, including transfusions and
chemotherapy, and focus on quality of life.
It was discussed in detail with the patient that prognosis
without interventions will likely reduce life expectancy from
weeks-months to days-weeks, as patient is continuing to require
IV antibiotics and blood product transfusions. Patient (with and
without wife present) states he is aware that his life
expectancy would change and declared that he would want to
pursue hospice.
We spoke at length about contingencies with regards to symptoms
and developed the following plan for his treatments for
transition to hospice.
Diabetes: Medications at this time of little benefit. stopped
insulin, oral hypoglycemic and fingersticks
Pain: Uptitrate oxycodone prn.
Anti-emetics: Will continue Ativan, Zofran po prn, and started
dexamethasone po prn. Hospice was contacted for an IV PRN order.
He will need port accessed on discharge so patient can have prn
IV Zofran if needed.
Blood products: Patient received transfusion 1U pRBC on ___
prior to discharge. Labs discontinued. Also ordered 1U pRBCs for
symptomatic relief to be administered following transition to
hospice, after which further blood products will be deferred.
These will be administered at 3PM on ___ floor on ___
and ___.
TRANSITIONAL
============
- Patient has IV breakthrough dilaudid and IV Zofran scripts
sent with the patient ___ cannot fill this, but
patient's wife informed that she can fill these scripts close to
home).
- PO pain pain, bowel, and nausea medications sent home via
___ bedside delivery.
- pain: oxycodone 10mg q4hr
- bowel regimen: senna, docusate, miralax
- nausea: Ativan 1mg q6h, Zofran 8mg q8h, dexamethasone 4mg
q12h
- Patient to get 2 additional blood transfusions over the next
week at ___. These are scheduled for 3PM on ___ ___ floor
on ___ and ___. He may decline these. They are for symptomatic
relief only. Do not check CBC. | 96 | 468 |
12904194-DS-4 | 26,065,234 | You were admitted for cellulitis of the left leg. You improved
(slowly) with IV antibiotics.
Please take Keflex four times daily after discharge. I have
given you a longer course of treatment than usual because your
immune system is suppressed to treat your recent UC flare and
your body is not very good at fighting infections right now.
If the redness spreads, or if you have fevers or chills, please
see a doctor for re-evaluation. If you feel like the infection
is getting worse again, you should NOT get more Remicade unless
GI tells you explicitly that it's OK. If you keep getting
better, no specific follow up is needed and you can get Remicade
as sheduled. | Mr. ___ is a ___ male with a history of ulcerative
colitis previously controlled without medication but with flare
3 weeks ago requiring prednisone and Remicade (at ___, who
presents with a red rash in two places on his left lower
extremity concerning for cellulitis.
#CELLULITIS OF LLE
Erythema and swelling, which appears clinically consistent with
cellulitis. He had a pattern of lymphangic spread to the medial
thigh, which generally is suggestive of streptococcus pyogenes.
He was treated with IV vancomycin, which was then switched to IV
Ancef with ongoing improvement. He is discharged on Keflex.
Giving a longer course (10 days total Abx) due to his slow
improvement and immunosuppressed status.
#TINEA PEDIS
Clotrimazole cream for tinea pedis BID x4 weeks.
#Rash
The patient has a residual orange-colored subcutaneous deposit
on the left posterior calf. The substance is hard and has
micro-nodular texture when palpated. This is of unclear etiology
but it is not spreading and does not appear like any
complication of cellulitis that I know of. He is advised to not
worry about it if it goes away, but to seek derm evaluation if
it persists or spreads.
#Ulcerative colitis:
Patient with previously well controlled UC who recently was
treated at ___ with severe flare. He was started on Remicade,
and on prednisone taper currently at 30mg daily. | 117 | 216 |
17028437-DS-22 | 25,817,306 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain. You underwent multiple tests including a
CAT scan, blood tests and urine tests that did not show signs of
infection or other serious process. Your tests did show mild
dehydration, which resolved with fluids. Your pain resolved and
you requested discharge home. | This is a ___ year old female with past medical history of
dementia, type 2 diabetes, hypertension, obstructive sleep apnea
on nocturnal O2, lumbar spinal stenosis, several recent
admissions for abdominal pain attributed to recurrent urinary
tract infections, admitted ___ w acute onset abdominal
pain, status post workup including CT and CTA imaging, UA
without clear evidence of UTI, polymicrobial urine culture, with
pain rapidly resolving before arriving the floor, remaining pain
free while under observation overnight, now requesting discharge
home
Active
# Abdominal Pain / Acute Kidney Injury - patient presented to ED
with abdominal pain, similar to prior presentations; workup in
ED only remarkable for ___ pain resolved before arrival to the
floor; workup included CBC, CMP, UA, Urine culture, and CT and
CTA imaging without clear causative etiology. Only notable
finding was Cr 1.1 (baseline 0.8), anion gap 20, lactate 2.6.
All resolved with fluid resuscitation. Patient was monitored
without need for additional pain medication. In prior similar
situations she has been treated for UTI; however, on this
admission there were no clear signs to suggest UTI (few bacteria
on UA, polymicrobial suggesting contamination on urine culture),
or other infection (no fevers/chills, leukocytosis, or
localizing signs on exam including dysuria). Team believed risk
of antibiotics (diarrhea, resistant infections) outweighed
benefit in this patient without convincing evidence for UTI.
Her Lasix was held (was being used for lower extremity edema per
report). After discussion with patient and son, she was
discharged home with scheduled PCP ___.
Inactive
# Hypertension / CAD - continued home amlodipine, metoprolol,
ASA, fish oil. Held simvastatin given potential for interaction
w amlodipine. Instructed patient to continue holding until
___ visit with PCP.
# COPD - continued inhaled fluticasone
# Chronic Pain - continued gabapentin
# GERD - continued ranitidine
# Diabetes type 2 - continued home NPH and sliding scale insulin
Transitional Issues
- Unclear what causes recurrent abdominal pain, but in this
case, broad work-up did not yield cause and symptoms rapidly
resolved
- Discharged home with services, home safety evaluation and home
social work
- Full code | 61 | 348 |
13603392-DS-20 | 29,164,879 | Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having severe abdominal pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you medicine to help with your abdominal pain.
- We did some labs to see if there was any damage to your heart
and did not see any.
- You had a stress test which showed your heart function was
normal. You did not have any concerning symptoms that needed
further cardiac evaluation.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is an ___ male with CAD s/p CABG,
AAA, and PUD who presented with progressive epigastric pain.
ACUTE ISSUES
============
# Epigastric Pain:
# GERD, history of PUD:
# History of CAD s/p CABG:
Admitted with burning abdominal pain and radiation to the back
and chest. EKG unchanged from prior. Troponins negative x2. Pain
similar to GERD pain but more severe; different from pain
preceeding CABG. CT with stable AAA, no acute abdominal process;
lipase normal at OSH. Given tenderness on palpation, increased
likelihood of abdominal etiology; pain significantly improved
with GI cocktail. Sent H. Pylori which was pending at time of
discharge. Patient remained hemodynamically stable. Given strong
cardiac history, exercise MIBI performed which showed no
evidence of ischemia.
CHRONIC ISSUES
==============
# DM2: Held home metformin and managed with insulin sliding
scale while admitted.
# HTN: Continued home HCTZ and verapamil.
# Prostate CA: s/p radiation and hormones in ___, now with
rising PSA. Underwent Lupron injections in ___ but was unable
to tolerate due to side effects. L4-5 uptake on bone scan.
Complaining of low back pain with TTP over spinous process in
lumbar region. Strength ___ ___ B/l and pt without bowel/bladder
incontinence. No concern for cord involvement at this time. CT
demonstrated no osseous lesions or fracture. Plan from oncology
has been to observe unless PSA rises further or symptoms worsen,
at which point targeted radiation could be considered.
TRANSITIONAL ISSUES
===================
[ ] Follow up back pain; if worsened would warrant MRI L spine
for investigation given previous bone scan with inc. uptake in
L4-L5.
[ ] Follow-up H. pylori stool Ag which was pending at time of
discharge. | 122 | 265 |
14009425-DS-2 | 22,499,309 | You were admitted to the hospital for your abdominal pain.
Imaging using ultrasound was performed of your liver,
gallbadder, and pelvis, and a CT was also performed of your
abdomen and pelvis. These showed some edema and lymphadenopathy
in your liver and gallstones in your gallbladder. They did not
show signs of gallbladder inflammation or obstruction. There
were also no signs of ovarian torsion.
Your pain is likely due to biliary colic, which is a condition
related to gallstones that can cause pain in the right upper
abdomen. The pain is worsened by eating large fatty meals. You
were given medications for pain and nausea and started on a
medication called ursodiol which can help treat biliary colic.
You were also started on ibuprofen as needed for pain, as
ibuprofen is thought to help with pain related to biliary colic.
During this admission, you were found to have an abnormal lab
test that suggests infection with hepatitis C (a positive
hepatitis C virus antibody, which indicates you have been
exposed to hepatitis C at some point in the past). A test of
your hepatitis C viral load was sent and is pending at the time
of discharge.
Following discharge:
- continue taking ursodiol 300mg twice a day
- continue taking ibuprofen 600mg every 8 hours as needed for
pain
- follow up in surgery clinic to discuss the option of getting
your gallbladder removed
- follow up with a liver doctor to discuss the results of your
hepatitis C testing and further management
- follow up with your primary care physician to discuss the
results of remaining tests, including tests for the sexually
transmitted infections gonorrhea and chlamydia | REASON FOR ADMISSION:
___ w acute right-sided abdominal pain x 1 day. | 270 | 11 |
10502365-DS-19 | 26,148,167 | You were evaluated at ___ for
your symptoms of facial weakness and double vision. We
evaluated you with studies including a lumbar puncture which was
unremarkable for any central nervous system infection, and an
MRI study which showed no acute abnormalities apart from
inflammation of a nerve which controls the muscles of the right
face. We believe your symptoms are due to a viral illness which
caused inflammation of the nerves and thus are causing the
facial weakness, and the double vision you are experiencing.
To treat the inflammation, we are discharging you on a course of
a steroid called prednisone to decrease the inflammation and
increase the speed at which your symptoms resolve. PLEASE NOTE,
if your symptoms of double vision worsen, or you experience
other symptoms different than those currently reported, you will
need to return to the emergency department for further
evaluation, promptly. | Ms. ___ is a ___ year old right-handed woman with a past
medical history of migraine headaches and family history of
multiple sclerosis who presented to the ___ ED on ___ with a
right facial droop, unsteadiness and diplopia. Neurologic exam
was remarkable for right sided facial weakness with right
abducens nerve palsy. NCHCT was unremarkable. She was admitted
to the neurology general wards service for further evaluation.
# NEUROLOGY
The initial differential for pt's presentation including
new-onset multiple sclerosis, neurosarcoidosis, aseptic
meningitis, and viral illness. She underwent a MRI of the brain
with and without contrast, chest CT and lumbar puncture for
further assessment. MRI showed asymmetric contrast enhancement
of the distal condyle ictal portion and first genu of the right
facial nerve with no evidence for demyelinating disease or other
signal abnormalities in the brain parenchyma, compatible with a
viral illness. Chest CT showed no hilar or mediastinal
lymphadenopathy concerning for sacoidosis. The lumbar puncture
was unremarkable with normal protein, glucose, and cell counts.
The MS profile was negative and the ACE level was normal in the
CSF. Cryptococcal antigen was negative and gram stain and
culture were negative.
Because imaging and CSF studies were negative, multiple
sclerosis, neurosarcoidosis and aseptic meningitis were
unlikely. Cranial nerve inflammation was attributed to a viral
illness. Pt clinically improved during hospital stay. She was
provided with an eye patch and gel to sleep at night to protect
her right eye. On day of discharge, right facial muscles had
minimal activation. Pt had a persistent right abducens nerve
palsy, however. She was started on a prednisone taper on day of
discharge to treat a possible viral infection. She will
follow-up closely with her outpatient neurologist, who she has
seen prior for migraine.
For pt's history of migraine, she was continued on her home
topamax and nortriptyline while in the hospital. On day of
discharge, she experienced a typical migraine that responded to
sumatriptan.
#HOSPITAL ISSUES
Pt was given heparin SQ for DVT prophylaxis while in the
hospital. She remained full code.
==========================
TRANSITIONS OF CARE
==========================
Ms. ___ presented with a peripheral right CN VII palsy and
right CN VI palsy. Work-up including chest CT and CXR (to assess
for sarcoidosis) was negative. LP was unremarkable. MRI showed
only inflammation of the right facial nerve. Pt was discharged
on a tapering course of prednisone for presumed viral-induced
cranial nerve inflammation. CSF fungal culture was pending at
time of discharge, please follow-up with these results. Serum
ACE level was also pending at time of discharge. | 149 | 413 |
13188363-DS-25 | 27,642,670 | * You were admitted to the hospital to work up your complaints
of difficulty swallowing, abdominal pain and diarrhea. All of
your tests including CT scans, barium swallow and endoscopy show
marked improvement and no source for dysphagia. Your stool
sample showed no infection but the diarrhea may be from dumping
syndrome post op. You should continue full tube feedings until
you feel like eating more.
* Flush your J tube 3 times a day with 30 mls water.
* J tube feedings: Jevity 1.5 at 20 cc's/hr, increase by 10 cc's
every 8 hrs to reach your goal rate of 70 cc's/hr. You can also
cycle the feedings over 18 hrs at 90 cc's/hr (from 4PM to 10 AM)
* Change the dressing over your left neck daily and more often
if it drains.
* Shower daily. OK to get the feeding tube wet, just pat dry.
* Increase your activity daily to improve your endurance.
* The pain clinic will help you wean some of your narcotics.
* Call Dr. ___ at ___ if you have any new
concerns or ddifficulties. | Mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further work up
of his dysphagia and diarrhea. He was cultured in the Emergency
Room as he had a fever prior to admission. He also had some
erythema around his J tube site. A chest and neck CT was done
which ruled out any leak, obstruction or distension and his
admission WBC was 12K. His blood culture grew coag negative
staph and he was placed on IV Vanco pending more blood cultures.
A barium swallow was done the following day which also ruled out
a leak and he began a liquid diet. He had a persistent pinhole
opening in his right neck which occasionally would drain
whatever he was eating but it was much less than his prior
admission and will eventually seal over in time. He was
encouraged to resume his tube feedings although he was
reluctant. He complained of persistent diarrhea as well. A stool
for C difficile was negative. Subsequent blood cultures were
also negative therefore his Vancomycin was stopped, assuming the
first culture was a contaminent. He remained afebrile.
He subsequently underwent an endoscopy on ___ which looked
great, the conduit was totally patent, no abnormal tissue to
biopsy and no clear reason for him to have dysphagia. The
Nutritionist discussed ___ with him in detail as it
seemed to be a strong possibility in light of his symptoms and
he was willing to avoid concentrated sweets from his diet. His J
tube feedings were resumed and a goal rate of 70 cc's/hr over 24
hrs was recommended, but he preferred doing feedings overnight
and will try to get cycled over 18 hrs at 90 cc's/hr.
He will be following recommendations from the BI pain clinic to
attempt to wean his narcotics and will also meet with his new
PCP, ___. In the interim he will continue a short
course of Augmentin to treat his superficial abdominal wound
infection which is clearing nicely. After an uncomplicated stay
he was dischanged home with ___ services on ___ and will
follow up with Dr. ___ on ___ at 1 ___.. | 180 | 365 |
15453014-DS-16 | 21,118,860 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital with
throat pain and were found to have a retropharyngeal abscess.
You were taken to the OR and the abscess were drained. After
your surgery you were monitored in the intensive care unit and
did well. You were continued on intravenous antibiotics.
There was concern that the infection was not improving and you
had a repeat CT scan. This showed that the abscess was actually
slightly larger than before. You were taken back to the OR for a
second drainage of the abscess and had drains placed. You did
well after the surgery and you continued to improve. The drains
were removed. You will finish a course of intravenous
antibiotics for your infection at home.
Please avoid showering for the next three days. Please keep your
wound clean with gauze and change the dressing daily. If have
you any questions or concerns about the wound, please call your
surgeon at ___. Please do not hesitate to come back to
the ED if you have any fevers or other concerns. You will
follow-up with the surgeon next week to remove the sutures.
Your appointments with your primary care doctor and surgeon are
listed below.
All the best,
Your ___ Team | Mr. ___ is ___ man with poorly-controlled
DMII and hypertension who presented to the ED from an outpatient
___ clinic visit after an outpatient CT demonstrated organized
retropharyngeal abscess s/p drainage by ENT on ___.
# Retropharyngeal Abscess: He is s/p drainage by ENT evening
___. He received 10 mg IV decadron and was continued on
unasyn. He was admitted to the MICU for close airway monitoring.
He was NPO for the first 24 hours following surgery. The patient
was called out to the floor after observation in the MICU,
without any acute events. He did well without difficulty
handling secretions and his diet was advanced. However, ENT
repeat scope on ___ showed increased right lateral pharyngeal
wall edema and fullness extending from oropharynx down to
pyriform sinus. He had a repeat CT neck which showed slight
worsening of the retropharyngeal abscess. He was brought back to
the OR on ___ for a transcervical drainage of
retropharyngeal abscess. Infectious Disease was consulted and
recommended broadening antibiotics to vancomycin, cefepime, and
flagyl. Wound culture grew mixed flora with ___ and
coagulase negative staph. He was evaluated daily by ENT via
bedside scope exam which showed improving pharyngeal wall
edema/fullness. A PICC line was placed on ___. ID
recommended a 14-day course of ertapenem. He received a dose of
ertapenem in the hospital which he tolerated and was discharged
home to complete his course of antibiotics. His pain was
controlled with tylenol and oxycodone. Pathology from the first
surgery was negative for malignancy.
# Hyponatremia: Resolved. Patient initially with mild
hyponatremia 130. Possibly secondary to acute infection vs
SIADH.
# Hypertension: His home losartan and HCTZ were continued.
# DM II: Poorly-controlled, last A1c of 11.8 on ___. ___
consulted at last admission. Continued home lantus and HISS.
# Microcytic Anemia: Recorded history of hemoglobinopathy. Labs
notable for microcytic anemia with baseline hemoglobin ___. No
electrophoresis in outpatient record.
==================== | 216 | 314 |
14113477-DS-6 | 27,967,512 | Mr. ___, you were admitted due to abdominal pain and
diarrhea. This was found to be due to an infection called
C.diff. You will need to complete 2 weeks of treatment with oral
vancomycin and follow up with Dr. ___ a colonoscopy.
You were found to have thrush and were started on a medication
called nystatin. Please continue this medication for 7 days.
Please call your doctor if your symptoms have not improved near
the end of your therapy. | ___ w/? ulcerative colitis presented with 4 days of abdominal
pain, nausea and diarrhea found to have Cdiff colitis.
Sepsid ue to acute Cdiff colitis with question of underlying
ulcerative colitis. Pt initally started on empiric cipro/flagyl
and underwent sigmoidoscopy given question of ulcerative
colitis. Found to have severe colitis. Biopsies were taken and
additional stool cultures sent. Cdiff then returned positive and
pt transitioned to oral vancomycin, as well as IV flagyl due to
concern for complicated C diff due to possible underlying IBD.
He ws then switched to just oral vancomycin, and will need to
complete a 2 week total course of therapy, and follow up with GI
for UC management and consideration of full colonoscopy.
Dehydration/Hypokalemia/Hypomag: He had significant hypokalemia,
hypomagnesemia during hospitalization, which resolved with
repletion and was likely related to diarrhea.
Coagulopathy: likely nutritional in etiology. He was treated
with vitamin K, without significant improvement, with INR 1.5.
Thrush: was started on treatment with nystatin with improvement.
Plan for 7 day course of therapy post discharge. | 78 | 171 |
12297892-DS-12 | 26,653,503 | Dear Mr. ___,
Why did I come to the hospital?
-You came to the hospital after you fell.
What happened while I was in the hospital?
-We took pictures of your arm and we found that you broke your
arm.
-Your liver tests were abnormal and this is because you had
alcoholic hepatitis, which is damage to the liver due to
alcohol.
-You also developed low blood counts. This was because of the
bleeding in your arm.
What should I do when I leave the hospital?
-You should not drink alcohol as this will damage your liver
-You should continue taking your medications as prescribed
-You should continue to work hard to strengthen your body so
that you gain strength
Best,
Your ___ Team | ___ hx alcohol abuse and alcoholic cirrhosis, HTN, HLD,
presented to ___ ___ s/p fall with alcoholic hepatitis and R
humerus facture.
#R HUMERUS FRACTURE:
#R RADIAL STYLOID FRACTURE:
Evaluated by Orthopaedics, found to have R oblique humerus
fracture, placed in coaptation splint and sling. R hand and
wrist films showed nondisplaced small fracture of the radial
styloid: this was not thought acute. He was recommended to have
___, and will follow-up with Orthopaedics as an outpatient.
#ALCOHOL ABUSE
#ALCOHOLIC HEPATITIS:
#CIRRHOSIS:
Pt has history of cirrhosis thought due to alcohol with previous
labs that included a TF sat 31.5%, AMA negative, ___ negative,
ceruloplasm 38 (wnl range), Alpha 1 antitrypsin 238 (slightly
above range). MRI of abdomen in ___ revealed cirrhosis. Hx of
ascites, which resolved with diuretics. No varices.
This admission, he had a DF of -49 and MELD 8 on presentation.
His presentation with ALT/AST < 300 with elevated T bili and INR
from baseline were thought consistent with alcoholic hepatitis.
He was intoxicated in the ED and had an elevated alcohol level.
He was treated with CIWA, IV (then PO) thiamine, folate, and a
multivitamin. Social work was consulted and met with the
patient.
His liver issues were addressed conservatively with nutrition
and IV fluids. His LFTs, bilirubin and INR were trending down
upon discharge.
#THROMBOCYTOPENIA:
As low as 52 during hospitalization. Likely combination of
thrombocytopenia from acute ETOH toxicity in setting of
alcoholic hepatitis (which is usually temporary) and splenic
sequestration. Thrombocytopenia improved upon discharge.
#ANEMIA:
Hb 11.7 upon admission. Hb 10.7 in ___. Iron studies with
evidence of ACD. Guaiac negative and no external hemorrhoids on
exam x2. Hb dropped to 6.6 on ___. CT of the torso ordered w/o
evidence of bleed. CT of the R arm with significant hematoma.
Hepatology was consulted and performed EGD on ___ and there was
no active bleed. Pt received 1 unit pRBCs on ___, stable since.
Hgb drop attributed to large right arm hematoma with fractured
humerus.
#URINARY TRACT INFECTION:
Pt complained of urinary symptoms. U/a with WBCs and bacteria.
Nitrite negative. Culture was not able to be drawn on same urine
sample and revealed mixed flora. Pt was treated with oral cipro
500mg BID.
#GASTRIC MASS:
The gastric mass was found on variceal screening in ___.
Several EUS's have been performed to evaluate, and biopsies/FNA
have been unrevealing. ___- 3- 4cm mass with central
umbilication at the antrum. Multiple large gap biopsies were
performed of the mass. These demonstrated ulcerations with acute
and chronic granulation tissue. ___- 4-5 cm lobulated
gastric mass in the antrum along the ___ curvature. Tissue
was soft to manipulation with the forceps. Biopsies again showed
sntral mucosa with foveolar hyperplasia and granulation tissue.
