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13376901-DS-9 | 21,330,418 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
You were admitted for the evaluation of falls at home and high
blood glucose. We took an X-ray of your left knee and there was
no evidence of fractures and effusions. We took an X-ray of your
left ankle and the results are pending at the time of discharge.
Please follow up with your primary care physicians regarding
results. We consulted neurology to rule out seizure as a
pontential cause of your falls. Neurology service concluded that
falls are most likely orthopedic and neuropathic in etiology and
very unlikely due to seizures. They recommended follow up with
your outpatient neurologist, Dr. ___.
We recommend that you use your walker at all times to ambulate
around the house. We recommend that you continue physical
therapy at home and consider rehab or group home.
Your diabetes was managed by your home dose insulin regimen in
addition to sliding scale. Please take your insulin as
instructed deligently.
Please take your medications as instructed. Please attend your
follow up appoinments as instructed by Dr. ___ Ms. ___. | Ms. ___ is a ___ y/o F with PMH of brittle DMII on insulin,
peripheral neuropathy, HTN, HL, and PVD who is admitted for
frequent falls, home safety, HTN, and hyperglycemia. | 186 | 31 |
10692683-DS-17 | 20,529,264 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you 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
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
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 | Mrs. ___ was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. She first
underwent an ERCP where a sphincterotomy was completed.
Post-procedure, Mrs. ___ lipase level was 5660. Serial
levels were obtained to evaluate for resolution of her lipase
levels before she underwent a choleystectomy.
The patient was taken to the operating room on ___ and
underwent a laparoscopic cholecystectomy. Please see operative
report for details of this procedure. She tolerated the
procedure well and was extubated upon completion. She we
subsequently taken to the PACU for recovery. She was
transferred to the surgical floor hemodynamically stable. Her
vital signs were routinely monitored and she remained afebrile
and hemodynamically stable. She was initially given IV fluids
postoperatively, which were discontinued when she was tolerating
PO's. Her diet was advanced on the morning of ___ to regular,
which she tolerated without abdominal pain, nausea, or vomiting.
She was voiding adequate amounts of urine without difficulty.
She was encouraged to mobilize out of bed and ambulate as
tolerated, which she was able to do independently. Her pain
level was routinely assessed and well controlled at discharge
with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up
with her PCP and ___ clinic in 2 - 3 weeks.
Mrs. ___ is currently hemodynamically stable with only general
"soreness" to her abdomen. Discharge instructions have been
provided. | 760 | 239 |
18703095-DS-9 | 24,936,686 | You were admitted to the ___ surgery service for observation
following a motor vehicle collision. You have remained stable,
and are now ready to return home to finish your recovery.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Please also
follow-up with your primary care physician. | Patient was admitted to the ___ service on ___ following
high speed MVC. She was observed overnight, and a tertiary
survey was performed on the morning of ___. No further
injuries were identified at that time, and her C-spine was
cleared, and she started a regular diet. We continued to
monitor her neurologic status throughout the day, which remained
stable. She was seen by occupational therapy and physical
therapy, who advised the patient was safe for home with
outpatient cognitive neurology follow up. On the day of
discharge, she remained afebrile, hemodynamically stable, and
neurologically intact, with improvement in pain level and
tolerating regular diet. | 252 | 110 |
19112631-DS-6 | 24,813,466 | Dear ___.
* Your injury caused Left ___ rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | The patient presented to Emergency Department on ___ after
a ___ transferred from an OSH. Pt. Given findings on trauma
immediate survey, the patient underwent imaging assessment
consisting of the following: | 253 | 32 |
12210632-DS-15 | 21,534,414 | You were admitted for work-up of abdominal pain and blood in
your stool. A colonoscopy was done, which showed bleeding
internal hemorrhoids and polyps in your colon. Biopsies were
taken of your polyps- you will be called with the results next
week. You can take Tramadol for pain as needed. If you continue
to have blood in your stool, your primary doctor can refer you
to a surgeon to discuss banding of the hemorrhoids. No other
changes were made to your home medications. | ___ with sarcoidosis, DM2, and asthma who presented with
subacute bloody diarrhea and new LUQ abd pain.
.
## Abdominal pain, bloody diarrhea: Patient was admitted for
pain control and work-up of bright red blood in her stool. A
colonoscopy was done, which showed bleeding internal hemorrhoids
and non-bleeding colon polyps. The hemorrhoids were thought to
be the source of her GI bleeding. Biopsies of the polyps were
taken- results are pending at the time of discharge. She was
advanced to a regular diet after the colonoscopy, which she
tolerated well. Her Hct and vitals were stable throughout the
admission. Pain was controlled with Tramadol, on which she was
discharged. She will follow-up per routine with GI as
outpatient.
.
## Type 2 DM controlled w/o complications: Home meds were
initially held while NPO but later restarted once her diet was
resumed.
.
## Sarcoidosis: Continued home Plaquenil.
.
## Asthma: Continued home inhalers.
.
## GERD: Continued PPI and H2 blocker.
. | 83 | 152 |
15622839-DS-19 | 20,589,644 | You came in with swelling in your legs. We gave you some IV
Lasix medication which allowed you to pee out the fluid. You
also worked with physical therapy who felt that you could
benefit from more intensive physical therapy to return to your
prior level of functioning. We are therefore discharging you to
a rehab facility for this rehabilitation.
Please return if you have worsening shortness of breath, leg
swelling, uncontrolled pain, or if you have any other concerns. | Mr. ___ is a ___ male with the past medical history
and findings noted above who presented with worsening bilateral
lower extremity edema, right popliteal pain, and increased DOE
and orthopnea, all consistent with an exacerbation of his
CHFrEF.
# Acute exacerbation of CHFrEF. Pt presented with increased ___
edema, elevated JVP,
pro-BNP elevated (though not markedly more so than previous
admission). Likely d/t medication non-compliance. Pt's son
reports helping him with medications but unclear how good he is
at administering medications and he is unsure of what meds he's
on. He was diuresed with several doses of 20mg IV lasix with
improvement in symptoms and ___ edema. He will be discharged on
home dose of 20mg PO Lasix. We also continued his home
metoprolol 25mg BID. He should speak with his Cardilogist
regarding whether or not this should be changed to Toprol XL
50mg.
# Right leg pain
# Hx of right popliteal non-occlusive DVT
# ___ stasis ulcers
Pt reported increased R leg pain in the same site of his
previous DVT. Repeat ___
were normal. There is no overlying erythema at the site -- his
lesions are stasis ulcers and do not appear infected. Abx were
not continued. Pain improved with improved edema. He was
discharged with home dose of Coumadin 2mg 5x/week and 4mg
2x/week
# ___ on CKD: Pt presented with Cr: 2.0 (b/l: 1.8's though has
fluctuated greatly in last few months). ___ likely
cardiorenal etiology given volume overload.
Improved with diuresis as above. Discharge Cr was 1.5.
# A fib. S/p pacemaker placement for tachy-brady syndrome.
CHADS-Vasc of 4. On warfarin for DVT as above.
# CAD s/p CABG ___ - 3V-disease with
SVG-LAD, SVG-PDA/RCA, SVG-OM1). Most recent cardiac cath in ___
noting 3VD, with occlusion of SVG-OM graft. ___ medically
managed given his advanced age. Trops on admission slightly
elevated at 0.05, but dowtrended without management. Continued
home ASA/BB. | 82 | 319 |
19133405-DS-57 | 23,125,850 | Dear Ms. ___,
You were admitted to ___ because of pain when you eat. While
here, you received pain medications and were evaluated by the
interventional pulmonology and ear-nose-throat doctors. ___ of
those teams felt that you did not have an infection or other
cause of your pain that would be amenable to intervention. For
this reason, you were admitted to general medicine for pain
control.
We would encourage you to continue working on trying to eat and
drink even if you have some mild discomfort as it should improve
over time.
Please follow-up with your PCP and pulmonologists.
It was a pleasure caring for you,
Your ___ Team | ___ F w/ lifelong trach secondary to tracheobronchomalacia from
premature birth, s/p 4 airway reconstructions, last at age ___,
bronchopulmonary dysplasia, chronic tracheitis and bronchitis on
chronic suppression, and laryngeal and tracheal stenosis who had
a recent admission to ___ for new ___ tube placement then
was readmitted for pain and fluid resuscitation, as well as
infectious workup, which was negative. Admitted for pain
control. | 104 | 65 |
18280019-DS-11 | 23,131,881 | Dear Mr. ___,
You were admitted to ___ because of upper abdominal pain. You
had an ultrasound and a MRI that showed that you had gallstones
which were likely causing your pain. You had a ERCP procedure to
remove a stone in your gallbladder, then a surgery to remove
your gallbladder. You did well after the surgery and you are
ready to be discharged to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | SUMMARY: ___ with a h/o hydrocephalus secondary to SAH s/p VP
shunt placement (___) with revision (___) who presents
to ED with RUQ pain. MRCP showed numerous gallstones with a
stone in the CBD. He had an ERCP with sphincterotomy that
revealed stones and sludge. Informed consent was obtained and he
was taken to the operating room for a laparoscopic converted to
open cholecystectomy on ___. He tolerated the procedure
well. He was extubated upon completion and transferred to the
PACU in stable condition. Post operatively he required
phenylephrine for hypotension. He received 2 units of packed red
blood cells and a pack of platelets. His hematocrit remained
stable, he was weaned of vasopressors and transferred to the
floor.
On POD0 he was transferred to the floor hemodynamically stable,
NPO with IV fluids, and IV pain medication.
On POD1 he had a head CT and was evaluated by neurosurgery to
assess the functioning of his shunt which appeared stable. His
mental status remained intact.
On POD2 his diet was advanced to regular with good tolerability.
He was given oral pain medications with good effect. He was seen
and evaluated by physical therapy who recommended discharge to
home.
On POD3 his pain was well controlled on oral medication, he was
tolerating a regular diet and voiding without difficulty. He was
discharged to rehab in stable condition. | 366 | 226 |
17985988-DS-17 | 21,246,205 | Ms. ___:
* Your injury caused multiple rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Regarding your thigh hematoma, you may elevate this and place
ice packs on it for comfort. You do not need to wrap or dress
the area. It will slowly get smaller over time but may turn
blue, purple, or green prior to disappearing. | Ms. ___ is a ___ year old female cyclist struck by a car on
___ who presented as trauma. In the trauma bay C/X/P XR
identified injuries including tiny apical left pneumothorax with
possible nondisplaced left sided rib fractures. Also identified
on initial exam were large left proximal thigh hematoma and
several minor facial abrasions and knee abrasions. She was given
tdap in the ED. She underwent CT imaging of head and Cspine and
these revealed no abnormalities. She complained of left shoulder
pain and thus XR of the left shoulder/humerus were completed and
these showed possible tiny humeral head fracture vs.
calcification however no other abnormalities. The patient was
transferrd to the floor for observation and pain management. Her
Hct at admission was 40. Once on the floor, her hematoma was
monitored and it remained stable in size. Her Hct decreased to
32 on ___ and further decreased to 28 in the AM on ___
however it subsequently stabilized and was 28.5 in the ___ of the
same day. Orthopaedic surgery was consulted to assess the
patient's left shoulder and they determined that her injury
represented superficial bruising and would benefit from ROM
exercise and non-op mgmt, these were begun. On ___ the
patient experienced one isolated episode of
dizziness/lightheadedness after standing quickly, however her
vitals remained appropriate and EKG showed no abnormalities. ___
assessment indicated orthostasis as likely responsible for these
symptoms. Ms. ___ continued to improve and experienced no
further episodes of dizziness. She was able to ambulate well,
achieved adequate pain control with oral medication, and
tolerated home diet. When appropriate she was discharged home
with instructions to contact the ACS and orthopaedic surgery
clinics, respectively, for follow up arrangements. | 299 | 285 |
18822620-DS-21 | 20,381,010 | ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with abdominal pain and diarrhea and
developed a cough and fever consistent with pneumonia.
For your abdominal pain and diarrhea, you were initially started
on antbiotics and seen by the gastroenterology service who
recommended an MRI of your abdomen. This MRI did not show
inflammation. Your abdominal pain improved.
You continued to have fever and symptoms consistent with
pneumonia. ID was consulted and while your symptoms may be due
to a virus, they recommended treating your with Azithromycin.
You should complete a total of 5 days of antibiotics.
You will be discharged with cough medication which may make you
sleepy. Do not drive and take this medication. Use only the
smallest amount needed.
We wish you the best,
Your ___ Care team | Pt is a ___ y.o woman with h.o Crohns disease, endometriosis s/p
hysterectomy, migraines, depression who
presents with abdominal pain, diarrhea, and fever, and developed
cough.
#Pneumonia
The patient presented with abdominal pain, fever and cough. She
had CXR with infiltrate. Initally, it was thought the patients
presentation was consistent with a viral process. Antibiotics
were not given. She continued to spike high fevers therefore ID
was consulted. While her symptoms may be due to a viral
infection, they recommended treating the patient with
Azithromycin for a 5 day course. The patient was discharged with
a prescription for cough suppressant given her ongoing
persistent cough.
#Abdominal pain/Diarrhea-
Initially concerning for ___ flare. However, thus far CRP
normal. GI was consulted and recommended an ___ which did not
show active inflammation She was given premedication given
concern for contrast allergy. She was given dicyclomine for pain
and also offered tylenol and a lidocaine patch. She was treated
with oral dilaudid during admission which was weaned down prior
to discharge. The patient was given a prescription for Bentyl
and phenergan on discharge.
Chronic issues:
#depression/anxiety-continued home Lexapro, clonazepam
#insomnia-home benedryl. Trazodone given for sleeping house.
#migraines-home lisinopril continued | 135 | 191 |
18068179-DS-16 | 23,178,513 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were having shortness of breath
- You were found to have a change on your EKG called a right
bundle branch block
What did you receive in the hospital?
- You had tests for a blood clot in your lungs which did not
show a blood clot
- You were given oxygen but subsequently improved and were able
to stop the oxygen
- You were given a diuretic because you had swelling in your
legs and concern for fluid in your lungs
What should you do once you leave the hospital?
- Continue to take your medications as prescribed
- Follow up with your primary care doctor and psychiatrist
We wish you the best!
Your ___ Care Team | ___ w/ PMH of IDDM, bipolar disorder, HTN, GERD with acute back
spasm and dyspnea who was admitted for hypoxia, tachycardia, and
new RBBB on EKG, V/Q scan normal with concern for new heart
failure.
# Dyspnea
# Hypoxemia
Shortness of breath at rest w/ sudden onset morning of ___.
CXR, CT did not show evidence of pneumonia. He required 1 L of
oxygen. EKG with new RBBB. TTE showed mildly dilated R
ventricle. Initially it thought to be due to PE but VQ scan was
negative. He had evidence of hypervolemia on exam (S3, ___
edema, crackles). He was given 20 mg IV Lasix ×2 with
improvement in his O2 sats and was weaned to room air.
Ultimately, he was discharged with 20mg PO Lasix and is to get a
BMP at his next PCP follow up. ___, please evaluate for
OSA given body habitus and evidence of RV overload on TTE.
# New right bundle branch block
He was found to be tachycardic with a new RBBB on EKG compared
with ___. TTE was obtained and showed mild R ventricle
dilatation. Initially concerned for PE; however, V/Q scan was
normal. Unlikely ACS given no chest pain, trops returned
negative x 2.
# Back pain
He had an episode of back pain prior to admission lasting 1.5
hrs, described as bilateral pain spreading up to the base of his
head. Likely due to paraspinal back spasm. Did not recur during
admission.
# Leukopenia, resolved
Patient leukopenic to 3.3 on admission (ANC 3000), subsequently
normalized. Antipsychotic medications (quetiapine, cariprazine)
could be contributory.
#Asymptomatic bacteriuria
Patient's UA on admission with bacteria, leuk esterase, WBCs.
Received one dose of ceftriaxone in ED for presumed UTI. Urine
culture grew Enterococcus. Home In___ was held. However,
patient denied dysuria, urinary frequency, incontinence,
fevers/chills so he did not receive further antibiotics.
=============== | 141 | 295 |
14689985-DS-37 | 27,528,678 | Dear Mr. ___,
You were hospitalized because you were having increased
ventilator requirements and altered mental status.
You were found to have an infection in your blood stream and an
infection in your lungs. For your infection in your lungs, you
were started on three antibiotics: Amikacin, Ceftazidime, and
vancomycin. You have completed your antibiotic course and do not
need to take these after discharge.
You were started on Daptomycin for your blood stream infection
and should complete a Four week course. You need a four week
course of this antibiotic to cover for a possible infection of
your heart, which we were unable to see because we could not
complete a transesophageal echocardiogram. The last day of
therapy is ___.
After discharge, please follow up with your providers at ___
___ as described below. | Mr. ___ is a ___ with PMH significant for AAA repair c/b
thoracic cord infarct with resultant paraplegia, COPD, multiple
HCAP/VAPs and chronic respiratory failure s/p tracheostomy/PEG
who presents from rehab with increased vent support and
inability to wean for the past few days.
=================
ACUTE ISSUES
=================
#VAP:
He has history of recurrent VAP, and is well known to the ID
service. Now presenting with increasing vent requirements with
CXR concerning for pneumonia. BAL with multiple GNRs,
Pseudomonas and Staph. Patient started on Amikacin, Ceftazidime,
and vancomycin to complete a 10 day course (last day ___. He
continued the flagyl and fluconazole for suppression.
#Bacteremia:
Blood cultures with MRSA and VRE. Likely from lung source vs
PICC line. PICC line removed. TTE negative for vegetation,
unable to get TEE as could not pass TEE probe into distal
esophagus due to patients complex anatomy. Patient treated with
daptomycin for his bacteremia. He has had several negative blood
cultures to date. As he was unable to have a TEE performed due
to inability to pass the TEE probe into the esophagus (despite
direct visualization via bronchoscopy), ID is recommending
treating with a 4 week course of Daptomycin for presumed
endocarditis, last day of therapy ___.
#RUE edema:
Concerning for PICC-associated DVT. Unlikely HIT despite history
of positive SRA given high plt. Pulmonary embolus is in
consideration given report of worsening respiratory status. Per
wife his LUE is also increased in diameter from baseline. UENI
negative for DVT. Edema likely secondary to low serum albumin
from chornic malnutrition.
#Leukocytosis:
He had leukocytosis to 45.9, which is substantially elevated
from previous (abnormal) baseline. Likely ___ bacteremia and
VAP. Leukocytosis waxing-waning with overall downward trend
during his admission.
#Hypercalcemia:
He was noted to have hypercalcemia of unknown duration. PTH was
appropriately suppressed and PTHrp was non-elevated. 25-Vitamin
D nonelevated. His calcium peaked at 10.9 (albumin 1.8) and
downtrended after IVF administration. He will need serum calcium
checked 1 week after discharge.
#Goals of care:
Palliative care consulted while in the hospital to discuss
symptom management.
================
CHRONIC ISSUES
================
#Chronic respiratory failure:
He initially received trach in the setting of recurrent VAPs and
underlying COPD. He has been dependent on CMV. Per report,
previous attempts to wean have been complicated by anxiety and
panic attacks.
#Chronic aortic graft infection: On chronic supressive abx
(cipro/flagyl).
#COPD: Stable. Continue duonebs
#Sacral decubitus ulcers: Stage IV, chronic. Wound care followed
patient while in the hospital.
#Chronic Anemia: He has known AVMs seen on colonoscopy during
last admission. Hgb on admission at baseline.
==================== | 133 | 408 |
19797153-DS-16 | 20,224,954 | Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
======================================
You were admitted to the hospital after almost falling on the
bus.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
=======================================
In the hospital, you were feeling a little more short of breath
than usual. We felt your breathing troubles were due to having
extra fluid in your body, so you received a medication called
Lasix to help remove the extra fluid. Your breathing felt better
after receiving this medication.
You were also seen by the speech and swallow experts, who
evaluated your swallowing and did not find any problems with it.
You were re-started on your home inhalers to help your
breathing.
You were seen by the neurology doctors, who felt that your
myasthenia ___ was at baseline.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
=================================================
- When you leave the hospital, please continue taking all your
medications as prescribed and follow-up with your doctors
___ information below).
- It is very important that you call the Pulmonary doctors and
make ___ appointment with them.
- After close monitoring in the hospital, it was determined that
you no longer need to wear oxygen at home. You should discuss
this further with the pulmonary doctors.
- Please weigh yourself every morning, and call your doctor if
your weight increases by more than 3 pounds.
It was a privilege caring for you, and we wish you well.