Repeat EGD was performed during hospitalization on ___: the
mass appeared the same in size and there was no active bleeding.
Pathology revealed only a hyperplastic polyp. | 113 | 471 |
17126352-DS-12 | 25,665,914 | Dear ___,
___ were admitted to ___ and
underwent evaluation for deep vein thrombosis. No new findings
were identified, although we did note the presence of a chronic
clot in your right femoral vein. With the improvement of your
symptoms and our negative testing, ___ are now ready to be
discharged. If ___ have recurrence of your symptoms or develop
leg pain, leg swelling, chest pain, difficulty breathing, or
other symptoms which are concerning to ___, please go to the
emergency room. ___ should follow up with your normally
scheduled ___ clinic appointment to make sure your INR
stays at a therapeutic level following your hospital admission.
Sincerely,
___ Vascular Surgery Team | Mrs. ___ was admitted on ___ from ___ for
evaluation of RLE DVT while on anticoagulation with coumadin.
Mrs. ___ labs were repeated upon admission which showed
that her INR was therapeutic, thus a heparin drip was not
immediatly required. Her coumadin and metformin were held and
she was made NPO in anticipation of a possible procedure. A CT
of her lower extremities was performed which did visualize a
clot but was complicated by a mistimed bolus of contrast. Venous
doppler was performed which did demonstrate a chronic appearing
non-occlusive thrombus in the R femoral vein, but no findings in
the popliteal or other veins to correlate to the patient's right
calf pain. Flow in the R iliac vein appeared normal. Clinically
Mrs. ___ was asymptomatic for the entirety of her admission,
and her INR was noted to be therapeutic on three consecutive
blood draws spaced 6 hours apart. It was determined no
interventions were required at this time and Mrs. ___ was
discharged with follow up at her regularly scheduled coumadin
clinc. | 113 | 174 |
17747005-DS-2 | 25,048,682 | 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.
-For your seizure you were started on a new medication
zonisamide. The zonisamide wills starte at 100 mg qhs on ___
with titration to 200 mg qhs on ___, then 300 mg qhs
the week after that.
ANTICOAGULATION:
- Please take heparin SC 5000units TID daily for 4 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- NWB LUE, ok for ADL, no abduction over 90 degrees, ROM as
tolerated otherwise
- please wear TLSO while OOB and while in the bed above 30
degrees
follow up:
Please follow up with ___ in the orthopedic trauma
clinic ___ days from discharge for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with the ___ in 2 weeks their number
is ___
Follow up in neurology clinic with Dr. ___ in the
___ Building of the ___ of ___ in ___.
Please call the office at ___ for questions or to
schedule appointments. We are planning to schedule your followup
appointment for ___ at 1:00pm, the same day as your
upcoming Sleep appointment.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Driving instructions
As discussed, by ___ law you cannot drive for 6 months
after ___, the day of your last seizure causing loss of
consciousness. Please obtain assistance with transportation to
your appointments here in ___.
Danger signs:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
NWB LUE, ok for ADL, no abduction over 90 degrees, ROM as
tolerated otherwise
WBAT BLE. When OOB and when head above bed greater than 20
degrees needs to be in TLSO
Treatments Frequency:
NWB LUE, ok for ADL, no abduction over 90 degrees, ROM as
tolerated otherwise
WBAT BLE. When OOB and when head above bed greater than 30
degrees needs to be in TLSO | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left proximal humers fracture and a L4 and T12 burst
fracture and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for his
left humerus fracture, which the patient tolerated well (for
full details please see the separately dictated operative
report). For his spine fractures he will be undergoing non
operative management with a TLSO brace. 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. On
POD 1 the patient became tachycardic and desaturated on the
floor. He was admitted to the TSICU for concern for PE. A CTPE
was done which was negative but he was started on levoquin for
pneumonia on POD 1. The patient was given perioperative
antibiotics and anticoagulation with subq haparin was started on
POD 2 per the orthopaedic spine recommendation. On POD 2 the
patient came out of the ICU and did well on the floor. Pneumonia
was ruled out and his antibiotics were stopped. He had elevated
CKs during the ICU and was treated for rhabdomyolitis and his
CKs were trended daily. On POD 5 his CK and electrolytes had
normalized. On POD 3 he was fitted for his TLSO and upright
films were obtained showing no kyphosis of the spine and
acceptable alignment. The patients home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
Neurology also was seeing the patient for his seizures. There
were following closely and recommended zonisamide 100 mg qhs
with titration to 200 mg
qhs after a week, then 300 mg qhs the week after that.
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 NWB LUE and WBAT on BLE while
wearing his TLSO and will be discharged on subq heparin 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. | 475 | 419 |
16120907-DS-13 | 24,590,345 | Ms. ___ were admitted to the surgery service at ___ for evaluation
of abdominal pain, nausea and no ostomy output. ___ were found
to have blood infection and were started on antibiotics. ___ are
now safe to return home to complete your recovery with the
following instructions:
.
Please call Dr. ___ office at ___ option 4 if ___
have any questions or concerns.
.
Please continue routine Ileostomy Care as before. | The patient well known to ___ service was re-admitted for
evaluation of the abdominal pain, nausea and decreased ostomy
output. On admission, patient was afebrile with WBC within
normal limits, her Cre was elevated concerning for dehydration.
Patient was started on IV fluids. Abdominal CT demonstrated
small bowel ileus, interval decreased rectal bed fluid
collection, she was made NPO and NG tube was placed. Patient's
blood cultures from ED was positive for GPR, and she was started
on Zosyn and ID team was consulted. On HD 2, ID recommended to
continue Zosyn. Patient's ostomy stool output improved. She
remained with elevated Cr secondary to dehydration and large NGT
output, she was continued on IVF and received IV boluses.
Patient reported to have nonproductive cough for last 2 month,
and IP was consulted. On HD3, patient underwent small bowel
study, which demonstrated mild to moderate esophageal
dysmotility and mild gastroesophageal reflux. Neck CT was
obtained per IP request and demonstrated no acute abnormalities
of the neck. Patient was started on Fluticasone Propionate. NG
tube output decreased, ostomy output increased and NGT was
removed. Patient will have a follow up with IP with PFT in
___, she will continue on inhaled cortical steroids until
follow up. Patient's diet was advanced to clears. Blood
cultures were positive for Clostridium species. Patient was
noticed to have leukopenia with WBC 2.6, which can be related to
Clostridial toxin, Zosyn or rectal bed fluid collection. On HD
4, patient's diet was advanced to regular, she continue to have
intermittent nausea, but was able to tolerate diet. She remained
afebrile, leukopenic, her follow up blood cultures were
negative. On HD #5 ID switch antibiotics regimen to meropenem
500 mg IV q6h for empiric coverage on which she was discharged
home.
.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 69 | 342 |
18713769-DS-4 | 29,107,954 | Dear Ms. ___,
It was a pleasure to care for you at ___.
WHY WERE YOU ADMITTED?
- You had chest pain.
WHAT HAPPENED THIS ADMISSION?
- You received another cardiac catheterization to visualize the
blood vessels supplying your heart. It did not find any
abnormalities that needed intervention. We do not believe your
chest pain is related to a lack of blood flow towards your
heart.
WHAT SHOULD YOU DO ON DISCHARGE?
- Follow up with your doctors as below.
- Take your medications as prescribed.
- If you have more chest pain, please re-present to care.
We wish you the best,
Your ___ team | ___ y/o female with PMHx significant for HLD, PCOS,
hypothyroidsm, asthma, and recent NSTEMI with spontaneous
coronary artery dissection with DES x2 to LCX on ___ and ___
who presented with chest pain, concerning for unstable angina in
the setting of known residual disease and a positive stress test
1 week ago.
===============
ACTIVE ISSUES:
===============
# Chest pain with c/f Unstable Angina:
# CAD s/p DES x2:
Patient presented with chest pain that was substernal and
relieved by nitroglycerin; she also had left shoulder pain which
may have been MSK pain as it was improved with lidocaine patch.
Trops this admission were persistently negative despite ongoing
intermittent chest pain. Unclear if her chest pain was truly
cardiac in nature. Recent cath at ___ showed residual
moderate to severe diffuse disease in the mid and distal LAD and
exercise MIBI showed reversible mod-severe perfusion defect in
the distal inferior wall involving part of the apex region. She
received cath on ___ which did not show any abnormalities or
disease that would be responsible for her symptoms, though she
was noted to have a narrow distal LAD; no intervention was
needed or performed. Given reassuring catherization, absence of
ischemic changes on EKG, and negative troponins, we do not
believe that her chest pain symptoms are related to myocardial
ischemia. Differential includes esophageal spasm given relief
s/p nitro, or reflux iso DAPT. She was continued on aspirin 81
mg qd, ticagrelor 90 mg PO BID, Lopressor 12.5 q6, Atorvastatin
80 mg PO QPM, ranolazine. Home imdur was fractionated to isordil
and uptitrated, reconsolidated to imdur 60 daily on discharge.
# Anemia:
Normocytic anemia with stable hgb in ___ this admission. Of
note, last hgb in our system in ___ was in the ___ range.
Unclear timeframe of anemia. Patient does report having one
heavy period since being started on DAPT recently.
================
CHRONIC ISSUES:
================
# PCOS
Held home metformin while inpatient; restarted after discharge.
# Hypothyroidism:
Continued Levothyroxine Sodium 88 mcg PO DAILY
# Stress incontinence:
Home Trospium non-fomulary while inpatient so held, restarted
after discharge.
# GERD:
Continued Omeprazole 20 mg PO DAILY
====================
TRANSITIONAL ISSUES:
====================
[] Please ensure she sets up follow up appointment with ___
cardiologist Dr. ___. Attempted to make follow up appointment
prior to discharge but unable to reach his office.
[] Monitor BPs for hypotension given imdur was uptitrated this
admission.
[] Monitor for recurrent chest pain; consider that differential
also includes likely non-cardiac causes such as GI (ex.
esophageal spasm with chest pressure) or MSK (ex. shoulder
arthritis with left arm pain). Given reassuring cath, ekg, and
enzymes, chest pain does not appear to be related to myocardial
ischemia.
# CODE STATUS: FULL (presumed)
# CONTACT: ___ (SISTER) - ___
Greater than 30 minutes spent on discharge planning. | 106 | 454 |
19199655-DS-18 | 27,516,803 | Ms. ___,
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight-bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
Weight-bearing as tolerated, right lower extremity
Range of motion as tolerated
Treatments Frequency:
General postoperative care
Wound monitoring
Dry sterile dressing as needed
Elevation
Lovenox education | ___ w/ open tibia fx s/p I&D & IMN. Met all criteria for safe
disposition. Cleared by ___ for home w/ services. LVX for 4
weeks. | 199 | 26 |
19981210-DS-31 | 25,095,273 | Dear Mr. ___,
You came to ___ because you were having shortness of breath
and leg and abdomen swelling consistent with heart failure
exacerbation. You were also in atrial fibrillation.
While here, you had an echocardiogram which showed decreased
ejection fraction. You also had a right heart catheterization
which confirmed fluid overload.
You underwent cardioversion which successfully converted you out
of atrial fibrillation, and you have been in normal sinus rhythm
since.
Now that the extra fluid has been diuresed off and you have been
transitioned to oral diuretic medication you are ready to be
discharged to continue your recovery at home with home visiting
nurse service. You will need to have labs drawn on ___. This
can be done either by the visiting nurse or at a lab.
It is important that you continue to weigh yourself every
morning, call MD if weight goes up more than 3 lbs. Continue to
eat a sodium restricted (<2000mg) diet and take your medications
as directed below.
Thank you for allowing us to participate in your care. | ___ with h/o CAD s/p 2v CABG (LIMA-LAD, SVG-LPL) in ___ and
multiple stents, bicuspid aortic valve s/p AVR ___, atrial
fibrillation/flutter, and tachy-brady syndrome s/p PPM placement
in ___ presented w/SOB found to have CHF exacerbation, now s/p
successful cardioversion and diuresis. Has been in NSR since
cardioversion.
ACTIVE ISSUES
=============
# Systolic and Diastolic HF: Pt reported increasing SOB in the
setting of abdomen and ___ edema and slight weight gain. CXR
showed pulmonary edema and bilateral pleural effusions which are
increased from prior. Elevated BNP. Repeat TTE ___ with
decreased EF from ___ (50% -> 35%), worsened TR and MR. ___
suspicion for low gradient low flow AS based on Dr. ___
___. Right heart cath ___ significant for elevated filling
pressures, with further diuresis recommended. Ddx for CHF
includes CAD (Stress test with new defect with LCx territory),
amiodarone toxicity. Afib also may have contributed; now in
sinus s/p cardioversion. Pt remained volume overloaded so
diuresis was continued and prior to discharge ___ was
transtioned to PO torsemide (had been on lasix 20mg PO daily at
home).
# CAD: Last TTE showed left ventricular systolic function as low
normal (LVEF = 50%) with mild global hypokinesis. Troponin 0.06
on admission labs, up to 0.10, down to ___ AM. Likely
secondary to CHF exacerbation and not ACS. ___ did have an
episode of chest discomfort ___ AM which he attributes to his
afib/anxiety. Similar to his chronic episodes at home, and EKG
unchanged. Likely represent chronic angina, pt reports episodes
when HR>100. Repeat TTE with EF worsened to 35%. Restarted
beta-blocker ___. Stress test ___ showed for moderate size,
moderate severity defect seen in the left circumflex territory.
Will hold off on cardiac cath for now, may reconsider
outpatient. ___ was discharged on increased valsartan dose
from 60mg (home) to 80mg. He was continued on home ASA/plavix,
atorvastatin, imdur, and metoprolol as below.
# Afib/Aflutter: CHADS 2 = 3 (HTN, age, DM). ___ on coumadin
5mg qd at home however INR supratherapeutic on admission so
intially held. Of note, pt had recent cardioversion which failed
to convert back to sinus rhythm. Pacer interrogation ___
significant for persistent AF since ___ with average V rates
<100bpm, max V rate 137 bpm, and 34% V pacing since ___. Per
EP recs, considering re-attempt at cardioversion now that he has
received higher dose amiodarone x 1 month. INR down to 2.7 on
___ labs and warfarin restarted at home dose. Metoprolol
restarted ___ at 12.5 qd (had been on previously then
discontinued by ___ outpatient secondary to worsening
asthma/COPD so had not been taking prior to admission), then
uptitrated to 25mg qd ___. Now s/p successful cardioversion ___
AM. Rhythm remains regular. Home diltiazem discontinued ___.
Metoprolol increased to 50mg qd on ___. On discharge,
amiodarone dose decreased to 200mg qd.
# Leukocytosis: pt with persistent leukocytosis, up to 13 on AM
labs ___, ___ elevated at 12.6 ___. UA ___ without evidence
for UTI. Pt without any symptoms or clinical signs of infection,
likely a stress response.
# Abdominal distension: Also present on ___ recent
admission where he was fluid overloaded; attributed to volume
overload at that time and reduced with diuresis. Now resolved
with diuresis.
CHRONIC ISSUES
==============
# HTN: continued home regimen as above, with newly increased
valsartan dose, and added metoprolol on this admission.
# T2DM: held home metformin while inpatient, and ___
received sliding scale insulin.
# Asthma: on home symbicort, albuterol PRN. Pt received Advair
in house as symbicort not formulary and pt did not have his
inhaler with him.
# GERD: continued home pantoprazole
# BPH: continued home tamsulosin
TRANSITIONAL ISSUES
===================
-___ being discharged home with ___ to help with medication
changes, heart failure teaching
-Will have labs drawn ___: INR, electrolytes that should
be followed-up
-TTE with significantly decreased EF since 6 weeks prior
-Consider repeat TTE on an outpatient basis now that pt is
diuresed
-Multiple cardiac medication changes: please refer to sheet | 172 | 665 |
18997295-DS-16 | 27,045,243 | Activity
Resume activity as tolerated.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
Medications
You may take Ibuprofen/ Motrin for pain.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
New weakness or changes in sensation in your arms or legs.
Difficulty urinating or incontinence of bowel and/or
bladder. | The patient was admitted to the neuroscience floor for close
monitoring on ___.
On ___, OSH imaging and neurologic exam were reviewed with Dr.
___ at the bedside where patient reported pain on
palpation to thoracic and lumbar spine and remained otherwise
neurologically intact. A CT of the thoracic and lumbar spine
were ordered and results are consistent with previous MRI
findings of chronic compression fractures in addition to a
subacute fracture at T11. No brace is needed for stable
fractures and patient is neurologically stable to discharge to
home.
At the time of discharge, Mr. ___ was afebrile, hemodynamically
and neurologically stable. | 114 | 103 |
15622839-DS-21 | 24,714,601 | Dear Mr. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You initially had arm and leg pain, but on presentation you
were found to have low blood pressures and to be confused.
WHAT HAPPENED IN THE HOSPITAL?
- You were diagnosed with a urinary tract infection.
- Your low blood pressure was because of your infection, and
also because your body is not able to produce its own steroid
hormones well ("adrenal insufficiency").
- You received antibiotics.
- You received high doses of steroids.
- You had an evaluation of your swallowing and there was concern
about you inhaling and choking on your food, called aspiration,
which can cause pneumonia, but you and your family decided to
accept these risks so you can eat.
WHAT SHOULD YOU DO ON DISCHARGE?
- Please take your medications as prescribed.
- Please go to your follow up appointments as scheduled.
- Weigh yourself every morning, call MD if weight goes up more
than 3 pounds in one day or 5 pounds in one week.
You can do some things to help decrease your risk of inhaling
food:
- have someone help you eat
- eat sitting straight up
- don't talk or do other things while you eat
- take small bites and sips
- don't eat and drink at the same time (eat, then drink)
- eat SLOWLY
- stop eating if you cough, have to clear your throat, or your
voice changes
We wish you the best,
Your ___ team | ___ male with history notable for CAD s/p CABG in ___
(SVG-LAD, SVG-PAD, SVG-OM), ischemic CM with HFrEF(EF 40%),
HTN, h/o DVT, AF (on warfarin), tachy-brady syndrome s/p
pacemaker (___), DM, CKD, adrenal insufficiency, and prior
multidrug resistant E. Coli UTI, who presented with sepsis,
found to have UTI. | 248 | 50 |
16571396-DS-12 | 21,265,242 | You were admitted to the the acute care surgery service after
being attached while you were drinking at a bar. You required
intubation while in the hospital and you suffered a left orbital
floor facial fracture and a small head bleed that does not need
any further intervention. You also suffered from a nasal
fracture. Please call the plastic surgery clinic and follow up
with them for further intervention and possible reduction.
Please take the medications as prescribed below. | The patient was admitted to the trauma ICU after being
assaulted. He has a small SAH and his neuro exam ans CT head
scan were monitored. He was successfully extubated on HD 1 and
his diet was advanced. He will be discharged today and follow up
as outlined below. | 79 | 49 |
16853729-DS-14 | 28,112,579 | Dear Ms ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital because of severe headache and
dizziness. We found that your blood pressure was dangerously
high. A scan of your head showed no abnormalities, and lab
tests showed was no damage to your heart. We tried to do an
ultrasound to look at the function of your heart, but you did
not tolerate the test. We increased your blood pressure
medicines to help bring your pressure down, and we gave your
pain medicine for your headaches. Your pain and your blood
pressure both improved with these medications.
Changes to your medications:
INCREASE Lisinopril to 30mg by mouth daily
START Imitrex ___ as needed for headache
START Ibuprofen 2 tabs as needed for headache (do not take more
than 2 pills/day)
STOPPED Atenolol
Thank you for allowing us to participate in your care. | ___ yo F with hypertension, DM2 and dementia who was admitted
with dizziness and hypertensive urgency.
ACTIVE ISSUES BY PROBLEM:
# Hypertensive urgency - Given lisinopril 20 mg in the ED with
minimal improvement in blood pressures, remained in the 180-190s
systolic the following morning. Atenolol was held due to
dizziness, lisinopril was up-titrated to 30 mg, and hydralazine
was used PRN with good response. Her blood pressure also
improved with better treatment of her headache. She was
discharged on lisinopril 30mg daily and isntructed to stop her
atenolol.
# Dizziness - unable to clearly define if her dizziness was
vertigo vs lightheadedness, as she gives inconstistent responses
and it is unclear if she understood the questions, even through
an interpreter. Did have bradycardia on admission, so her
symptoms may have been due to orthostasis from beta blockade. No
arrhythmia seen on ECG or on telemetry monitoring. Cardiac
enzymes negative. Other possible etiologies included vascular
event such as cerebellar stroke, so neurology service was
consulted. They felt her symptoms were not related to a stroke,
but rather orthostasis. Her beta blocker was stopped and she was
instructed to not continue taking this on discharge.
# Headaches - Patient cannot describe location or quality, but
suspect headache was related to hypertension, less likely
migraine vs tension headache. Unclear headache history,
daughter says she complains of headaches and general body pain
every day, so it is hard to parse out if this headache was
different. No neurological deficits, no acute abnormalities
seen on head CT. Initially had some concern for acute bleed,
considering she often gets up at night and could have fallen,
however there was no bleed seen on CT. She was treated
symptomatically with toradol and standing tylenol with some
improvement. She was discharged with a prescription for imitrex
to try as an abortive agent for migraines while at home and
ibuprofen.
# Bradycardia - HR in ___ after taking atenolol on morning of
admission. Given the possible contribution of her beta blocker
to her presentation, this was stopped. | 155 | 355 |
17853367-DS-18 | 27,100,413 | Dear Mr ___,
It was a pleasure caring of you at ___.
WHY WAS I ___ THE HOSPITAL?
- You were admitted to the hospital because you fell and broke
bones ___ your head, which resulted ___ bleeding ___ your brain
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- You received imaging studies confirming multiple bleeds ___
your brain and a broken bone ___ your skull. No surgery was
deemed necessary but you were placed ___ a collar for protection
of your neck.
- You developed diverticulitis and pneumonia, which were treated
with antibiotics and placement of a drain ___ the abscess ___ your
abdomen
- You developed blood clots ___ her lungs and legs and were
started on a drip of a blood thinning medication
- You had bleeding from your stomach and required blood
transfusions
- You had a tube placed ___ your stomach to give you nutrition
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please be sure to follow up with your appointment with Dr
___ ___ ___
- Please see the recommendations below from the neurosurgery
team regarding traumatic brain injuries
We wish you the best!
Sincerely,
Your ___ Team
================================
RECOMMENDATIONS FROM NEUROSURGERY:
================================
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.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications:
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness ___ the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | Mr. ___ is a ___ with HTN, EtOH use disorder
who presented on ___ as a transfer from ___ after an
unwitnessed fall, found to have skull fracture and multiple
areas of bilateral intracranial hemorrhages (___, ___, IPH) but
not requiring neurosurgical intervention. He was noted to have
multiple neurologic deficits, including aphasia, right sided
weakness. His hospital course was complicated by acute
diverticulitis and sigmoid colon abscess requiring JP drain
placement, as well as DVT and bilateral pulmonary embolisms. He
also developed an acute upper GI bleed from peptic ulcers,
resulting ___ hypovolemic shock and MICU transfer. He was
subsequently called back out to the floor, where he was
maintained on anticoagulation for PE and had a G-tube placed for
nutrition. | 598 | 121 |
19295574-DS-6 | 25,556,745 | Dear Mr. ___,
You were admitted transferred from the ___ ICU to the ___
___ ICU after a fall, and then transferred to our medicine
floor. You were found to have low blood counts and slightly low
blood pressure.