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ with a history of myasthenia ___,
?chronic hypoxemic respiratory failure (on 2L home O2), HFpEF
c/b recurrent pleural effusion, and atrial fibrillation (not on
AC due to prior GIB), who presented with a near fall on the bus,
found to have mild HFpEF exacerbation that resolved with IV
Lasix 120mg x1. | 232 | 56 |
14346384-DS-23 | 20,913,777 | Dear Ms. ___,
It was our pleasure to care for you at ___. You were admitted
for shortness of breath and found to have a COPD exacerbation.
We treated you with antibiotics and steriods. We also had our
occupational therapists see you in the hospital and they deemed
that you need 24 hour care. We will have you get continued care
of your COPD exacerbation at ___.
We made the following changes to your medications: | ___ year old female with COPD (FEV1 of 44% in ___, asthma
and dementia who presented with lower extremity swelling,
shortness of breath, hypoxia. | 79 | 26 |
19219647-DS-4 | 27,247,946 | Dear Mr. ___,
It was a pleasure to care for you. You were admitted to ___
after a fall, and were found to have a fracture of your radius
bone (arm bone). You also continued to have shortness of breath
due to not taking your prednisone or azithromcyin for your
recent COPD exacerbation. We treated you with nebulizers,
prednisone, and azithromycin to complete your course of
treatment. Because you were still feeling short of breath with
activity (worse than you had been recently), physical therapy
evaluated you and felt a short time in rehabilitation facility
would be the safest plan for you.
It is very important that you limit your alcohol intake. The
recommended limit per day for men is 3 drinks or less. Given
your poor nutrition and recent illness and falls, we recommend
stopping alcohol.
Please start multivitamins and ensure supplements at home. | BRIEF HOSPITAL COURSE
___ y/o with history of COPD ___ for COPD
exacerbation), CVA, HTN who presented following mechanical fall
with L distal radius and ulnar styloid fracture, admitted from
ED for dyspnea and hypoxia.
ACTIVE ISSUES
-------------
# COPD exacerbation: Pt had recent exacerbation with admission
___, treated with prednisone and azithromycin. It
appears pt did not continue prednisone and azithromycin at
discharge. At home he is on nebs q4h. In the ED he developed
dyspnea and hypoxia, likely secondary to an extended stretch
without receiving COPD treatment, including nebs. His
respiratory status improved following their administration.
During this admission he was continued on prednisone and
azithromycin through ___, for a total course of ___ days
beginning at his prior admission and interrupted by his
discharge prior to re-presenting. During this admission, he did
not develop respiratory distress and reported improved SOB and
cough. He remained afebrile throughout course; had a mild
leukocytosis which resolved prior to discharge. Pt had
significant dyspnea with ___ on moving to edge of bed and
standing; likely due to baseline COPD (exercise tolerance ~20
feet at home) in setting of deconditioning from hospitalization
(clinically, he has had slowly declining lung function over
recent months, has not follow up with pulm as outpatient. Low
suspicion for PE, pneumonia as cause. Prior to discharge, he had
O2 sat of 95% sitting in a chair.
# Mechanical fall, L wrist fracture: Pt fell at home on his left
side. L sided imaging revealed impacted fracture of the distal
radius with dorsal angulation of the distal fragment as well
minimally displaced ulnar styloid fracture. Other imaging was
negative for fracture. Fracture was treated with closed
reduction/splinting by hand plastics team. Pt later complained
of L ___ metacarpal pain under cast, and cast was adjusted which
relieved the pain. Pt was evaluated by physical therapy and
occupational therapy who recommended acute rehab. Pt pain was
treated with tylenol and tramadol. Pt will follow up in hand
clinic for future fixation of left distal radius.
# Etoh dependence: Pt drinks ___ beers per day at baseline.
Denies history of withdrawal. Last drink ___ AM. Score on CIWA
initially 2 (coarse tremor), then was 0 for multiple days. Pt
never required treatment with diazepam. Started on folate, MVI,
thiamine. Please encourage alcohol abstinence.
# Hyponatremia: Pt has hx of SIADH due to pulmonary disease per
PCP ___. On last admission, Na was 119-129. Urine electrolytes
showed urine Na of < 10 and was felt to possibly be consistent
with a diagnosis of beer potomania vs volume depletion. Pt
reports poor intake. On this admission, urine osm 631 and Na
<10, consistent with volume depletion. Received 1 L NS ___. Na
improved to 129 at discharge.
- Please check repeat Na in one week and encourage PO intake.
# Hyperglycemia: fsbg ranged between 100 and 200 in setting of
prednisone treatment. Given short term prednisone course,
insulin therapy was not given to avoid hyperglycemia.
CHRONIC ISSUES.
----------------
# HTN: Pt remained normotensive during admission and home
lisinopril 20 mg was held (was actually stopped on recent
admission). As such, please monitor his blood pressures at rehab
and re-consider starting anti hypertensive regimen as an
outpatient.
# H/o CVA: Has some residual RUE weakness. Continued on aspirin
325 and simvastatin.
# Bladder thickening on CT scan: Ct scan with 3.4 x 3.9cm cyst
adjacent to R kidney; bladder with mild anterior wall
thickening. UA was unremarkable. Please follow this up as an
outpatient.
===================
TRANSITIONAL ISSUES
===================
# Hyponatremia
- encourage po intake
- check serum Na in 1 week
# FOLLOW UP INCIDENTALOMAS:
- a 3.4 x 3.9 cm cystic structure adjacent to the right kidney,
likely a partially imaged exophytic renal cyst.
- aorta is heavily calcified, as are the bilateral common iliac
arteries, internal and external iliac arteries, and femoral
arteries.
- urinary bladder features mild diffuse anterior wall
thickening, without obvious mass. UA negative during admission.
# Code status: DNR, ok to intubate (discussed with ___
# Emergency contact: ___- ___,
___
# Studies pending on discharge: ___ 09:43 BLOOD CULTURE
Blood Culture, Routine | 144 | 666 |
12809721-DS-14 | 26,287,365 | Activity:
- Continue to be full weight bearing on your legs
- You should not lift anything greater than 5 pounds.
- Elevate legs to reduce swelling and pain.
Other Instructions
- Resume your regular diet. Avoid salty or fatty foods.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity as tolerated Activity: Ambulate twice daily if patient
able
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake | Ms. ___ was admitted to the Orthopedic service on ___ for
her multiple pelvic fracture's including bilateral sacral ala
fractures and pubic rami fractures after being evaluated in the
emergency room. Her injuries were deemed non-operative and she
was admitted for pain control and physical therapy.
Medicine was consulted regarding management of her hyponatremia,
which was felt to be chronic in nature. Her sodium was monitored
daily and, per Medicine's request, her home HCTZ was
discontinued as it was felt to be an exacerbating factor. A TSH
level was checked, but came back normal. At time of discharge,
her sodium had increased to her likely baseline level. It is
recommended that the patient have her sodium checked every ___
days while at rehab and follow-up with her primary care
physician regarding further management.
On hospital day 2, Ms. ___ was noted to have developed
bilateral edema in her legs, raising some concern for DVT. Her
Wells score for DVT was 1,low risk, with an especially low
degree of suspicion for bilateral DVTs causing her new-onset
bilateral lower extremity edema. However, she had been
bed-ridden with poor mobility for weeks, has recent fractures
and pedal edema that is new for a few weeks, placing her at risk
of DVT. Consequently, she received bilateral lower extremity
doppler studies to assess for DVT, which showed no evidence of
DVT.
She had adequate pain management and worked with physical
therapy while in the hospital. The remainder of her hospital
course was uneventful and Ms. ___ is being discharged to
rehab in stable condition. | 233 | 261 |
10777944-DS-11 | 21,734,212 | You were admitted for evaluation of shortness of breath and
found to have pulmonary emboli. For this, you were started on IV
heparin and converted to lovenox injections which you will need
to take indefinitely.
In addition, you had a stable headache during admission.
However, should you have a worsened headache or any new findings
such as weakness, nausea, vomiting, tingling, please seek
attention.
You were also found to have a new herpes rash on your skin for
which you were started on antivirals to take for 7 days.
You were started on calcium, vitamin D to protect your bones
while on steroids and Bactrim (an antibiotic to prevent PCP
___ while on steroids. Please discuss with your oncology
team when you may stop these medications.
Your steroids were downtitrated to dexamethasone 2mg in the
morning and 1mg at 2pm. Please discuss further changes with your
radiation team. | ___ PMH of High grade anaplastic meningioma (s/p resection in
the
posterior fossa in ___ undergoing radiotherapy) who
presents with dyspnea on exertion, found to have acute PE.
#Acute pulmonary embolism:
#symptomatic tachycardia and dyspnea:
Patient with some relative immobility over the past few weeks
and
is likely hypercoaguable ___ malignancy as main predisposing
factors. CT head negative for bleed in ED so continued on IV
heparin, NSGY did not feel recent surgery was contraindication
for anticoagulation.
Cardiology consulted in the ED for septal bowing on ED ECHO and
declined
intervention, but rec'd continued anticoagulation. Official echo
and ___ unrevealing. She remained stable on IV heparin and thus
was transitioned to ___ lovenox ___ which she appeared to
tolerate well. She was provided with supportive care for
exertional tachypnea and tachycardia.
#High grade anaplastic meningioma (s/p resection in the
posterior
fossa in ___ undergoing radiotherapy). Pt continued her
daily XRT sessions while admitted. Radiation oncology
recommended trying to taper her dexamethasone and recommended
2mg QAM and 1mg Q2pm for now. Further taper per outpt XRT. She
was started on ca, vit D, and Bactrim for pcp ___.
#HSV ulcer on the buttock and presumed in the mouth. Dermatology
was consulted and performed a smear confirming HSV. She was
given acyclovir during admission and transitioned to Valtrex on
dc for 7 days.
#Chronic Headaches
While patient had headaches during admission was consistent with
typical
daily headaches without any new change in symptoms or neurologic
changes. Head CT on admit without bleeding. Provided symptomatic
tx per outpt regimen.
#Leukocytosis
Likely related to stress of PE, as is without fever/chills or
symptoms suggestive of infection. Alternatively may be ___
chronic dexamethasone. | 145 | 262 |
17436136-DS-5 | 25,210,433 | You were admitted to ___ on ___ for back pain. Because of
your history of abdominal aortic aneurysm (AAA), you had a
CT-scan which showed that your was stable. Your pain improved,
however, your blood pressure was elevated and you were started
on a nitroglycerin drip for control. You were started on your
home medications and your blood pressure was under control at
time of discharge. You should follow-up with your PCP, ___.
___ discharge to continue management of your medical
problems. You have a follow-up appointment on ___
at 9:45am with Dr. ___. There is no surgery indicated now,
but you have a follow-up appointment with Dr. ___ on
___ at 11:00am.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider ___:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your ___ dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised ___ taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, ___ sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, ___, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: ___, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your ___ dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and ___ when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much ___ you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When ___ is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way ___ works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products. | Mr. ___ is an ___ male with PMH most notable for
CAD s/p 4v-CABG, atrial fibrillation, CKD (baseline Cr 1.4), L
renal artery stenosis s/p stent, who had a known AAA with both
infrarenal and suprarenal components. He was transferred to
___ from ___ on ___, with complaint of back
pain over the last few days. On arrival and exam, he was
conversive, in no distress, and hemodynamically stable. He
reported no pain while laying in bed. His motor and sensory exam
was intact throughout, with palpable distal pulses. His exam
was reassuring. He underwent a CTA chest/abdomen/pelvis on
___ which showed a stable AAA compared to his last study.
His back pain resolved and he was started on all of his home
medications. His blood pressure was controlled intitially with a
nitroglycerin gtt which was titrated off the morning of
discharge as he was restarted on his home anti-hypertensive
regimen. We advised him to follow-up with his PCP ___ ___
regarding his BP and coumadin management. His PCP's office was
notified and he has an appointment on ___. His was given his
daily coumadin 5mg (INR 3.2) on day of discharge.
At the time of discharge on ___, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He will
follow-up with Dr. ___ on ___ @ 11:00am. | 624 | 264 |
13060936-DS-7 | 23,010,240 | Dear Ms. ___,
You were transferred to ___ after
arriving at an outside hospital with difficulty speaking; there,
you were found to have a blocked blood vessel leading to an
acute ischemic stroke, and received a medication (tPA) to help
break up the clot causing your stroke. After transfer, an MRI of
your brain confirmed your stroke. You continued to have
difficulty speaking and swallowing safely after transfer, with
evidence of weakness on your right side. After discussion with
your family, your goals of care were shifted to focusing on your
comfort.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___ | Ms. ___ is an ___ woman with history notable for
dementia, HTN, HLD, CKD and ___ transferred from
___ after presenting with aphasia. NCHCT at
___ was negative for acute hemorrhage, and tPA was administered
on ___ at 11:30 AM. CT angiogram revealed distal M1
occlusion with distal reconstitution, though thrombectomy was
deferred due to time since last known well as well as pre-stroke
functional status. Follow-up MRI confirmed inferior division of
M2 ischemic infarct. In consultation with Ms. ___ family
and her previously expressed wishes in her living will, she was
transitioned to comfort measures care and discharged to a
___ facility. She was comfortable at time of transfer.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (X) Yes - () No
4. LDL documented? (X) Yes (LDL = 168) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (X) No [if LDL
>70, reason not given: pt made comfort measures only
[ ] Statin medication allergy
[X] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
() non-smoker - (X) unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[X] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist - pt
made CMO
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (X) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A | 102 | 411 |
12674349-DS-20 | 24,444,985 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You presented to the hospital after your found
to have a new mass in your colon. You underwent a colonoscopy
with biopsy that demonstrated colon cancer.
You also were noted to have fluid around your lung which was
drained. While you are in the hospital you were also found to
have aortic stenosis, which is thickening of one of the valves
of your heart. This will need to be monitored as an outpatient.
Please continue all medications as prescribed and follow up with
all appointments.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with past medical history of atrial
fibrillation (not on chronic anticoagulation), HTN, HLD, prior
diffuse large B-cell lymphoma, who presented to ___ with new
colonic mass and was found to have a large right-sided pleural
effusion and atrial fibrillation with RVR.
# COLON MASS:
This was initially seen on CT scan at ___.
Imaging showed a "large, approximately 10 cm heterogenous mass
in the distal transverse colon highly concerning for
malignancy." Per discussion with GI, the appearance on imaging
was more concerning with lymphoma rather than primary colon
cancer. The patient underwent flex sigmoidoscopy on ___
which showed normal mucosa with normal pathology on biopsy,
however the large colon mass was not sampled. Options for biopsy
included colonoscopy versus CT-guided transabdominal approach
with ___. The latter was felt to be suboptimal given risk of
perforation. She underwent colonoscopy with biopsy of the mass
that demonstrated invasive adenocarcinoma. Oncology and
Colorectal Surgery were consulted. Colorectal surgery
recommended ___ surgery to review and elective colectomy
in the near future, as well as gynecology referral for prominent
endometrium seen on CT scan at ___. She was scheduled
for new patient visit with Dr. ___ on ___.
# IPMN:
She underwent CT scan (pancreatic protocol) to assess a 1.1cm
pancreatic lesion seen on the original CT scan at ___.
It showed a 9mm lesion in the uncinate process likely
representing IPMN. This may be further worked up with, but
should discuss with her oncologist.
#Possible DIVERTICULITIS:
Equivocal diagnosis was made during recent ___
admission, where she was discharged on Cipro/Flagyl. There was
low suspicion for diverticulitis at ___, so Cipro/Flagyl were
held without any complications.
# Possible UTI:
This was diagnosed at recent ___ admission, but the
patient had no urinary complaints during her stay at ___ and
___ was unremarkable. Thus, she was not treated with antibiotics
during this hospitalization.
# ATRIAL FIBRILLATION:
Chronicity was unclear after discussion with the patient and her
son. They stated that they first heard about Afib only recently.
However, the patient's medication list does include several rate
control agents, and review of ___ records suggests this
is a more longstanding process. She was in RVR on presentation,
which was likely related to the patient missing several doses of
her home medications. ___ notes, it seems that
anticoagulation was held due to frequent falls. However, the
risks and benefits of anticoagulation were discussed at length
with the patient and her son, and they were leaning towards
anticoagulation, which was deferred while awaiting biopsy of
colonic mass.
# SEVERE AORTIC STENOSIS:
She had a notable systolic murmur on exam and this was diagnosed
on TTE. She denied symptoms of angina or syncope. No evidence
of CHF exacerbation on exam. This will need to be considered if
she is considers surgery in the future.
# PRESUMED SICK EUTHYROID:
TSH was mildly elevated and free T4 mildly low. However, recent
TSH at ___ was normal, so this likely represented sick
euthyroid. The patient will require repeat TFT's in several
weeks in the outpatient setting.
# PLEURAL EFFUSION:
She underwent thoracentesis of the right pleural effusion by IP
by ___ with 800 cc serous fluid removed and it was
transudative per their assessment. Cytology was negative for
malignant cells. CT abdomen on ___ showed moderate right
and small left pleural effusions similar to prior imaging, with
minimal increase. She was not hypoxic and respiratory status
was stable during her hospital course.
# T9 COMPRESSION FX:
# Rib fractures:
Chronicity was unclear. The patient denied any back pain and had
no pinpoint tenderness over her spine. She had ___ strength in
all 4 extremities. This could potentially be related to one of
her recent falls. Spine evaluated patient and felt there was no
intervention indicated.
She had no pain on exam and no intervention was indicated for
the rib fractures.
TRANSITIONAL ISSUES:
=================
There were serious concerns about a safe discharge for Ms.
___. She was ambulatory, but given her history of falls and
dementia, she was evaluated by ___ and OT, who both recommended
rehab consistently. Her son ___ is her healthcare proxy
and was very adamant against short term rehab. The patient had
been living in ___ alone and this was certainly not a
safe plan for her to return home alone. Her son lives in
___ with his adult son and he insisted on taking her back
there for a few days, then returning to her home in ___
with her. He was very against allowing any home services ___,
OT, skilled nursing, health aides) due to poor experiences in
the past, here in ___ or ___. He seemed to
lack insight into the degree of care his mother required with
ADLs and without outside assistance. The patient has dementia
(always oriented to person, not consistently to time or place)
and he seemed impatient with her at times, speaking to her with
disdain and yelling at her. She expressed concerns about the
plan to go home with him "not going to work" and several times
said she'd end up having to cook and clean there. At one point,
her son admitted he could not take care of her himself (but said
he could be with her ___, yet would refuse any home services.
He said he'd been trying to get her to a long term care facility
on ___, but could not recall the name and financially it
was not possible yet. All of our team including myself (her
physician), multiple nursing staff, social work, case management
all repeatedly strongly recommended short term rehab for
___ needs and as a safe place to go while getting
longer term options set up. He changed his story and plan
multiple times. He insisted on taking her home with him in
___ for a day then going with her back to ___,
yet wanting to bring her to oncology appointment next week. He
made threats about leaving against medical advice and getting an
attorney. The patient herself would intermittently express
concerns about having adequate care at home with him, but then
in the end insisted on going home, saying that how they managed
at home was their business and not the staff's business. She
was medically stable for discharge, but the concern was about
having a safe plan in place which should include, at minimum,
home services. Ultimately after consulting with social work,
nursing staff, and case management, there was no legal way to
prevent the patient's son from taking her home with him. He did
eventually agree to having ___ services assist. Social work
planned to file with ___ in ___ to see if
they can follow up and make sure she is getting adequate care.
We (physician, ___, social work) had serious concerns about
his decision making for his mother's care. He often said that
___ and OT were not helpful for his mother because of her age,
yet was adamant that she would definitely want full treatment
for her newly diagnosed cancer and was often talking about chemo
and other possible treatment options. I explained that they
would learn more about prognosis and potential treatment options
at the oncology appointment, but did want him to consider that
one option is no treatment. Earlier in her stay, the patient
made statements saying "I'm ___, if it's my time, it's my time"
and this seemed in conflict with her son's assessment that she
would want to pursue treatment.
Check if applies: [ 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. | 109 | 1,301 |
18583988-DS-10 | 27,587,724 | You were admitted to the hospital after you had a fall and were
found to have a fracture in your pelvis and some bleeding. The
bleeding stabilized. Physical therapy worked with you towards
regaining mobility after your fall. You will go to a
rehabilitation facility to continue working on your strength and
mobility.
Return to the ER if:
* If you experience increased lightheadedness or weakness,
increased pain in your side or back
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, chest pain, shortness of breath, or
anything else that is troubling you.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* No strenuous activity until instructed by your surgeon. | The patient was admitted to the Trauma surgery service to the
ICU on ___ for pelvis fracture and retroperitoneal bleed
after a mechanical fall and had an arteriogram performed on
___, which did not show a source of active bleeding. Patient
was transferred to the floor on ___.
Neuro: The patient received Morphine IV with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: The patient was given IV fluids until tolerating oral
intake. Her diet was advanced when appropriate, which was
tolerated well. She was also continued on her bowel regimen to
encourage bowel movement. Foley was left in place as the patient
has a neurogenic bladder and a chronic indwelling foley
catheter. Intake and output were closely monitored.
ID: The patient did not require antibiotics during her
hospitalization. The patient's temperature was closely watched
for signs of infection.
Heme: The patient was anemic secondary to her retroperitoneal
bleed. Hematocrits were monitored regularly and stabilized.
Prophylaxis: The patient received subcutaneous heparin after her
hematocrit stabilized during this stay, and was encouraged to
work with physical therapy towards regaining mobility and
walking as early as possible.
At the time of discharge on HD#5, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
working with physical therapy for mobility and strength, voiding
with indwelling foley, and pain was well controlled. | 194 | 256 |
18050590-DS-7 | 27,395,558 | Ms. ___
It was a pleasure caring for you. You were admitted with a
Pneumonia, and treated with antibiotics, fluids, and breathing
treatments.
You were also found to have ulcerations ___ your Aorta, one of
the major blood vessels ___ your body. Because of this, we did
vascular surgery was consulted to opted to monitor for symptoms
for now.
It was a pleasure,
___ Team | ___ with a h/o DM, HTN, HLD, who presents with respiratory
symptoms, fever, and presyncope, found to have PNA. She also
had anterior TWI's on initial EKG which have resolved on f/u
EKG, and negative trop x2. Incidentally, on CTA (obtained due
to wide mediastinum), she had aortic ulcerations, and
non-propogated abdominal aortic dissection.
# Community Acquired PNA: Although CXR was equivocal, her lung
bases do show opacities at bases on CT, and clinically she
initially had leukocytosis with neutrophilia, fever, and
respiratory symptoms, altogether consistent with bacterial PNA.
She was initially hypotensive requiring IVF, but has since been
resuscitated and stabilized. Influenza negative. Treated with
CTX, Azithromycin (___), later transitioned to Levaquin
(last day ___. Also given nebulizers and cough suppressants.
WBC count and fever curve improved with antibiotics.
# Aortic Pathology: On CTA was found to have aortic ulcerations
and
non-propogated abdominal aortic dissection. Per Vascular
Surgery resident/intern, this is likely something that will
require intervention this admission, but no final rec's yet.
Found incidentally, as CTA was obtained ___ setting of wide
mediastinum on CXR, and all of her presenting complaints are
better explained by her pneumonia. Vascular Surgery recommended
keeping sbp < 140 and follow up as needed.
# Growth on Urine culture: No urinary symptoms. Did have
fever. UCx grew E coli resistant to CTX but decided not to
pursue treatment due to lack of symptoms.
# Presyncope: Likely secondary to hypovolemia ___ setting of
infection, nausea/vomiting, and concurrent antihypertensive
medication use. Improved with IVF.
# ___: Patient presented with Cr of 1.5 with unclear baseline.
Improved to baseline following IVF. Likely pre-renal azotemia
___ setting of infection and poor PO.
# Anterior T-Wave inversions: No prior EKG to compare, but
dynamic EKG changes on admission, V2-V4 TWI's, with resolution
of V2 TWI after volume resuscitation, and further improvement on
f/u EKG on ___. Trop negative x2. Per discussion with PCP ___
___, has a history of stress test and cath for atypical chest
pain many years ago, with negative cath.
# Tongue Mass: Left sided purple tongue lesion, appears most
consistent with a hemangioma. Present for years. PCP had noted
this at prior appointment this month. She has intermittently
had bleeding from it. Concern for a possible source of bleeding
if she is started on anticoagulation (already bleeding
intermittently). Seen by ENT ___ house on ___.
# HTN:
- Held irbesartan, atenolol ___ setting of relative hypotension
and ___, restarted on discharge.
# HLD: changed simvastatin to atorvastatin
TRANSITIONAL ISSUES
==================
- D/c Antibiotics regimen: Levaquin x ___
- Changed simvastatin to atorvastatin given high likelihood of
CAD given T-wave inversions, which resolved, seen on initial
EKG
- Started Asa 81 and consider further optimization of cardiac
medications (increasing statin, starting BB if needed) given
possible CAD
- Please target SBP < 140 given aorta findings
- Vascular surgery follow-up ___ ___ weeks with Dr. ___
- ___ EGD as outpatient as patient intermittently
complained of food getting stuck ___ throat
- Added albuterol inhaler as needed to medications given it did
give her symptomatic relief with coughing
#CODE: Confirmed full
#COMMUNICATION: ___, daughter, ___ | 63 | 531 |
11167566-DS-5 | 26,853,190 | Dear Ms. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital for evaluation of chest pain. Your
chest pain resolved en route to the hospital. You had lab tests,
EKG and a nuclear stress test which showed no evidence of a new
heart problem.
After discharge, please follow up with your doctors as
recommended below. | Ms. ___ is ___ ___ w/ hypertension, hyperlipidemia, CAD (100%
___ RCA, 80% mid RCA, ___ ___ LAD, 50-60% first diag) s/p
DES x2 to RCA on ___, now presenting with recurrent chest pain.
# Chest pain:
She had recurrent substernal chest pain which resolved after
administration of nitroglycerin SL by EMS en route. EKG
unchanged from post-MI and trop negative x2. She had nuclear
stress test which showed no evidence of reversible myocardial
defect, LVEF 57%. Detailed results as above. She was discharged
with PCP and cardiology ___.
# CAD: She was continued on home atenolol, atorvastatin, ASA,
Plavix.
# Hypertension: Continued lisinopril | 64 | 104 |
18178247-DS-16 | 22,850,693 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- ___ were admitted for an MRI finding of concern of a vascular
defect known as an aortic dissection
What was done for me while I was in the hospital?
- ___ underwent repeat imaging to reassess the vascular defect
- ___ were evaluated by both the vascular surgeons and the
vascular medicine physicians who stated that there is no
surgical indication at this time. ___ will follow-up with them
within one month and will have repeat imaging at that time
- ___ were started on an antibiotic for concern for urinary
tract infection. ___ will continue this medication for 2d as an
outpatient
- ___ were given pain medications to treat your back pain, which
was felt to be due to muscle tendinitis
- Your blood pressure medication, lisinopril, was increased
What should I do when I leave the hospital?
- ___ should keep all of your medications
- ___ should keep all of your appointment scheduled
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES:
========================
[] Medications STARTED: cefpodoxamine 200mg PO BID for two days,
nicotine patch once daily, lidocaine patch daily
[] Medications CHANGED: Lisinopril 20mg to 40mg once daily,
acetaminophen increased to 1g QID PRN for pain, buproprion 150mg
PO BID --> 75mg PO BID
[] Medications HELD: spironolactone 12.5mg PO daily
[] Vascular
- Follow-up in clinic with vascular medicine and vascular
surgery for further management of SMA dissection and extensive
aortic atherosclerosis
- Repeat CT in ___ months post-discharge for re-assessment of
SMA dissection
[] Cardiology:
- Lisinopril was increased from 20mg to 40mg, please titrate
accordingly
- Patient reportedly taking spironolactone 12.5mg PO daily,
however, she reports she was not taking it as she does not
tolerate it so it was held on discharge
- Consider adding PCSK9 inhibitor vs ezetimibe for further
lipid-lowering given extensive vascular history (multi-vessel
CAD s/p CABG and stenting, extensive aortic atherosclerosis) and
continued high cardiovascular risk, LDL remaining >70 despite
atorvastatin 80MG (LDL 103 this admission):
___ MS, ___ RP, ___ AC, et al., on behalf of the
___ Steering Committee and Investigators. Evolocumab and
Clinical Outcomes in Patients with Cardiovascular Disease. N
___ J Med ___.
- Consider evaluation for anti-inflammatory therapy for ASCVD
with canakinumab given history of prior MI and CRP >2:
___, ___, ___, et al.; ___ Trial Group.
Antiinflammatory therapy with canakinumab for atherosclerotic
disease. N ___ J Med. ___ 377:___.
[] PCP:
- ___ BUN, creatinine, potassium at follow-up given
uptitration of lisinopril
- Continued discussion of smoking cessation; provided nicotine
patches on discharge
- MRI demonstrating likely left adrenal adenoma which should be
followed up with repeat imaging in ___ months
- Patient would be benefit from titrating off her dilaudid and
colonazepam
- Patient had reportedly been taking bupropion 150mg PO BID at
home. We decreased to 75mg PO BID while inpatient and she
tolerated this well. Consider downtitrating to 75mg PO BID
#CODE: Full Code presumed
#CONTACT: ___ (Husband) ___ | 186 | 305 |
17620129-DS-23 | 22,483,897 | Dear Mr. ___,
It was a pleasure taking part in your care.
WHY DID YOU COME TO THE HOSPITAL?:
You came to the hospital because you were feeling weak, dizzy,
and had pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?:
- You were given a new type of pain medicine called dilaudid for
your pain
- You were seen by the palliative care doctors who helped ___
your pain
- Some of your medications were stopped that we thought might be
contributing to your dizziness and lightheadedness
- You met with the hospice team and you were discharged home
with hospice care
It was a pleasure caring for you.
Sincerely,
Your Medical Team | SUMMARY:
Mr. ___ is an ___ year-old gentleman with a history of
hypertension, COPD and metastatic NSCLC currently on
pembrolizumab (___) who was admitted on ___ for syncope
and encephalopathy, and was found to have ___, hyponatremia, and
hyperkalemia.
PROBLEMS:
#Metastatic NSCLC
#Cancer associated pain
Family reported the patient experienced significant confusion
with morphine, likely in setting ___ leading to accumulation.
Family refused further morphine. Patient was switched to
dilaudid PRN and transitioned to oxycontin for basal dose with
oxycodone and dilaudid for breakthrough. Gabapentin was held due
to confusion and ___. The patient will be scheduled to see Dr.
___ as an outpatient for consideration of palliative
radiation for pain control to his spinal lesions.
#GOALS OF CARE
The patient's family requested that the patient be discharged
home to hospice. He is confirmed DNR/DNI. There will be no
further cancer-directed treatment.
#Syncope
#Orthostatic symptoms
The etiology of the patient's syncopal symptoms were most likely
multifactorial in the setting of poor PO intake, low heart rate
while on metoprolol, and sedation while on morphine. He was
given IVF with improvement. His metoprolol was discontinued.
#Dementia
#Encephalopathy
#Hospital Delirium
The patient's family reported that he was at his baseline mental
status. He was intermittently confused and agitated while in the
hospital. He was provided with Seroquel to assist with sleep and
agitation at night. His gabapentin was held as above due to
confusion. His pain medications were changed to oxycontin and
oxycodone for breakthrough as above.
___
#Volume depletion
___ was due to poor PO intake and improved after volume
resuscitation (1.4>1.1 after IVF). His lisinopril was stopped
during admission.
#Anemia
Hgb was at baseline during admission (7 - 8). It is likely in
the setting of chronic inflammation and cancer. He remained
hemodynamically stable and there were no signs of bleeding or
hemolysis.
#Severe protein calorie malnutrition
The patient was given thiamine, remeron, ensure, and MVI.
#PAD
#Right lateral ___ ulcer
Atorvastatin and aspirin were continued while in the hospital
but after goals of care discussions he will not require these
medications as an outpatient.
#Hypertension
#CAD s/p CABG
Antihypertensive medications and asa were discontinued.
#COPD
-Continued inhaled fluticasone
TRANSITIONAL ISSUES:
====================
HELD MEDICATIONS:
[] Gabapentin held due to confusion and changing renal function
[] Discontinued Metoprolol given bradycardia and syncope
[] Patient will no longer require ASA or Atorvastatin in hospice
NEW PAIN REGIMEN:
[] Oxycontin 10mg Q12H, please titrate up as tolerated
[] Dilaudid PO ___ mg PO Q3H PRN Breakthrough Pain
[] Consider starting a bisphosphonate for bone pain/mets
TO DO:
[] Follow-up with Dr. ___ consideration of palliative
radiation for pain control.
[] Please up-titrate bowel regimen as needed for constipation
[] Please up-titrate pain medications as needed for worsening
pain
[] Please consider starting a bisphosphonate if bone pain not
controlled with pain medications or if patient is unable to
start radiation therapy
[] Please help the patient arrange an appointment with Dr.
___ oncology at ___ for palliative radiation
for pain control. The phone number is, ___.
CODE: DNR/DNI
Name of health care proxy: ___
___: son
Phone number: ___
Cell phone: ___ | 112 | 500 |
16944102-DS-3 | 29,903,480 | Dear ___ were admitted to the hospital with acute pancreatitis due to
a gallstone causing irritation of your pancreas. ___ improved
with supportive care including IV fluids, bowel rest, slow
advancement of diet, pain medications, and anti-nausea
medicines. ___ were seen by the pancreas team as well as the
surgery teams. An Upper Endoscopy was performed during your
hospitalization and showed mild inactive inflammation in the
stomach which was reassuring. The surgeons advised that ___ have
your gallbladder removed laparoscopically to prevent future
episodes of pancreatitis.
___ tolerated the procedure well and are now being discharged
home to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o ___ may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless ___ were told
otherwise.
o ___ may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if ___ take it before your
pain gets too severe.
o Talk with your surgeon about how long ___ will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
Best wishes for your continued healing.
Take care,
Your ___ Care Team | SUMMARY:
___ year old Female with PMH of recurrent abdominal pain
(beginning ___ and s/p BSO for benign adnexal mass
(___) who presented to the ED with acute pancreatitis. | 802 | 28 |
10860566-DS-7 | 25,725,672 | Dear Mr. ___,
It was a pleasure caring for ___ while ___ were hospitalized at
the ___ were hospitalized because of your
increasing yellow skin tone. On admission, we consulted with the
liver doctors who had ___ during your recent admission.
They agreed that no further work-up or intervention was
necessary.
The following changes were made to your medication list:
1. DECREASE hydroxyzine to once daily dosing
2. START fexofenadine 60 mg twice daily for pruritis
3. START sarna lotion as needed for pruritis | HOSPITAL COURSE:
This is an ___ year old gentleman with a recent h/o cephalexin
and Bactrim-induced indirect hyperbilirubinemia with preserved
hepatic function (assessed by normalization of INR off coumadin)
who presented to the hospital for concern for worsening
hyperbilirubinemia. His total bilirubin was infact improving. He
was evaluated by Physical therapy and discharged to rehab.
. | 79 | 54 |
11999982-DS-12 | 20,011,679 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently hospitalized after your wound
on your buttocks was bleeding. You were evaluated by the
surgeons ___ the emergency department who took away the dead
tissue to allow for better healing. You were evaluated with an
imaging test, MRI, which showed an infection of the bone. You
are being discharged to complete a 6 week course of antibiotics
to heal this infection.
Please take all of your medications as prescribed and keep your
follow up appointments.
We wish you the ___,
Your ___ Care Team | ___ w/pmh Diabetes, Hypertension, recent subdural hematoma, new
afib not on AC presenting with worsening of her R gluteal wound
with discharge and changes concerning for superinfection.
# Sepsis ___ Right gluteal wound infection
# Coccygeal Osteomyelitis
Pt p/w worsening of chronic R gluteal wound, a/w tachycardia and
leukocytosis c/f sepsis. CRP elevated and wound probes at least
2-3cm deep, making osteomyelitis a risk, later confirmed on MRI.
General surgery consulted ___ the ED, bedside debridement. MRI
consistent with coccygeal osteomyelitis. No evidence of
bloodstream infection. Debrided x2 bedside by ACS. ID was
consulted and recommended vanomycin, ciprofloxacin, and
metronidazole.While MSSA was the only isolate, given this was
from a wound swab, and the patient/family refused bone biopsy,
ID recommended daptomycin and ertapenem and on discharge given
her penicillin allergy. She will require 6 weeks therapy and
should follow up with ID and ACS. She may benefit from future
evaluation for wound closure given her good functional status
prior to her fall and injury.
# Microcytic anemia
Hb 6.4 from recent baseline of 7.5-8. Unclear etiology as
patient denies melena or bleeding elsewhere, but was found to
have guaiac positive stool. Per prior documentation, patient has
chronic anemia, likely due to renal insufficiency. She may have
an element of chronic GI losses.
# Afib
CHADS2 = 4. Recently diagnosed last admission and was not on
anticoagulation given subdural hematoma. She spontaneously
converted to sinus rhythm after initiation of treatment.
# Diarrhea
-Patient had several episodes of loose stool leakage during her
stay. Negative c. diff, felt to be related to antibiotics, as
she was being treated with ciprofloxacin, metronidazole, and
vancomycin.
CHRONIC ISSUES:
===============
# HTN
- held home amLODIPine 5 mg PO DAILY and Losartan Potassium 100
mg PO DAILY given sepsis. These should be restarted once she is
stable.
# HLD
- Cont home Aspirin 81 mg PO DAILY
# Optho
- Cont home Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES
QHS
- Cont home Timolol Maleate 0.5% 1 DROP BOTH EYES BID | 97 | 357 |
12173700-DS-9 | 26,925,756 | Dear Ms. ___,
You were admitted to ___ because you had an infection on your
Left foot and ankle. It improved with IV antibiotics so we
switched you to pills of antibiotics which you should continue
through ___. You should follow up with Dr. ___ as you
discussed with the podiatry team.
We wish you all the best.
Sincerely,
Your care team at ___ | Ms. ___ is a ___ woman with history of pAF
not on anticoagulation, DMII, HTN, left
charcot foot presenting with left lower extremity cellulitis. | 60 | 23 |
12352817-DS-6 | 20,007,881 | ___ were admitted to the hospital with lower abdominal pain.
___ underwent a cat scan of the abdomen and ___ wee found to
have appendicitis. ___ were started on antibiotics. ___ are
preparing for discharge home but will need to have your appendix
removed at some later time. ___ are preparing for discharge
home with the following instructions:
Please call your doctor or return to the emergency room if ___
have any of the following:
* ___ have a recurrence of your abdominal pain
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ 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.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ 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 ___.
* Please resume all regular home medications and take any new
meds
as ordered. | The patient was re-admitted to the hospital with lower abdominal
pain. Upon admission, she was made NPO, given intravenous
fluids, and underwent imaging. An x-ray of the abdomen was done
which showed no evidence of bowel obstruction or free air. To
further identify the etiology of her pain, the patient underwent
a cat scan of the abdomen which showed a dilated fluid-filled
appendix with adjacent fat stranding suggestive of appendicitis.
There was no evidence of perforation or abscess. The patient was
started on a 2 week course of ciprofloxacin and flagyl and
underwent serial abdominal examinations. Because of her history
of ulcerative colitis, the GI service was consulted who
supported current management with antibiotics as well as an
interval appendectomy. The patient's vital signs have been
stable and she has been afebrile. She was tolerating a regular
diet. She was discharged home on HD # 5 in stable condition
with instructions to complete the antibiotic course. An
appointment for follow-up was made with the acute care service
and with her primary care provider.
Of note: report of cat scan : 1 cm nodule within the right
adrenal gland seen, recommendation made for adrenal cat scan or
MRI. Patient informed of these findings and copy of report
given to patient. Follow-up with primary care provider
___. | 213 | 231 |
17484350-DS-11 | 23,370,490 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You had abdominal pain and dark diarrhea. Your blood counts
were low (anemia), which was concerning for more blood loss from
your digestive tract.
-You had difficulty breathing too.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-Our gastroenterologists looked at your digestive tract from
above, also known as an upper endoscopy.
-You swallowed a pill with a camera that took pictures of your
digestive tract. Unfortunately, the equipment malfunctioned and
our gastroenterologists were not able to review the pictures.
The pill was sent to the manufacturing company. They might be
able to retrieve the pictures. If not, it is suggested that the
study be repeated in the outpatient setting.
-You received two blood transfusions. Your blood counts improved
and stayed there after that.
-You received Lasix (water pill) through your IV to help dry out
your lungs. You were breathing more comfortably by the time you
left the hospital.
-You had a CT scan to plan for your upcoming aortic valve
replacement.
-Your buspirone was increased to 7.5 mg three times daily to
help with your anxiety.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Please schedule a follow-up appointment with your primary care
physician, ___, within one week.
-Your blood counts should be checked at this follow-up visit and
he should arrange for a blood transfusion if needed.
-We would like you to follow-up with your cardiologist,
pulmonologist, gastroenterologist, and structural heart team
too.