We were worried your blood counts might be low from bleeding,
but the counts were stable here and we don't think there's any
bleeding. Your blood pressure was also stable. Because of low
potassium, we decreased your dose of furosemide (Lasix). We feel
it's safe for you to return to ___.
Please take all of your medications as prescribed as follow up
with all appointments. It was a pleasure to take part in your
medical care.
Sincerely,
Your ___ Health Team | Mr. ___ was admitted as a transfer from the ___ ICU
after a fall when he was found to be borderline hypotensive and
pancytopenic. After further investigating it was found that that
the patient has baseline low BPs, and the pancytopenia has been
chronic over the course of years. There was initial concern for
GI bleed given hemoglobin in ___ range, but patient was stable
during his admission and he received 1U PRBCs in the MICU with
appropriate increase in Hct. His abdominal pain was stable at
his baseline. MELD labs were stable. Pt notably low potassium to
2.9 on ___ presumed due to Lasix, repleted by discharged but
Lasix dose changed to 20mg BID from 80mg BID. He was maintained
on home spironolactone. Of note, his NSAIDS were stopped given
his risk of GI bleeding and low Hct reserve.
# Pancytopenia: Patient presenting with Hgb 7, which is stable
from recent outpatient labs at the beginning of ___. Per talks
with ___ patient has been pancytopenic
for years. Has been noncompliant with appointments with GI and
hematology for workup, but during prior admissions to Good
Same___ was reportedly seen by these specialists. Cause
unknown at this point, possible marrow suppression in setting up
hepC/cirrhosis. Hemoglobin was stable inpatient in ___, did
not require transfusion. Discharged in stable condition,
appointment with hepatology and recommendation for heme/onc
followup.
# Hypotension: Patient presented with BP ___, which the
patient reports is at his baseline. He has been in the low 100's
and is asymptomatic. No e/o infection, and bcx with no growth.
Restarted Lasix/spironolactone. Per conversation with patient
and nursing home patient runs low normally, does not have
history of hypotension or orthostatic hypotension, discharged
with stable BPs.
# Abdominal Pain: Patient with abdominal pain which he reports
has been present for the past two months but acutely worse on
the day of admission. Denied any fevers but did report some
chills and nausea, concerning for possible SBP. However, bedside
US did not show large pocket of ascites to tap and no e/o portal
vein thrombosis. Pain attributed to underlying cirrhosis,
continued PO PPI and discharged in stable condition on admission
pain regimen.
# Cirrhosis: Patient with cirrhosis ___ HCV complicated by
ascites, HE, and varices. Last EGD at ___ in ___ per pt
report, and he reports that he has had varicies in the past.
Lasix and spironolactone restarted given ascites on CT scan and
HD stability. Continue Lactulose 30 mL PO QID and Rifaximin 550
mg PO BID, held Nadolol in setting of borderline hypotension.
Base on hypokalemia on ___, reduced dose of furosemide to
20mg BID from 80mg BID, held spironolactone dose the same.
Nadolol was initially held in the setting of concern for
hypotension (as above), but it was restarted at the time of
discharge.
# History of fall: patient fell when out having a cigarette on
___, sustained some facial trauma and peripheral abrasions
but got up and was asymptomatic, admitted to ___ ICU, where
the patient was mildly hypotensive with SBP 90/50 which prompted
admission to the MICU. Per nursing home patient has history of
falls, not related to hypotension but because patient is
non-compliant with rolling walked. Patient had no falls
inpatient, discharged in stable condition with recommendation to
use rolling walker.
# Chronic pain: Patient with diagnosis of chronic pain and has
been taking PO opioids as an outpatient. Continued OxyCODONE SR
(OxyconTIN) 30 mg PO Q8H, increased OxyCODONE to 20 mg PO q6h
PRN pain while acute abdominal pain, discharged with adequate
pain control.
# BPH: Continued Tamsulosin 0.8 mg PO QHS.
TRANSITIONAL ISSUES
===================
[] Furosemide was decreased to 20mg PO BID
[] Ibuprofen was stopped
[] Potassium chloride pills were stopped
[] Follow up with hepatologist Dr. ___ on ___
at 4:20 ___
[] Please draw chem-10 on ___ given changes to Lasix dosing
and recent hypokalemia
[] Patient would likely benefit from hematology consult in the
outpatient setting if he is willing | 116 | 652 |
14658826-DS-19 | 26,619,202 | Dear ___,
___ were admitted to the hospital for workup of your headache.
___ had your port removed and your headache improved. Your brain
MRI showed that your lung cancer has likely spread to your
brain. ___ do not need emergency treatment for this however ___
will discuss with Dr. ___ in her office at 3:30 ___ ___ your options moving forward. In addition, Radiation Oncology
will call ___ on ___ to schedule an outpatient consultation.
___ can reach them at ___ if ___ do not hear back from
them by 3 pm. | Mrs. ___ is a ___ with MM (never treated) and recurrent stage
IIIa NSCLC who is admitted for persitent port related pain and
headache.
# Port site pain: Removed on day of admission. Pain greatly
improved. Could consider infection given recent increase in
pain, but no clinical signs of infection around site. Cultures
pending. No antibiotics were administered.
- f/u port cultures
# Headache: Patient with a long history of migraine, often
exacerbated by pain meds. Suspect may be an exacerbation of her
typical headaches in setting of worsening port site pain. Brain
MRI revealed numerous small metastasis to the brain without
evidence of swelling, midline shift, nor mass effect. Her
headache had nearly resolved and now ___ which is her
baseline x ___ years. Her neuro exam was non-focal. Radiation
oncology was consulted but pt and husband did not want to wait
to see them. Radiation oncology resident informed me that her
office will call pt on ___ to arrange a consultation for likely
WBR. She will see her primary oncologist this ___ to
discuss the results. No steroids or anti-epileptics are
indicated at this time.
# Multiple Myeloma: Stable and followed as outaptient
# NSCLC: Has had multiple rounds of different chemotherapies.
Has remained relatively stable on navelbine. Held navelbine
C10D15 on day of admission. Additional plans per outpatient team
to be discussed this ___.
FEN: Regular, encourage PO, replete electrolytes
PPX: HSQ
ACCESS: PIV
CODE: Full (confirmed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (Husband) ___
DISPO: Home today
NOTE: >30 min were spent coordinating care for discharge
______________
___, D.O.
Heme/Onc Hospitalist
___ | 92 | 264 |
17219004-DS-20 | 27,798,089 | Dear Ms. ___,
You were admitted to ___ for confusion, and found to have a
urinary tract infection requiring ICU admission. You improved
quickly and were transferred to the medical floor. You were
prescribed an antibiotic to treat the infection. Your heart rate
was fast, and your diltiazem was temporarily increased and your
coreg was reinitiated. Over time, with adequate treatment with
the UTI, your HR improved and the diltiazem was returned to its
regular home dose.
You will be discharged to rehab for general strengthening. You
will be continued with antibiotics till ___. We wish you the
best! | ___ with history of receptive and expressive aphasia from prior
stroke in ___, a fib on rivaroxaban who presents to the
emergency department from home for concern of increasing
confusion and lethargy, admitted to the MICU for sepsis ___ UTI,
started on broad spectrum antibiotics and called out to the
floor. Antibiotics were tailored to ciprofloxacin. She did have
episodes of a fib with RVR, which were managed with extra dosing
of PO diltiazem.
# Sepsis ___ UTI: Patient with tachycardia and fever in the ED
concerning for infection, elevated creatinine, elevated lactate.
Initially on vanc/cefepime. She had a positive UA growing
citrobacter and was switched to ciprofloxacin Currently
improving s/p abx and volume resuscitation. Continued cipro for
~10 days (longer course due to complicated UTI, sepsis). She
continued to do well with the antibiotics and had no further
episodes of fever, leukocytosis or confusion.
# ___: Resolved - initially with elevated creatinine to 1.2
from baseline around 0.8. Likely pre-renal due to sepsis and
poor PO intake. Resolved.
# CV: HTN, CAD, Afib w/RVR on Xarelto. During this
hospitalization, she developed afib with RVR in setting of
infection. She is on diltiazem and xarelto at home. Patient with
deeper TWI on EKG in ED, worsened from prior. Possibly rate
related. Troponins negative, no CP or SOB concerning for angina.
She was given increased dose of dilt and then with treatment of
infection, her HR returned to ___ - with evidence of NSR. She
was placed back on her home dosing of dilt back to home 30 mg
QID. Also on coreg. The rivaroxaban dosing is lower than usual
- and despite efforts to communicate to Dr. ___ not
establish whether this was the optimal dose. This can be
addressed as an outpt. Continue atorvastatin
# TWI: Patient with deeper TWI on EKG in ED, worsened from
prior. Possibly rate related. Troponins negative, no CP or SOB
concerning for angina.
# Rectal ecchymosis. Patient has a large circular ecchymotic
area surrounding her rectum which is non-tender. FICU nurse
signed out to floor nursing that they were concerned re: home
situation (this was not signed out by MD). Placed SW consult for
assistance, possible elder services involvement. Very low
suspicion for elder abuse based on interactions with the
family.
# Hx of ischemic strokes: Stable. Has hx of both expressive and
receptive aphasia; does better reading words than listening to
them. No new focal neurologic deficits. We continued
rivaroxaban, atorvastatin.
# Hypertension: Held home antihypertensives
# Hyperlipidemia: continued atorvastatin
# Hypothyroidism: continued levothyroxine
TRANSITIONAL ISSUES
# Communication: HCP: ___ home: ___, cell
___
# Code: DNR/OK to intubate
- Consider alternative dosing of rivaroxaban. | 102 | 461 |
16335352-DS-24 | 22,954,992 | Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ for fever and
confusion. You were given antibiotics for a likely infection on
your right lower leg. You will need to continue these
antibiotics for a total of 7-days (last day ___.
Please follow-up with your primary care provider (see upcoming
appointments below) to ensure resolution of your infection. | PRIMARY REASON FOR HOSPITALIZATION:
___ y/o male with EtOH cirrhosis complicated by esophageal
varices s/p TIPS, who p/w with fever and abdominal pain. | 67 | 22 |
18022845-DS-8 | 27,522,677 | Dear Mr. ___,
You were admitted to ___ after
a fall from a roof and you had loss of consciousness, a
concussion, a small puncture of your left lung, left lung
bruising, left and right wrist fractures and a spleen laceration
with associated bleeding. For the spleen laceration, you were
taken to the procedure room with Interventional Radiology and
underwent embolization of the bleeding artery. You had repeat
imaging which demonstrated that the bleed was stable. The
Orthopedic Surgery service was consulted for your wrist
fractures. Your right wrist fracture was reduced in the
emergency room and splinted, and your left wrist fracture was
also splinted. Surgery was not indicated and it was recommended
that you refrain from bearing weight on your forearms. You have
worked with Physical and Occupational Therapy and you are now
ready to be discharged home with outpatient occupational therapy
services to continue your recovery. Please note the following
discharge instructions:
Instructions regarding your spleen laceration:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Instructions for your left and right wrist fractures:
-Do not bear weight on both forearms.
-Elevate both arms on pillows at all times while sitting or
lying down to prevent swelling
General Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Mr. ___ is a ___ y/o M who presented to ___ s/p fall
from roof. He had +LOC and he was found to have a small left
pneumothorax, pulmonary contusions, b/l distal radius fractures,
splenic laceration with pseudoaneurysm . In the ED, the
patient's right wrist was reduced by orthopedic surgery and both
wrists were splinted. The patient was taken to Interventional
Radiology and attempted distal splenic artery embolization,
however during the procedure, the patient moved his leg and
tried to get off the table and he developed a proximal splenic
artery disection. He, therefore, underwent splenic embolization
proximally with a large plug. The procedure went well. HCTs
were trended and the patient received 1u PRBC. After 1U PRBC,
HCT remained stable. The patient had repeat imaging, including a
CTA on HD3 and HD7 which demonstrated decrease in the size of
the retroperitoneal hematoma and that the splenic artery
reconstitutes distal to the Amplatzer plug through collateral
vessels. Once HCTs were stable, the patient was started on a
regular diet which he tolerated well. Given that the patient is
on methadone at home, the Chronic Pain Service was consulted and
medication recommendations were provided and implemented.
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. | 495 | 252 |
18395075-DS-21 | 28,776,243 | Dear Ms. ___,
You were admitted to ___ worsening facial swelling and left
arm swelling, after a recent admission for similar symptoms. You
underwent a CAT scan which showed relatively stable obstruction
of your superior vena cava (SVC), which is the cause of your
symptoms. You have already undergone radiation therapy for this
and often, it takes several weeks to see the full effects of
radiation therapy.
While you were here, you were found to have low oxygen level
while walking. We set you up with oxygen at home. You should use
this when you are active, to maintain an oxygen saturation of
>92%.
Please continue to take lovenox (enoxaparin) twice a day. Please
continue your prednisone taper as previously prescribed. Please
follow up with your oncologist on ___.
If you notice chest pain, difficulty breathing, significant
headache, or confusion, please call your oncologist or present
to the Emergency Department immediately.
It was a pleasure taking care of you,
Your ___ Care Team | Ms. ___ is a ___ female with a history of metastatic NSCLC,
recently found to have SVC occlusion and SVC syndrome s/p
radiation treatment, who presented with worsening facial
fullness and left upper extremity swelling. CT scan showed
unchanged adenopathy with ongoing near occlusion and possible
invasion of SVC. LUE ultrasound showed no DVT. She was seen by
vascular surgery, who did not feel that stenting was indicated
at this time. Radiation therapy also reviewed the case, who felt
that there was no role for additional radiation therapy acutely.
During admission, patient was also found to have oxygen
desaturation with ambulation, likely due to underlying
malignancy (CXR without fluid overload and on systemic
anticoagulation making PE less likely). Patient was discharged
with home O2
#hypoxia: patient has been on room air, however on ___ was
found to be hypoxic saturating 88-89%, particularly with
ambulation. CXR PA/Lat ___ without any acute changes, including
no pna or edema. PE on differential, though patient already on
anticoagulation. Likely related to underlying malignancy. ___ be
related to SVC syndrome, though this is less likely. Thus,
patient was discharged with home O2.
# SVC syndrome: Symptoms progressive despite XRT. Relatively
stable imaging on repeat CT in the ED. Vascular surgery was
consulted, given that her symptoms were not immediately
life-threatening, they did not recommend stenting. Per radiation
oncology, her XRT results may take additional ___ weeks to see
full effect.
#Left upper extremity swelling: no s/s of infection, U/S
negative for thrombophlebitis or thrombosis. CT imaging on
admission to the ED was unchanged for prior. Likely related to
known SVC syndrome.
# Metastatic NSCLC: Progressed through second line palliative
nivolumab, to which she developed hepatitis requiring high dose
steroids. She is currently on a steroid taper. Will need to
follow up with her outpatient oncologists about any additional
palliative chemotherapy.
***TRANSITIONAL ISSUES***
-patient discharged on home O2 to use with ambulation. Continue
to wean/titrate as able
-continue enoxaparin 60mg q12h for SVC syndrome
-continue prednisone taper: ___ start 50mg, on ___, on
___, on ___, on ___ on ___ STOP
-Code: Full
-Contact: Husband ___
(___) ___
(___
(___ | 160 | 345 |
14920863-DS-13 | 27,370,847 | Dear Ms. ___,
You were admitted after a fainting episode. We observed you
overnight, and feel that this event was similar to your prior
fainting episodes. You do have evidence of anemia which is mild
and may be due to poor nutrition. We recommend that you follow
up with Dr. ___ how to deal with this long term.
In the short term, we are not concerned for any active bleeding
or other dangerous ongoing process. | Ms. ___ is an ___ year old woman with a history of
hypothyroidism and recurrent syncopal episodes througout her
adult life who presented with syncope x 2 consistent with prior
episodes of vasovagal syncope.
#Syncope: Likely vasovagal syncope in the setting of large BM
and self described "dehydration". Seizure less likely given no
post ictal state and normal workup ___ years ago. No evidence of
arryhtmia or structural heart disease (normal echo in ___ and
no new murmurs, normal EKG/tele). Subacute blood loss less
likely (see anemia below). Orthostatic vital signs after 3L NS
were normal. TSH was unrevealing, and was able to ambulate
without difficulty. Coccygeal pain treated with tylenol.
# Anemia: Hematocrit was normal and at baseline upon admission,
but dropped to 32 after 3L NS consistent with hemodilution.
Likely that baseline hematocrit has dropped and initially was
hemoconcentrated upon admission. Normal prior c scopy in ___
with hemorrhoids, guiac negative stool on exam. Iron studies
consistent with anemia of chronic disease, and B12 normal. This
will require outpatient follow up and possible non-urgent upper
endoscopy if anemia persists or further stool studies
demonstrate guiac positive stool.
#Hypothyroidism: Levothyroxine was continued.
#HLD: Simvastatin was continued. | 78 | 206 |
12856008-DS-11 | 28,923,736 | Mr. ___,
It was a pleasure taking care of you. You were admitted with
right leg pain. We were concerned that this was related to your
circulation, so we performed an angiogram. While it did
demonstrate that you have peripheral arterial disease, it did
not explain your pain. It is likely that this pain was in part
from your neuropathy. You might need a procedure in the future
to improve your blood flow, but it is not necessary at this
time. No changes were made to your medications. It is very
important that you remain on your aspirin and statin every day
and follow up with Dr. ___ in one month. It is very
important for your health to quit smoking. | Mr. ___ was admitted to the vascular surgery service and
started on a heparin drip with concern for ischemic rest pain.
He underwent ABI of his right lower extremity, which read 0.6.
Pulse volume recordings are monophasic and dampened throughout.
He tolerated Heparin well. His pain resolved with narcotic pain
medication. He underwent angiogram on ___, which demonstrated
severe PVD that was unlikely to be the cause of his acute pain.
No intervention was made as it was felt that it would not have
benefited the patient. He was started atorvastatin and his
anticoagulation was discontinued. There is no indication for
anticoagulation. He was discharged home in stable condition.
Smoking cessation is reviewed. He should remain on his aspirin
and statin. Aside from the addition of statin therapy, no
changes were made to his medications. He will follow up in 1
month to discuss elective revascularization intervention. | 128 | 159 |
13369123-DS-19 | 21,956,174 | Dear ___ , it was a pleasure taking care of you in ___.
You were admitted to the ED with abdominal pain. You had a
workup done which included Lab works and a CT of your abdomen.
These ruled out any intra abdominal pathology.
You were treated with IV fluids and pain medications and you
responded well. You are now ready to be discharged back to your
rehab facility for further recovery with the following
recommendations:
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. | Ms. ___ with the above mentioned HPI is s/p ostomy takedown
and ileostomy she had sigmoidectomy for ischemic colon w
perforation with ___ procedure c/b ischemic colostomy
needed to be taken down. the patient had exploratory laparotomy
with primary colorectal anastomosis and protective ileostomy.
This was c/b wound infection and currently she is been taken
care of in a rehabilitation facility. She came from rehab
complaining of lower pelvic pain and transferred to ___. On
exam, no distress without peritonitis. Wounds with granulation
and no evidence of infection. Ileostomy appears functional.
Patient was admitted for observation. CT revealed only a 5 cm
fibroid. No leak and no abscess. No obstruction.
The patient was Hydrated and treated with pain medication
(Tramadol and Tylenol). On the day of her discharge she seems to
be very comfortable but still some complains of deep pelvic
discomfort. No leukocytosis or evidence of sepsis. No acute
surgical problem. CT also noted slight dilatation of pancreatic
duct and slight elevated lipase; but her discomfort is in her
lower pelvis and cannot be explained by theses findings. UA
-WNL.
As her medical condition seems stable with no acute surgical
pathology she is now being discharged back to her rehabilitation
facility for further recovery. | 294 | 208 |
16006141-DS-10 | 25,329,761 | Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for confusion and was found to have a urinary tract infection.
We started you on antibiotics and you improved. You had no
fevers and were much oriented and able to carry conversation by
discharge.
Please CONTINUE the antibiotic, amoxicillin, for 6 more days,
THROUGH ___.
You also had multiple episodes of elevated blood pressures and
were started on Amlodipine 5mg daily. Please continue to take.
If you have any side effects such as dizziness, or leg swelling,
please stop taking the medication.
You also developed some diarrhea while you were in the hospital.
This is likely a side effect of the antibiotic and should
resolve after you complete the antibiotic course.
We wish you all the best,
Your ___ Team | Mr. ___ is a ___ with PMH signficant for ___ body
dementia, seizures, gout and recurrent UTIs who presented w/ 1
day hx AMS and fever with a positive UA concerning for UTI.
#Fever: Enterococcal UTI. Patient was initially on ceftriaxone
and switched to augmentin (day ___, end date ___
once organism and sensitivities retured. Patient has history of
recurrent UTIs, review of micro data shows that no organisms
have been detected in the past but this time had enterococcus
(amp sensitive. LP done in ED was WNLs but still received
meningitic dosing of Vanc/CTX in the ED.
#Altered mental status: Waxing and waning and at baseline. AMS
on presentation likely related to fever/ acute infectious
process as above on top of baseline poor mental status. Patient
might have been more difficult to arouse on hospital day 1 as he
also received IV morphine and ativan in the ED for agitation
following his LP. His mental status was back to baseline prior
to discharge with ability to hold conversation and oriented x1
throughout and x3 (on and off)
# Hypertension: Patient had episodes of hypertension (in the
170s-180s systolic) while inpatient. Was started on a low dose
of amlodipine 5mg daily.
# Diarrhea: Nurse reported 2 episodes of diarrhea. Most likely
in the setting of abx.
# ___ body dementia: Baseline mental status as above, will
continued on home namenda
# Seizure d/o: Stable, no evidence of seizure currently. Unclear
when last seizure was. Continued home keppra.
## TRANSITIONAL ISSUES:
- complete 10 day course of amoxicillin, THROUGH ___
- started amlodipine 5mg daily for hypertension | 130 | 265 |
17451383-DS-9 | 26,082,858 | Dear Mr. ___,
Thank you for seeking your care at ___.
You were admitted for 5 weeks of left neck and arm pain. For
this, we obtained imaging of your neck and arm, which revealed
evidence of a possible bone infection in your neck spine as well
as bony changes of the spine and vertebral discs that could also
result in nerve pain. The orthopedic doctors determined there
was no indication for any emergent surgical intervention.
For the possible bone infection, we discussed the risks and
benefits of a bone biopsy and it was determined that the
anatomical approach to biopsy your vertebrae was not safe.
Therefore, we decided to treat the presumed bone infection with
antibiotics, which you will complete on ___.
For your arm and neck pain, the physical therapy team also
worked with you to improve mobility of your left shoulder.
Continued ___ after you leave the hospital may result in improved
mobility of your shoulder.
Importantly, we also adjusted your pain medication. We realized
that the oxycodone and dilaudid was not adequately treating your
arm and shoulder pain and putting you at risk for falls.
Alternatively, we continued you on Gabapentin, Cyclobenzaprine,
Lidocaine patches, and an less sedating pain medication called
"Tramadol".
We also discussed goals of care with you and your family and it
was felt that you would benefit greatly from rehab after
discharge from the hospital. Given that your arm and neck pain
was in the setting of a possible fall weeks ago, rehab will help
you become more steady on your feet and hopefully improve the
pain in your shoulder and arm, which the ___ chronic pain team
felt was due, in part, to a type of injury called "frozen
shoulder" or "adhesive capsulitis". The main mode of treatment
for this condition is physical therapy.