-Take your torsemide (water pill) daily. Weigh yourself daily
and call your cardiologist if your weight goes up by three
pounds.
-We recommend that you continue your apixaban (blood thinner)
for now, but continue to discuss the risks of this medicine with
your primary care physician and cardiologist.
-We held your losartan (blood pressure medication) because it
was not needed. Do not restart it until instructed by your
cardiologist.
-Take all of your other medications as prescribed.
-Continue using your BiPAP at night and as needed during the
day.
-Refrain from taking benzodiazepines unless instructed
otherwise.
-Call or return to the emergency department if you have
difficulty breathing or notice blood in your stool.
We wish you all the best!
Sincerely,
Your ___ Care Team | ___ female with COPD, on home O2 3L, lung cancer s/p
wedge resection, severe aortic stenosis, newly diagnosed
paroxysmal atrial fibrillation, on apixaban, newly diagnosed
heart failure with reduced ejection fraction, and recent
prolonged hospitalization for respiratory failure complicated by
gastrointestinal bleed now readmitted one week later for
abdominal pain and melenic diarrhea in the context of 2-point
hemoglobin decline concerning for ongoing occult
gastrointestinal blood loss.
#) Acute on chronic anemia, normocytic: hemodynamically stable.
Hemoglobin 6.6 from 8.5 on prior discharge, concerning for
ongoing occult gastrointestinal blood loss. EGD redemonstrated
erosive gastritis without stigmata of active bleeding.
Colonoscopy was recommended, though patient and family declined.
Capsule endoscopy was thus pursued, which was ultimately
non-diagnostic due to technical malfunction. Hemoglobin
stabilized in the 8-range after 2 units pRBCs. Suspect GI losses
are due to an unappreciated AVM, especially in the context of
aortic stenosis. Apixaban and aspirin reintroduced in that
regard without subsequent bleeding. Approaching
transfusion-dependency, should no actionable lesion be
identified.
CHRONIC/STABLE ISSUES
#) Atrial fibrillation, paroxysmal: home Toprol XL resumed when
cardiogenic shock was excluded. Home apixaban likewise resumed,
as she initially responded and stabilized after transfusion.
Systemic anticoagulation favored, given CHA2DS2-VASc 6. Should
anemia persist, and she become transfusion-dependent, ongoing
discussion of competing stroke and bleeding risks will be in
order.
#) Chronic systolic heart failure: LVEF = 40-45% to 30%. Aortic
stenosis likely under-appreciated in that regard. Home Toprol XL
and ___ initially held due to concern for decompensation, but,
in
actuality, at baseline, by virtue of euvolemia and stable CXR.
Received a short course of Lasix 40-80 mg IV to minimize
pulmonary edema and ensure euvolemia. Home Toprol XL and
maintenance torsemide 20 mg ultimately resumed, whereas losartan
was held at discharge for low-normal systolic.
#) COPD: azithromycin/corticosteroids initiated for presumptive
exacerbation, then aborted in the absence of ill-appearance or
respiratory distress. Tachypneic at times, though confounded by
severe anxiety. At baseline O2 requirement throughout
hospitalizaiton.
#) Anxiety disorder, unspecified: buspirone increased to 7.5 mg
TID, after discussion with psychiatry, Offered 0.25 mg Ativan in
the evenings, while in a controlled environment, but otherwise
held benzodiazepines.
#) Aortic stenosis, severe: CTA for TAVR planning performed. Not
amenable to carotid approach per vascular surgery.
#) h/o NSTEMI: safe to restart ASA for secondary prevention.
#) NIDDM2: home metformin held in favor of HISS. | 359 | 382 |
14648269-DS-24 | 20,939,320 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
You came to the hospital because you were having belly pain.
This is because you had "acute diverticulitis," which is when
you have an infection of an outpouching of your colon. We gave
you antibiotics, which you should continue when you leave the
hospital. Your kidneys were also damaged because you were unable
to drink a lot of fluids. We gave you fluids and your kidneys
are slowly recovering.
It is important that you follow up with your doctors as listed
below and take your medications as prescribed. Do not stop
taking your antibiotics even if you feel better.
We wish you the best,
your care team at ___ | Mr. ___ is a ___ year old gentleman with a past medical history
significant for CKD (stage 4 with proteinuria) due to lithium
use
with evidence of secondary FSGS, HTN, HLD, CAD, bipolar
disorder,
asthma/COPD, OSA, psoriasis and substance abuse (cocaine,
tobacco, marijuana) presenting with abdominal pain and found to
have acute uncomplicated diverticulitis. His course was c/b ___
on CKD likely pre-prerenal in the setting of poor po intake. | 118 | 67 |
11892979-DS-14 | 28,669,927 | Dear Ms. ___,
You were admitted to ___ with concern for your
recent fever, cough and shortness of breath. While admitted, you
underwent imaging which was concerning for continue pneumonia.
You were started on IV antibiotics to help treat this infection
which helped greatly. We were hoping to have you continue IV
antibiotics at discharge as this is the medically advised and
safest course but you did not wish to complete this therapy.
While you are strongly advised to continue IV antibiotics, we
will prescribe PO medication you can take, which again, may not
have the same efficiacy and put you at severe risk of worsened
pneumonia and subsequent adverse effects.
Please make sure you call your oncologist if you experience
shortness of breath or worsening cough.
We wish you the best!
Your ___ team | ___ woman being treated for multiple myeloma with
Cytoxan/Revelimid/Dexamethasone presented with cough, fever, and
SOB found to have healthcare associated pneumonia. Patient
started on IV antibiotics with vancomycin / cefepime for a total
of 4 days. The plan was to continue treatment with IV
antibiotics for a total of 7 days however the patient did not
wish to continue IV treatments. Despite encouragement otherwise,
the patient strongly wished to leave without infusion services.
She was prescribed augmentin PO to complete ___nd was
advised to call her nurse ___ should she develop any
concerning symptoms. She will follow-up with her outpatient
provider this upcoming ___.
1. HEALTHCARE ASSOCIATED PNEUMONIA: Clear infiltrate on CXR with
supportive clinical syndrome. Recent chemotherapy and
neutropenia necessitate extended antibiotic coverage. Only had a
partial response to levofloxacin- perhaps this suggests
resistance to the antibiotic, or perhaps her neutropenia and
myeloma-related immunosuppression precluded recovery following
antibiotic cessation. Attemptted sputum culture to guide future
narrowing but returned inadequate. Patient initially on O2 then
slowly weaned without requirement on day of discharge. Patient
did not allow for ambulatory saturations prior to her discharge.
Recieved 4 days of vanc/cefepime, planned for ___ placement for
continuation as outpatient, however, patient defered despite
being strongly advised. Patient will continue PO agumentin in
lieu for additional 7 days.
2. MULTIPLE MYELOMA: On Cytoxan/Revelimid/Dexamethasone with
acyclovir and bactrim prophylaxis. Continued lamivudine for HepB
exposure in the past (core and surface AB positive). Continued
with neupogen.
3. NEUTROPENIA: initially neutropenic but now WBC improved to
16.5 with 61% N, that is likely a result of neupogen. Plan to
follow-up with bloodwork at outpatient visit this coming ___
___ as appropriate.
CHRONIC ISSUES
4. PULMONARY HYPERTENSION: Seems to be improving as an outpt.
Given lasix 40 mg IV on ___ early AM. Further management per
outpatient provider.
5. HYPERTENSION: continued labetalol
6. ASTHMA: ipratroprium/albuterol nebs and PRN albuterol as
inpatient.
TRANSITIONAL ISSUES
-Continue Augmentin up to and on ___ | 132 | 316 |
13239996-DS-19 | 20,006,862 | Mr. ___,
You were admitted to ___ with fevers and found to have a
tick-borne infection called anaplasmosis. The doxycycline should
clear up this infection. Please be sure to sit up fully during
and for 30 minutes after taking doxycycline and drink plenty of
water while taking it. Please have labs drawn on ___ and send
them to your primary care provider. | #Anaplasmosis: The patient presented with two weeks of fevers
originally without localizing signs or symptoms of infection.
Two day into his admission he developed lymphopenia,
thrombocytopenia, and liver enzyme elevation. Smear shows
neutrophil inclusions indicating anaplasmosis, and anaplasma PCR
returned positive. The original serology testing was sent soon
after fevers started, so IgM would not have developed. PCR is
recommended for early testing (within 3 weeks of start of
symptoms). Original evaluation for Lyme Western Blot, Babesia,
UA/UCx, CXR, Influenza had been negative. Patient had normal
colonoscopy in ___. LENIs without VTE. TTE showed a non-mobile
echobright spot thought most likely to be calcium. Blood
cultures remained negative. He lacked other features or risks of
Q fever. No attacks of abdominal or joint pain suggestive of
familial Mediterranean fever. Repeat Lyme IgM was positive, but
this is most likely cross-reactivity with anaplasmosis (commonly
seen, B. miyamotoi is transmitted by the same Ixodes tick that
transmits Lyme and Anaplasma). When his liver enzymes started
rising viral hepatitis studies were also sent. His heterophile
test returned reactive. ID was consulted whether this
represented true infection (infectious mononucleosis or EBV
hepatitis, but they felt it was likely a false positive in the
setting of alternative infxn, which has been documented in other
settings (Dengue fever, ___: ___ CMV, ___: ___
Babesia, ___: ___ Malaria, ___: ___. RUQ Doppler
showed patent hepatic vasculature and normal echotexture. His
Tbili and INR normalized, but his ALT and AST remain elevated at
the time of discharge. This is most likely from anaplasmosis,
but recheck should be obtained on ___ to ensure resolution.
CMV and quant gold are pending at the time of discharge, but now
that anaplasma was discovered and the patient has markedly
improved, the clinical suspicion for other infections is low.
- Continue doxycycline 100 mg BID for 10 days total (through
___. Instructed on technique to prevent pill esophagitis
- Dimenhydrinate 1 hr prior to doxy may be used to help prevent
upset stomach
Transitional issues
[ ] Hepatitis B vaccination (not protected on serology)
[ ] Re-check labs on ___
Mr. ___ was seen and examined on the day of discharge and
is clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. | 61 | 382 |
12578346-DS-4 | 22,661,008 | Dear Ms. ___,
You were hospitalized due to symptoms of headache and
weakness all over your body. Your headache has gone away, and
you have recovered your strength. You have experienced these
symptoms in the past and recovered without any intervention, and
any weakness you are currently experiencing seems to be
explained by your chronic joint pain. Your MRI cervical ___
revealed age-related changes in your spinal cord; you should
wear a soft cervical collar at night. Imaging and laboratory
studies were conducted to rule out possible causes of your
symptoms, and they all revealed no evidence concerning for an
illness that would require current treatment.
To further investigate what might be causing your symptoms,
please follow up with the neurology clinic on an outpatient
basis to undergo more evaluation, including imaging of your
neck: details are listed below. Please continue to take your
medications as prescribed.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ with HTN presenting with acute onset of
headache and weakness who was admitted to the Neurology stroke
service. On presentation, she reported left-sided weakness, but
the history changed to mild headache and generalized weakness
and malaise upon re-interview. Physical exam showed mild
weakness in bilateral proximal muscles in lower extremities and
mild left sided extensor weakness with resolution on re-exam
within 24 hours, excluding pain-related limitations secondary to
chronic arthralgia, no residual evidence of neurological motor
deficits. She has had this presentation many times in the past,
and the symptoms have always resolved within days without
intervention. ___ MRI, CT, and CTA revealed no evidence of an
acute process. MRI suggested an old right parietal infarction
that seems unrelated to the present illness. CRP and ESR were
measured due to concern for PMR but were within normal limits.
Integrating data from history, physical exam, laboratory
results, and imaging studies reveals no evidence of an acute
stroke. Her bifrontal pressure like headache was treated with
fluid and IVF, and it resolved. Her pain and pain-limiting
weakness are more consistent with her significant generalized
joint disease. An MRI cervical ___ revealed degenerative
changes of the cervical ___ most significant at C4-5 and C5-C6
where there is mild spinal canal narrowing and moderate
bilateral neural foraminal narrowing. A soft collar at night was
recommended and provided.
Evaluation of her ambulatory function revealed the need for
physical therapy. She was discharged to rehab with spontaneous
resolution of initial presenting symptoms.
Transitional Issues:
[ ] F/u with PCP
[ ] F/u with Neurology
[ ] assess success of soft collar at night
[ ] pain control for joint pain | 280 | 277 |
10952022-DS-13 | 20,759,237 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for confusion, which seemed to
resolve on its own. There was no evidence of any infection and
you had a head CT which was normal.
We spoke with the neurologist you had seen in clinic, Dr.
___ said it is alright to stop taking carbamazepine
if you feel it is contributing to your confusion.
Please make the following changes to your medications:
# STOP taking carbamazepine
# DECREASE lorazepam to 0.5 mg three times a day as needed for
anxiety. You can take an additional dose if necessary
Continue all other medications as prescribed. We recommend
talking to your outpatient doctors about ___ to
control your anxiety better. | ___ yo M with HIV on HAART, history of Hodgkins lymphoma s/p
treatment, with SCC of the tongue dxed ___, currently
receiving chemo (Cetuximab) and XRT presenting with
confusion/AMS.
.
ACTIVE ISSUES:
# AMS/Confusion - Pt presented with relatively acute confusional
event in setting post Ativan, with major presenting symptom
being concern that his partner was trying to hurt him. By time
of arrival to the floor, his symptoms had already started to
improve. Per the patient and his partner, he has had
intermittent mild confusion, which they temporally relate to
starting carbamazepine. The suspected etiology of his confusion
was combination of polypharmacy/medication effects, along with
acute anxiety related to the long holiday weekend and decreased
interaction with healthcare providers. Per his partner, the
patient often gets increasingly anxious over the weekends when
he doesn't have daily interactions with healthcare providers.
During his hospitalization, his outpatient neurologist was
contacted (Dr. ___ who agreed with discontinuation of
carbamazepine. He also had a head CT and infectious work up
which were unrevealing. We will arrange to have a home health
assessment by ___ to assess the need for nursing care,
particularly over the weekends. His lorazepam dose was decreased
during this hospitalization and he tolerated this well;
therefore he was discharged on a lower dose. Interestingly, his
tox screen on admission was negative for benzos, despite
reporting taking Ativan at home.
.
# SSC of tongue: Pt has T4aN1 SCC of the BOT receiving
concurrent Cetuximab and radiation therapy, currently on cycle
one. Pt is currently undergoing pain control with fentanyl patch
and oxocodone-acetaminophen elixir. He received radiation
treatment while in house. His chemotherapy was differed one day
while hospitalized, to be resumed on discharge. His primary
oncologist was aware of the plan.
. | 119 | 290 |
18813819-DS-4 | 28,589,470 | Dear Ms. ___,
You were admitted for lightheadedness and unsteady gait as well
as your MRI findings.
We had our cardiologists see you, who felt that the symptoms you
are experiencing are not from your aortic stenosis. However,
they did say that some of your shortness of breath may be from
your aortic stenosis and they recommend that you follow up very
closely with your cardiologist Dr. ___, as your valve has
worsened very quickly over the past year and may need to be
replaced.
We think your presenting symptoms are due to BPPV (benign
paroxysmal positional vertigo) which is a problem with the inner
ear that can make you feel off balance. We taught you some
exercises to help with these symptoms (or search the "Epley
maneuver" online). These symptoms should resolve with physical
therapy and time!
Incidentally, we found a mass in your brain. What you have is
called a pituitary adenoma. This is a benign, slow growing
tumor. It can secrete hormones abnormally, which we checked you
for. Your prolactin is high, so we think the tumor might be
secreting this hormone. We consulted the endocrinologists for
further recommendations. The other problem this tumor can cause
is compression of your optic nerves, which can lead to decreased
peripheral vision. We had the ophthalmologists see you, and we
also did visual field testing so we can watch you over time and
intervene if your vision starts to be effected.
We want you to follow up in ___, which is a
___ clinic with endocrinology, neurosurgery, and
MRI scanning.
You should also follow up with neuro-ophthalmology and have
repeat visual field testing ___.
Please see your PCP ___ ___ weeks after discharge.
Continue to follow up with your cardiologist Dr. ___
discharge for your aortic stenosis and possible need for valve
replacement.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ Neurology Team | ___ is a ___ female with history of severe
aortic stenosis, hypertension, hyperlipidemia who presented to
OSH (___) for evaluation of intermittent episodes of
lightheadedness and unsteady gait, found to have suprasellar
tumor on MRI, subsequently transferred to ___ for potential
neurosurgical intervention.
#Suprasellar tumor
On admission to ___, neurosurgery was consulted in the ED and
said there was no urgent surgical intervention needed, and
recommended outpatient follow up. Imaging was reviewed with
neuroradiology and thought to be consistent with meningioma vs
pituitary adenoma. Both of these tumors are slow growing lesions
and do not account for her presenting symptoms. Neuro-oncology
was consulted, who recommended MRI pituitary and orbit to get a
closer look at the lesion. Pituitary hormone studies were sent,
which revealed an elevated prolactin. Endocrinology was
consulted, who recommended sending a diluted prolactin level.
This level came back slightly elevated which they felt was due
to stalk effect, so endocrinology did not recommend any
medications (such as cabergoline) because they felt it was less
likely a prolactinoma. We also consulted neuro-ophthalmology and
sent the patient for formal visual field testing so that we can
follow visual fields in the future. She had slight visual field
defects in a nasal distribution on formal testing, could be
concerning for either glaucoma, optic nerve head drusen, rim
artifact, or other. Ophthalmology planned to repeat visual
fields in 3 months. Follow up with ___ clinic and
ophthalmology was arranged for outpatient.
#Episodes of lightheadedness
Patient had been experiencing episodes of lightheadedness
usually in the context of movement. ___ maneuver was
positive, with reproduction of patient's symptoms. Patient was
seen by physical therapy for vestibular ___. She learned the
epley maneuver, and would have 24 hour supervision from her
husband at home. ___ did not recommend any home ___, as she was
walking stairs well. They recommended outpatient vestibular ___
follow up for balance: ___ Health Care Center at ___,
patient to make appointment.
#Aortic stenosis
Patient was seen by cardiology as there was concern that severe
AS was contributing to lightheadedness. Cardiology felt that the
episodes started so acutely it would be unlikely to be due to
AS. However, she reported dyspnea on exertion which cardiology
felt is secondary to AS. They recommend close follow up with her
cardiologist Dr. ___ potential need for aortic valve
replacement given severe AS (>0.8).
#HTN
We continued home medications including Aspirin 81 mg daily,
Atorvastatin 20 mg daily, and continued amlodipine 2.5 mg daily. | 318 | 405 |
14110681-DS-15 | 24,634,142 | You were admitted after having fallen. You were initially
thought to have pneumonia, and were given IV antibiotics, but
your chest x-ray looked better than it had previously. You are
being discharged on a short course of Levaquin for bronchitis,
since you did have a change in your sputum. You will need to
follow up closely with your Oncologist. | Mr. ___ is a ___ y/o male with a history of AF previously on
coumadin, COPD, IDDM, and 40 pack-year history of smoking with
recently diagnosed ___ who presents from ___ after fall,
admitted for ? of pneumonia and for ? of failure to thrive
(recent 10 pound weight loss).
His fall was thought to be mechanical in the context of having
fallen asleep. He displayed few signs of pneumonia, but rather a
potential bronchitis with a change in sputum character, and was
given a course of Levaquin. It was difficult to conclude that
this morbidly obese gentleman observed to have a robust appetite
here had any obvious failure to thrive. On the contrary, he
endorsed an intentional dieting; he was evaluated by the
nutrition service. He did have some subjective weakness, and was
evaluated by the ___ service.
CHRONIC ISSUES:
# NSCLC: Stage IV, squamous on pathology. Patient is s/p
palliative radiation and cycle 1 of ___. Presented day
of admission for consideration of start of cycle 2.
- held chemo for now in setting of possible acute infection
- continued home pain control with oxycodone and gabapentin
- established outpatient followup with oncologist
# Atrial Fibrilation: previously on coumadin, but held last
admission secondary to hemoptysis and still on hold.
- continued home labetalol
- continued home ASA
- continued to hold coumadin for now
# COPD: stable, no wheezing
- continued home symbicort
- continued home ipratropium-albuterol
# IDDM:
- continued home glargine 40 units BID and humalog 15 units TID
with meals
- ISS
# HTN: stable
- continued home lisinopril and labetalol
# CAD s/p ___ ___
- continued home ASA, statin
# OSA: on CPAP
- continued home CPAP
- continued home lasix and spironolactone for now | 59 | 301 |
18759300-DS-12 | 25,424,801 | Dear Ms. ___,
It was a pleasure taking part in your care. You were admitted to
the hospital because you were experiencing uncontrolled pain at
the site of your recent surgery. While in the hospital we gave
you morphine for pain control, and we evaluated the site with
ultrasound which showed a small fluid collection that was too
small to drain. We also did an ultrasound of the liver to
evaluate the lesions seen previously on CT scan. They were not
visualized on the ultraound. You should bring this to the
attention of your oncologist and PCP to follow up with you.
While with us, we also evaluated the swelling of your legs. We
did a CT with the adjusted technique to visualize the veins
specifically, and saw that there was a clot in the inferior vena
cava, a large vein in the abdomen. This clot is likely what
caused the leg swelling. We started you on the medication
lovenox, which is a blood thinner that will stabilize the clot
and allow your body to reabsorb it over time. You will likely
require this medication on an ongoing basis.
Regarding your back pain, we started the lidocaine patch, and
the medication nortyptiline, which is shown to bring relief to
nerve pain. Please continue these and continue working with the
pain control clinic.
Please make the following changes to your medications:
1. START lovenox 90mg by subcutaneous injection every 12 hours
2. START lidocaine patch. Use one patch daily on lower back. 12
hours on and 12 hours off to preserve its potency
3. START nortryptiline 10mg by mouth nightly
Please keep all followup appointments and continue your other
medications as previously prescribed. | PRIMARY REASON FOR HOSPITALIZATION: Patient is a ___ female
with PMH of HTN and pancreatic cancer from ___ s/p whipple,
cycles of adjuvant gemcitabine, and cyberknife radiation who
presents with acute abdominal pain around incision site from
recent incisional hernia repair. She was admitted for pain
control. Review of prior CTA revealed clot of IVC. She initiated
anticoagulation on lovenox. Abdominal pain improved on discharge
and she went home with continued anticoagulation and PCP and
hem/onc follow-up.
. | 274 | 77 |
19676805-DS-30 | 28,888,352 | Dear Mr. ___,
You were admitted with diarrhea of unclear cause, which resolved
spontaneously. While here, you were found to have ventricular
tachycardia, resulting in an ICD shock. You were seen by the EP
service and initiated on a new medication (sotalol) along with a
different formulation of your home metoprolol.
It will be important to follow up with your cardiology team for
your heart failure and this arrhythmia. In addition, you will
need to follow up with Drs. ___ for ongoing
investigation of your abdominal pain and likely malnutrition.
Your weight at discharge was 179.5 lbs. Please weigh yourself
daily and take your home Lasix 40mg for weight gain >2 lbs per
day or 5 lbs per week.
With best wishes,
___ Medicine | ___ hx chronic systolic CHF (EF 25% w/ mod AI, ICD for ppx), CKD
stage III, gastric cancer status post total gastrectomy
w/esophagojejunostomy ___, appendiceal carcinoma s/p chemoXRT
and R hemicolectomy ___ c/b radiation enteritis/colitis,
perforation, and enterocutaneous fistula requiring ileostomy and
subsequent reversal, pancreatic insufficiency, chronic abdominal
pain (on opiates), s/p CCY, adrenal insufficiency,
hypothyroidism, RLE DVT (on apixaban) admitted with diarrhea and
___, with course complicated by VT for which he received an
appropriate shock on ___ and SVT.
# Diarrhea:
# Chronic abdominal pain and nausea:
# Pancreatic insufficiency:
# Severe protein calorie malnutrition:
P/w ___ episodes of watery diarrhea per day with hypovolemia.
Unclear etiology, but suspect viral gastroenteritis given
spontaneous improvement (norovirus was negative). DDx includes
drug-induced (although new recent meds - valacylovir for
shingles
and apixaban - are not common culprits) and known pancreatic
insufficiency, for which he is on Creon. C.diff negative. Low
suspicion for radiation-induced enteritis this far out from
chemoXRT (in ___. Lactate was elevated as below, likely from
hypovolemia and improved with IVFs, with lower suspicion for
ischemic colitis or mesenteric ischemia in absence of worsening
abdominal pain (chronic abdominal pain for years of unclear
etiology was unchanged and abd exam was benign). CTAP this
admission showed no acute process, though limited by lack of
contrast in setting of ___. His diarrhea resolved
spontaneously, and he was having ___ formed BMs at the time of
discharge with his baseline minimal nausea and chronic abdominal
pain. Of note, patient was admitted in ___ with profound
diarrhea and hypovolemic shock, concerning for protein-losing
enteropathy for which he briefly required TPN. W/u that
admission
was unrevealing. He is currently followed by GI as outpatient
(Drs. ___ for ongoing w/u of chronic abdominal pain,
possible malabsorption, and malnutrition. Labs this admission
were concerning for ongoing malnutrition from likely GI source,
with albumin of 1.9. He will be discharged to ___ with Drs.
___ for further w/u; may need to consider supplemental
nutrition going forward. Home Creon was continued on discharge,
as was his home dilaudid (for which no additional prescriptions
were given; would attempt to taper dilaudid as outpatient if
possible). Would also avoid addition of QTC-prolonging
medications, including anti-emetics, going forward giving
QTC-prolonging effects of anti-arrhythmics (see below).
# Elevated lactate:
Lactate 4.8 on admission, likely secondary to hypovolemia from
diarrhea. Ultimately resolved with IVFs (~4L this admission) and
resolution of diarrhea. Low suspicion for bowel ischemia as
above
as abdominal pain was mild and chronic. CTAP without acute
pathology, though limited by lack of contrast in setting of CKD.
Asymptomatic bacteriuria, but low suspicion for sepsis and BCx
negative. No e/o cardiogenic shock, with TTE unchanged from
prior.
# Ventricular tachycardia:
# ICD shock:
# SVT:
Developed 1 min of MMVT on ___, for which ATP was unsuccessful
and he received a 41J shock. Rhythm converted to PMVT and then
self-converted prior to second shock. Unclear trigger, likely
electrolyte derangements from diarrhea, with low suspicion for
cardiac ischemia given negative biomarkers and non-ischemic EKG.
TTE was performed and was unchanged from prior, with severe
regional LV systolic dysfunction most c/w multivessel CAD (EF
20%). Seen by EP, who adjusted ICD ATP threshold and recommended
initiation of sotalol (started ___, dosed at 80mg daily given
CrCl ~52. Home metoprolol was initially held in the setting of
sotalol initiation. He continued to have short runs of
asymptomatic NSVT (including 17 beat run on the day of
discharge), as well as intermittent regular SVT. He was
evaluated
by EP on the day of discharge, who felt that he was safe for
discharge on sotalol 80mg daily with reinitiation of metoprolol
at half his home dose (Toprol 25mg daily in place of home
metoprolol tartrate 25mg BID). He will ___ with his PCP ___ ___
and with his cardiologist (Dr. ___ in ___ on ___
___ see NP ___. QTC should be rechecked at that appointment
and consideration should be given to increasing sotalolol to BID
dosing if CrCl>60. QTC 471 on ___. Magnesium supplementation
was prescribed on discharge.
# Macrocytic anemia:
# Thrombocytopenia:
# Low fibrinogen:
Appears to have chronic macrocytic anemia, thrombocytopenia, and
low fibrinogen levels going back to ___ be secondary to
chronic malabsorption vs marrow process. Hgb was 11.5 on
admission with plt 150, likely hemoconcentration. Hgb remained
stable in the ___ range with platelets in the low 100s during
his hospitalization, not far from his prior baseline. Fibrinogen
was in the ___ with no e/o DIC/hemolysis in the absence of
schistocytes on RBC smear and nl LDH. There was no e/o bleeding.
Hgb 9.5 and plt 106 on discharge. He will ___ with Drs. ___ for further w/u of possible GI causes for malabsorption.
In
addition, would recommend that he be referred for outpatient
hematology evaluation.
# Acute Renal Failure:
# Chronic Kidney Disease stage III:
Cr 2.7 on admission, likely pre-renal in setting of diarrhea.
Improved to 1.4 at discharge (b/l 1.2-1.7) with IVFs and
resolution of diarrhea.
# Chronic Systolic CHF:
EF ___ with moderate AI, unchanged on repeat TTE this
admission. Initially dehydrated in setting of diarrhea, for
which
PRN Lasix was held and fluids were given. Sotalol was initiated
and metoprolol adjusted as above. He appeared euvolemic at
discharge, with discharge weight of 179.5 lbs. Home lasix 40mg
daily PRN for weight gain was resumed on discharge. He will ___
with his outpatient cardiologist on ___ for CHF and VT. Would
consider initiation of ACE-in and spironolactone going forward
if
able to tolerate.
# Coagulopathy:
INR initially elevated to 2.8, out of proportion to apixaban
use.
Likely component of malnutrition and improved to 1.7 at
discharge
with vit K administration (residual elevation likely
attributable
to apixaban).
# Asymptomatic Bacteriuria:
# Urinary retention:
UCx on admission with VRE. Pt without urinary symptoms and low
suspicion for sepsis. Not treated. Home finasteride and
Tamsulosin continued without e/o urinary retention.
# Chronic Adrenal Insufficiency:
He is not on chronic maintenance steroids, but took low-dose
prednisone in the week prior to admission for shingles as
instructed by his outpatient endocrinologist. Rec'd 100 mg
hydrocortisone in ED in setting of diarrhea. AM cortisol WNL.
SBPs were at baseline in ___, with no evidence for adrenal
insufficiency. In the setting of VT this admission, however, he
received his outpatient protocol of prednisone 3mg x 1d, 2mg x
1d, and 1mg x 1d, completed ___. He will ___ with outpatient
endocrinology on ___.
# Shingles:
Developed shingles of L chest in the days prior to admission,
for
which PCP initiated valacyclovir, discontinued prior to
admission
for diarrhea (not a common side effect). Rash had crusted on
admission, and valacyclovir was not resumed.
# RLE DVT:
Continued home apixaban (no indication for renal dosing) RLE DVT
diagnosed ___. Duration deferred to outpatient providers.
# GERD: continued home PPI
# HLD: continued home statin.
# Hypothyroidism: continued home levothyroxine
** TRANSITIONAL **
[ ] repeat CBC and BMP at PCP ___ on ___
[ ] ___ anemia/thrombocytopenia/low fibrinogen; consider heme
referral
[ ] trend QTC on sotalol; avoid QTC-prolonging medications
[ ] ___ VT and SVT on sotalol and adjusted metoprolol; may
increase sotalol to BID dosing if CrCl >60 if HRs/QTC can
tolerate
[ ] trend weights; d/c weight 179.5 lbs, resumed home Lasix 40mg
daily PRN weight for weight gain
[ ] cardiology ___ for HFrEF; consider ACE-in and spironolactone
if able to tolerate
[ ] ___ with Drs. ___ for chronic abdominal pain/nausea
and malnutrition; may need to consider supplemental nutrition
[ ] taper dilaudid if able
- Code: Full, confirmed by admitting MD
- Dispo: home with services (___) on ___ | 121 | 1,124 |
12679677-DS-9 | 20,954,604 | Dear Ms. ___,
You were admitted to the hospital with re-accumulation of fluid
in your left lung. You had a procedure where this fluid was
evaluated and it showed possible infection. You were treated
with antibiotics and you also had a thorascopy procedure with
pleurodesis and chest tube placement. Biopsies were taken and
your chest tube was removed before discharge.
Please take your medications as directed. Please follow up with
Dr. ___ on ___ for possible Pleurx removal, suture
removal, and to discuss
biopsy results.
We wish you the best!
Sincerely,
Your care team at ___ | ___ w/ hx of type 1 diabetes with re-accumulation of a pleural
effusion, L sided found be lymphocyte-predominancy excudative in
nature of unknown etiology, now s/p ___ medical thorascopy,
plueral biopsies, talc pleurodesis, and placement of Pleurx and
___ chest tube.
#Pleural Effusion
#Possible pulmonary infection - Patient febrile on admission,
started on vancomycin/levaquin/flagyl (___) for broad
coverage. Vanc was discontinued on ___ as MRSA swab negative. IP
was consulted and patient underwent thorascopy on ___ with
pleural biopsies, talc pleurodesis, PleurX catheter and large
bore chest tube placement. Pleural effusion and chest tubes were
monitored with daily CXR. Pleural fluid cytology and micro
returned neg and pleural biopsy tissue culture negative. Outputs
from chest tube and pleurx have decreased and CT chest ___
showed very small area of residual effusion. Her large bore
chest tube was discontinued ___ and Pleurx catheter was capped.
She completed course of Levo/flagyl during hospitalization.
-f/u biopsy results
-Pleurx catheter to be drained MWF per IP to keep pleural space
dry and promote pleurodesis
- standing APAP and PRN oxycodone. cont lidocaine patch
- IP to arrange arrange for outpatient follow-up with Dr. ___
on ___ for possible Pleurx removal, suture removal, and to
discuss biopsy results
#Diabetes type 1 - patient with insulin pump which she manages
at home. Initially, patient hyperglycemic in setting on
infection therefore ___ was consulted. Her insulin pump
regimen was adjusted with good effect.
#Afib: her home xarelto was held per IP recs, she was continued
on metoprolol. xarleto was restarted when her large bore chest
tube was removed.
#Hypertension
-continued lisinopril and metoprolol
#Constipation: worsened during admission in setting of opiate
use. bowel regimen was increased and constipation resolved prior
to discharge.
#Hx diastolic CHF
-On a prior admission was on Lasix ___ dCHF. Currently does not
have any leg edema. Echo as above. She remains off her Lasix,
which was discontinued by cardiology as outpatient.
#Thyroid nodule: ___ noted this and documented the following
The left thyroid nodule 1.2 cm hypoechoeic on posterior aspect
-thyroid ultrasound as outpatient. | 93 | 333 |
16560800-DS-6 | 26,714,994 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
-VAC changes every 3 days by visiting nurse service. first
change will be on ___. The midline VAC is a wound
VAC and the medial wound with sutures is an incisional VAC.
Please run VAC machine at 120mmHg.
******WEIGHT-BEARING*******
Touch down weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
-You will require 6 wks of IV ertapenam and the PO ciprofloxacin
until the hardware is removed. You will need weekly lab draws
that will be faxed to the ID doctors.
*****ANTICOAGULATION******
- No chemical DVT prophylaxis needed. You should be out of bed
moving around with crutches.
********Lab Monitoring********
RECOMMENDED LABORATORY MONITORING:
(Please check testing needed)
CBC with differential (weekly) ( x )
BUN/Cr (weekly) ( x )
AST/ALT (weekly) ( x )
Alk Phos (weekly) ( x )
Total bili (weekly) ( x )
ESR/CRP (weekly) ( x)
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
******FOLLOW-UP**********
Please follow up with ___ in 1 week ___
___ wound evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
Touch down weight bearing RLE
Treatments Frequency:
Ertapenam 1g IV q24hrs for 6 weeks
VAC change q3days
weekly lab draws with results faxed to ID
RECOMMENDED LABORATORY MONITORING:
(Please check testing needed)
CBC with differential (weekly) ( x )
BUN/Cr (weekly) ( x )
AST/ALT (weekly) ( x )
Alk Phos (weekly) ( x )
Total bili (weekly) ( x )
ESR/CRP (weekly) ( x)
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed. | The patient was admitted to the Orthopaedic Trauma Service for
right ankle wound infection. The patient was taken to the OR and
underwent an uncomplicated I&D and VAC placement. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. Infectious diseases was consulted for an
antibiotic regimen. Their recommendations are 6 weeks of IV
ertapenam then followed by PO ciprofloxacin until the hardware
is removed. He received a PICC line on ___. He will require
weekly lab's that will need to be faxed to ID. The patient
tolerated diet advancement without difficulty and made steady
progress with ___ and does not require outpatient ___.
Weight bearing status: touch down weight bearing RLE with
crutches.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will not require continued chemical
DVT prophylaxis after discahrge. All questions were answered
prior to discharge and the patient expressed readiness for
discharge. | 451 | 224 |
16003832-DS-11 | 25,843,457 | Dear Ms. ___,
You were admitted to the hospital because you seemed more
confused than normal. We found that your sodium levels were
very low, which might have been partially to blame for your
confusion. We gave you fluids with salt in them to help correct
this problem. It will be important that you make sure to eat at
least some food every meal of the day in order to help prevent
this from happening again. You will also have your sodium
levels checked every day while at rehab to make sure it does not
drop low again.
While you were here, we also found that your thyroid levels were
low. We increased your levothyroxine, and you should have these
levels checked again in ___ weeks to make sure that your body is
responding correctly.
Changes to your medications:
START seroquel 6.25mg every night (scheduled) plus an additional
twice daily as needed for agitation
START miralax daily as needed for constipation
START tylenol by mouth or IV
START lidocaine 5% patch (for back pain)
INCREASE levothyroxine to 100 mcg daily by mouth or 50mcg daily
by IV
It was a pleasure taking care of you at ___! | ___ yo female with vascular dementia and recent admission for
falls and worsening mental status, now re-admitted with altered
mental status and found to have significant hyponatremia. | 200 | 27 |
16388704-DS-21 | 29,123,445 | You were admitted to ___ for observation for complaints of
bleeding from your rectum after a ileoscopy and sigmoidoscopy.
Your labs revealed some mild kidney dysfunction. You were
observed, given IV fluids and your bleeding resolved. You blood
counts were stable and your kidney function started to improve.
You also said you had increased ostomy output and your stool was
sent for cultures. This should be follow up by Dr. ___
your PCP. You should follow up with your PCP and Dr. ___.
.
Medication changes:
- | ___ yo F w/Crohn's disease and multiple abdominal surgeries,
cirrhosis presents with BRBPR post sigmoidoscopy with a Hgb of
13.3
.
# Acute Lower GI Bleed in the setting of coagulopathy and
thrombocytopenia
This was thought to be due to friable mucosa seen on
sigmoidoscopy in the setting of thrombocytopenia and
coagulopathy. The patient was monitored in house and her bloody
rectal output and sense of urgency resolved on the day of
discharge. No blood products were administered. Her Hgb on the
day of discharge was 13.0. GI saw the patient in house and
agreed with conservative management. Her coagulopathy and
thrombocytopenia are chronic and likely due to cirrhosis. The
patient should follow up with Dr. ___ in ___ weeks.
.
# Crohn's Disease:
The patient was continued on her oral steroids during her
course. The impatient GI team recommended canasa for her rectal
bleeding but by the day of discharge her symptoms resolved. The
patient also voiced a preference not to use anything rectally
per the recommendations of Dr. ___. It was also noted that the
patients had an allergy in OMR to asacol. As a result the
patient was not discharged on this medication.
.
# Increased ostomy output
The patient tolerated a diet well, but continued to have
significant ostomy output following this. This has been an
ongoing problem for the patient and is currently attempting to
wean off home TPN and onto a diet. She also acknowledged on the
day of discharge a foul odor to her ostomy output. As a result,
stools studies were sent. The patient was afebrile, had a
normal WBC and it was felt that the patient was safe to go home
on oral fluids and TPN.
.
# ___
The patient presented with a creatinine of 1.3 with a BUN of 44.
This was thought to be due to dehydration and pre-renal in
etiology. Her creatinine improved overnight with IV hydration.
The patient was able to tolerate food by mouth and had a strong
preference to be d/c. She takes TPN at home through her port
and with the TPN and oral fluid intake, the patient felt that
she would be able to adequately rehydrate herself. The patient
was informed of the risks associated with renal failure and the
importance of hydration. She understood and still desired a
discharge home. The patient will have a creatinine drawn is ___
days and have the results sent to her PCP.
.
# Transitional Issues:
- Follow up with her PCP ___ ___ weeks with follow up labs (CBC
and BMP) drawn prior to the visit
- Follow up with Dr. ___ in ___ weeks for routine GI follow up
and to follow up pending stool cultures
. | 90 | 460 |
19618753-DS-5 | 24,471,920 | Dear Mr. ___,
You were admitted to the hospital with a bacterial infection
(MRSA) ___ your blood. This infection was introduced by IV drug
use.
The infection spread to your heart (endocarditis) and to the
joints and muscles of your left leg. You required multiple
surgeries from the orthopedic team to wash out the infection
from your hip joint, and had drains placed to remove pockets of
pus from the muscles of your buttocks.
You required 6 weeks of antibiotics (vancomycin) to treat the
MRSA infection ___ your blood. You also grew some other bacteria
and yeast ___ your hip which required additional antibiotics.
At the time of your discharge you are totally off ALL opiate
pain medications. Because you are already fully detoxed from
your opiate addiction, you did not want to start Suboxone or
methadone. Even without the physical addiction you will still be
at high risk to relapse. If you get any cravings SEEK HELP. We
do not want you to have another life-threatening infection.