We wish you all the best. Please remember to take your
medications and attend all your follow-up appointments.
Warmly,
Your ___ Team | ___ previously on hospice for decompensated NASH cirrhosis with
PMH significant for CAD (s/p RCA stent in ___ and LAD stent in
___, HTN, dyslipidemia, CLL s/p chemotherapy about ___ years
ago, and DM II, presenting with 5 weeks of neck/L arm pain in
the setting of possible fall 8 weeks prior to admission.
#L arm and neck pain: MRI c-spine, CT c-spine, and MRI shoulder
were obtained of the patient's neck and left shoulder. Imaging
showed no acute fractures or significant cord compression that
would require emergent surgery. However, there was concern for
osteomyelitis and discitis at C6-C7 on the c-spine MRI with
phlegmonous changes. It was not clear if this was the etiology
of his pain as it was felt that the pain localized to his left
shoulder and arm was more consistent with an adhesive capsulitis
vs. radiculopathy pain syndrome. Ultimately, it was felt that
his pain may be multifactorial and the risks and benefits of
treating the presumed osteomyelitis/discitis were discussed with
the patient and his family. Ultimately, orthopedics felt he was
not a candidate for open surgical biopsy due to his significant
medical comorbidities and ___ felt there was no safe approach for
cervical bone biopsy given proximity to the spine, especially in
the setting of his prior goals of care (had previously been
under hospice care at home, presumably mainly due to cirrhosis
for which he is not a transplant candidate). Notably, the
patient had a febrile episode a few weeks prior at ___
___, from which the true cause of the fever was unknown,
though SBP was suspected. It was felt that hematogenous seeding
of his cervical spine causing osteomyelitis/discitis may have
occurred in this setting. He did have one blood culture positive
for coagulase negative staph at that ___ admission, but it
was felt to be a contaminant. During this ___
hospitalization, he notably had no positive blood cultures, no
fevers or leukocytosis, but there was no alternate explanation
of the findings on his cervical spine on MRI except for
infection. The shoulder was also considered as a possible site
of primary infection with possibly septic arthritis, but again,
he did not exhibit signs of septic arthritis at the shoulder and
other signs and symptoms did not support this, so no
arthrocentesis was performed. In this setting, it was initially
decided to go ahead with empiric treatment of possible cervical
discitis/osteomyelitis with vancomycin and ceftriaxone for a 6
week course, starting on ___. On ___, the patient
asked to stop the antibiotic treatment because it made him
nauseous and have abdominal pain, but after discussion about
alternatives and risk/benefit the patient decided to continue
his treatment with the Vancomycin-CTX for a 6-week course.
Physical therapy worked with the patient to improve mobility of
his shoulder during this hospitalization. The patients pain
regimen was also adjusted on this admission to maximize pain
control and minimize sedative effects because the patient had a
documented fall in the hospital and history of falls at home. On
admission the patient was taking 2 mg hydromorphone q6h and on
discharge, he was transitioned to tramadol 25 mg QHS, which may
be uptitrated in concert with his PCP.
#Pancytopenia with moderate neutropenia: All cell lines down and
diff is nearly normal. Unclear baseline; has a history of CLL
s/p chemotherapy and cirrhosis may be contributing. Copper, B12,
and iron were normal. TSH was borderline low (0.22).
___: On admission Cr peaked at 2.3, which improved after
Albumin IVF challenge to 1.1. Previous baseline per OSH and our
records was 1.5-1.7. Renal US and bladder scan negative for
post-renal etiology. UA negative.
#Chronic SMV thrombosis: Treated for over a year, per GI note
here it was diagnosed in ___. Warfarin held for ___ days
pending possible cervical biopsy, then re-started once it was
determined patient was not going to have biopsy.
#Decompensated NASH cirrhosis on hospice: patient was home
hospice. Came in to hospital due to acute worsening of pain, but
was previously DNH as well. Diuretics initially held in setting
of ___, then re-started a couple days before discharge. RUQ
ultrasound was obtained, which showed a patient portal vein and
no tappable ascites.
#DMII: Pt on Tresiba FlexTouch U-200 (long acting insulin) and
glimepride at home. ISS while inpatient.
#CAD s/p RCA stent in ___ and LAD stent in ___: Cotinued ASA,
atorvastatin
#BPH: Continued tamsulosin and finasteride
#Hypothyroidism: Continued levothyroxine
#HLD: Continued atorvastatin, fenofibrate
#Depression: Continued escitalopram
CORE MEASURES:
=======================
# CODE: DNR/DNI, confirmed with patient,
Name of health care proxy: ___
___: Wife
Phone number: ___ | 321 | 774 |
16229235-DS-16 | 29,486,437 | Dear ___ ,
It was a pleasure participating in your care. Please read
through the following information.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted because your feeding tube "gastrojejunal tube"
was blocked. You also had a worsening of your kidney function
and your because of dehydration.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given IV fluids to correct the dehydration.
- The Feeding tube was replaced with another tube.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is
52.2 kg (115.08 lb) . Please seek medical attention if your
weight goes up more than 3 lbs in 2 days.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
-Your ___ Care Team | SUMMARY
========
Mrs. ___ is a ___ year with a complicated past medical history
most notable for ischemic cardiomyopathy s/p orthotopic heart
transplant on ___, CMV viremia (now cleared), refractory
gastroparesis with multiple GJ tube exchanges, ___ secondary
recurrent dehydration and poor tolerance of tube feeds, and
compression fractures with back pain who presents with a clogged
GJ tube.
ACTIVE ISSUES:
==============
#Gastroparesis
#Clogged GJ tube
The patient had been unable to get tube feeds for 3 days prior
to presenting on ___, and was not able to tolerate oral
intake besides fluids. Per GI, causes of gastroparesis is either
nerve injury, diabetes or functional. GJ tube was exchanged on
___ by ___ team. She was continued on home pantoprazole,
Metoclopramide, Amitriptyline, lorazepam, Simethicone,
pyridoxine and viscous lidocaine. The patient is scheduled for
her gastric emptying study and video swallow on ___.
#Acute kidney injury (___)
Creatinine on admission was 1.6 from b/l Cr 1.1-1.2. ___ is
prerenal in the setting of poor oral intake and clogged G-J
tube. Creatinine improved with maintenance fluids. Cr on
discharge 1.4 after improving to 1.2. She was given a bolus of
IV NS 250cc before leaving the floor. The patient was encouraged
to drink water and continue oral feeds.
Chronic Issues
================
#Ischemic cardiomyopathy s/p orthotopic heart transplant ___
#New HFrEF, borderline
Recent TTE in ___ with LVEF stable at 45-50% from previous
TTE in ___. The patient had recent right heart
catheterization on ___ as part of routine surveillance for
rejection (Cellular rejection grading: Interstitial and/or
perivascular infiltrate with NO foci of myocyte damage; ISHLT
Grade 1R, mild rejection). Grade 1R has very low potential to
progress and does not require further management. She will need
a repeat RHC/EMBx on ___.
The patient was continued on tacrolimus 2mg BiD, Mycophenolate
Sodium ___ 180 mg BiD and nyastatin rinses. Atovaquone was
resumed for PJP prophylaxis after exchanging GJ tube.
#CMV Viremia.
Valacyclovir was discontinued on ___ after completing
induction and one month of maintenance. The patient has been
taking valacyclovir every other day. The patient and her husband
were made aware to stop it.
#Backpain
#T12 Compression fracture
The patient has chronic back pain secondary to T12 compression
fracture (L-spine xrays on ___ in the setting of osteoporosis
as evident by her DEXA scan. She was seen by ortho on her last
___ hospital admission who recommended spine brace which
has not helped. We will avoid opioids as it may worsen
gastroparesis.
- Continued Tylenol ___ Q8,
- Continued Gabapentin 300 mg PO/NG TID
- Continued Tramadol 50 mg PO BID PRN
- Continued vitamin D 1000 daily
#Palpitations
#SVT on Zio patch.
-Continued metoprolol succinate 25 mg daily
#Hyperlipidemia
-Continued Pravastatin 40 mg PO QPM
#Type 2 diabetes
Will hold Metformin due to fluctuating kidney function.
Transitional Issues:
===============
#Discharge weight: 52.2 kg (115.08 lb)
#Discharge Cr: 1.4
#CODE STATUS: Full
#Health Care Proxy (HCP)
Name of health care proxy: ___
Phone ___
___
[] Please repeat chem-7 on ___ to follow-up
[] Encourage oral intake
# CMV viremia
[] CMV virus levels every two weeks for two months - (last one
___ | 180 | 505 |
18661114-DS-16 | 23,706,486 | Dear Mr. ___,
You were admitted to ___ due to abdominal pain and abnormal
liver enzymes. After careful evaluation with ultrasound, CT,
and labs, we could not find a source of your pain. Your liver
function tests decreased without interventions. Please follow-up
with your primary care doctor, and it may be beneficial to see
gastroenterology as well.
It was a pleasure taking care of you. We wish you all the best. | Mr. ___ is a ___ y/o male with history of fatty liver disease
and chronic pain secondary to fibromyalgia who presented with
acute on chronic RUQ abdominal pain.
# Abdominal Pain:
Unclear etiology for abdominal pain. Fatty liver on ultrasound
as well as elevated LFTs in hepatocellular pattern are
suggestive of ___. No e/o gallbladder pathology on imaging or
labs. Radiation to right flank could be suggestive of renal
pathology, though Cr normal and normal kidneys on CT. With
weight loss, there is always concern for malignanayc as well.
Postprandial nausea could be suggestive of gastric pathology,
such as ulcer or mass. Functional abdominal pain is also on the
differential, though this is a true diagnosis of exlcusion. CT
was unremarkable. Given clinical stability and pain control
with oral meds, pt. was discharged home with close outpatient
follow-up.
# Transaminitis:
Hepatocellular pattern of injury. No e/o significant biliary
injury. Could be consistent with known fatty liver disease or
possibly steatohepatitis. Not high enough for acute viral
hepatitis and past serologies negative. No recent EtOH or
acetaminophen use. Other etiologies include medication side
effect (oxycodone, benzos). LFTs downtrended without
intervention and pt. will follow-up with hepatology given
recurrent episodes of transaminitis.
# Depression/Anxiety:
Continued clonazepam/sertraline.
# Vit D Deficiency:
Continued vit d.
# Chronic Pain ___ Fibromyalgia:
Continued oxycodone and oxycontin
# Transitional issues:
- Consider GI c/s and potential EGD
- Code status: Full, confirmed
- Emergency contact: ___ (___, ___ | 71 | 247 |
10650522-DS-18 | 20,785,822 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because of an abnormal heart
rhythm found by your primary care physician, called atrial
fibrillation. Your heart converted back to a normal rhythm while
you were in the hospital. We started a new medication called
amiodarone to keep your heart in a normal rhythm. You should
take this as follows: amiodarone 400mg 3 times per day for 3
days (___), 400mg 2 timers per day for 1 week (___),
then 200mg 2 times per day thereafter.
We also changed one of your medications, metoprolol, to
labetolol for better blood pressure control. As we discussed,
atrial fibrillation puts you at an increased risk for stroke. We
generally start patients with irregular heart rhythm on a blood
thinner. However, your labs showed anemia. You did not have any
signs of bleeding on exam. We recommend you talk to your primary
care physician about work up for gastrointestinal bleeding, as
well as starting a blood thinner to prevent strokes. | Mr. ___ is a ___ w/PMH sig for CAD s/p CABG (___), PAD,
DM, HTN, HL, presenting from clinic with new atrial fibrillation
with concern for ischemia and found to have a new anemia.
# new onset Afib: Noted incidentally today in clinic. Rate
controlled with metoprolol XL 50mg bid. CHADS2 score 3 (CHF,
HTN, DM), however given decreased Hgb/Hct and concern for a GIB,
AC initiation will be deferred. He converted to NSR in the ER
spontaneously and Amiodarone was initiated for rhythm control.
Plan for Amiodarone initiation: 400mg Amio TID x 3 days ___
noon - ___, then 400mg BID x 1 week [___], followed by
200mg BID thereafter. Home metoprolol succ 50mg BID was
converted to labetalol 200mg BID for better blood pressure
control. Troponin in ER = negative, stable EKG, no ACS symptoms.
UA/CXR with no evidence of infection, and he remained afebrile.
TSH was elevated to 5.58, but free T4 was WNL. This was
believed to represent possible subclinical hypothyroidism, not
likely to be the etiology of his atrial fibrillation.
# HTN: hypertensive upon admission 190/80's. Likely due to
inadherence with medications. Home regimen of lisinopril, and
amlodipine were continued and the metoprolol was changed to
labetalol.
# Anemia: Normocytic. Admission hgb down to 10.5 from 12.2 in
___, however up to 11.1 on repeat. Guaiac negative x 2. No
symptoms of GI bleed (hematochezia, melena, hemetemesis, etc).
Mr. ___ follow up as an outpatient for anemia work up.
Will defer AC until anemia workup complete.
# Throat pain: Pt has history of GERD and symptoms c/w GERD as
described as epigastric pain associated with reflux. He was
given omepraxzole 20mg daily, as well as maalox PRN.
# Acute-on-chronic kidney disease: Cr on admission 1.7, up from
baseline 1.5. Most likely due to poor po intake. UA consistent
with changes of chronic kidney disease, with protein of 100. He
was ecouraged to increase po intake.
# CAD s/p CABG in ___: EKG at baseline, lateral T wave
inversions seen in past EKGs (from ___. Troponin was
negative in the ER. His home ASA and crestor were continued,
but his plavix was held pending outpatient decision about
anticoagulation for atrial fibrillation.
# PAD: followed by Dr. ___. carotid bruit heard b/l and
peripheral pulses diminished. TP pulses palpated bilaterally,
DP's were present and equal qualitatively by doppler,
extremities were warm and well perfused with <1 second cap
refill. Statin, and ASA were continued; plavix was held (See
above).
# DMII: Hyperglycemic on presentation with POC Blood glucose
>400, was given 10units humalog x 2. Missed home lantus dose
the morning of admission. His UA was negative for ketones.
============================================================
TRANSITIONAL ISSUES
[ ] Anemia: Stable, of unknown etiology. No symptoms of GI
bleed, no known bleeding/bruising. Guaiax negative x 2.
[ ] Anticoagulation in the setting of Atrial Fibrillation:
CHADS2 score of 3. Initiation of anticoagulation was deferred
to his outpatient cardiologist after longer-term stability of
his anemia demonstrated.
[ ] Outpatient ECHO
[ ] Plavix: Was held due to concern about decreased
hemoglobin/hematocrit and pending anticoagulation decision.
[ ] Partner has concern about Mr. ___ exhibiting anhedonia
as well as paranoid behaviors and beliefs. He asked that his
stool be tested for wood chips. She was also surprised that he
closed his school. Mood disorder should be explored | 172 | 561 |
19530517-DS-20 | 25,285,274 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. 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.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Ms. ___ was admitted on ___ under the acute care
surgery service for management of her acute appendicitis. She
was taken to the operating room and underwent a laparoscopic
appendectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. He was subsequently taken to the PACU for
recovery.
He was transferred to the surgical floor hemodynamically stable.
Her vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when she was
tolerating PO's. Her diet was advanced on the POD 0 to regular,
which she tolerated without abdominal pain, nausea, or vomiting.
He was voiding adequate amounts of urine without difficulty. He
was encouraged to mobilize out of bed and ambulate as tolerated,
which he was able to do independently. Her pain level was
routinely assessed and well controlled at discharge with an oral
regimen as needed.
___, she was discharged home with scheduled follow up in
___ clinic. | 766 | 169 |
12362110-DS-23 | 29,924,208 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because your PEG tube was dislodged.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given fluids through an IV while waiting for your
feeding tube to be replaced.
- Your PEG tube was replaced by the interventional radiologists.
- You were given antibiotics for a urinary tract infection.
- You were ready to leave the hospital.
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 SUMMARY
===============
This is a ___ female with a history of thalamic stroke, severe
dementia, afib not on anticoagulation, HTN, arthritis, and
repeated G-tube dislodgements requiring replacement, who
presented with self removal of the G-tube. In the hospital, she
was found to have a likely urinary tract infection, and was
treated with IV antibiotics. She also had an episode of
respiratory distress requiring intubation and transfer to the
MICU, though subsequently recovered. Her G-tube was replaced by
interventional radiology, and she was ready to leave the
hospital. She was also started on vancomycin for uncomplicated C
diff infection.
TRANSITIONAL ISSUES
====================
[] This is at least the ___ time Ms. ___ has dislodged her
PEG tube and been hospitalized. Her family and providers should
continue to assess whether this is the most viable option for
her moving forward.
[] Aspirin should be avoided as was listed as an allergy, she
had received one dose in the period preceding her acute
hypoxemic respiratory event raising question of NSAID induced
asthma. Can also consider having her evaluated by an allergist
as an outpatient.
[] Echo with evidence of HFpEF with elevated PCWP on this
admission (___)
[] Started lisinopril 2.5 mg daily and decreased metoprolol from
25 to 12.5mg q6h. Will need monitoring of blood pressure.
[] C diff testing was sent while patient was having diarrhea and
was still pending at the time of discharge. For the two days
prior to discharge, however, she only had one bowel movement
daily and therefore there was no clinical suspicion for active C
diff infection. The pending testing will be followed up and you
will be notified if it is positive and requires treatment.
#CODE: FC (MOLST form on file at ___, is Full
Code)
#CONTACT: Health Care Proxy: ___ | 120 | 286 |
12535940-DS-24 | 21,147,596 | You were admitted overnight for observation for suspected
cholecystis after a routine PET-CT with some abdominal
discomfort. During your evaluation, we were able to determine
that you physical exam was with in normal limits. Also your lab
results showed no signs of an acute infection, which was also
confirmed on an ultrasound. During your observation, you
received a food challenge, and did well. You are now ready to
return home. | Ms. ___ was admitted overnight on ___ for observation for
suspected cholecystis after a routine PET-CT with some abdominal
discomfort. She underwent serial abdominal exams that revealed a
normal clinical abdomen. Her lab results showed no signs of an
acute infection, which was also confirmed on a right upper
quadrant ultrasound. Ms. ___ subsequently received a food
challenge and her diet was advanced without any complications.
From a cardiopulmonary standpoit, Ms ___ remained stable and her
oral intake and output was within normal limits.
Ms. ___ was subsequently discharged to home after observation.
She received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 70 | 109 |
14348068-DS-14 | 27,641,844 | Dear Ms. ___,
It was a pleasure taking care of you during your stay. You were
admitted for shortness of breath. During your hospitalization,
you were treated for pneumonia and a asthma/COPD exacerbation.
In addition, we found that your heart is not pumping well. This
caused heart failure that contributed to your shortness of
breath. Our cardiologists consulted, and performed a cardiac
catheterization. The found a blockage in one of your arteries,
requiring stent placement. We started several new medications
during this admission to help protect your heart. Please follow
up with cardiology after discharge. We wish you the best!
Your ___ care team | ___ with PMH significant for COPD, chronic pain, multiple
abdominal surgeries for abdominal hernias, and T2DM on insulin
who presented with shortness of breath initially treated for
pneumonia and COPD exacerbation, with hospital course
complicated by ischemic cardiomyopathy, ___, and C.diff
infection.
# Shortness of Breath: Patient's initial presentation of
shortness of breath is likely multifactorial ___ to community
acquired pneumonia, ___ exacerbation, and COPD exacerbation.
She was treated for CAP initially with ceftriaxone/azithromycin,
then transitioned to levofloxacin. She completed her antibiotic
course during this admission. In addition, she was treated for a
asthma/COPD flare with 5 days of a steroids. She was also found
to have new systolic CHF with echo showing dilated
cardiomyopathy (see below), s/p diuresis. Her oxygen requirement
improved and by discharge she was satting well on room air. She
was discharged on her home COPD medications and Lasix.
# Ischemic dilated cardiomyopathy complicated by acute systolic
CHF: Patient with newly found dilated cardiomyopathy with EF of
25%. Cardiology consulted. She underwent pharmacologic stress
test that showed partially reversible, severe perfusion defect
involving the RCA/LCx territory. Given concern for ischemia, she
underwent heart catheterization that showed blockage in the RCA,
s/p 2 DES. She was started on aspirin, plavix, atorvastatin,
metoprolol, and spironolactone. Her lisinopril was continued.
She will need cardiology followup for monitoring of her heart
function.
# Acute systolic CHF exacerbation: The patient had clinical
evidence of heart failure with ___ edema, mild pulmonary edema on
CXR, and elevated BNP to >4000s. She was initially diuresed with
60 IV Lasix BID with improvement in her hypoxia. However, the
diuresis had to be stopped given rise in creatinine. She was
discharged home on 60mg PO Lasix with cardiology follow up.
# ___ on CKD: The patient had ___ in the setting of diuresis,
which improved after the Lasix was held for a few days. In
addition, the patient got cardiac catheterization with contrast
which could be contributing. Other causes less likely: UA bland,
and no evidence of AIN or ATN on urine microscopy. However, the
patient had evidence of underlying kidney disease due to
diabetic nephropathy given persistent proteinuria. Urine
protein/creatinine was 5.4. Before discharge the patient was
started on 60mg PO Lasix with stable creatinine.
# C. difficile: The patient had fever and leukocytosis during
admission, with stool testing positive for C.difficile. The
patient had recent antibiotics use for pneumonia and
pyelonephritis during admission, which likely predisposed her to
the infection. She will be treated with PO vanc q6h for 14 days
(Day 1 = ___, Day 14 = ___.
# Pyelonephritis: The patient initially had dysuria, flank pain,
and positive UA suggestive of pyelonephritis. Urine culture was
negative. She was initially treated with ceftriaxone,
transitioned to levofloxacin. She completed her antibiotic
course during this admission.
# Chronic Pain and anxiety: The patient was continued on her
home oxycodone and gabapentin for chronic pain related to her
numerous abdominal surgeries and neuropathy. She also has
significant anxiety, and was continued on her home lorazepam. No
acute issues.
# T2DM: Patient with uncontrolled glucose levels this admission,
likely exacerbated by poor diet (refusing diabetic diet) and
prednisone. Her insulin regimen was uptitrated during admission.
___ consulted given uncontrolled sugars even with insulin
adjustments. She was discharged on 50 units of lantus, a reduced
dose of the metformin, glimepiride and a Humalog sliding scale.
Her metformin was use should be monitored given renal function
and CHF. | 102 | 571 |
11155645-DS-12 | 27,911,899 | Medications:
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort. | ___ with worse headache of life started the morning of ___
presented to OSH with negative head CT but bloody CSF on LP,
concerning for SAH. She was loaded with fosphenytoin in the ED
for seizure prophylaxis and continued on maintenance dosing.
She was admitted under Neurosurgery to the Neuro ICU for close
monitoring with plans for cerebral angiogram the next morning.
Cerebral angiography performed on ___ demonstrated a small
protuberance versus infundibulum versus aneurysm at the junction
of the distal right posterior communicating artery and posterior
cerebral artery and an absent/hypoplastic left A1 segment.
CT Angiogram demonstrated no obvious aneurysm or vascular
anomaly. Neurology was consulted about headaches and it was
determined that her headaches were tension related. Patient was
started on Fioricet and Flexeril with good response. Now
patient is afebrile and vital signs are stable. She will be
discharge and instructed to follow-up with Neurology for her
tension headaches and will see Dr. ___ in Clinic in 4 weeks
with an MRI/A Brain to follow the infundibulum. | 26 | 175 |
19565640-DS-18 | 26,587,548 | 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 approximately 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
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Patient was admitted on ___ and placed on vanco and
cefazolin for sternal erythema. He was diuresed. A
transesophageal echocardiogram was done and interpreted by
cardiology as stable moderate pericardial effusion. He remained
in rate controlled afib/flutter, continued on warfarin in light
of stable pericardial effusion. Repeat TTE ___ showed
continued stable effusion. Infectious disease was consulted and
a PICC line was placed to treat MSSA positive blood cultures x
4. His sternal wound was opened and debrided by Dr. ___
required sternal packing to mid and lower pole wound openings.
His WBC has remained stable. Vanco was discontinued and he was
continued on Cefazolin Q8 until ___. CT from ___ re read
here->? potential fluid collection deep to sternum, which
remains not completely approximated- repeat CT scan ___
shoed no significant fluid collections per ___. He was
discharged to home on HD ___ with with intravenous antibiotics,
infectious disease follow-up and continued dressing changes. He
will follow-up in the cardiac surgery office next week for his
wound check. | 101 | 174 |
19663837-DS-11 | 28,383,809 | 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.
¨ 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.
¨ You were on Coumadin prior to your injury, the decision to
restart this will be made at your followup appointment
¨ You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
¨ 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ Any signs of infection at the wound site: redness,
swelling, tenderness, or drainage.
¨ Fever greater than or equal to 101.5° F. | ___ with 2 problems:
1)Headache:
2)Abdominal Pain/R hip pain
#L SDH:
Recent CT at OSH ED on ___ negative for intracranial bleed.
This is important finding as she is anticoagulated and she
sufferred fall out of bed >2w ago. She reports having had CT
head following fall (that day). Her headache has not changed in
character since her CT on ___. She has associated R neck
muscle tightness/spasm suggesting possible muskuloskeletal
component. Important feature of PMH is resected pituitary
macroadenoma. I spoke to PCP to confirm that patient had visit
at OSH ED where CT head was performed and did not show
intra-cranial hemorrhage. Patient also saw her rheumatologist
recently who felt that patient did not have features consistent
with GCA and that her ESR was only modestly elevated and in the
past she has had chronic headache. Given the past pituitary
macroadenoma resection, a pituitary MRI was obtained and this
showed L SDH with 9mm mid-line shift. Neurosurgery consulted
and she was transferred to Neuro-ICU. She received FFP and
coumadin and ASA were stopped.
2)Abdominal pain
3)R hip pain
4)PMR:
Bilateral low quadrant abd painCT x2 this week of the abdomen
pelvis has been relieving. She has no obvious deformities or
easily appreciated hernias. She had unremarkable pelvic and
bimanual exam. There is no role for antibiotics. I spoke with
radiology who did not see evidence of avascular necrosis in her
hips/femur. I suspect possible worsening of her PMR causing hip
girdle pain and headache. I spoke with her rheumatologist who
concurs and advised repeating ESR/CRP and initiating prednisone
20mg daily.
5)Chronic PE:
--hold coumadin as INR >3
#DM2: listed in problem list but not on therapy and her A1c is
6.3 in her pcp ___
#hypertension: continue amlodipine 5mg, lisinopril 20mg,
metoprolol 25mg daily
I spoke with PCP directly on ___ and I spoke with
rheumatologist on ___ and then PCP coverage on ___.
Patient was transferred to the neurosurgery service. On ___, she
was taken to the OR for a left subdural hematoma evacuation.
She was extubated without incident and transferred to ICU for
further managment. Post op CT on ___ showed minimal residual
left SDH and improved shift. Clinically she improved. There
was minimal drainage from SD drain as a result it was removed in
routine fashion. ___ was d/c'd and was transferred to floor
in stable conditon. ___ was consulted.
On ___, the patient continued with complaints of right upper
extremity arthritic pain which made moving the upper extremity
difficult. Her SBP was 90 while lying this morning and 70 upon
sitting up. She received a 500cc normal saline bolus. She was
started on Bactrim for a positive urine culture.
On ___, the patient continued with right upper extremity pain
secondary to baseline arthritis. Aspirin 81mg was re-started.
She was seen by physical therapy who recommended on ___ that
the patient be discharged to rehab and rehab screen was
initiated.
On ___ she remained stable while awaiting rehab and was
mobilizing with ___ utilizing a walker.
On ___ she continued to ambulate with a walker with ___ and was
awaiting a rehab bed.
ON ___ Patient remained stable, awaiting rehab placement
On ___ Patient's sutures were removed. Her incision was c/d/i.
She was discharged to rehab in good condition with instructions
for follow up. | 276 | 560 |
18510965-DS-2 | 22,482,990 | It was a pleasure to take care of you during your stay at ___.
You came in with shortness of breath and were found to have an
abnormal fast heart rhythm called atrial fibrillation. We were
unable to slow down your heart rate with medicines, so we
scheduled you for an echocardiogram (ultrasound of the heart)
which showed no clot, and then shocked the heart. This
successfully converted your heart back to normal rhythm.
You had a little extra fluid on your body from your heart not
pumping efficiently while it was in Afib. We diuresed you with
lasix and will be sending you home a small dose of lasix 20mg to
take daily at home.
After the conversion, you had some very long pauses of your
heart beat. Because of this we want you to wear a heart rhythm
monitor for ___ weeks at home, to make sure you are not having
more pauses, and also monitor if you go back into Afib. ___
___ will be in touch with you about this heart monitor,
which you will receive at home in the mail within 3 business
days.
We discussed the importance of wearing your CPAP to prevent
converting back to Afib, and also to prevent the pauses we
observed. Talk to your PCP about getting reconnected to a sleep
center to keep your CPAP machine maintained and make sure you
have the best-fitting mask.
When people are in atrial fibrillation, they are at risk of
developing clots in the heart, which can break off and cause a
stroke. To prevent this risk, you will need to take a blood
thinner called warfarin, in case you go back into atrial
fibrillation. You will have to get your INR (a measure of how
thin your blood is) checked regularly with the ___
clinic at ___ to make sure you are on the right
dose of warfarin. You should get your INR checked tomorrow,
___. | ___ yo female presenting with dyspnea on exertion found with new
onset symptomatic Afib with RVR and signs of volume overload.
# New onset Afib w/RVR: Pt presenting with shortness of breath
and dyspnea on exertion which has acutely worsened over the week
prior to admission. Pt thought to be in Afib for >48 hours upon
presentation, outside of the window for cardioversion without
TEE. Pt describes months of episodic dyspnea on exertion,
self-treated as asthma with albuterol inhaler, but were perhaps
possibly ___ paroxysms of Afib. Rate was not controlled on max
dose diltiazem 15 mg/hr and metoprolol 400mg daily. She was
bridged with heparin to a therapeutic INR on warfarin and
underwent TEE/cardioversion with successful converstion to sinus
rhythm. However, after cardioversion, pt developed >4.5 sec
sinus pauses and bradycardia to ___. For this reason, she was
not discharged on a beta blocker. She was set up to have an
event monitor, with a plan to start low dose metoprolol
succinate if she no longer has sinus pauses. INR was 3.6 on day
of discharge; pt was prescribed warfarin 1mg, with instructions
to hold the warfarin until INR check at ___
___ clinic on the day after discharge.
# sinus pauses: occurred overnight after cardioversion, >4.5
sec, asymptomatic. Unclear if these pauses occurred while
patient was lying supine; she was not wearing CPAP at the time.
Differential includes OSA vs. excessive nodal blockade vs. sick
sinus syndrome. Pt has a history of non-compliance with CPAP and
was counseled on the importance of CPAP for preventing sinus
pauses and ectopy that could re-initiate her atrial
fibrillation. Betablockade was held as above. Pt observed for 24
hours while compliant with CPAP and did not have significant
sinus pauses. She was arranged to have event monitor for ___
weeks, and to follow up with Dr. ___ in one month to monitor
for further sinus pauses while off the beta blocker.
# orthopnea: CXR with vascular congestion. Pt likely with flash
pulmonary edema ___ tachyarrythmia. Echo showed preserved
systolic function, suboptimal images, could not comment on PA
pressure. Given hives to HCTZ, a sulfa-moeity, initially avoided
lasix in favor of ethacrynic acid, however net even with this
agent. Ultimately diuresed with lasix IV without skin reaction,
and orthopnea resolved. Pt still with baseline dyspnea on
exertion.
# Leukocytosis: Pt afebrile without focal infection signs.
Leukocytosis persisted for 3 days; UA positive however culture
grew mixed flora suggesting fecal contaminant. Leukocytosis
resolved after removal of foley and 3 day course of ceftriaxone.
# HTN: Home atenolol and amlodipine held while titrating nodal
agents. Pt discharged on home dose of amlodipine but held beta
blockade as above.
# OSA: Patient intermittently uses CPAP at home. Encouraged use
and educated on importance of CPAP. Pt observed to be compliant
towards the end of the admission. | 322 | 467 |
12330461-DS-23 | 24,493,229 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
worsening shortness of breath. We think this was from your heart
failure.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We gave you IV medications to help remove some of the fluid
causing your shortness of breath.
- You had a CT scan study done in preparation for your aortic
valve replacement later in ___.
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.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES
====================
- Patient's diuretic increased to Lasix 40mg daily. Please
monitor daily weights, Cr, and electrolytes closely.
- Discharge weight: 176 lbs.
- Discharge Cr: 2.1
- Please ensure that patient follows up with ___ structural
heart team for TAVR.
- The distal abdominal aorta demonstrates focal ectasia. This
should be followed with repeat US in ___ years.
IMAGING TRANSITIONAL ISSUES
===========================
After the patient was discharged, a wet read of the CTA Abdomen
and Pelvis returned. The patient was contacted regarding the
results, and an outpatient appointment was made for an echo the
day after discharge. Please ___ the final read of CTA. See
below for transitional issues from the wet read of the CAT:
-severe thyromegaly with a large left thyroid mass measuring
approximately 5.9 x 7.1 x 7.4 cm resulting in rightward
deviation and narrowing of the trachea.
-Prominent left supraclavicular lymph node measuring 0.8 cm in
short axis without meeting CT size criteria for lymphadenopathy
(302; 54). There is mediastinal lymphadenopathy measuring up to
1.4 cm in short axis in aright paratracheal node (302; 139).
There is right hilar lymphadenopathy measuring up to 1.2 x 2.5
cm (302; 190). A prominent left hilar lymph node measures 1.1 x
1.7 cm.
-There is a large pericardial effusion, of unknown chronicity,
increased from ___ are moderate aortic valve
calcifications. There are mild coronary artery calcifications.
There are severe atherosclerotic calcifications and plaque in
the thoracic aorta.
-There is an irregular pulmonary nodule measuring 1.1 x1.4 cm
(302; 109), concerning for malignancy.
-There is a focal dissection in the infrarenal abdominal aorta
(302; 555).
-There is an infrarenal abdominal aortic aneurysm measuring up
to 2.9 cm just inferior to the take-off of the inferior
mesenteric artery.
-There are bilateral innumerable hypodense lesions in the
kidneys, the largest in the left kidney measuring 4.5 x 4.0 cm
in the left lower pole, and the largest in the right kidney
measuring 6.2 x 6.7 cm, are consistent with renal cysts,
correlate with history of polycystic kidney disease or prior
lithium use.
SUMMARY STATEMENT
=================
The patient is a ___ man with severe AS, HFpEF, CAD,
HTN, HLD, BPH, CKD stage III, DM2, who p/w dyspnea ___ HFpEF
exacerbation iso severe AS. His respiratory status improved with
IV diuresis. The structural heart team evaluated him while
inpatient and determined that he should ___ as previously
scheduled for further evaluation. He was discharged with PCP and
cardiology ___.
HOSPITAL COURSE BY PROBLEM
==========================
#Acute on chronic diastolic heart failure
#Severe AS
The patient presented with acute dyspnea with elevated proBNP
and CXR showing pulmonary edema in setting of severe AS and HTN.
Cath on ___ with mild non-hemodynamically significant CAD. EF
of 65% TTE w/severe AS, severe TR, and moderate to severe MR. ___
velocity 4.3, mean gradient 51, valvae area 0.6. Was evaluated
by c-surg during last admission, determined to be a better
candidate for TAVR as TR/MR may not be as severe as originally
documented. While inpatient this admission, the Cardiac surgery
team was re-consulted, and the patient was considered
intermediate risk, scheduled for outpatient procedure on
___. He was diuresed with IV Lasix 40mg daily, which was
transitioned to PO Lasix 40mg daily upon discharge. For
afterload, his hydralazine 75mg TID and Irbesartan 300 mg were
held during the admission and at discharge given normotension.
He was continued on Verapamil 120 mg (reduced from 240 mg BID
home dosing).
#CAD
Coronary angiogram on ___ with mild non-hemodynamically
significant CAD. He was continued on home Atorvastatin 40 mg
PO/NG QPM and home ASA 81 mg.
#HTN
The patient's blood pressure was well-controlled on verapamil
120mg daily with SBPs in 120-150s. This is within range given
patient's severe aortic stenosis as above. His home hydralazine,
irbesartan, and HCTZ were held in the hospital and at discharge.
#CKD III:
Baseline creatinine per Atrius records 2.1. Cr was at baseline
during this hospitalization.
#T2 Diabetes:
Diet-controlled, recent A1c 6.6 in ___.
#BPH:
Continued home terazosin
#Glaucoma
Continued home brimonidine and latanoprost | 132 | 645 |
16824120-DS-19 | 23,160,123 | You were admitted to ___ with
throat pain due to radiation. This improved with pain
medications and you were able to eat and drink before leaving
the hospital. | ___ yo F with uterine leomyosarcoma with mets to lung and bone,
recently completed XRT to T9 verterbral lesion, admitted for
throat pain and inability to tolerate POs. Pain improving and
EGD
c/w esophagitis.
# Throat/Epigastric pain: Endoscopy on ___ with from 25 to 35
cm
in the esophagus, whitish exudate in a linear pattern with
friable mucose. Most consistent with radiation esophagitis Less
likely fungal or HSV esophagitis. No PUD, gastritis on EGD.
She
was initially on an IV PPI, changed to oral PPI. She was given
sucralfate and viscous Lidocaine for pain control and has not
needed narcotic. She was able to tolerate a thick liquid diet
on ___ and this was subsequently advanced.
# Uterine leiomyosarcoma, metastatic: Plan per Dr. ___ will
be determined as an outpatient. Patient also to be followed by
radiation oncology.
# Hypothyroidism: Continued home synthroid
# DVT ppx: Heparin SC
# Code status: Full | 29 | 146 |
13421904-DS-9 | 27,632,788 | Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with kidney damage.
Further testing showed obstruction to the flow of urine and you
had stents put in both the kidneys with improvement in you
kidney function. You were also treated with antibiotics. You are
feeling better now but are still deconditioned and would benefit
from acute rehab to regain strength before returning to home.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck! | ___ year old male with history of type 2 diabetes, hypertension,
pulmonary embolism (on warfarin), metastatic prostate cancer (on
Lupron, planned to start enzalutamide soon), presented with ___
related to left hydronephrosis, now s/p bilateral PCN placement.
# Acute kidney injury
# Hydronephrosis
Postobstructive etiology with bilateral left hydronephrosis
identified on renal ultraound. s/p bilateral PCN placement.
Foley placed on ___ to see if improves creatinine with no
effect. Urology and ___ were contacted and consulted. CTU
performed showing moderate left hydroureteronephrosis and
encasement of left ureter. Per Urology, cannot stent ureter out
of concern of possibly malignant encasement. Bilateral PCNs
placed on ___. Right PCNU was capped, left PCN left to drain.
___ follow up as outpatient in 2 weeks for attempting
internalization.
Left PCN noted to have blood tinge, which is expected as he has
evidence of hemorrhagic cyst in L kidney. As long as no flank
pain and no clots, small amount of hematuria is expected,
especially on anticoagulant.
# Sepsis: based on fever, tachycardia, hypoxia and tachypnea on
___, as well as leukocytosis. Unclear cause. Was started on
empiric antibiotics. Cultures have been negative, complete a
total of 10 day course for presumed GU infection.
# Respiratory failure, acute: new oxygen requirement ___,
weaned off oxygen, no significant findings on CXR save
atelectasis. Patient was provided incentive spirometry. TTE
was performed but not of good quality, but with no overt
findings.
# History of pulmonary embolism: patient had elevated INR on
admission, and given vitamin K. INR drifted down, and patient
was placed on a heparin gtt, which was held at the time of PCN
placement. Heparin gtt was restarted for bridging with coumadin
and his INR is therapeutic now. Continue coumadin and INR
monitoring. 3mg is his chronic dose
# Metastatic prostate cancer: patient will continue to follow up
with Dr. ___ was updated during the patient's stay. He
is planning to start patient on a new medications during his
rehab stay and coordination this through patient's wife.
# Type 2 diabetes: held Metformin/Tradjenta, ISS provided during
admission.
TRANSITIONS OF CARE
-------------------
# Follow-up:
#HCP/Contact: wife ___ who is his HCP ___
#Code: Full presumed | 96 | 366 |
13785448-DS-9 | 28,000,839 | * Your injury caused Left ___ and 6th rib fractures and left
clavicle fracture which can cause severe pain and subsequently
cause you to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | Ms. ___ is a ___ year old Female who presents from an OSH
after a mechanical fall. On torso CT the patient has evidence of
left clavicle as well as left ___ and 6th rib fractures. The
patient has a history of atrial fibrillation and was tachycardic
at the time of arrival. She was treated with IV diltiazem. The
heart rate came down and the patient was admitted to the floor
for pain control and pulmonary toilet on ___. A sling was
left in place on her right arm to wear at all times.
Ms. ___ was placed in pain medication with
morphine sulfate IV, dilaudid IV breaktrough, and oxycodone
immediate release 2.5 mg q6PRN. A bowel regimen was started with
Colace and Senna. She was also placed in 2L NC. Pain was an
issue during the first hospital day. On ___ her oxycodone
dose was increased and her pain started to subside. She
continued to be on ___ L NC. On ___ her left chest wall pain
was well controlled but she continued to be on ___ L NC and
remained in the hospital one more night for observation. On
___ she was weaned from the O2 supplementation and tolerated
well, currently saturating 95% on RA. Her pain is well
controlled and is now being discharged to rehabilitation to
continue her recovery. | 250 | 222 |
14912902-DS-15 | 22,590,567 | Dear Mr ___,
We are discharging you on levaquin, an antibiotic, which you
should take as indicated below. We are also giving you a
prescription for you to use for your nebulizer machine, which
you can use every six hours, to help with your breathing. You
have a follow up appointment with your oncologist this coming
___ at 9 AM. | Mr. ___ is a ___ w/ metastatic adenocarcinoma of unknown
primary and extensive pulmonary metastases presents with fevers,
hypoxia, and CXR opacity c/f pneumonia.
# Hypoxic respiratory failure: Patient met ___ SIRS criteria.
CXR findings were most consistent with pneumonia, likely
aspiration in setting of vomiting. He was started on
vanc/zosyn/azithro. Due shortage, zosyn was soon switched to
cefepime/flagyl. Ultrasound of his chest was done, which noted a
small amount of fluid at R lung base, which was not enough to
safely tap. By time of transfer from ICU he was satting in the
mid to high ___ on 2L NC. On the floor, his oxygenation
improved. We attempted repeat ultrasound, however there was
still not enough fluid to tap. We narrowed his antibiotics
course to levaquin, which he will continue as an outpatient for
an additional 5 days. We also prescribed him duoneb solution
which he can use on his home nebulizer machine. He has a
follow up appointment with ___ on ___,
___. Repeat CXR prior to discharge showed concern for
worsening number/size of pulmonary metastases.
# Tachycardia: Infection vs PE vs hypovolemia/distributive
picture. EKG with sinus tachycardia. Pain and anxiety was
although thought to contribute as could extensive underlying
malignancy. HR in outpatient settings tend to be elevated as
well. He was treated with IVF, pain meds and anxiolytics. | 62 | 229 |
10583892-DS-3 | 27,282,067 | Dear Ms. ___,
You were hospitalized due to symptoms of difficultly with
balance resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. We would like to add back your blood pressure goals
to maintain a goal of 120-150 as outpatient. We transitioned
you from aspirin to Plavix to help prevent strokes in the
future.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ woman with PMH significant for HTN, HLD and recent stroke
(___) who presents as a transfer from ___ with an MRI
showing a left cerebellar infarct. This is the second stroke
that the patient has had in 3 months without a clear cause
identified. These strokes appear embolic, likely artery to
artery without history of atrial fibrillation. Her CTA is
notable for diffuse intra- and extracranial atherosclerosis,
also w/ high-grade left vert stenosis, R M1 focal stenosis and
50% L ICA stenosis, in addition to an ulcerated aortic arch
plaque. Echo was w/ normal EF but LVH and mild pulmonary
hypertension. Given absence of LV thrombus,patient was stopped
on home ASA 81mg and started on Clopidogrel 75mg to be continued
at least until next clinic visit with Stroke Specialists.
Overall the patients symptoms are mild with some rebound,
trouble with fine motor and mirroring on the left.
- Lipids LDL 57/A1C 6.2
- Tele during admission without atrial fibrillation
- There was some concern about prior bright red blood per
rectum, but after speaking w/ PCP was thought to be due to
hemorrhoids and w/o any significant GI bleed in the past.
- Started on Clopidogrel 75mg daily for recurrent stroke in
setting of daily aspirin
- Stopped home ASA 81mg daily
- Continue home atorvastatin 40mg daily
Pulm:
-CXR w/ 1.1cm mass
-Chest CT showing innumerable small nodules without focal mass
per prelim read
-ESR 9/CRP 3.3 | 279 | 238 |
10074556-DS-29 | 23,864,934 | Dear Mr. ___,
You were admitted after having low grade fevers, chills and
nasal congestion. We checked you for the flu which was
negative. We also did a chest x-ray which did not show any
pneumonia. You did not have any fevers while you were here. You
likely have a virus which is causing nasal congestion. Please
keep your follow-up appointments and take your medications as
listed below.
It was a pleasure taking care of you,
-Your ___ Team | Mr. ___ is a ___ with Hodgkin's lymphoma and primary
mediastinal lymphoma who presented with 1 day of low grade fever
(max 100.2F) and chills consistent with an upper respiratory
infection, likely viral in nature.
# Low-grade temperatures
# Chills
# Nasal congestion/rhinitis: No documented fever but chills, low
grade temps, and nasal congestion/rhinitis c/f acute URTI. No
other clear infectious symptoms. Young children at home with
cold-like symptoms. Flu swab negative, additional respiratory
viral panel pending. He likely has as viral process. He had no
fevers while inpatient and was able to be discharged with
follow-up.
# Primary mediastinal lymphoma
# Classical Hodgkin's lymphoma: SP 6 cycles EPOCH for
mediastinal
DLBCL. Now with residual classical Hodgkin's lymphoma. SP C1 ICE
with plan for second cycle followed by auto-SCT consolidation.
He
has recovered his counts from prior ICE cycle and is no longer
on
neupogen or levoflox ppx. He was continued on home Bactrim and
acyclovir ppx.
# Tachycardia:
Patient has history of bigeminal PVC's and sinus tachycardia.
EKG in ED showed sinus tach with PVC's. He is asymptomatic.