For your anxiety, your nerve pain, and to help you through the
tail end of the withdrawal process (which can take up to a month
or so to resolve fully) we have continued your scripts for
KLONOPIN and GABAPENTIN. These medications have some potential
for abuse and your new primary care doctor may or may not think
it is ___ your best interst to continue them. If your urine tests
positive for opiates or negative for Klonopin, they certainly
will not be continued.
It was a privilege to care for you ___ the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team | BRIEF SUMMARY
___ w/ IVDU, opiate dependence, anxiety, admitted with septic
arthritis of L hip (s/p multiple washouts on this admission -
growing ___, MRSA endocarditis of
tricuspid valve, and MRSA abscess of L iliacus and gluteus
maximus (s/p ___ drains ___. He completed micafungin,
ciprofloxacin, and six weeks of MRSA coverage ___ house
(initially vanco, then ceftaroline, then daptomycin).
ACTIVE ISSUES
=============
# Left Hip Septic Arthritis
# Left Hip Muscle Abscesses
Presented with five days for worsening left hip pain and
inability to bear weight. Initial work up revealed a WBC 10, ESR
89, CRP > 300, with left hip ultrasound showing a 4.7 x 0.9 x
3.3 cm fluid collection within the left hip. He initially
underwent an ___ guided hip aspiration and then OR washout by
orthopedic surgery on ___. Initial studies showed bacterial
joint infection with cultures growing MRSA. He then underwent
another washout and had two drains placed by ___ ___ the left
thigh muscles on ___. Due to worsening hip pain and incision
site purulence, he underwent another washout on ___. Cultures
grew MRSA as well as GNRs and ___. His antibiotics were
broadened from vancomycin to
vancomycin/ceftazidime/fluconazole. GNRs later speciated to
ceftaz-resistant pseudomonas so he was switched to cefepime and
then later ciprofloxacin on ___ due to concern for
cefepime-induced drug fever. Given persistent fevers, he
underwent further washouts on ___ and then again on ___ after
imaging showed fluid reaccumulation within the surgical bed. The
final washout revealed hematoma without signs of infection.
Later, fluconazole was switched to micafungin given concern for
drug fevers/rash and vancomycin was switched to daptomycin due
to eosinophilia. He completed a two week course of antifungal
coverage and pseudomonas coverage (___), and continued
daptomycin to complete a 6 week course for MRSA (___).
# Triscupid endocarditis
# High Grade MRSA Bacteremia
Patient presented with hip pain, found to have high grade
bacteremia with seeding of his joints and muscles. TEE on ___
demonstrated a tricuspid vegetation, no abscess, and possible
perforation with eccentric jet. He was evaluated by cardiac
surgery, who recommended non-operative management. He was
treated with vancomycin, briefly switched to ceftaroline
(___) given difficult to quench bacteremia before
transitioning back. He then was switched to daptomycin on ___
after worsening mild eosinophilia. He completed a 6 week course
(end date ___.
# Morbiliform rash
Developed a mildly pruritic rash over his trunk on ___,
which was felt to be due to a drug reaction from ceftazidime. He
was switched to cefepime and then later ciprofloxacin. Later ___
the hospital course, he had recurrent, though more severe, rash
over his trunk with progression into all four extremities. No
oral or palmar involvement. He had a mild eosinophilia without
LFT abnormalities. Ultimately fluconazole was switched to
micafungin and vancomycin was switched to daptomycin with
resolution of his rash. Fluconazole was added to his allergy
list per ID recommendations.
#Drug Fevers
Hospital course complicated by nightly fevers following
source control of his infection. Overall presentation consistent
with drug fevers, likely due to fluconazole. He was switched to
micafungin with resolution of his fevers ___ 2 days. Fluconazole
was added to his allergy list per ID recommendations.
# Suicidal Ideation
The patient underwent ___ prior to ___ transfer
given suicidal statements ___ the setting of the infection. He
reported having one prior suicide attempt ___ years ago from
hanging. He was seen by psychiatry who felt there were no acute
safety concerns. Following improvement ___ the infection, his
mood stabilized.
# IVDU (Heroin)
Long history of IV heroin use and had most recently been
sober for approximately one year. He was treated symptomatically
with clonidine TID for anxiety. Clonidine was tapered off and he
was monitored for rebound hypertension. SW discussed with
patient about starting methadone or suboxone to help him
maintain sobriety, but since he had entirely detoxed while being
___ the hospital for six weeks, he quite logically felt that this
would just re-introduce a physical dependence. To help him stay
clean without opiate replacement, he was offered the option of
Vivitrol, but he declined that also. Despite being told that he
is statistically unlikely to succeed, he wants to stay clean the
"old fashioned way." He will need outpatient follow up for
ongoing support and management.
# Left-sided sciatica
The patient complained of left sided sciatica ___ the setting
of his infection. He was resumed on gabapentin with good effect.
This medication has street value among opiate users and would
consider tapering him off it as he continues to recover.
# Anxiety and insomnia
The patient reports a longstanding history of anxiety and
insomnia and has been on Klonopin ___ the past. Inpatient
providers found it necessary to resume this medication ___ house,
especially since late symptoms of opiate withdrawal include
exacerbation of anxiety and insomnia. This medication has street
value and abuse potential and would consider tapering him off it
as he continues to recover. He was given a ten day supply at
discharge.
CHRONIC/STABLE ISSUES
=====================
# Normocytic Anemia
Admission labs notable for anemia, unclear baseline. Normal RBC
morphology. Iron saturation 18%, ferritin elevated ___ setting of
infection. Etiology felt to be a combination of iron deficiency
and anemia of inflammation. He will need outpatient follow up
for colonoscopy screening (49 and anemia).
# Bilateral shoulder pain
On ___, the patient reported bilateral shoulder pain. Given
high grade bacteremia, he underwent aspiration with ___ on ___,
which showed no signs of septic joint. His pain improved with
time and symptomatic treatment.
# Hepatitis C
Noted to have positive HCV antibody with viral load 5.7. LFTs
weren't normal. He will need outpatient hepatology follow up for
genotyping and treatment.
# Vitamin D deficiency
Gave weekly high-dose repletion ___ house.
TRANSITIONAL ISSUES
==================
[] Continue to strongly encourage Suboxone or Vivitrol given
high rate of IVDU relapse.
[] ___ have iron deficiency, and thus needs outpatient
colonoscopy
[] Refer for treatment of HCV, provided social situation remains
stable enough to ensure adherence with treatment.
[] Lung nodule: 8 mm lingula nodule should be followed on repeat
CT ___ ___ ___ this high-risk patient.
[] Would repeat TTE (or a careful physical exam of the heart) at
some point ___ the future to make sure his TR hasn't progressed
to a degree that could cause complications and potentially
require further specialist referral.
[] As he went through opiate withdrawal ___ house, his providers
have found it necessary to restart him on Klonopin and
gabapentin. Because he is doing well on these, they were also
continued at discharge for a ten-day supply. He was advised that
these medications have abuse potential/street value and that his
PCP may or may not think it is ___ his best interest to continue
them. He was also advised that if there is any evidence he is
diverting them or misusing then they certainly will not be
renewed. | 267 | 1,150 |
16748212-DS-16 | 28,963,356 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because you
were having increased shortness of breath recently. This is
likely due to the narrowing of your aortic valve. While you were
here, you were treated with an increased dose of your home
medication to help you lose some of the fluid that was causing
your discomfort.
While you were here, some of your medications were changed:
Please begin taking TORSEMIDE 40 mg daily
Please begin taking METOPROLOL SUCCINATE 150 mg daily (1.5
tablets)
Please follow-up with Dr. ___ as discussed below. Dr. ___
___ will continue to work on scheduling your outpatient CT
scan. Your visiting nurse ___ draw blood this ___,
___, and those results will be sent to ___.
Please weigh yourself when you return home and every morning,
call your doctor if your weight goes up more than 3 lbs. | Ms. ___ is a ___ with critical aortic stenosis ___
<0.8cm2 on TTE ___ status post balloon aortic valvuloplasty
in ___ complicated by pericardial tamponade requiring
pericardiocentesis, recurrent left-sided pleural effusions
status post pleurodesis, atrial fibrillation/flutter on
warfarin, nonobstructive coronary artery disease, diastolic
congestive heart failure (LVEF 70% on ___, chronic kidney
disease (stage IV), and renal artery stenosis status post right
renal artery stenting who presented with worsening shortness of
breath, likely due to acute-on-chronic congestive heart failure
in the setting of known aortic stenosis.
<< Active Issues
#Acute-on-chronic diastolic congestive heart failure in the
setting of known aortic stenosis: Progressive shortness of
breath accompanied by JVD, pulmonary crackles, peripheral edema,
elevated ___, and CXR with vascular congestion likely
reflected heart failure exacerbation in the setting of known
chronic diastolic congestive heart failure (LVEF 70% on ___
and critical aortic stenosis ___ 0.70cm2 on ___. Given
preload dependence, she received gentle diuresis with torsemide
40mg daily and occasionally bid, up from 40mg 3 days a week and
20mg 4 days a week at home, with some clinical improvement in
volume status on the basis of reduction in crackles and
peripheral edema, though there was occasionally discordance
between daily weights and I/Os; overall, her weight decreased
from 98.1 kg on admission (versus uncertain dry weight) to 96.7
kg at discharge. She remained on 2L NC oxygen intermittently
throughout admission, consistent with her home requirement. She
was discharged on 40mg torsemide daily, with close cardiology
follow-up for continued evaluation for ___ placement.
#Chronic kidney disease: With daily torsemide as above,
creatinine uptrended mildly from 1.9 on admission to 2.2 by the
time of discharge, consistent with baseline in the setting of
known chronic kidney disease. Reevaluation of renal function and
electrolytes by ___ was arranged for 3 days post-discharge, with
results to be reviewed by heart failure nurse ___
___.
#Atrial fibrillation/flutter: She remained in atrial
fibrillation/flutter on telemetry throughout admission. Home
metoprolol tartrate 100mg bid was continued throughout admission
and discontinued in favor of metoprolol succinate 150mg daily at
discharge for ease of administration. Following INR of 1.8 on
admission, INR remained largely within the therapeutic range
with administration of warfarin 4mg daily, with increase to INR
3.5 on hospital day 4, at which time warfarin was held, and
return to 2.5 the following day at the time of discharge.
Warfarin 4mg daily was continued at discharge, with plans for
INR check by ___ 3 days post-discharge for review by
___ clinic.
#Hyponatremia: Likely in the setting of hypervolemia, Na fell
intermittently to 132, down from 135-140 at baseline. As noted
above, reevaluation of renal function and electrolytes by ___
was arranged for 3 days post-discharge, with results to be
reviewed by heart failure nurse ___.
<< Inactive Issues
#Type 2 diabetes mellitus: Last HA1c unknown. She remained
largely euglycemic on home NPH regimen with Humalog insulin
sliding scale.
#Hypertension: She remained normotensive throughout admission on
home metoprolol tartrate, with transition to metoprolol
succinate at discharge as above.
#Hyperlipidemia: Home simvastatin was continued throughout
admission.
#Normocytic anemia: Hct remained essentially stable, 25.6-28.6,
and consistent with baseline in the setting of known thalassemia
and history of iron deficiency, with anemia of chronic disease
noted on the last admission. Home ferrous sulfate was continued
throughout admission, and she denied melena/BRBPR throughout
admission.
#Chronic pain: Home Vidocin lidocaine patch, and amitriptyline
were continued for chronic pain.
<< Transitional Issues
-Close cardiology follow-up was arranged for continued
evaluation for ___ placement.
-Reevaluation of renal function and electrolytes on torsemide,
given chronic kidney disease and mild intermittent hyponatremia,
was arranged for 3 days post-discharge, with heart failure nurse
___ to review results.
-Reevaluation of INR was arranged for 3 days post-discharge,
with results to be reviewed by ___ clinic. | 151 | 619 |
14275115-DS-19 | 24,574,395 | Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you had some confusion, high blood
sugars, and high blood pressures.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were resumed on your home insulin regimen to manage your
high blood sugars. You were also started on blood pressure
medications to reduce your blood pressures.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please follow up with your primary care provider ___.
___ further blood pressure management
- Please follow up with Dr. ___ at the ___
after discharge
We wish you the best!
Sincerely,
Your ___ Team | ___ woman with IDDM2, dysthymia, HTN, prior L SDH after
trauma with no residual deficits presenting with mild confusion,
hyperglycemia, and hypertensive urgency.
# Altered mental status:
Patient presented after ___ thought her to be slightly confused.
Son, who spoke to the patient at the time, denied significant
confusion and believed the patient to be at her baseline on
admission to the hospital. To the extent that she was mildly
confused, may have been secondary to hypertensive urgency vs
dehydration in setting of hyperglycemia. Low suspicion for
intracranial process, including infection or bleed.
CXR negative. UA with 12 WBCs, but patient without convincing
urinary symptoms or fever/leukocytosis. UCx with mixed flora.
She
received CTX x1 dose in the ED, but antibiotics were not
continued in the hospital (of note, the patient's son requested
repeat UA/UCx prior to discharge, but patient was unable to
produce a specimen - son was instructed to take patient to her
PCP for new urinary symptoms for repeat urine testing there if
deemed appropriate). Patient was not objectively confused
in-hospital (AOX3, able to recall details of medical history)
and
was thought by her son to be at her baseline at the time of
discharge. She was seen by OT, who was concerned about her
ability to safely self-administer medications and recommended
24h
supervision initially with home services. The patient's son,
___, will be providing ___ supervision and medication
assistance initially, and home ___, OT, and home safety
evaluation were arranged on discharge.
# Hypertensive urgency:
Presented with SBPs in the 200s without clear evidence of
end-organ damage (although mild confusion may have been related,
as above). Carries a diagnosis of HTN (with prior tx with
Lisinopril and spironolactone/HCTZ) with EKG and prior
echocardiographic evidence of chronic HTN, but patient denies
current anti-HTN therapy and reports well-controlled BPs at home
in the days prior to admission. Unclear etiology for acute
hypertension if her BPs are usually well-controlled off therapy,
but low suspicion for intracerebral hemorrhage, volume overload,
or pheochromocytoma. She was initially treated with low-dose
captopril, discontinued after discussion with PCP revealed some
concern for prior angioedema with ACE-inhibitors. Given that she
was recently prescribed HCTZ/spironolactone (25mg of each), she
was started on HCTZ 25mg daily on the day of discharge with
resolution of her hypertension. Spironolactone was not included
to avoid overcorrection of BP. She will require close PCP ___
for
titration of her antihypertensives and for a BMP check for
potassium monitoring. Unfortunately, the PCP's office was closed
on the day of discharge, but the patient and her son were
instructed to call on ___ to schedule an appointment for ___
days after discharge.
# Hyperglycemia:
# Type 2 diabetes mellitus:
Patient presented with fingersticks in the 400s, likely
secondary
to missing home doses of insulin after transition to home alone
after living with her son. No e/o DKA or HHS. Her fingersticks
improved with re-initiation of her home NPH 32u qAM/7u qPM. A1c
was 8.2%, approximately at goal. She will ___ with her ___
endocrinologist on ___. She was provided with an NPH pen on
discharge to assist with ease of administration, but the patient
reported that she was used to drawing up insulin with a syringe
and was unable to demonstrate an ability to transition to the
pen
despite nursing instruction. ___ and son will attempt to
instruct
patient at home, with the plan to revert to prior syringe
administration of same doses if patient prefers.
# HLD:
Continued home atorvastatin.
#Dysthymia
Continued home sertraline and risperidone.
#Glaucoma:
Continued home eye drops.
#Vit D Deficiency:
Continued home Vit D | 121 | 535 |
12930405-DS-8 | 23,032,817 | Dear, Mr. ___,
You were admitted to the hospital because you were confused.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given medications to help reduce your confusion.
- You were ___ on your home medications.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[] PCP
- ___ require Ca, Phos, albumin labs within 1 week of
discharge. Based on recommendations of endocrine team, ___
goal to be off calcium supplementation with goal correct Ca of
9. Should be scheduled for repeat labs draws q1week until follow
up with Endocrinology (___)
- Please monitor tubefeeding efficacy (history of clogs)
[] ___ cirrhosis
- Repeat EGD planned for ___
- Medication ___ and social support remain barriers
to transplant ___.
- ___ Labs Needed: PTH, Calcium,
Phosphorous, albumin within 1 week.
- Incidental Findings: None
- Discharge weight: 168.69 lb
# CODE: Full Code
# CONTACT: ___ (nephew) ___
BRIEF HOSPITAL SUMMARY
======================
Mr. ___ is a ___ male with history of decompensated
NASH cirrhosis complicated by SBP, esophageal varices, and
ascites s/p TIPS (___) previously on transplant list but now
off it due to medication ___ and recent primary
hyperparathyroidism s/p parathyroidectomy ___ presenting with
hepatic encephalopathy secondary to medication ___
and recent feeding tube clogs. ___ was managed with
increased doses of lactulose with improvement of his mental
status to baseline. Tolerated tubefeedings at goal 70cc/h
x20h/day. He was discharged home without services.
ACTIVE ISSUES
=============
#Hepatic encephalopathy
#NASH Cirrhosis
#Transplant candidacy
CP:C, ___ 23. Complicated in past by HE, esophageal varices,
___ ascites s/p TIPS ___, and SBP on
prophylactic bactrim. Presenting with encephalopathy likely in
setting of medication ___. Improved mental status
with increased lactulose. Minimal ascites and no evidence of
infection or bleeding on presentation ___. Will need to
obtain improved social support and prove medication compliance
prior to ___ on transplant list. The ___
midodrine need for blood pressure was reduced while inpatient
from 15 mg TID to 5 mg with maintained SBPs in ___.
#Severe Malnutrition
#Deconditioning
NGT was placed and tube feeds were started ___. Per family,
tube was clogged on multiple occasions since last admission.
___ is down 10lbs since last discharge date. ___ consulted -
no immediate needs. Tubefeeding Nepro at goal 70cc/h x20h/d with
phos repletion
#Parathyroid adenomas s/p parathyroidectomy
#Hypercalcemia
Last hospitalization: 4DCT of the neck showed 2 parathyroid
adenomas. Right superior and left inferior parathyroidectomy ___
with no complications. ___ had been started on calcium
carbonate 1000mg TID and vitamin D 1000 U daily. Endocrine
follow
up scheduled on ___. Admission corrected Ca ___. Based on
endocrine recommendations, discontinued calcium carbonate, goal
corrected Ca should be close to 9, with plan to ___ Ca,
Phos, albumin in 1 week if he is discharged (one extra lab date
prior to endocrine follow up).
CHRONIC ISSUES
==============
#History of hepatorenal syndrome
Noted on previous admission. Cr/BUN stable.
#Cerebellar IPH
___ with recent history of cerebellar IPH. Head CT noncom
unremarkable for bleeding
#Chronic Anemia
Hgb baseline ___. Currently, no signs of bleeding, no
hematochezia or melena. Hgb on discharge ___, admission Hgb
9.0, stable.
#Chronic thrombocytopenia
Likely due to liver disease, previous work up negative for HIT
and has been on Bactrim ppx chronically. | 145 | 462 |
19697164-DS-11 | 27,231,248 | Dear Mr ___,
You were admitted to the hospital because of tingling in the
hands and feet and decreased reflexes. We performed an EMG that
showed subtle abnormalities consistent with Guillain ___
Syndrome, and we gave you a medication to treat this syndrome.
We performed an MRI of your spine, and we sent multiple other
lab tests that did not show any abnormalities that could have
caused these symptoms. | Mr ___ presented to the hospital because of tingling in his
hands and feet and decreased reflexes, and he was admitted to
the Neurology service. He had an EMG that demonstrated subtle
abnormalities consistent with Guillain ___ Syndrome, and
therefore, we treated him with four days of IVIg. He had some
improvement in his symptoms during treatment. We also performed
an MRI of his ___ that did not demonstrate any
abnormalities. He had several lab tests sent but these were
negative, and we did not identify the cause of his neuropathy.
His course was complicated by mild increase in his BUN, but this
resolved with aggressive hydration. | 68 | 107 |
17178524-DS-14 | 23,690,033 | Surgery
You underwent a surgery called a craniectomy to have infection
removed from your brain.
Please keep your sutures along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear the helmet at all times when OOB.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | This is an ___ year old female transferred from ___
___ with concern
for infection after left frontal meningioma resection ___
with Dr. ___. Recently, the patient's care taker noticed
swelling at the surgical site, puffiness of the left face, and
erythema around the left eye. She was admitted to the
neurosurgical service for further evaluation and management.