Appears similar to outpatient rates. Pt states that this is his
baseline. Home metoprolol was continued.
# History of pancreatitis: Continued home creon.
# Biopsychocial
- Cont home nortyptiline
- Cont home ativan | 82 | 201 |
18948691-DS-13 | 20,651,486 | Dear Mr. ___,
You were sent to the hospital because you were confused at home.
WHAT HAPPENED IN THE HOSPITAL?
You were started on lactulose and given frequently enough to
promote regular bowel movements. You felt less confused and back
to your normal self the next day.
WHAT ARE THE NEXT STEPS?
- Please continue your home medications. Remember to take
lactulose more frequently (up to every two hours) to make sure
you have ___ BMs per day. If you start to feel confused, you can
take more.
- Please follow up with your doctors as below.
It was a pleasure taking care of you!
- Your ___ Care Team | ___ M w/ PMH EtOH/NASH cirrhosis c/b varices s/p TIPS (___),
ascites, HE, alcohol use disorder, CAD s/p MI, HTN, sCHF, DM2,
p/w altered mental status likely from hepatic encephalopathy in
the setting of constipation from recently started iron pills. He
was treated with rifaximin and lactulose q2h until having
regular BMs. Pt improved and was discharged home.
ACUTE ISSUES
=============
#Altered mental status
#Hepatic encephalopathy
The patient presented with acute confusion in the morning. He
had a negative infectious work up, episodes of bleeding, or
changes in medications. The only possible trigger elicited was
recent supplementation with iron, which can cause constipation.
He has had prior hospitalizations for hepatic encephalopathy. He
was started on q2h lactulose which improved his mental status,
and continued on rifaximin. Per his HCP, he was back to his
baseline.
#EtOH/NASH cirrhosis
On admission, MELD 13, not on transplant list. He had a normal
RUQ US. Initially, his home Lasix and spironolactone were held
___ possible ___, however they were restarted by discharge. He
was not on SBP or bleeding ppx. His last EGD was in ___ with
three cords of medium varices; he had underwent TIPS to control
bleeding at that time. He had a stable 0.7 cm lesion on his
liver on most recent MRI, with an outpatient repeat scan
scheduled. Nutrition were following, continued on thiamine,
folate, MVI.
___
Cr recent baseline 0.6-0.9, on admission 1.2. Likely from
prerenal etiology iso confusion and decrease PO intake. He
received a total of 100 g albumin which improved his Cr to 1.1
the following day. His diuretics will be resumed on discharge.
#Lactic acidosis
Presented w/ lactate 4, AG slightly elevated 17, HCO3 21. Likely
iso decrease PO intake, less likely diabetes or infection
related. Other than encephalopathy, patient had no other
symptoms. A repeat lactate downtrended to 2.2.
CHRONIC ISSUES
==============
#DM2
Home metformin held, placed on SSI.
#HTN
#HFrEF
#CAD s/p stents
Most recent EF 55%. Continued metoprolol, aspirin, atorvastatin;
diuretics were held ___ ___ but resumed by discharge.
#GERD
Continued omeprazole.
#Anemia
Hx of anemia, recently taking iron supplements.
#Hx of C diff
Continued his PO vanc ppx. | 103 | 333 |
11626181-DS-21 | 27,704,640 | Dear Ms ___,
It was a pleasure taking care of you at ___
___. You were admitted for aspiration and poor
nutritional status. You had a video swallow study which showed
aspiration when you were first admitted. You had a repeat
evaluation later in your hospitalization and it is safe for you
to take thin liquids and pureed solids. You were also evaluated
by both ENT and GI while here. You had a replacement PEG tube
done by GI to assist in feeding as it seems that you have not
been able to take adequate nutrition since your G-tube was
removed. You were also noticed to have increased blood pressure
so we started you on 2 new medications to help control your
blood pressure.
.
Please make the following changes to your medications:
1. Start metoprolol 50mg daily.
2. Start lisinopril 5mg daily.
3. Please take tylenol ___ mg every 8 hours for pain control
4. Please do not take morphine as this seems to make you
confused. | ___ yo female with history of tongue cancer s/p radiation
treatment and G tube placement/removal who presents following a
witnessed aspiration event in the setting of increased
difficulty swallowing x1 week. Patient failed speech and swallow
study so she had PEG tube placed to continue enteral feedings.
. | 161 | 47 |
11502574-DS-5 | 26,388,581 | Dear ___,
You were admitted to ___ because of severe abdominal pain and
constipation. We found that your constipation and abdominal
pain was caused by proctitis, or inflammation of your rectal
wall. We took swabs from your rectum and sent bacterial and
viral cultures to determine the cause of your proctitis. Your
results came back positive for chylamidia and gonorrhea. Other
results are still pending. We treated you with several
medications to treat bacterial, viral causes of proctitis,
including azithromycin, ceftriaxone, and acyclovir.
You also had severe constipation and were not having regular
bowel movements. You had a CT scan and x-rays of your abdomen
to help determine why you were having constipation and if you
had any perforation of your intestines. The tests showed that
you did not have perforated bowels but did show a large amount
of stool sitting in your colon. To treat your abdominal pain,
we gave you ketorolac, morphine, hydroxymorphone, and oxycodone,
different kinds of pain killers. To treat your constipation, we
gave you stool softeners, including senna and docusate. We also
gave you lactulose, a drug that can help your bowels move.
Because those did not work, we tried soapsuds, mineral oil, and
tap water enemas to help you pass stool. We tried but could not
manually disimpact your stool because it was too far up your
intestines.
It is very important for you to take acyclovir and doxycycline
as prescribed until we receive the full results of your
cultures. You have upcoming appointments scheduled (please see
the below "recommended follow-up" section). Please follow up
with your doctor about your culture results and for continued
treatment of your constipation, abdominal pain, and gas.
If you experience sudden and severe abdominal pain, fevers, and
chills, or you continue to have severe constipation or other
symptoms that concern you, please seek immediate medical
attention.
It was an absolute pleasure taking care of you.
Sincerely,
Your ___ team | ___ year old man with well-controlled HIV and chronic HBV
infection who presented with infectious proctitis complicated by
pain and constipation.
# Infectious proctitis: Patient presented with two weeks of
constipation, anal pain, tenesmus and BRBR. Rectal wall
inflammation seen on multiple CTs c/w proctitis. Patient
reported recent receptive intercourse with a herpes positive
man. Pt was started on acyclovir for herpes and was given
empiric ceftriaxone and azithromycin for GC. Stool cultures
negative for E coli, shigella, salmonella. Urine culture
negative for organisms. Culture results that returned after
discharge shows infection with gonorrhea and chlamydia by PCP
and positive LGV serologies. Herpes cultures were collected but
yield is low as they were collected after already starting
acyclovir therapy. Patient was discharged on doxycycline and
acyclovir with planned follow up with PCP.
# Constipation complicated by severe abdominal pain: Mr ___
presented with 2 week history of constipation thought to be ___
infectious proctocolitis. During the hospitalization he was
given increasingly agressive bowel regimens. In this setting he
had intermittent episodes of severe abdominal pain with nausea
and vomiting that were eventually relieved by passing of gas or
small amounts stool. During these severe episodes there was some
concern for bowel perforation, and so imaging was acquired. KUBs
were negative for free air and repeat CT scan did not show
evidence of perforation. The severe pain was attributed to
lactulose causing gas that patient had trouble passing ___
inflammation from proctitis with mass effect. On day of
discharge patient had started to consistently pass small liquid
bowel movements with improvement in distention and pain.
CHRONIC
-------
# HIV: Well controlled:
-continued home emtricitabine , tenofovir, rilpivirine
# HBV
-continued home tenofovir
# anxiety/depression
-continued home meds (bupropion, escitalopram) | 336 | 285 |
10669559-DS-7 | 21,236,880 | Dear Mr ___,
It was a great pleasure to participate in your care. You were
admitted to the hospital with abdominal distension. We found
that you have fluid in your abdomen (called ascites) and that
you have cancer in your stomach and lymph nodes. You were
treated with chemotherapy and recommended that you follow-up
with oncology as an outpatient. You will be seen at ___.
During your stay, it was found that your kidneys were not
functioning well. With IV fluids your kidney function slowly but
dramatically improved close to your baseline level but did not
go back to normal values. Kidney doctors were following with you
during your stay.
We also found that you have liver disease and the initial work
up did not help to diagnose the possible etiology. The liver
doctors ___ and recommended liver biopsy at some stage
in the future to help further diagnosis.
In addition, your heart was beating fast without symptoms in a
rhythm called (NSVT). Heart doctors were involved in your care
and recommended to start a new medication called metoprolol
(please see below). Echo was done and did not show abnormal
heart wall motion.
Please make the following changes to your medications:
- Please START Neupogen 480 mcg injection daily
- Please START metoprolol 25 mg twice daily
- Please STOP aspirin 81 mg daily
Please see below for your follow-up appointment at ___. | The patient is a ___ man with past history significant
only for remote history of lower extremity DVT who was
transferred from ___ on ___ after presenting with
abdominal bloating and abnormal labs. In the ___ there, he was
found to have acute kidney injury and ascites. Since transfer
here, has been found to have malignant ascites, most likely
lymphoblastic lymphoma (myc mutation positive) based on gastric
biopsy ___ pending) with widespread nodal disease. He
underwent a bone marrow biopsy on ___, with abnormal cells
seen, formal results pending at this time. Pt received Velcade,
Mesna and cytoxan in addition to steroid pulse. His kidney
function improved to Cr of 1.3 on discharge day which seemed
most likely a pre-renal etiology. He required Rasburicase to
lower his uric acid in addition to allopurinol. His LDH and uric
acid were much better upon discharge compared to admission
values. During his stay, he was found to have new cirrhosis with
splenomegaly. He will be followed for his oncological issues
with Dr ___ at ___ ___ at 10 AM.
.
# Plasmblastic lymphoma vs Plasmablastic myeloma : Patient was
admitted with new onset ascites, with diagnostic tap concerning
for 91% "other" cells. This raised concern for malignancy, which
prompted CT chest/abdomen/pelvis. His CT scan was suggestive of
metastatic cancer, suspicious for gastric primary, with
widespread nodal disease including omentum, mesentery,
retroperitoneal, epicardial and anterior pericardium. Patient
had a TTE which was not suggestive of any impaired cardiac
funtion secondary to epicardial/pericardial involvement. His
cytology and pathology revealled findings suggestive of
lymphoblastic lymphoma with myc mutation positive. Alternative
diagnosis of anaplastic myeloma was also entertained. He was
transferred to the ___ service for continued treatment. He
received Dexamethasone 40 mg IV DAILY for 4 days,
Cyclophosphamide 760 mg IV Q12H on Days 1, 2 and 3. ___,
___ and ___, Mesna 1520 mg IV Days 1, 2 and 3.
___ and ___ (600 mg/m2), Bortezomib 3.3 mg
IV Day 1. (___) (1.3 mg/m2) and 2.6 mg IV Day 4 on
(___) (1.3 mg/m2). Tumor lysis labs were checked every 8
hours. These improved with IVF's initially and upon initial
improvement, IVF's were held given volume overload. His labs
remained stable. He is discharged with neupogen 480 mcg sq
injection daily for 10 days with 2 refills. There was no
allopurinol on discharge.
.
# Ascites: Patient's new onset ascites was thought to be
secondary to malignant ascites. His initially diagnostic tap
revealled 5700 WBC, for which he was started of ceftriaxone.
However, the differential cell count revealled no PMNs, with 91%
other cells so his antibiotics were discontinued. Because of his
renal failure, we did not attempt diuresis, but patient did have
(3L) therapeutic paracentesis with improvement in his symptoms.
His abdomen became less distended during hospital course after
initiation of chemotherapy and did not require additional
paracenteses.
.
# Cirrhosis: Patient had evidence of cirrhosis noted on
ultrasound and CT scan. Patient had no history of previous liver
dysfunction, denied any history of heavy alcohol use though
noted to dirnk alcohol on social history. His LFTs were stable
and his hepatitis panel was negative for hep A, B, and C. His
___ was also negative, and there was no evidence of
hemochromotosis. He had no physical exam findings concerning for
decompensated cirrhosis. Hepatology was consulted while in house
and have recommended liver biopsy for further evaluation. He
does not have evidence of portal hypertension (thrombocytopenia,
varices) or end stage liver disease (hyperbilirubinemia or
coagulopathy). Low albumin likely associated with malignancy.
Instructions were given not to drink any alcohol beverages.
.
# Acute kidney injury: Patient was admitted with creatinine of
2.5 from baseline 1.1. FeNa here 0.1%, which supports that this
is pre-renal from depleted intravascular volume. He received 25g
albumin on admission, 50 g following day, then had 500cc fluid
challenge with no response, which suggests possible hepatorenal
syndrome type physiology. However, liver team didn't feel
strongly about hepatorenal syndrome. His urine sediment was
unrevealing other than uric acid crystals, no evidence of ATN,
only trace protein in urine. There was concern about possible
urate nephropathy contributing to his renal failure, however the
renal team did not feel this was likely given that he was not
oliguric. Diuresis was held given renal failure. Renal function
overall improved gradually with Cr down to 1.3 on discharge day.
SPEP & UPEP negative. Instructions were given to avoid high
potassium diet.
.
# Elevated uric acid: Patient had uric acid crystals on urine
sedimentation. His serum uric acid was elevated initially to
15.5, with worsening to 18. His other electrolytes were normal
so there was no concern for spontaneous tumor lysis. Given that
his uric acid continued to rise, he received 2 doses of
rasburicase during his stay. He was on allopurinol in between
and till discharge day. His uric acid was 3.7 on discharge. No
allopurinol on discharge.
.
# NSVT: He developed asymptomatic 29 beats of NSVT while asleep
___ AM. Cardiology team was consulted. There was a
question from hypoxia (?OSA though no prior diagnosis or sleep
study) versus previous coronary disease. No ventricular
dysfunction seen on Echo, but could not rule out given poor
image quality. Also, EKG with Qs inferiorly, ? previous MI. Tpn
< 0.01. Repeat echo was of poor image quality but didn't show
significant difference from prior or pericardial/myocardial
involvement. Metoprolol 25 mg twice daily was initiated with no
HR > 100 afterwards. He had a very brief few beats of NSVT
following metoprolol initiation but remained vitally stable and
asymptomatic throughout.
.
# Likely oral thrush. Patient reported pain while swallowing
since endoscopy ___. This was managed by fluconazole 200mg
daily and Nystatin swish and spit four times a day and resulted
in resolution of symptoms and signs.
.
. | 234 | 960 |
14677579-DS-5 | 28,381,869 | Dear Ms. ___,
You came to ___ because you experienced weakness and pain in
your left leg. Please see more details listed below about what
happened while you were in the hospital and your instructions
for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- You were evaluated for evidence of neurologic emergency (cord
compression) that was negative. It was determined that the most
likely cause of your leg weakness and pain was an inflammation
of the nerves in your back (lumbar radiculopathy) and
inflammation of soft tissue in your thigh (trochanteric
bursitis).
- You were treated with anti-inflammatory medication and pain
medication. You were also seen by physical therapy to establish
a regimen to strengthen your leg muscles and prevent falls in
the future.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Please, follow up with your primary care provider.
Your ___ care team | Ms. ___ is a ___ female with PMH significant for
unspecified colitis and bronchitis who presents with acute onset
leg and hip pain, with a long standing h/o urinary incontinence
and two episodes of fecal incontinence while urinating. During
this hospitalization, patient received was evaluated for cord
compression that was ruled out with an MRI. Her physical exam
was also reassuring for a combination of lumbar radiculopathy
and trochanteric bursitis contributing to her left leg pain and
weakness. She evaluated by physical therapy and was treated with
Tylenol. On discharge, her pain and weakness had significantly
improved.
ACUTE ISSUES
=============
# LLE weakness and Pain: Patient presented with ___ of LLE
weakness and pain, longstanding ___ urinary incontinence and two
episodes of fecal incontinence. Cord compression was ruled out
with a negative MRI. Her physical exam was most consistent with
lumbar radiculopathy and trochanteric bursitis as causes of her
pain and weakness. Patient was seen by physical therapy and was
treated with Tylenol. Pain and weakness had improved at time of
discharge. | 163 | 171 |
18715578-DS-14 | 26,765,664 | Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you were
falling at home. We did some imaging of your ribs and you did
not break any bones. We had the physical therapists walk with
you and they said that you are unsteady on their feet. We think
that going to rehab facility would benefit you.
It is also VERY important that you continue to take your
lactulose; you should be having ___ bowel movements every day.
We did not make any changes to your medications. Please
continue taking everything as prescribed. | Ms. ___ is ___ with history of HCV cirrhosis and depression
recently discharged for depression and encephalopathy who is
presenting from home s/p multiple falls and feeling overwhelmed.
# falls: The patient reports that she has been unstable on her
feet and has been falling intermittently at home since her most
recent discharge from hospital. Pt reports that falls are
mechanical in nature, as she says she has been unsteady on her
feet. The patient was evaluated by ___ and it was decided that
she would benefit from a rehab facility. The patient also had
rib films that were done that were negative for any fractures.
# abdominal pain: The patient was complaining of abdominal pain;
initially in the left side. She had negative L sided rib films;
the patient's abdominal pain improved during the course of the
admission. It was thought that the pain was in the setting of
her recent fall. The patient was also c/o some right sided
abdominal pain, but reports that this is similar to her chronic
abdominal pain, with no change in severity or in quality.
Hepatology was contacted, and they deemed that no other
intervention or imaging studies were indicated at this time
given her negative work up in the past.
# depression: The patient has history of depression and past
suicide attempts; although currently denies any SI. Psych
evaluated patient in the ED and said that she does not meet
___ criteria. She was continued on her home medications,
including nortriptyline and quetiapine.
# hepatic encephalopathy: The patient reports having increased
confusion over the last one week, in the setting of having
constipation. Her lactulose was increased to four times a day
while in patient, for goal of ___ BMs daily. The importance of
taking her lactulose was stressed. Upon discharge, the
patient's confusion had cleared.
# HCV: The patient has history of HCV cirrhosis, not eligible
for transplant list given her history of medication
non-compliance and depression. Her MELD on admission was 18.
Daily MELD labs were checked and the patient was continued on
rifaxamin and lactulose. Her LFTs were consistent with her
baseline.
# GERD: The patient was continued on her omeprazole,
ranitidine, and Zofran PRN.
# DM2: The patient was continued on her ___ insulin regimen.
# thrombocytopenia: The patient has history of
thrombocytopenia, likely in the setting of cirrhosis. Her
platelets were trended.
# glaucoma: The patient was continued on her home eye drops. | 112 | 422 |
11008891-DS-26 | 21,523,504 | Ms. ___,
It has been a pleasure taking care of you at ___
___. You came into the hospital with a cough and
difficulty breathing. You were found to have pneumonia and a
urinary tract infection. Both were treated with antibiotics.
We sending you home on a 2 day course of levofloxacin for your
pneumonia. You were given a dose of ertapenem today (___) as
final treatment for your urinary tract infection. | Ms. ___ is ___ woman with a history of interstitial lung
disease/Bronchiectasis on 4L O2 at home, lupus, diabetes, CKD,
recurrent UTI, CVA w/residual left hemiparesis, who presented to
___ with a productive cough, dyspnea and was admitted to ICU
given her hypoxia, tachypnea and soft blood pressures.
# Tachypnea: She was started on vancomycin, levofloxacin, and
meropenem in the ED. On the floor, she was continued on
vancomycin, levofloxacin for concern for HCAP and over the next
day her condition and respiratory status improved. The urine
culture drawn in the ED grew Proteus resistant to levofloxacin
so patient was restarted on meropenem. ID was consulted, and
additional sensitivity information about the proteus in her
urine was added on- the patient was transitioned from meropenem
to ertapenem which she received on the day of discharge to
complete a 5 day course. The pna was felt to be rapidly improved
and therefore unlikely to be MRSA and vanc was discontinued. PCP
pna was considered, but felt unlikely given rapid improvement
with levofloxacin.
# GPC bacteremia: Coag neg staph felt to be a skin contaminant.
Her toe eschar was exonerated by vascular surgery as unlikely
source of infection, currently stable.
# dCHF: To evaluate whether patient's pulmonary pathology was
complicated by her diastolic heart failure and aortic stenosis,
patietn recieved a trans thoracic echocardiogram. The TTE
showed worsening aortic stenosis- valve has decreased from
1.2cm2 in ___ to 0.8cm2 and the peak gradient has increased
from 48 to 72 mm Hg. She was informed of these results, and she
and her son confirmed that they did not wish to work this up
further or consider valve replacement. Their PCP manages her
fluid status and extra visits to the cardiologist have been felt
not to be worth the effort and cost of transport. She was felt
to be hypovolemic on admission, and lactate cleared with 500ccNS
x2. Lasix was restarted two days prior to discharge. The son and
patient were counseled on monitoring daily weights and
encouraging adequate, though not aggressive hydration.
# Goals of Care: A discussion with the patient and son confirmed
that the son is basically providing 24 hr comfort care at home
with plan for rehospitalization for any reversible insult such
as pneumonia or volume overload. Hospice services were offered,
but declined since this would involve changing her current ___
company to whom she has grown appropriately attached. Palliative
care was also declined as the patient prefers not to have extra
appointments and overall is not suffering greatly. | 81 | 425 |
15146755-DS-15 | 22,106,920 | Ms. ___,
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital after falling from your wheelchair.
WHAT WAS DONE FOR YOU WHILE YOU WERE HERE?
- You had imaging of your head done to make sure there wasn't
any injury from your fall.
- You had x-rays of the left side of your body to make sure
there wasn't any injury from your fall.
- You had an EKG of your heart done to make sure your fall
wasn't caused by cardiac problems.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You should continue working with your rehab team.
- You can continue taking acetaminophen if you are having pain.
It was a pleasure taking care of you at BIMDC.
Sincerely,
Your Care Team | Ms. ___ is a ___ y/o woman with PMH of laryngeal SCC s/p
surgery + radiation, multifactorial respiratory failure unable
to be weaned from vent ___ s/p trach/PEG placement, DM, COPD,
CKD, hypothyroidism, RA presenting from ___ following a
fall.
#S/P FALL: Precipitant for fall remains unclear. Per family,
patient slipped out of wheelchair and fell, making mechanical
fall most likely etiology. Syncope workup, including basic labs,
EKG, and trops were negative. Non-contrast head CT without e/o
bleed. Patient reported pain over left wrist, left shoulder, and
humerus. Shoulder, wrist, elbow, pelvis, femur x-rays all
negative for fracture or dislocation. She was given
acetaminophen for pain control.
#INSULIN-DEPENDENT DM:
Reportedly poor control in the past. There were no signs of DKA
on labs and blood glucose was 203 on presentation to ED. Patient
was continued on home lantus 28 units Q12H as per her home
insulin regimen.
#RESPIRATORY FAILURE STATUS POST TRACH/PEG:
Patient previously had trach/PEG placed ___ following
several failed extubations for multifactorial respiratory
failure. The patient was successfully placed intermittently on
trach collar, however required ventilator support again on
___. Trach weaning should continue at new rehab facility.
Patient did not require much ventilatory support during
admission.