#Intracranial Abscess
MRI with contrast on admission confirmed large intracranial
fluid collection with a thick enhancing rim appears to
communicate with a smaller subgaleal collection with similar
properties, suggestive of abscess. On ___ the patient was
taken to the ___ for left craniectomy and abscess drainage. The
incision was closed with staples and interrupted sutures.
Cultures were sent from the OR and eventually grew back gram
positive rods consistent with P.acnes. The patient will follow
up with Dr. ___ 4 weeks after completion of IV antibiotics.
She will need an MRI head with and without contrast at that
time.
#Infectious disease
Perioperatively the patient was started on broad spectrum
antibiotics. Cultures were sent from the OR which eventually
grew back gram positive rods. Her course of antibiotics was
changed to IV vancomycin 1250g q24h. This was transfused through
a PICC line placed in interventional radiology on ___.
Unfortunately the patient self removed the PICC line overnight
on ___, therefore a second PICC placement in ___ was ordered.
The patient will continued IV vancomycin for 6 weeks. She will
follow up in infectious disease clinic later this month. She
should have a head CT scan with and without contrast at the end
of the antibiotic course completion. The patient should have
weekly Vanco trough drawn as her goal is ___. On day of
discharge the patient's trough was 14.1. | 530 | 286 |
18845673-DS-4 | 23,215,584 | Dear Mr. ___,
You were admitted to ___ due to increasing pain in your
abdomen. A repeat paracentesis showed no evidence of infection
in the fluid in your abdomen. You had several stones in your
gallbladder, however, and we believe these are the source of
your recurrent pain. The surgeons evaluated you for possible
removal of your gallbladder, and felt that surgical intervention
was not acutely neccesary. You can follow-up with them in ___
weeks for furtehr discussion of future surgical management.
Please continue on the ursodiol, which may help prevent the
pain.
You were also noted to have low blood levels. We watched your
levels closly and gave you a unit of blood. We did not feel
your were having active bleeding, but please see your primary
care physician for repeat blood testing within 1 week of
discharge.
You should follow-up with your primary care physician and
transplant surgery for further management.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___ | Mr. ___ is a ___ gentleman with decompensated HCV
and EtOH cirrhosis complicated by ascites, variceal bleeding in
___, and recent SBP (currently on CTX) who presents with RUQ
abdominal pain consistent with biliary colic.
# Biliary colic:
Pain most consistent with biliary colic given location, positive
___ sign, and multiple stones seen on U/S. Pt. with
history of repeated episodes. Labs, however, do not suggest
cholestatic picture. ___ be recurrent/chronic cholecystitis with
active passage of stones. HIDA scan showed no obstructing stones
or gall bladder dyskinesia. SBP unlikely as ascitic fluid with
270 WBCs and 6% PMNs. RUQ u/s showed no portal vein thrombosis.
Pt. evaluated by surgery who recommended no need for immediate
cholecystectomy, but recommended outpatient follow-up.
# ___: Initially elevated on admission, but returned to baseline
of 1.0 with intravenous fluids and albumin.
# C. difficile: Diagnosed at OSH and started on metronidazole on
___. Pt. completed 14 days of treatment, and was
discharged off metronidazole.
# SBP: Pt. diagnosed with SBP at OSH on ___ and started on
ceftriaxone. Pt. completed five day course. Repeat diagnostic
paracentesis showed no evidence of SBP. He was placed on
ciprofloxacin for SBP prophylaxis.
# Anemia: Pt. noted to be anemic during the hospitalization. No
evidence of bleeding on history or physical. Stools were guaiac
negative. Pt. received 1U PRBC with appropriate response.
Anemia felt to be dilutional, and pt. will follow-up with his
PCP for repeat CBC.
# HCV and EtOH Cirrhosis: Decompensated with ascites, recent
SBP, and variceal bleeds in ___. MELD is stable at 12 on
admission. Patient is on the transplant list but inactive due
to low MELD score. He was maintained on spironolactone,
furosemide, nadolol, and lactulose. He completed ceftriaxone
fro SBP and was started on ciprofloxacin prophylaxis.
# IDDM: Pt.'s home insulin was decreased on admission due to
poor PO intake. It was titrated up as his intake improved.
# COPD: Pt. was continued on his home inhalers.
# Transitional issues:
- please continue to monitor his CBC; consider EGD and
colonoscopy if pt's anemia persists or worsens
- pt. will follow-up with transplant surgery for potential
cholecystectomy | 176 | 367 |
17607781-DS-3 | 28,894,687 | Dear ___,
___ were seen at ___ during this admission due to persistent
left lower quadrant abdominal pain. A CT scan of your abdomen
indicated that you have acute diverticulitis. In addition, we
also found a small abcess collection that was involving the area
around your ovaries and a mass in your right axilla.
We initially tried to treat your diverticulitis and your
infection conservatively with bowel rest and antibiotics
respectively. However, as you did not show signs of improvement
after 9 days of medical treatment, we decided to pursue with
surgery.
As a result on ___, you had a laparoscopic procedure to
drain the abcess, a right salpingetomy and a right axillary mass
excitional biopsy.
Please, follow-up with us in clinic to discuss the biopsy
findings on a couple of weeks. Meanwhile you can resume your
normal daily activities except the ones described below
Your ___ team | Patient was admitted to the colorectal service. She was made
NPO, IV fluids was started for hydration and well as IV
antibiotics given the acute signoid diverticulitis seen on CT
abdomen from OSH. Her course of conservative treatment was
marked by poor pain control, eventually requiring a Dilaudid
PCA. On ___ CT abdomen showed diffuse colonic diverticulosis
with heavy involvement of the sigmoid and abscess extending into
the right adnexa. She failed conservative management and
underwent a diagnostic laparoscopy, extensive laparoscopic,
lysis of adhesions, drainage of pelvic abscess, and right
salpingectomy on ___. An axillary lymph node excision was also
performed at the same time for known lymphoma. She tolerated the
procedure well. Her post operative course was uncomplicated.
Her pain gradually improved to only requiring PO Dilaudid. Diet
was advanced with return of bowel function and she was able to
tolerated a diet with out nausea/emesis. Her JP drain was DC'd
on ___ with 30cc of serosanguinous drainge in 6 hours.
At time of discharge, she was afebrile, hemodynamically and
neurologically intact. | 148 | 180 |
19219660-DS-26 | 28,341,834 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
You were admitted for fevers and abdominal pain, concerning for
an abdominal infection, although no collection of infection was
noted on your CT scan. Your other tests (urine, blood culture,
chest x-ray, lab results) were negative for other causes of
infection. Your abdominal pain most likely is from your
cyberknife therapy and your tumor. You improved with antibiotics
and are being discharged on antibiotics with ciprofloxacin and
flagyl which should be continued through ___.
Wishing you the best,
Your ___ team | ___ locally advanced pancreatic adenocarcinoma s/p definitive tx
with C3 Gemcitabine currently undergoing cyberknife treatment
presenting with fever, nausea.
# abdominal pain: Patient presented with subjective fevers,
leukocytosis and abdominal pain, concerning for possible
infection w/abdominal source. CT A&P did not reveal a source
and no other GI symptoms other than nausea and emesis. Etiology
most likely from tumor progression vs cyberknife therapy. UA,
LFTs, CXR and CT scan were otherwise without other identifiable
source of infection. His lactate elevation trended down with
IVF on admit and he remained afebrile at discharge on
cipro/flagyl (initially on IV cefepime/flagyl). His abdominal
pain improved with ranitidine and simiethicone as well as with
uptitration of his home oxycontin and oxycodone regimen. He will
complete a 7-day course of cipro/flagyl through ___.
# Pancreatic adenocarcinoma: Patient with history of locally
advanced pancreatic adenocarcinoma s/p C3 gemcitabine, currently
undergoing cyberknife tx with 4 out of 5 completed. On
discussion with Dr. ___ Dr. ___
treatment of cyberknife was still undecided. He will have
follow-up with Dr. ___ on ___ for further
chemotherapy. He was continued on simethicone and ranitidine
while inpt while undergoing Cyberknife. | 95 | 197 |
13031024-DS-16 | 21,249,331 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with chest pain and trouble breathing. Your workup
including EKG and chest x-ray were reassuring. It seems these
symptoms are unrelated to your heart.
Please follow-up at the appointments listed below. Please
continue to take all of your home medications. Please work on
stopping smoking as this is very important for your lung health.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ with h/o HTN, obesity, asthma, dCHF, IDDM, hypothyroidism,
recent diagnosis of presumed Langerhans histocytosis, and recent
admission for chest pain/dyspnea with negative cath (___)
presenting with c/o chest pain and exertional dyspnea.
# Non-cardiac chest pain: Etiology is unclear. ACS ruled out and
pt known to have clean coronaries 6wks ago on cath. DDx also
includes GERD (though pt on PPI), MSK pain. Pain is not
pleuritic, nor associated with tachycardia or hypoxemia so PE
seems unlikely. This could be manifestaton of hypertensive
emergencies given improvement since presentation with
improvement in BPs.
.
# DOE: likely multifactorial in setting of dCHF though no signs
of volume overload currently other than mild ___ edema, ?recent
diagnosis Langerhans histiocytosis, obesity hypoventilation,
deconditioning, HTN, and tobacco use. Pt satting in high ___ on
RA and maintained sat of 98% RA with ambulation. Pt was
evaluated by cardiology in the ED who did not think CHF playing
a role and diuresis not needed, especially given recent cath
with normal filling pressures.
.
# Diarrhea/vomiting: seems most suggestive of self-limited
community acquired gastroenteritis. Patient without vomiting or
diarrhea during admission.
.
# dCHF: preserved EF with ___ MR on ECHO ___ and cath in
___ with normal LV filling pressures. BNP 369.
.
# HTN: significantly hypertense on arrival, ?due to medication
non absorbtion in setting of GI illness. Continued home coreg,
nifedipine, lisinopril.
.
# IDDM: continued lantus, hold metformin, ISS in house
.
# Langerhans histiocytosi: ?diagnosis made by ___ based on CT
findings of upper lobe cysts (___). Based on last
___ note main intervention at this time is smoking cessation.
Encouraged smoking cessation. Continued flovent
.
# Anxiety: continue fluoxetine
.
>> transitional issues:
# Code: full
# Emergency Contact: sister ___ ___ husband ___
___ ___
# F/u with PCP, pulm and cardiologist who is at ___
# No med changes | 82 | 303 |
15869025-DS-25 | 21,102,859 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___ ___. You came to ___ because you felt
unsafe at home. It was felt that we could assist you best with
an admission to a specialized ___ facility. | ___ yo female with hx of bipolar disorder with psychotic
features, multiple SAs, DM2, and HL presenting for requested
psychiatric admission for feeling unsafe who was admitted to
medicine for acidosis who is now MEDICALLY STABLE FOR
PSYCHIATRIC TRANSFER | 42 | 39 |
13291750-DS-5 | 27,864,654 | Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with chest, abdominal and back pain. You had a cardiac
catheterization to evaluate the vessels that supply blood to
your heart which did not show any severe obstructive disease.
You had a CT scan which showed a small aneurysm of your aorta
that should be followed up in one year with an ultrasound. You
also had a high cortisol level (hormone) that should be
rechecked by your primary care doctor.
Please discuss resumption of your lisinopril with your primary
care doctor at follow ___. ___ not take it for now until you see
your doctor. | Mr. ___ is a ___ year-old male with a past medical history of
hypertension, hyperlipidemia, chronic kidney disease,
obstructive sleep apnea, coronary artery disease s/p multipLe
PCIs who presented with chest pain/back/abd pain.
Active Issues:
# Chest pain with ST elevations: Patient presented with severe
chest pain, n/v, diaphoresis, dyspnea, but was found to have
severe diffuse 3 vessel disease without a clear culprit.
Troponins were negative on admission. ST elevations most likely
due to demand ischemia.
# Hypovolemic Shock: The patient presented with tachycardia in
the 140s, leukocytosis of 13, and a lactate of 5.5 on admission.
Hemodynamics improved after intravenous fluids and lactate
normalized to 1.5 prior to discharge. Infectious workup included
a CT abdomen/pelvis showing no evidence of ischemic bowel or
infectious or inflammatory process as well as a negative
urinalysis, urine culture, blood culture, and legionella antigen
testing. Most likely etiology was viral illness complicated by
dehydration from nausea and vomiting. | 109 | 156 |
19666743-DS-7 | 21,595,401 | Mrs. ___,
___ were admitted to ___ for shortness of
breath. ___ were found to have low oxygen levels and sent to
the ICU where they put ___ on mechanical ventilation. ___ were
given antibiotics for a possible pneumonia and also blood stream
infection. Once stabilized, ___ were sent to the floor where
your medical issues were stable
Please STOP the following medications
-Digoxin
-Ativan
-Trazadone
-___ (This interaction interacts with your current
antibiotic, please address this after ___ are done taking your
antibiotic)
We have CHANGED the following medications:
-Seroquel twice a day to just taking it at night before bed | ___ female nursing home resident, history of CHF, COPD, anemia,
CAD, DM and HTN presenting with shortness of breath, respiratory
failure and anemia ___ setting of recent URI symptoms, found to
have RML collapse and requiring intubation ___ the setting of
concern for tiring out ___ the ED, admitted to the MICU.
# Hypoxia: Presented with sats ___ ___ requiring NRB, and
required intubation when appeared to be tiring out ___ the ED.
Most concerning for CHF exerbation as discussed below, possibly
triggered by URI. Vent measurements were not consistent with
COPD exacerbation. Pulmonary embolism effectively ruled out ___
patient with low Wells score, neg d-dimer, and negative CTPA.
She was successfully extubated prior to being called out from
the MICU, but was still requiring supplemental O2. She was
given a few doses of IV lasix ___ the MICU as well, which may
have contributed to her approval. While on the floor, she
continued to require 2L O2 and desatted to the upper ___ on room
air. The thought was she likely has both a COPD and CHF
component contributing to her increased O2 requirement
# RML collapse: CT showed RML collapse and narrowed airways,
bronchoscopy showed only narrowed airways, and scoped could not
be passed into the RML brochus. No fevers or leukocytosis on
initial presentation but was initially treated empirically for
HCAP with vanc/zosyn/azitho (day 1 ___, but these were
switched to daptomycin/zosyn when blood cultures grew VRE as
discussed below and ID was consulted. Daptomycin was started
instead of linezolid because she is on citalopram and there is a
black box contraindication. Sputum cultures grew only
respiratory flora, however she did spike fevers and source of
VRE was not identified, so broad antibiotic coverage was
continued upon being called out of the MICU. Urine legionella
was negative, as was flu swab. Zosyn was later discontinued as
patient did not clinically look like she had pneumonia. Her
clinical status did not change off of zosyn.
#VRE ___ blood culture: Unclear source, no indwelling lines,
urine cultures were negative. Discontinued vancomycin (had been
febrile on this), consulted ID, changed coverage to zosyn and
daptomycin. TEE was negative for vegetations, but suboptimal
image quality commented on ___ report. Daily surveillance
cultures were negative. ID planned for a 2 week course of
dapto. Her CK was monitored. A PICC line was placed for plans
to complete her course on ___
# Acute on chronic heart failure: TTE this admission with EF of
50%, so likely mostly diastolic etiology. Presented with
dysnpea, hypoxia, pulmonary edema on imaging, elevated BNP,
suggestive of left sided failure. Minimal lower extremity edema
appreciated. She was diuresed with IV furosemide boluses while
PO daily dose was held, and was net negative 3L at time of
transfer from MICU. Digoxin level was 1.1 on admission, this was
rechecked and restarted. Lisinopril was held for acute kidney
injury, and metoprolol was converted to shorter acting while ___
the MICU. On the floor, we tried to diurese her more with IV
lasix but her Cr bumped, indicating she may be at her baseline
with 2L of O2. We then resumed her home dose oral lasix. We
also discontinued her digoxin as there was no clear systolic
component to her heart failure per her echo. Her lisinopril was
restarted at discharge
# Dementia with superimposed dementia: Oriented to person and
place at baseline, usually not date. More acutely confused ___ ED
as respiratory status decompensated, with escalating agitation
following extubation. Continued donepezil, buspirone,
citalopram, standing seroquel. Re-added home agitation prn
medications as needed (seroquel, trazodone, ativan). She had a
great deal of agitation and confusion following extubation,
easily managed with soft restraints to avoid interference with
care and with intermittent seroquel and haldol. On the floor
she was very sedated, so trazadone, ativan, and seroquel were
all held. As she continued to be agitated at night, her PCP
recommended that the seroquel be added back for a night time
dose.
# Normocytic Anemia: Presented with Hgb 6.3, Hct 21.7 with labs
3wk prior showing hct 27, and ___ showing hct 30, symptomtic
with SOB but with expanded differential as discussed above,
otherwise asymptomatic. Most likely explanation is slow GI
bleeding from known polyps seen on colonoscopy ___ ___ or
esophagitis seen on EGD ___ ___. Hemolysis labs were negative,
iron studies showed significant iron deficiency. She received 1
unit pRBC transfusion ___ the ED this admission and was
hemodynamically stable with stable hematocrits thereafter. GI
was consulted but there was no indication for urgent endoscopy.
Colonoscopy was recommended as an outpatient as Hct was stable
here
# Acute kidney injury: Creatinine elevated to 1.6 on admission
with BUN 69 suggestive of prerenal etiology. Baseline creatinine
1.1 ___ late ___. Most likely due to volume depletion ___
setting of acute illness and possible subacute GI bleeding, as
well as renal vascular congestion from heart failure. Improved
with blood transfusion as well as diuresis, likely due to
improved renal perfusion. Urine lytes were not exceptionally low
___ sodium but were obtained while patient taking furosemide.
ACEI was held until discharge when creatinine improved
# Paroxysmal atrial fibrillation: Formerly on coumadin, but no
long anticoagulated because of history of GI bleeding, confirmed
with PCP ___. Had Afib with RVR while ___ the MICU,
maintained blood pressures, acheived rate control with
metoprolol, diltiazem, digoxin. Pt went back into sinus on the
floor. Dig was stopped as above.
CHRONIC ISSUES
# COPD: We did not suspect exacerbation triggered by URI at this
time as patient without wheezing, has good air movement,
measurements on ventilator including plateau pressures and PIP
not consistent with COPD flair. Continued
Fluticasone-Salmeterol, tiotropium, added prn albuterol.
# HTN: Borderline low blood pressures on admission to MICU,
metoprolol was continued but converted to short acting,
diltiazem initially held but then gradually restarted for rate
control ___ short acting form, lisinopril held for ___, PO
furosemide held for diuresis with IV furosemide, and then
restarted on the floor. She was kept on short acting metoprolol
and diltizem on the floor and discharged with her home doses
# CAD: continued ASA 81mg
# DM: Held metformin, glipizde, used ISS and 70/30 at home
doses, adjusted for NPO
# Hyperlipidemia: held ___ Calcium 20 mg PO DAILY once
started daptomycin for risk of myopathy
# GERD: continued omeprazole 20 mg PO DAILY, Sucralfate 1 gm PO
TID
# Vit D deficiency: continued Vitamin D 50,000 UNIT PO 1X/WEEK
(WE) | 97 | 1,086 |
13441813-DS-20 | 20,182,091 | Dear Mr. ___,
You were admitted to the hospital because of abdominal pain.
There are several possibilities for your abdominal pain,
including a mild form of pancreatitis. This is based on your
exam and lab studies. However, other things, such as stomach or
small intestinal inflammation or gallstones, can sometimes cause
similar symptoms. Your pain improved with some pain medications
and a lot of fluid. You were able to tolerate your food. It
will be important for you to stay away from oily food, sour, or
spicy food to help the inflammation to calm down.
It may be important for you to talk to your primary care
physician about getting an upper endoscopy (camera) to look at
your esophagus, stomach, and small intestines if you continue to
have pain.
For constipation, you can first start taking Colace twice a day
to soften your stool. If you do not see effect, you can add on
senna and/or Miralax as needed to help with the movement.
Please note the changes in your medications.
- Start Colace. This will soften your stool.
- Start Senna. This will help with your bowel movement.
- Start Miralax. This will help with your bowel movement. | ___ yo M with HTN, HLD, cholelithiasis presents with 1 day of
abdominal pain and N/V. | 203 | 16 |
12030696-DS-13 | 25,902,783 | 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.
WOUND CARE:
- Keep your splint on, clean, and dry when in bed and ambulating
out of your home.