===================================
TRANSITIONAL ISSUES
#Insulin-dependent DM: Should follow-up with primary care
provider
___ have speech therapy evaluate and place ___
speaking valve | 119 | 216 |
19889694-DS-48 | 26,986,243 | Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you were having
chest pain that was worse with breathing. We were concerned
that this was due to a blood clot in your lungs (called a
pulmonary embolus) and you were admitted for further evaluation
of the possible blood clot.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- While you were in the hospital, your breathing and heart were
closely monitored. Your chest pain improved and you were
breathing comfortably on room air.
- You were started on a heparin drip (an anticoagulant) in the
setting of concern for a blood clot in your lungs. The heparin
drip was stopped after imaging showed you likely did not have a
blood clot.
- You had several types of imaging of your chest including a
chest x-ray and a ventilation-perfusion scan (V/Q Scan) that
helped us determine that it was unlikely you had a pulmonary
embolus.
- You also had an ultrasound of your lower extremities and there
were no new blood clots in your legs.
- You were seen by the kidney transplant team and they helped in
making medical decisions in the setting of your transplanted
kidney. They determined that your kidney function had not
changed and no changes were made to your home medications.
- Your symptoms improved and breathing remained stable and were
deemed ready for discharge home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all of your medications and follow up
with your doctors at your ___ appointments.
- Weigh yourself every morning, call your doctor if weight goes
up more than 3 lbs.
We wish you all the best!
Sincerely,
Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
Ms. ___ is a ___ year old woman with a history of SLE
complicated by lupus nephritis s/p DDRT ___ now with allograft
CKD (baseline Cr 1.4-1.7), provoked DVTs now off anticoagulation
since ___, HTN, and Sjogren's syndrome who presented to the
ED with pleuritic chest pain concerning for PE, now determined
to be less likely given normal V/Q scan.
While in the hospital, Ms. ___ was closely monitored for her
chest pain and breathing status. During this admission, she had
continuous symptomatic improvement of chest pain and had oxygen
saturation >95% on room air. She was started on heparin drip
given concern of PE. She underwent bilateral lower extremity
ultrasounds that demonstrated no new DVTs. Chest x-ray did not
demonstrate any pneumonia, pulmonary edema, or pleural
effusions. There was persistent globular enlargement of the
cardiac silhouette that has been stable since ___. V/Q scan
demonstrated normal ventilation and perfusion with low
likelihood of PE. Given symptomatic improvement with low concern
for PE, she was taken off of anticoagulation and was deemed
ready for discharge with close outpatient follow-up.
TRANSITIONAL ISSUES
===================
[ ] Patient may require long term anticoagulation given history
of provoked DVTs and hypercoagulable state in the setting of
SLE. Her outpatient hematologist (Dr. ___ has been notified
of her admission. Of note, patient desiring pregnancy and would
like to stay off of warfarin (which has been her anticoagulant
in the past given CKD).
[ ] Globular enlargement of cardiac silhouette again seen on
chest x-ray this admission. Stable since ___ but may require
outpatient work-up with echocardiogram.
ACUTE ISSUES
============
#Pleuritic chest pain
Patient with history of two provoked DVT ___ and ___ in
the setting of refusing heparin prophylaxis while inpatient had
presented with pleuritic chest pain. Recent cessation of
warfarin in ___ after 6 months of anticoagulation. Given
history of DVTs, patient was admitted for V/Q scan with concern
for PE. CTA was contraindicated given CKD. However, bilateral
LENIs ruled out new DVT (but possible residual proximal DVTs
unable to be seen on ultrasound) and CXR and V/Q scan indicated
low probability of PE. Patient had been started on heparin drip
which was discontinued after normal V/Q scan. Etiology of chest
pain remains unclear but given low suspicion for PE and patient
symptomatically improving and without acute shortness of breath,
tachycardia or desaturations, patient was deemed ready for
discharge home with close follow up.
CHRONIC ISSUES
==============
# Immunosuppression
# ESRD due to lupus nephritis, s/p DDRT
Patient's renal function at baseline with creatinine at 1.5 on
discharge. The transplant renal team assessed the patient during
this admission and the patient was deemed to be stable. Her home
medications were continued and tacrolimus levels were monitored.
She was not exposed to any contrast.
#Lupus: Patient continued on home hydroxychloroquine
#Anxiety: Patient continued on home Ativan and trazodone
#Depression: Patient continued on home ziprasidone and
mirtazapine
#Hypertention: Patient continued on home metoprolol
#Sleep Apnea: Patient reports no longer using CPAP at home.
Patient was not on CPAP during this admission.
# CODE: Presumed FULL
# CONTACT: sister ___ ___ Boyfriend ___ | 302 | 496 |
16534990-DS-2 | 26,956,166 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated, left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add dilaudid as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take subcutaneous heparin 5000 units three times daily
for 4 weeks from your operation - end date ___.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Weight bearing as tolerates in the left lower extremity
Range of motion as tolerated in the left lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L intertrochanteric hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for L dynamic hip screw, 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. Given the patient's
ESRD consultation was sought from the nephrology team who helped
with her care and coordinated her MWF dialysis. The patient did
asymptomatic low hematocrit post-operatively for which she
received a single unit of pRBCs during a dialysis session. The
patient worked with ___ throughout her hospital stay who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding spontaneously. The patient is weight bearing
as range of motion as tolerated in the left lower extremity, and
will be discharged on heparin for DVT prophylaxis given her
ESRD. 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. | 575 | 299 |
19764344-DS-11 | 23,122,898 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
trouble swallowing. A swallow study was normal and a CT of your
chest and abdomen demonstrated no cause for your difficulty
swallowing. We have arranged follow up with ENT as an
outpatient. You have recovered and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
MEDICATIONS:
- Take all the medicines you were on 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.
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
trouble swallowing. A swallow study was normal and a CT of your
chest and abdomen demonstrated no cause for your difficulty
swallowing. We have arranged follow up with ENT as an
outpatient. You have recovered and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
MEDICATIONS:
- Take all the medicines you were on 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. ___ was admitted to ___ the setting of dysphagia of
liquids vomiting with a past medical history of esophageal
cancer status post esophagectomy to concern for recurrence or
other obstructive pathology. He underwent an upper endoscopy on
___ which was essentially normal. On ___ underwent
a CT of his chest, abdomen, and pelvis which similarly
demonstrated no obvious obstructive pathology or evidence of
recurrent/metastatic disease. Of note the CT of his chest
demonstrated incidentally discovered pulmonary nodules which
will be left patient with a scan. His diet was advanced,
initially performed on ___, without nausea/vomiting,
and then on ___. Mechanical diet which he similarly
tolerated well without evidence of dysphagia. Outpatient
follow-up with ENT was arranged for further evaluation of his
dysphagia due to a suspected oropharyngeal component. He was
discharged home, tolerating a soft mechanical diet, ambulating,
hemodynamically stable without evidence of infection. | 253 | 153 |
15254963-DS-9 | 29,842,517 | Dear Mr. ___,
You were hospitalized due to symptoms of right facial droop and
right sided weakness and numbness resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. High blood pressure
2. High cholesterol
3. Diabetes
4. Previous TIA
We are changing your medications as follows:
1. SWITCHING your Aspirin to Plavix 75mg daily.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization. | #ACUTE ISCHEMIC STROKE:
Mr. ___ is a ___ year old right handed man with history of
HTN, HLD, DM II and recent admission for TIA work-up for
transient slurring of speech and R facial droop who presented to
___ from his rehab facility with with signifcant dysarthria,
right facial droop and right hemiparesis, arm>leg. His exam on
arrival was notable for no aphasia or visual symptoms. A ___
done in the emergency room revealed no acute bleed or infarct.
There was concern for left internal capsule/basal ganglia
infarct and patient was admitted to the stroke service for
further work up. An MRI was done which revealed an infarct of
the left Corona radiata, left caudate nucleus, involving the
posterior aspect of the basal ganglia. CTA showed no significant
occlusion.
His ASA was changed to Plavix 75mg and he was continued on his
Atorvastatin 80mg. Most recent TTE was done 1 week prior
(showing normal biventricular regional/global systolic function
and grade I diastolic function), and therefore was not repeated
during this admission.
#DIABETES:
Mr. ___ was placed on an insulin sliding scale along with
his home doses of long acting insulin in the AM and ___ after he
passed his swallow study and was able to take PO. However, his
fingersticks were noted to be low in the AM and, as a result,
his long acting ___ insulin dose was decreased from 44 to 20
units. At the same time, his daytime fingersticks were noted to
be high and his AM long acting insulin was increased from
44units to 50units. These fluctuations were attributed to Mr.
___ inconsistent eating while in the hospital (skipping
dinner because he did not like it, but eating a large
breakfast).
#HYPERTENSION
His home hypertensives were held in the setting of acute stroke
and blood pressure was allowed to autoregulate; however, his
these were resumed prior to discharge.
#RIGHT WRIST FRACTURE
Orthopedics was consulted in the ER on arrival given significant
swelling of Mr. ___ distal radius/ulna fracture on ___
s/p closed reduction. They placed his right wrist in a splint
and then placed a cast on ___ after repeat films were obtained.
During his hospitalization, he did develop right shoulder pain
from and we obtained right shoulder xrays that did not show
subluxation. Orthopedics will follow up as outpatient in 4
weeks. He did unfortunately develop a pressure ulcer 1cm x 1cm
under the initial arm splint, which was cleaned and dressed when
new cast was placed.
#REHAB
Mr. ___ was evaluated by physical therapy and it was
determined that he would benefit most from a rehabilitation
facility that would address his impairments and
functional limitations prior to safe return to home.
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes () No
5. Intensive statin therapy administered? (X) Yes - () No
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (X) N/A | 165 | 634 |
13460406-DS-13 | 29,665,096 | 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 coumadin as you were prior to this hospitalization
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- No dressing is needed if wound continues to be non-draining.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
ACTIVITY AND WEIGHT BEARING:
- NWB LLE
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
___ change dressing over tibial wound daily with dry gauze
through window on cast. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L open tibia fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for I&D and closed reduction/casting, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the LLE extremity, and will
be discharged on coumadin 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. | 167 | 237 |
19674244-DS-31 | 28,478,629 | Dear Mr. ___,
You were admitted to the hospital with excess fluid due to an
exacerbation of your chronic congestive heart failure. We gave
you medications to help remove the extra fluid. You also had
hospital-acquired pnuemonia and we gave you antibiotics. You had
chest pain that was concerning for cardiac pain and we treated
you with medical therapy. You had abdominal pain and you were
found to have a bowel obstruction that required surgery to
removed dead bowel. You were also unable to come off of the
ventilator and therefore required a tracheostomy and feeding
tube. You are now ready for discharge to a long-term care
facility to continue your recovery. You will need to follow up
in the Acute Care Surgery clinic as well as your other
healthcare providers.
Please read the following instructions for discharge:
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. | ___ yo M w/ DM, HTN, CAD s/p CABGx4, ESRD secondary to FSGS s/p
renal transplant x 2 p/w DOE, +anasarca p/w ___ swelling and
decreased UOP found to have acute on chronic systolic CHF
exacerbation (in setting of newly depressed EF) diuresed but
course c/b NSTEMI, HCAP, worsening pleural effusion and SBO
requiring exploratory laparotomy. ***
NEURO: Patient's pain was well-controlled on PRN Tylenol and
narcotics. During periods of intubation, patient was sedated on
propofol and fentanyl drips. On ___, patient was noticed to
have a left-sided neglect while working with Physical Therapy.
CT head was negative for stroke or acute intracranial process.
CARDIOVASCULAR: Patient had multiple cardiac issues during this
admission.
# Acute on chronic systolic CHF exacerbation: Newly depressed EF
(30% from 50-55%, though had previously been 35% ___ w/ hx
CAD s/p 4 CABGs. Initially on lasix drip with twice daily
dosing of chlorothiazide 500 mg plus lasix 160 mg, then
transitioned to torsemide 20 mg daily once at dry weight ___
kg.) Continued home aspirin, atorvastatin, hydralazine,
metoprolol, nitroglycerin prn, isosorbide mononitrate.
# NSTEMI: Trop elevation up to 0.17 on ___ w/ dynamic STD in
V5-V6 during episodes of chest pain. Likely lost a vein graft in
the last month or so given regional wall motion abnormalitites
on TTE. Received heparin gtt x 48 hours from ___ to ___.
Continued imdur, hydralazine, ASA, atorvastatin. Cardiology
consulted, recommended mycoardial viability study, which was
completed ___ and showed moderate inferior and inferoseptal wall
defects at 20 minutes that improved at 4 hours and 24 hours,
suggesting viable myocardium. No fixed focal perfusion
abnormalities. Cardiac catheterization was put on hold due to
SBO.
#PEA arrest: Patient was extubated on ___ but required
re-intubation several hours later due to hypoxia. Shortly after
re-intubation, he became hemodynamically unstable without
immediate improvement in oxygenation. He became extremely
tachycardic and hypotension and went into PEA arrest requiring a
___ min of chest compressions and epinephrine with ROSC. After
chest tube placement for suspected pneumothorax, the patient had
a second PEA arrest with ROSC after ___ of chest compressions.
An informal bedside Echo done during this time showed severe LV
hypokinesis with EF 15%. He subsequently required quadruple
pressors to maintain his MAP but was able to wean off all
pressors in less than 24 hours.
#Supraventricular arrhythmia: After pressors were weaned,
patient was resumed on IV metoprolol - the dosing was increased
per Cardiology to control tachycardia with a supraventricular
arrhythmia.
#History of CAD & CABG: Patient was continued was home aspirin,
Plavix. Metoprolol was resumed when appropriate.
PULMONARY: Patient had multiple pulmonary issues during this
admission.
# Bilateral pleural effusions: In setting of CHF exacerbation
and HCAP (see below), noted to be worsening on CXR and CT with
higher oxygen requirement than at home (between ___ L O2 during
admission in comparison to 2L intermittently at home.)
#HCAP: See "Infectious Disease"
#COPD: Patient was continued on home albuterol and ipratropium
inhalers.
#Respiratory failure: The patient was intubated for his bowel
resection and remained intubated until POD1 after re-anastomosis
and abdominal closure was completed. He failed extubation on
___ due to hypoxia. His oxygenation did not immediately improve
with upon re-intubation, and CXR showed complete white out of
his left lung. Shortly after the film was shot, he became
extremely hemodynamically unstable and went into PEA arrest x2
(as described under "Cardiovascular"). A left chest tube was
placed due to suspicion for a pneumothorax without much
improvement. A bronchoscopy was done showing copious thick
yellow secretions in the left bronchial tree. After these
secretions were suctioned, oxygenation improved significantly.
Though the patient was able to wean to minimal ventilatory
support, there was great concern that he would not be able to
tolerate extubation and a tracheostomy was placed. He was unable
to wean to trach mask due to significant anxiety.
GASTROINTESTINAL:
#SBO: During his hospital course, patient developed worsening
abdominal pain with associated leukocytosis; KUB and CT showed
closed loop obstruction. On ___, he underwent an exploratory
laparotomy with small bowel resection in left in discontinuity
with open abdomen. He returned to the OR two days lover for
re-anastomosis of the jejunum to the D4 portion of the duodenum.
A CT abd/pelv was done on ___ in the setting of worsening
leukocytosis, which showed no anastomotic leak. Regardless, the
patient complained of worsening abdominal pain and taken back to
the OR on ___ for exploration - the anastomosis was intact. One
liter of ascitic fluid was drained, and the abdomen was washed
out. A
#Wound infection: Noted on OR take back on ___. Fascia was
closed and the wound was left open with a wound VAC that was
changed q3 days with good wound healing.
#SBP: Given finding of ascites on his ___ CT, a diagnostic
paracentesis was performed on. Only a small amount of fluid was
drained ___ but it eventually grew VRE, and the patient was
started on linezolid.
#Malnutrition: Given the patient's ventilator-dependence and
severity of illness, the patient received nutrition via enteral
feeds (Nepro). He received a gastronomy tube with the
tracheostomy.
#C diff infection: see "Infectious Disease" | 346 | 841 |
13265698-DS-9 | 28,668,734 | Ms ___,
You came to the hospital for abdominal pain and abnormal labs
and were found to have a clot in your left leg and a pancreatic
mass with spread to your liver. We performed a biopsy of your
liver, the results of which are still pending. We also started
you on a blood thinner for clots in your leg and in your lungs
which you will continue taking at home. You started having some
fevers in the hospital. We are treating you with antibiotics for
possible pneumonia which you will need to continue taking for a
few more days at home. Please continue to use your incentive
spirometer at home.
You may continue to have some fevers at home--this is because
the fevers could also be due to your pancreatic mass or your
blood clots. If you start having fevers as well as other new
symptoms like worsening cough, burning when you urinate,
headaches, etc then please come back to the hospital. If you
just have mild fevers at home without new symptoms, please
follow up with your PCP. | ___ yo F PMHx HTN, hypothyroidism, asthma, cognitive delay who
presented with epigastric abdominal pain and weight loss, found
to have iron deficiency anemia, pancreatic mass, liver masses
concerning for mets, and LLE DVT.
# Liver masses
# Pancreatic mass
Initial presentation and findings concerning for malignancy,
?pancreatic primary. No signs of biliary or GI obstruction.
Mild elevation of ALP, AST which remained stable during stay. ___
team was consulted for biopsy of liver mass as the GI team felt
pancreatic mass was not easily targetable for biopsy. She
underwent biopsy of liver mass by ___ on ___. Bx results were
still pending at time of discharge. Pt will f/u with oncology on
___ for further evaluation. She had CT CAP done inpt. Initial
CT AP at OSH w/o contrast showed small bowel wall thickening;
repeat CT w/ contrast did not show this.
# DVT of left femoral, left popliteal vein
# PEs
# Splenic vein thrombus
No recent history of immobility or surgery. Concern likely in
setting of malignancy. Given lovenox in ED. Switched to heparin
gtt in anticipation of procedures. She was kept on heparin gtt
during her stay here and then transitioned apixaban 5 bid on
discharge. She did not have any O2 requirement while here.
#Fever:
#PNA
#Leukocytosis
Pt been having intermittent fevers since ___ (prior to bx).
Leukocytosis w/
WBC upto 18 on discharge. Doesnt have any focal symptoms other
than ___
abd pain. Doesnt feel chills or poorly when she fevers. UA
appears c/f UTI altho denies any symptoms and multiple ucx have
been contaminated. Her CXR ___ with c/f RLL PNA. She is not
complaining of cough or URI symptoms. Her CT Chest doesnt appear
to show PNA but has RML collapse which can be a cause for
post-obstructive PNA. Fevers may also likely be ___ tumor
burden and clots. She was started on vanc/cefepime on ___ and
then switched to levaquin on ___. She will complete a 7 day
course for HCAP. MRSA swab still pending at time of discharge.
She did not have any fevers on discharge. If she fevers while on
antibiotics without any other symtpoms, it is quite likely this
is due to clots and tumor burden.
#RML collapse:
CXR obtained to r/o infection and there was increased soft
tissue enlargement in the region of the lower neck and
upper chest, with concomitant leftward tracheal deviation. For
this reason, CT chest obtained which showed RML collapse. Spoke
with pulm and they suggested this may indicate atelactasis ___
mucous plugging. No worsening in breathing, no O2 req, no cough,
SOB. Mass can also not be excluded altho would be unusual
for pancreatic cancer to spread to RML lung.
-Incentive spirometry, will continue at home
-tx for HCAP as above
- may need repeat CT chest in the future to monitor for
resolution
# Epigastric abdominal pain
# Weight loss
# Severe malnutrition
CT scan as above with pancreatic mass and liver masses. This is
likely source of her pain and wt loss. Pain improved somewhat
during admission with oxycodone but still had low appetite
- Nutrition consulted who recommended ensure TID
- Given reports of chronic NSAIDs use, trialed on PO PPI and she
was discharged with this
- Low dose Tylenol PRN, lidocaine patch, low dose oxycodone
PRN-->prescribed on discharge
-can consider appetite stimulant in the future
# Hematuria
Unclear etiology. CT w/o obvious renal abnormality or stone.
No
signs of Ucx growth making UTI unlikely. Creatinine is not
significantly elevated though unable to completely rule out
glomerular process
- urine cytology ordered and pending
- will f/u with urology outpt
# Normocytic anemia
# Anemia of chronic disease
- Monitor H/H and for signs of bleeding
#Hx MN goiter:
Large MN goiter on CT chest. Has hx of thyroid nodules,
presumably benign based on prior path.
# HTN
On enalapril at home but this was held due to softer BPs
# HLD
- Continue atorvastatin 20
# Asthma
- Continue home Advair
Transitional issues:
[] f/u bx results
[] f/u urine cytology and urology f/u for hematuria
( )f/u BPs, can resume enalapril if needed
( )may need repeat CT chest to eval for RML improvement
( )monitor for fevers-->currently completing course for possible
PNA, but fevers could also be ___ tumor and clots
( )consider appetite stimulant
[X] Ms. ___ is clinically stable for discharge today. The
total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes. | 179 | 712 |
11204369-DS-10 | 21,632,734 | Dear ___
___ were transferred to the ___
in ___ because ___ had chest pain. We evaluated ___ here and
found that ___ had some abnormalities in and near your
esophagus. We also found that ___ had a normal appearing heart
on a stress test. We also found that ___ had a growth in your
esophagus. We subsequently took ___ for an endoscopy, which
showed severe inflammation of your esophagus but no masses. We
took some biopsies, and the gastroenterologists will contact ___
when the results of the biopsies are available. | ___ year old man with HTN, paranoid schizophrenia, and ? prior
CAD / NSTEMI (trop ~2 early ___ who presented with left sided
substernal chest pain, found to have mild troponin elevation to
0.03 without EKG changes concerning for possible cardiac pain vs
esophageal pain.
# Acute Coronary Syndrome vs. esophageal pain: Patient presented
from OSH after having chest pain, trops elevated to 0.03, no
signifcant ischemic EKG changes for possible cath. Patient's
risk factors include prior 40 pk-yr h/o smoking, HTN, and LVH
per EKG. Of note, CTA was performed for elevated d-dimer which
showed no PE but evidence of esophageal thickening,
paraesophgeal and mediastinal adenopathy. The PCP was contacted
who confirmed that on a prior recent hospitalization in early
___ trops were elevated to ~2 after last hospitalization in
the setting ___ which was thought to be ___ demand and not
NSTEMI. As it was unclear if this was cardiac chest pain, given
concern for possible esophageal cancer based on CTA, he
underwent pharmacological stress with perfusion imaging which
showed no concerning abnormalities, however at the time of
discharge final report is still pending. Per ACS, patient was
treated initially with heparin drip, and continued on full dose
Aspirin 325mg daily x 1 month, atorvastatin 80mg Daily,
metoprolol tartrate 25mg BID, lisinopril 20mg daily. Lipids and
A1c were checked and were within normal limits (see results
section for specific values).
# Concern for Esophageal malignancy - Patient has history of
GERD, and 20lb unintentional weight loss in 5 mo. He denies
dysphagia recently. He has anemia and endorses black stools.
Given adenopathy seen on initial CT read, concern for metastatic
disease at this point. Patient states that he had a relatively
recent upper endoscopy, but PCP is unaware of an endoscopy. Pt
underwent EGD which showed severe esophagitis, for which pt was
treated wtih 40 omeprazole BID and carafate slurries 1g QID. GI
will follow-up with the patient with biopsy results.
# Hypertension - Patient was continue lisinopril and amlodipine
5mg daily
# Paranoid schizophrenia - Patient lives in a group home. Per
PCP, pt is unable to make his own decisions, but HCP is ___
___. Pt able to provide certain aspects of history reliably.
Patient was continued on amitryptiline, trazodone, lorazepam.
His HCP is his cousin ___ ___
# GERD - stable, given high dose 40 BID omeprazole, ranitidine,
and carafate 1g qid for severe esophagitis (as described above)
# Anemia - Patient was continued on ferrous sulfate.
TRANSITION ISSUES
#CONTACT: Patient, HCP is ___ (cousin) ___
#Follow-up final pharmacologic stress test (___) and EGD
biopsies from ___ | 90 | 435 |
11958578-DS-21 | 22,524,385 | Dear Mr. ___,
WHY WERE YOU ADMITTED?
- You were admitted for fever, confusion, and cough with
vomiting. We diagnosed you with pneumonia.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- You were continued on your oral antibiotics.
- You did not need to be started on IV antibiotics.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- It is important that you complete your antibiotic course (5
days, complete on ___.
It was a pleasure taking care of you!
- Your ___ Team | Mr. ___. is an ___ male with PMH of progressive
Alzheimer's dementia who presented from SNF with fever, altered
mental status, cough and emesis. He had already been empirically
started with levofloxacin at his nursing facility but given
increasing lethargy, he was transferred to ___ for further
management. | 77 | 48 |
16071145-DS-20 | 20,304,019 | Ms. ___,
You were admitted to the gynecology service in the setting of
anemia requiring a blood transfusion. It is unclear why you are
having vaginal bleeding, but it could be due to fibroids. There
are also tests pending (which should return in ___ days)
regarding whether or not the bleeding may be due to cancer.
Right now, we don't have those results back.
Regarding your bleeding, this has normalized with stopping your
coumadin and taking medication to reverse the effects of
coumadin. For the time being, we recommend stopping the
coumadin. It is likely that you will need to restart this, but
right now the risk of taking it is higher than the risk of not
taking it because of the bleeding you had.
Please follow these instructions:
- Do not take coumadin until instructed to do so by your
cardiologist, or after cleared from gynecology service
- If you have any concerning signs of vaginal bleeding, call the
on call number ___.
Regarding your history of heart failure,
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- If your blood pressure is very low, avoid taking your blood
pressure medications. It is still important for you to take your
carvedilol. | Ms. ___ is a ___ with atrial fibrillation on anticoagulation,
CHF, thalassemia and long standing h/o postmenopausal bleeding,
who was transferred from OSH and admitted with worsening
bleeding and blood loss anemia with a concern for a cervical
mass. Her coumadin was held and her vaginal bleeding improved.
She had received 3 units packed red blood cells and 2 unit FFP
at the OSH and subsequently remained hemodynamically stable. She
was seen by cardiology for her history of atrial fibrillation
and aortic stenosis with recs to hold anticoagulation in setting
of acute bleeding and to maintain a hematocrit over 21.
She had a CT abd/pelvis as she was unable to tolerate a MRI
given claustrophobia. Imaging showed apparent soft tissue
fullness in the area of the cervix, overall similar in
appearance to scan from ___. No definitive cervical mass.
Stable appearance of a lobulated, fibroid uterus.
Findings were discussed with patient and, given her stable HCT
and improved vaginal bleeding, decision was made to pursue work
up of her cervical lesion as an outpatient. She has biopsy
pathology, CA-125, ___, CEA labs pending. On hospital day 1,
she was discharged home in stable condition with outpatient
follow up. She will also follow-up with her ___ clinic to
restart anticoagulation later this week. | 202 | 213 |
18892464-DS-22 | 20,775,084 | Ms. ___,
You were admitted to ___ after an allergic reaction to a
medication, ciprofloxacin. You were evaluated and treated by the
medicine service and your condition improved. Please follow-up
with your primary care doctor and urology doctor. | Ms. ___ is a ___ year-old woman with Afib and recent urethral
biopsy presents in the setting of likely allergic reaction to
ciprofloxacin. | 39 | 25 |
17993788-DS-14 | 28,592,469 | Mr. ___,
===================================
Why did you come to the hospital?
===================================
-You were very confused and sleepy
===================================
What happened at the hospital?
===================================
-The most likely cause of your symptoms is a buildup of toxins
from your liver disease. We treated this aggressively with 2
medications called rifaximin and lactulose, which helps excrete
these toxins in the stool.
-You were also having fever/cough so we treated you with
antibiotics for pneumonia.
-Your diabetes is very poorly controlled. You were seen by
diabetes specialists who helped with your insulin regimen.
===================================================
What needs to happen when you leave the hospital?
===================================================
-Make sure to take enough lactulose to have ___ bowel movements
per day
-Take the rifaxmin every day
-Finish your antibiotics for pneumonia
-Monitor your blood sugar first thing in the morning and 2 hours
after breakfast, lunch, and dinner. Record these values and
bring them to your follow up appointment. This will help with
adjusting your insulin. | ***TRANSITIONAL ISSUES***
___ speaking only
#No established providers in the ___ prior to
admission
#Poorly controlled DM, A1C 11%, seen by ___ during admission,
please use blood sugar log to adjust insulin as needed
#Cirrhosis likely ___ ___ need screening EGD.
#Please ensure ___ bowel movements per day with lactulose
#MRI recommended for the following: outside hospital head CT
which demonstrated focus of left frontal subcortical white
matter hypodensity, ddx by radiology included acute to subacute
infarct and vasogenic edema from occult underlying lesion.
#Discharge weight: 76.3 kg
#Last day of CAP antibiotics ___
#New meds: Flomax, Rifaximin
#Changed meds: Insulin regimen Lantus 50 units at night with
Humalog 18 units + sliding scale with breakfast, lunch, and
dinner
#Discontinued meds: none
SUMMARY: Mr. ___ is a ___ year old male, ___
speaking only, with a medical history notable for poorly
controlled DM, cirrhosis likely ___ ___, and chronic renal
failure. He presented with fever and severely depressed mental
status, ultimately responded to aggressive lactulose/rifaximin
and treatment of community acquired pneumonia. His poorly
controlled diabetes was also addressed with insulin uptitration.
#Altered mental status: ultimately presumed ___ hepatic
encephalopathy secondary to increased nitrogen load from lack of
bowel movements. Over a ___ hour period he returned to his
baseline mental status with aggressive lactulose and rifaximin
treatment. Hgb was stable so concern for bleeding was low. See
infectious workup below.
#Fever: LP did not show evidence of meningitis, a RUQ u/s did
not show evidence of ascites so SBP thought to be unlikely,
blood cultures only grew 1 bottle of coag negative staph over 5
days which was presumed skin contaminant. Given his associated
cough a diagnosis of CAP was made despite no obvious infiltrate
on his CXR. He was treated with ceftriaxone/azithromycin for 5
days.
___ 02:44PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-13* Polys-0
___ Macroph-26
___ 02:44PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-202*
Polys-0 ___ Macroph-16
___ 02:44PM CEREBROSPINAL FLUID (CSF) TotProt-37
Glucose-147
#Poorly controlled DM: Tough to control during his stay. His A1C
was 11% and he demonstrated considerable insulin resistance in
the setting of lactulose therapy. ___ was consulted for
insulin management recommendations and his insulin regimen was
uptitrated. The diabetes educator spent time at the bedside and
a full set diabetic supplies were prescribed upon discharge.
#Cirrhosis: Patient had a diagnosis of "cryptogenic cirrhosis"
on presentation. We reviewed records from ___, which all
studies were negative. We repeated a large workup (see below)
which was negative, and the working diagnosis is ___ cirrhosis
at this time. He had a RUQ ultrasound which did not show any
ascites and he was not volume overloaded on exam. His varices
status is unknown. An AFP was within normal limits.
___ Abdominal Ultrasound with Doppler
1. Suboptimal visualization of the atrophic left hepatic lobe
and associated Doppler measurements.
2. Patent main portal vein with reversal of flow. Patent
right, middle, left hepatic, splenic, and superior mesenteric
veins.
3. Coarsened hepatic echotexture and splenomegaly. No ascites.
___ 07:50PM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-
negative
___ 07:15AM BLOOD HCV Ab-Negative
___ 06:00AM BLOOD HBV VL-NOT DETECT
___ 07:15AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive* HAV Ab-Positive
___ 07:50PM BLOOD AMA-NEGATIVE Smooth-POSITIVE A (1:20)
___ 06:00AM BLOOD AFP-3.5=
___ 06:35AM BLOOD ALT-62* AST-62* LD(LDH)-299* AlkPhos-182*
TotBili-0.6
___ 06:00AM BLOOD Albumin-2.8*
___ 07:41PM BLOOD WBC-4.6 RBC-3.66* Hgb-10.5* Hct-30.8*
MCV-84 MCH-28.7 MCHC-34.1 RDW-15.0 RDWSD-45.8 Plt ___
___ 07:41PM BLOOD ___ PTT-30.7 ___
#CKD: Likely related to diabetic nephropathy. He has
proteinuria on screening labs. His lisinopril was held given ___
on presentation and restarted at the time of discharge.
#Given nursing concerns with straining while urinating and his
known chronic renal failure, in addition to prostatomegally
found on an abdominal ultrasound performed in ___, we
started tamsulosin to help with urinary flow. | 153 | 618 |
19962126-DS-19 | 21,472,938 | Mr. ___,
___ were admitted to ___ after being found without a pulse.
___ were successfully resuscitated and were transfered to ___
where ___ required intubation to maintain your oxygen and carbon
dioxide levels. The reason we think that ___ might have had a
cardiopulmonary arrest is due to a severe COPD exacerbation
causing retention of carbon dioxide, or an abnormal rhythm of
your heart causing it to beat too fast.
___ were also treated for a pneumonia with antibiotics and for
your COPD with steroids. Your breathing improved and the
breathing tube was removed.
___ developed a slowing of your intestines causing vomiting.
There seemed to also be slow bleeding from your stomach. ___
were put on medication for the bleeding and a tube was placed ___
your nose to your stomach to relieve the fluid and air buildup.
Your intestines recovered and the tube was removed and your diet
was started. ___ still had trouble swallowing thin liquids
which can happen to people who require intubation. This usually
recovers over time, but ___ need to be careful to use the
techniques taught to ___ by the swallowing experts to avoid
choking and aspirating on food and liquids.
___ were discharged to a rehab facility. | ___ year old man with COPD, alcohol dependence, and schizophrenia
on risperidone BIBA after he was found down without a pulse.
#LOC/PEA:
Unclear etiology for cardiac arrest. Most likely breath stacking
by patient due to underlying COPD/emphysema with subsequent
decompression with CPR allowing for ROSC vs. tachyarrhythmia
(Afib with RVR) causing absence of palpable pulse. LENIs were
negative and CTA was negative. Trops peaked at 0.07, which was
felt to be due to demand ischemia. Cardiology did not feel it
was necessary to cath the patient at that time. TTE showed
___ EF which was felt to be due to myocardial stunning ___
setting of acute stress. Repeat echo with normal EF prior to
discharge.
# Respiratory distress/hypoxia/CAP/COPD: Patient intubated ___
the ED for respiratory distress. Most likely due to his COPD and
aspiration pneumonia. He was extubated without incident. He was
given 10 day burst of steroids for COPD exacerbation. He was
also treated for CAP/aspiration with vanc/cefepime/levofloxacin
because he was noted to have thick, purulent secretions. He was
then narrowed to ceftriaxone to complete an ___fter
sputum cx's returned. See above. Patient had some episodes
post-extubation of hypoxia and tachypnea which were felt to be
due to his COPD with wheezing on exams. Patient improved with
duonebs and oxygen NC. There was also some concern that patient
aspirated ___ setting of vomiting (see below) but patient was
able to maintain O2Sats on NC after extubation and was weaned
down to ___. CXR on ___ did not show PNA but did show
atelectasis. Would continue incentive spirometry and
bronchodilators. He will need a REPEAT CT of the chest to
evaluate for interval change.
#Alcohol Dependence: Patient with a history of alcohol
dependence. Negative for alcohol per ED toxicology screen.
Concern for risk of withdrawal based on history. He was started
on a phenobarbital protocol which was eventually d/c'ed as he
did not appear to be withdrawing. He received high dose thiamine
x 3 days and then 100 mg daily along with folate and MVI.
#Ileus/gastritis: Patient had copious vomiting the night after
extubation. An NGT was placed. KUB showed distended loops of
bowel consistent with ileus, but no signs of volvulus or SBO.
Patient was not passing gas. He was given a suppository and
other aggressive bowel regimen meds and he started to have bowel
movements. On day of transfer from the unit, pt was draining
dark reddish fluid from NGT, felt to be due to gastritis. Pt was
placed on a PPI IV BID which was then increased ___ dose when
fluid from NGT returned guaiac positive. AXR on ___ showed
resolving ileus, pt was passing gas. NGT clamped on ___, pt
denied pain or nausea. No residual. Was reexamined by speech
and swallow on ___ and allowed a nectar thickened and soft
diet. NGT removed. Stools guaiac negative. Continued on PPI.
#Cardiomyopathy, EF 20%: Initially diuresed due to feeling that
patient was fluid overloaded and his respiratory status
improved. Creatinine eventually bumped and diuresis was stopped.
Given his NPO status, patient eventually became hypernatremic
and was given free water flushes as well as IV D5 free water.
Repeat TTE showed normal EF. He will follow up with cardiology
after discharge.
#Atrial Fibrillation: Patient found to have afib with RVR
shortly after ROSC. Felt to be new onset. Subsequently ___ sinus
rhythm. Patient was started on aspirin for CHADS 1.
#Schizophrenia: Existing diagnosis. Risperdal was held during
admission and can consider restarting at discharge.
#Social situation: Mr. ___ lives at the ___ and has
no HCP. His brother confirmed that he "is his own guardian".
After extubation, the patient stated that he did not want the
medical team to contact anyone ___ particular. He had difficulty
comprehending the reasons behind his admission, however, and an
ICU consent and code status could not be obtained. He was full
code.
.
#anemia, acute renal failure and alkalosis improved.
.
#nutrition-on nectar thickened, soft diet. Please adat and
continue swallow therapy. | 213 | 660 |
15162528-DS-9 | 20,879,211 | Dear Mr. ___,
You were admitted to the hospital after presenting with neck and
arm pain that was concerning for recurrent ischemic symptoms
similar to what you've been experiencing from your coronary
artery disease. You were evaluated with blood work and imaging
which showed you had low blood counts. Your blood counts may
have been lower than usual because of recently starting
everolimus. Because your blood counts were low, it was likely
that your heart was receiving less oxygen than it usually did.
Because of this you felt similar kinds of symptoms to the
"stressed" response of the heart during a heart attack. You were
given a transfusion of blood, after which your symptoms and
laboratory values improved. You also presented with an INR that
was high at 4.0, so your warfarin was held while you were in the
hospital. You were discharged back on 3 mg per day. Please
follow-up with your regular ___ clinic.
Please follow-up with your primary care doctor as well as your
renal cancer doctor. You may require adjustment of your
everolimus vs. other chemotherapy plans. We also recommend you
schedule follow-up with your cardiologist.
We have switched your atenolol to metoprolol given your reduced
kidney function. We have also started you on a medication called
isosorbide. Please withhold your amlodipine until you follow-up
with your primary care doctor.
It was a pleasure to be involved with your care at ___
Your ___ Team | Mr. ___ is a ___ male with a past medical history
of coronary artery disease status post CABG, A. fib on Coumadin,
and renal cell cancer who is presenting for evaluation of 1
evening of unremitting neck/left arm/chest pain, concerning for
NSTEMI in the setting of anemia.
# Demand ischemia, NSTEMI # Neck/left arm pain # lactatemia:
Patient presented approximately 1 month after starting
everolimus for his renal cell carcinoma. He previously had
dyspnea in response to new chemotherapeutic agents. He described
the emergence of familiar anginal type symptoms of neck and arm
pain which were not relieved by nitroglycerine. He demonstrated
a Hb of 8.0 down from 11, with EKG findings of new T wave
inversions V1-V4 and other ischemic changes. Initial troponins
showed uptrend up to 0.64. He was transfused 1 unit PRBCs in the
emergency room, after which his troponin trend slowly improved.
He had an echocardiography that showed worsened mitral and
tricuspid regurgitation, along with regional wall motion
abnormalities and decline in LVEF. Cardiology weighed the
risk/benefit of a cath procedure in the setting of CKD/other
comorbidities and recommended conservative medical management.
He had also demonstrated slight lactatemia and acute on chronic
kidney injury on admission, which showed signs of improvement
after receiving blood. His INR was found to be supratherapeutic
at 4.0 on admission, after which his warfarin was held for 2
days. He was discharged on 3 mg of warfarin daily.
# Anemia: Patient presened with evidence of anemia, thought to
most likely be reflective of AoCD in the setting setting of new
everolimus initiation. It was thought pt had hypoproliferative
marrow. Also appeared to have some element of iron deficience.
# Acute Kidney Injury: Patient presented with Cr 2.4 on
admission from Cr baseline 1.4-1.7. He had no overt poor PO
history. Most worrisome was be poor perfusion/ATN in the setting
of ACS. Renal ultrasound suggested no obstruction.
# ? pneumonia on chest ___: Initially on admission a LLL
consolidation ? pneumonia was called on CXR. Clinically there
was no suspected post-obstructive pneumonia. Everolimus was not
be expected to immunosuppress patient significantly. Antibiotics
were deferred.
# Atrial Fibrillation / Coagulopathy: Patient presented with
elevated INR and hematuria with evidence of subacute Hb drop
over time. Patient did not have evidence of acute bleed despite
microscopic hematuria. It was elected not to reverse patient
with vitamin K, but instead hold warfarin until two days before
discharge. Patient was converted from atenolol to metoprolol
succinate on ___ due to worsened renal clearance in the setting
of CKD.
# Metastatic Renal Cancer: s/p R nephrectomy at ___ in ___
--pT3aNxMx-extension to renal pelvis. Patient claimed he was
recently started on everolimus, which had contributed to his
fatigue. He was discharged off of everolimus given concern it
contributed to his anemia. He was discharged with oncology
followup recommended.
*Chronic Issues:
# HTN: switched from atenolol to metoprolol this admission.
Amlodipine was also held due to concern re: reduced renal
clearance. He was converted to a regimen of metoprolol
succinate/imdur.
# IDDM c/b neuropathy: continued lantus/Humalog, home gabapentin
# anxiety: continued home alprazolam
# Nutrition: continued home calcium | 236 | 512 |
16344412-DS-25 | 26,865,095 | You were admitted to ___ with shortness of breath. After labs
and imaging, it is likely that you have a pneumonia. We have
started you on 2 antibiotics which you will continue for several
days.
You should follow up with your PCP next week and with your
Pulmonologist in 1 month (appointments listed below).
***You will need a repeat chest x-ray in ___ weeks to ensure
that your pneumonia has resolved.***
The following medication changes were made:
-START AZITHROMYCIN 250mg daily for 5 total days (through ___
-START CEFPODOXIME 200mg twice a day for total 7 days (through
___
-Please HOLD CEPHALEXIN (KEFLEX) only while you are on the
Cefpodoxime; as soon as the Cefpodoxime is finished then please
restart the Cephalexin (Keflex). | This is the brief hospital course for a ___ year-old female s/p
right total knee replacement in ___ complicated by a late
strep viridans septic arthritis in ___ (on chronic Keflex at
home) and history of MAC lung disease admitted ___ for
worsening dyspnea and cough X 5 days. She was found to have CXR
infiltrates concerning for pneumonia. She was treated for
community acquired pneumonia as she had no risk factors for
hospital acquired transmissions.
.
# Dyspnea: Patient with worsened dyspnea from her reported
baseline. Was using home oxygen more consistently, and at a
higher flow. She had no PE risk factors, therefore, CTA was not
done. Her chest x-ray showed a likely left lower lobe and
possible early right middle lobe infiltrative pneumonia. She was
started on IV Levofloxacin 750mg X 1, PO Azithromycin 500mg X 1,
and IV Methylpred 125mg X 1 in the ER, and given one set of
duonebs. These interventions improved her status greatly.
Steroids were not continued as the patient did not have a COPD
history. Levofloxacin was transitioned to oral cefodpoxime, and
azithromycin remained on. Sputum culture was not sent as patient
not producing sputum. The team decided to cover the patient with
both Cefpodoxime and Azithromycin because she has a history of
high risk exposure organisms causing infections in her past. CT
was considered for imaging and further investigation of
infiltrates, but on review of past imaging, no conclusions were
likely to be drawn from more studies as her baseline findings
are very confusing. Treated empirically. She will receive a
follow-up chest x-ray in 4 weeks to follow the assumed
pneumonia's hopeful resolution.
- continue home inhalers and nebulizers meds
- continue oxygen prn (O2 at home at baseline ___
- continue Azithro X 5 days and Cefpodoxime X 7 days
- follow-up pending cultures and Beta-glucan testing
- follow-up chest x-ray in 4 weeks
.
# Hx Strep Viridans Late R Prosthetic Knee Septic Arthritis
___
Keflex ___ Q12 @ home will be replaced by PO Cefpodoxime X 7
days and then she will continue on the Keflex ___ Q12H PPX.
.
# Anemia: long standing issue and pt is on iron supplementation
at home as Fe-deficiency anemia proven in past.
-continue home iron
.
# Endometrial carcinoma s/p hysterectomy in ___: Stable per
pt, and is followed by GYN at ___. No active issues.
.
# Anxiety: Pt on home at___ prn
-continue home at___ prn
.
# CODE: FULL CODE (discussed and confirmed w/ patient) | 122 | 435 |
19231238-DS-23 | 26,990,512 | You were admitted to the hospital with crampy abdominal pain,
nausea, and vomitting. You had a tube placed in your stomach
for bowel decompression. A cat scan was done which showed a
small bowel obstruction. You were placed on bowel rest. After
return of bowel function, the tube in your stomach was removed.
You resumed a regular diet, and your abdominal pain has
decreased. You are preparing for discharge home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* recurrence of abdominal pain
* 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. | ___ year old female admitted to the hospital with abdominal pain,
nausea, vomiting. She was also noted to have an elevated white
blood cell count. Upon admission, the patient was made NPO,
given intravenous fluids, and underwent imaging. Cat scan
imaging showed a small bowel obstruction with a possible
transition point in the RLQ. The patient underwent serial
abdominal examinations.
After admission to the hospital, the patient was noted to have
an elelvated blood pressure. She was admitted to the intensive
care unit for blood pressure monitoring and intravenous
administration of her anti-hypertensive agents. THe patient
required intermittent dosing of intravenous hydralazine and
metoprolol. The patient eventually was started on a labetalol
drip for blood pressure management. She was noted to have a
transient episode of atrial fibrillation which resolved after
her home cardiac medications were resumed. Her abdominal pain
began to resolve within 24 hours and the ___ tube was
removed. The patient was started on clear liquids. She resumed
her home anti-hypertensive agents and the labatelol drip was
discontinued.
The patient was transferred to the surgical floor on HD # 3.
Her vital signs remained stable and she was tolerating a regular
diet. She was passing flatus, along with bouts of loose stool.
Since the patient was ambulatory, there was no indication for
physical therapy evaluation. The patient was discharged home
with ___ services, under supervision of her daughter. At the
time of discharge, she had resumed her home meds and her blood
pressure normalized. The patient was discharged in stable
condition on HD #5. She had a appointment scheduled with her
primary care provider ___ 2 weeks. | 230 | 286 |
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