- Keep the wound clean and dry until follow up
- 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:
- Non weight bearing left upper extremity (do not lift anything
heavier than a cup)
- Passive range of motion and active assist range of motion as
tolerated left elbow
- No active range of motion left elbow initially (progress as
tolerated with occupational therapy)
- Please attend occupational therapy per the prescription given
prior to discharge | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left capitellar shear fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of left capitellar shear fracture, 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 per routine. The patient worked with
OT who determined that discharge to home was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, the patient was ambulating safely and was
voiding/moving bowels spontaneously. The patient is non weight
bearing in the left upper extremity with passive/active assist
range of motion as tolerated, no active range of motion. The
patient will follow up in 2 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. | 188 | 240 |
13482244-DS-21 | 24,494,198 | Please call Dr. ___ office ___ if you have
any of the following: temperature of 101, chills, nausea,
vomiting, unable to have a BM, abdominal pain worsens
-continue colace and senna (decrease doses or stop if diarrhea) | ___ F with grade IV left liver laceration and right hepatic
vein thrombus s/p MVC, previously anticoagulated, presented with
abdominal pain x 1 day. CT A/P showed new hypoattenuating area
in segments 4a and 4b with no new vessel thrombosis.
Hypoattenuation could be evolving infarct in area of previous
laceration, although patient's intermittent pattern of pain is
unlikely to be caused by an infarct. Constipation was seen on
CT. She was started on colace and senna and given Milk of Mag.
Pain medication was stopped.
Liver duplex ultrasound was done the next morning ___ to
assess hepatic vasculature for thrombosis. All vessels were
patent and no fluid collection was seen.
The patient was discharged in good condition. Her
constipation-related pain and discomfort resolved after senna,
colace, and milk of magnesia x2. She has a follow-up
appointment with Dr. ___ will be arranged for her a few
months after her discharge. | 36 | 152 |
13146404-DS-21 | 21,616,653 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with a COPD exacerbation which was treated with steroids and
nebulizer treatments. You were also found to have a possible
pneumonia so you were treated with antibiotics as well. You had
a brief episode of hypoxia (low oxygen levels) and needed to go
briefly to the ICU but were able to be transferred back to the
floor after we helped your breathing. Your breathing improved
and you were able to be discharged.
Please take your medications as prescribed and keep you follow
up appointments.
Best wishes,
Your ___ medicine team | Ms. ___ is an ___ with a PMH of COPD and asthma who
presented with a 2 day history of cough, subjective fevers and
increased shortness of breath consistent with prior COPD
exacerbations per patient. Pt transferred to MICU on ___ after
acute hypoxic event, where she was started on BiPAP found to
have new pulmonary edema and pna. Pt was weaned to 2L O2 NC and
transferred back to floor on ___. | 103 | 73 |
10668617-DS-20 | 29,781,076 | Dear Mr. ___,
You were admitted for transient visual loss in the R eye,
consistant with amurosis fugax. Luckily your symptoms resolved
and you have no neurologic defecits. Your MRI was normal which
ruled out any other strokes.
Your INR was 2.1 at the time of your episode of vision loss, and
we recommend a higher INR goal of 2.5-3.5 to prevent further
episodes of stroke. And echocardiogram was done in the hospital
and showed that your valve is normal. Vessel imaging of your
head and neck did not show any other causes of stroke. You had
an A1C and LDL drawn in the hospital which were pending at time
of discharge, your PCP should follow up on these to also help
modify your stroke risk factors.
Please increase your coumadin to 3 mg daily, and check your INR
on ___, and call your cardiologist to adjust coumadin dosing.
Please also ask your cardiologist to schedule a close follow up
appointment in the next week. Also please call your PCP to
schedule an appointment in the next 2 weeks.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo male, pmh of AVR s/p mechanical valve, who presents with
transient vision loss. Neuro exam on admission was normal. MRI
negative for stroke. CTA head and neck did not show any
evidence of carotid stenosis. The likely etiology of the embolic
stroke is due to the mechanical valve. TTE without embolus and
similar to prior ECHOs. INR during event was 2.1, so we
recommend his INR goal to be increased to 2.5-3.5, so coumadin
was increased to 3 mg daily on discharge. INR on day of
discharge ws 2.7. LDL (105) and A1c (5.5%) were pending at time
of discharge. He improved to discharge home and to check INR on
___ and to follow up with cardiology neurology and pcp. | 189 | 125 |
13528441-DS-14 | 22,455,524 | Dear ___,
___ came into the hospital after experiencing a fall. ___ were
found to have a fracture in your cervical spine (at C4). For
your cervical spine fracture, ___ were seen by neurosurgery. ___
should wear a hard cervical collar for 2 weeks and then
follow-up with the neurosurgeon who saw ___ in the hospital, Dr.
___.
Initially, we had concern that your posterior brain vessels may
have had some abnormality but fortunately repeat imaging did not
demonstrate any vertebral artery occlusion or dissection which
was in question.
Please also follow-up with the stroke neurologist who saw ___ in
the hospital, Dr. ___. Please see below for information on how
to schedule these appointments.
We wish ___ all the best! | ___ presented after a fall. She had evidence of C4
transverse process fracture on CT and CTA was concerning for
irregularity of the left vertebral artery. She was admitted for
monitoring and assessment of vertebral injury. She did not
develop any symptoms concerning for dissection and MRA with fat
sat images demonstrated patent arteries & no dissection. A hard
cervical collar remained in place at the time of discharge and
she will follow up in ___ clinic in one month.
She has 3 brief episodes of isolated vertigo with movement.
These were thought to be post-traumatic in nature & required no
specific treatment.
For her right knee osteoarthritis she was evaluated by physical
therapy who recommended home physical therapy.
She had significant peripheral edema which started after
starting amlodipine. She has had similar symptoms in the past.
No changes were made to her medications but her rheumatologist,
the prescribing physician, was notified of this adverse effect. | 121 | 153 |
10353794-DS-18 | 26,216,293 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and inability to tolerate a regular diet.
You had a CT scan and MRCP that did not reveal any new acute
problems. Your pain was most likely related to chronic
pancreatitis. You were given IV fluids and pain medication. You
were gradually advanced to a regular diet. You are now
tolerating a regular diet, on your home medications, and are
ready to be discharged to home to continue your recovery.
Please follow up with your outpatient pain management provider
as needed.
We recommend that you follow up with your primary care provider
___ 30 days of discharge from the hospital. Please talk to
your provider about scheduling ___ repeat MRI in 3 months to
follow up on new lesions noted in your spleen.
We scheduled you and appointment with Dr. ___ as
listed below.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
service on ___ with increasing abdominal pain. He has a
complicated history of choledocolithiasis, gallstone panreatitis
and subsequent development of a large pancreatic pseudocyst in
___. He has chronic abdominal pain that worsened in the past
week. He had a CT scan and MRCP which were unremarkable. He was
admitted to the surgical floor for further evaluation and pain
control.
He was seen and evaluated by the ___ Surgery team who
agreed that there is no acute surgical need at this time and
recommended outpatient follow-up with Dr. ___ for
___ chronic pain.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV dilaudid
and then transitioned to oral oxycodone once tolerating a diet.
He is managed by a chronic pain specialist outpatient and
resumed on his home regimen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with IV fluids.
On HD2 his diet was advanced to clear and subsequently to
regular on HD3 which he tolerated well. He abdomen remained
tender but reportedly at baseline. Patient's intake and output
were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled. | 331 | 335 |
12286087-DS-21 | 29,701,146 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because of
constipation and urinary symptoms. While you were here, we did
imaging of your spine which revealed spinal compression
fractures. There was a question of whether this could be related
to something else, like metastatic cancer, so it will be
important to follow this up as an outpatient.
Your kidney function returned to baseline while you were here
with the help of the foley catheter. You will need to keep the
foley catheter in place until you follow up with your urologist.
We don't know why you were constipated but you should have a
repeat colonoscopy within the year per prior recommendations.
We wish you all the best. | ___ with past medical history of cerebral palsy, L1/L3
compression fractures in ___nd elevated PSA's
who presents with new constipation and urinary incontinence,
found to have acute kidney injury and likely metastatic disease
of spine.
#Acute Kidney Injury: Likely in the setting of obstruction given
clinical history of urinary incontinence. Had Foley placed with
difficulty which suggests worsening prostate disease. His renal
function returned to baseline with decompression. He was
discharged with the foley for outpatient urology follow up. He
was also started on finasteride and tamsulosin.
#Enhancing Lesions on MRI - Concerning for metastatic disease.
Per Radiology, they seem more consistent with mets from
something like prostate disease vs myeloma. Heme/onc was
consulted who did not believe this was secondary to prostate
cancer. Rising PSA thought to be secondary to BPH.
#Compression Fractures - HAs known compression fractures
secondary to a fall in ___. Currently has no back pain and
neurologically is intact.
#Urinary Incontinence:
Likely from worsening prostatic disease acusing overflow
incontinence. He was started on tamsulosin and finasteride. He
was discharged with the foley.
#Constipation
No evidence of obstruction on CXR and no stool in rectal vault.
He was placed on an aggressive bowel regimen and was having
regular BMs at discharge.
TRANSITIONAL ISSUES:
* extensive conversations held with outpatient providers
regarding further work up of his worrisome MRI reading
indicating potential metastatic disease | 128 | 235 |
19486131-DS-15 | 25,817,454 | You were admitted with a pneumonia. You were treated with
antibiotics and you improved. Your flu test was negative. | ___ yo w/HIV presents with cough due to pneumonia. Flu swab was
negative. He was discharged on levofloxacin. | 19 | 18 |
12961910-DS-18 | 27,993,710 | Dear Ms. ___,
You were admitted to the hospital because you were having pain
in your chest, fever, and difficulty breathing. Please see below
for your detailed hospital course.
Thank you for allowing us to be a part of your care,
Your ___ Team
WHILE IN YOU WERE IN THE HOSPITAL:
-You had x-rays and CAT scans of your chest, which showed a
pneumonia on the right side of your lungs
-You were given antibiotics for your infection
-You were given medications to help with your symptoms of chest
pain, nausea, and difficulty breathing
-You were also found to have a small pocket of air
(pneumothorax) in the sac around your right lungs. It is not
clear how this occurred. It is possible that this was a
complication of your infection, but also a possible complication
of your recent procedure (renal cyst aspiration), performed
before coming to the hospital
-You had more x-rays of your chest, which did not show any
worsening or growth in this air pocket
WHAT TO DO AFTER YOU LEAVE THE HOSPITAL:
-Please continue taking your antibiotics for a full 7 day course
(first day = ___, last day = ___
-Please follow up with your primary care doctor | Pleasant ___ year old woman with stigmata of pneumonia who
endorsed progressive symptoms after treatment empirically for
CAP (levofloxacin) was improving on broad therapy but persistent
non-productive cough, intermittent low grade fevers, and
pleuritic right chest/flank pain. Imaging now confirming RML and
RLL PNA, likely CAP with incidental finding of PTX of unclear
etiology. She improved with broaden therapy (Azithromycin and
Ceftriaxone).
More than 35 minutes was spent on discharge process including
education, treatment and follow-up plans. | 191 | 77 |
17818674-DS-13 | 20,317,933 | You were admitted to ___ with abdominal pain nausea and
vomiting. CT scan showed a small bowel obstruction. You were
initially treated non-operatively with bowel rest, IV fluids,
and a nasogastric tube for stomach decompression. After a few
days you still had not resolved the obstruction so you were
taken to the operating room for an exploratory laparotomy.
Post-operatively, your hospital course was complicated by a very
slow return of bowel function. You have been getting nutrition
(TPN) intravenously through your ___ line. You are now having
bowel movements and on a regular diet but because you are not
taking in a sufficient amount of food by mouth, you are being
discharged to rehab and will continue getting TPN until you are
eating enough.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment. | The patient presented to pre-op/Emergency Department on
___ with a high grade small bowel obstruction with a
transition point in the distal small bowel. He was admitted to
the ___ service and initially was managed conservatively with
NGT decompression, NPO, and IV fluids. After 3 days, the
patient's abdominal distension had not improved, and his bowel
function had not returned. Given these findings, the patient was
taken to the operating room for on ___ for an exploratory
laparotomy in an effort to identify the transition point and
relieve his bowel obstruction. There were no adverse events in
the operating room; please see the operative note for details.
The patient was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert throughout hospitalization, however
he was intermittently confused and agitated. His home
psychiatric medications were initially held during his
hospitalization. Psychiatry was consulted for assistance in
developing an equivalent IV medication regimen while awaiting
return of bowel function. His orientation and agitation improved
with restarting anti-psychotic medication, and the psychiatric
team continued to provide recommendations throughout his
admission. The patient's pain pain was initially managed with IV
dilaudid and tylenol and then transitioned to oral medication
once tolerating a diet. His pain was limited throughout this
hospitalization, and he required minimal narcotic pain
medication.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient presented with a high grade small bowel
obstruction and failed non-operative management. As such, the
patient was taken to the operating room, but no mechanical
source of obstruction was identified during his exploratory
laparotomy.Post-operatively, the patient was initially kept NPO
with a ___ tube in place for decompression. On
___, the patient's bowel function returned and his NGT
was removed. His diet was slowly advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored. The night of ___ TPN was
stopped as oral intake improved. Of note, psychiatry believed
that the patient's home antipsychotic, clozapine, was likely the
cause of the patient's small bowel obstruction and recommended
that the patient start an alternative antipsychotic regimen at
discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. The patient did have a
leukocytosis which peaked at 21.6, however his infectious workup
failed to identify a source. His leukocytosis was downtrending
to a 14 WBC at the time of discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 399 | 525 |
16027768-DS-17 | 27,287,559 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted because you had worsening shortness of
breath and were found to have bacteria in your bloodstream. The
source of your infection was determined to be from the skin
infection in your leg.
What was done for me while I was in the hospital?
- You were treated for your infection with an IV antibiotic
called Ceftriaxone. You had a line placed in your arm so you can
continue to receive IV antibiotics after discharge. Your skin
infection improved. You were also treated with fluids for an
acute kidney injury that occurred in the setting of low blood
pressure.
- You were tested for signs of infection in your bone. You had
fluid removed from your right hip which did not show bacterial
infection. You had an MRI of your left foot which also did not
show signs of infection of your bone.
- You were treated for a blood clot that was found in your leg.
You were started on a blood thinner to called Apixaban to
prevent more blood clot from forming. You will continue to take
this medication after you leave the hospital. You should follow
up with your regular doctor to determine how long you should
continue to take this medication.
- You were tested for a urinary tract infection because of your
increased urinary frequency, but you did not have a urinary
tract infection.
What should I do when I leave the hospital?
- You will go to a short term rehabilitation center to work on
increasing your strength
- You will continue to take IV antibiotics through the line
placed in your arm while you were in the hospital. You will take
antibiotics for about 6 weeks and will follow up with the
infectious disease doctors to monitor your progress.
- You should follow up with your regular doctor about how long
to take your Apixaban for, and about your concerns regarding
increased urinary frequency
- You should determine who you would like your Health Care Proxy
to be, and you should have a conversation with your regular
doctor about what you would like to happen if you were to get
really sick in the future.
- Please take your medications as detailed in the discharge
papers.
- Please go to your follow up appointments as scheduled in the
discharge papers.
- Please monitor for worsening symptoms, such as fevers, chills,
or worsening redness or swelling of your leg. If you do not feel
like you are getting better or have any other concerns, please
call your doctor to discuss or return to the emergency room.
Sincerely,
Your ___ Care Team | Ms. ___ is an ___ year old F with history of asthma, COPD,
and schizoaffective disorder who presented with acute on chronic
shortness of breath, found to have sepsis secondary to Group B
streptococcus bacteremia and lower left leg
cellulitis, status post treatment with ceftriaxone. Course
further complicated by left femoral deep venous thrombosis,
status post treatment with apixiban. | 446 | 59 |
15592513-DS-19 | 22,079,854 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
-You had a large blood clot in your leg
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
-You were given blood thinners
WHAT SHOULD I DO WHEN I GO HOME?
-Take you apixaban as directed
-Be careful when you ride your bike
-If you have bleeding that will not stop call your doctor or go
to the ED
Be well!
Your ___ Care Team | ___ with PMHx prior DVT ___, HTN, and gout who presents with
two days
of acute right lower extremity swelling found to have
significant
RLE DVT burden. Given this was unprovoked and a recurrent DVT,
he merits lifelong anticoagulation. | 74 | 38 |
15378450-DS-11 | 28,753,252 | Dear ___,
___ was an absolute pleasure taking care of you during your
admission to the ___. You were
admitted for worsening confusion and high blood sugar.
When you arrived, your blood sugar levels were very high. You
were treated with IV fluids and insulin until your blood sugar
levels came down into the normal range. During your admission,
we started you on a nighttime dose of long acting insulin to
help control your blood sugars. We checked your blood sugar
after meals and gave you more insulin if you needed it. You
were seen by specialists from the ___ and
they recommended a new medication called Glipizide 10mg by mouth
every morning in addition to your Metformin 1000g by mouth twice
daily. Your blood sugars were well controlled on this new
regimen. When you leave rehab, please call your PCP ___
___ ___ and make an appointment for follow-up and
management of your blood sugar and to make sure that the
medications are working well.
You were very confused when you arrived. Head CT was negative.
We also performed a chest X-ray to determine whether you had an
infection which can also cause confusion. There was no evidence
of a pneumonia or other lung infection on the Chest Xray. We
think your confusion was due to the very high blood sugar
levels. After your blood sugar levels became normal, you were
awake and alert and interactive. It is very important that you
take your medications for your diabetes to keep your blood sugar
levels within a normal range. To help you with resources and
support so that you can take your medications every day, we
obtained a social work consult.
We also found on examination, that you have a yeast infection.
This is also likely due to your high blood sugars. We treated
your yeast infection with fluconazole 150mg one tablet by mouth.
We did not give you your medications for hypertension because
your blood pressure was normal during your admission. Please
call your PCP ___ an appointment 2 days after discharge
for management of your hypertension and medications. | ___ year old woman with poorly controlled DM2 who presents with
altered mental status and was found to have hyperglycemia.
# Altered mental status: Her AMS is most likely due to her
poorly controlled diabetes. Hb A1C 12.5. A non contrast head CT
was performed which showed no acute process. CBC reassuring that
no signs of acute infection. A social work consult was obtained
for assistance with barriers to medication compliance, meals,
clutter issue.
# DM type II: poorly controlled with A1C of 12.5%. ___ was
consulted and recommended starting glargine 15 U at night,
Metformin at home dose (1000mg PO BID) and starting glipizide ER
10mg PO daily. Her blood sugars were well controlled on this
regimen (averaged <200s most of the day). We provided diabetes
teaching including diet and medication compliance. She will go
to rehab with metformin, glipizide, glargine and ISS. However,
at discharge from rehab, she would idealy have a simplified
regimen of just metformin, glipizide and glargine. (Sliding
scale will likely be too complex for her). The ___ diabetes
doctors are happy to follow up with her outpatient, however it
will first require a referal from her PCP.
# Mechanical fall: Two days prior to discharge, she sustained a
fall while attempting to walk to the bathroom. Her neurological
exam was unchanged from baseline (at baseline she has a
bells-palsy) and a head CT without contrast showed no evidence
of intracranial bleeding, soft tissue or bone abnormalities.
# Pseudohyponatremia: She presented with serum Na of 125 in
setting of hyperglycemia and the corrected Na was 135. It
resolved completely with administration of IV fluids. This is
due to hyperglycemia.
# Hypertension/CAD: normal range of BP 118-120/50-60s. Given ASA
81mg PO daily. We held all of her home blood pressure
medications in setting of initialy lower blood pressures.
# Hypotension: patient was hypotensive to ___ while on the
floor. She was given IV fluid bolus of 1L NS. Her BP improved to
102/48 after bolus. We held home Amlodipine, Losartan, Atenolol
and HCTZ given hypotension. BP improved and stayed around
90-112s/50-70s. | 353 | 344 |
11392593-DS-18 | 20,513,208 | Ms. ___,
You were admitted to ___ with a
low blood count. You were found to have an infection in your
gastrointestinal tract called C. diff colitis. We started you on
antibiotics for this infection but you became very sick and were
in the ICU with a breathing tube for a day. We were able to
remove the breathing tube but you developed a very bad pneumonia
(an infection in the lungs). We treated you with powerful
antiobiotics and you continued to get worse. In speaking with
your niece (HCP) and you, it was decided that you would not want
invasive measures to prolong your life and that we should focus
on comfort measures only. As a result, we stopped all of your
antibiotics and other medications and only gave you medications
to make you more comfortable. | The patient is a ___ woman with a complicated medical
history who was recently admitted for anemia who was referred
back tody for anemia, though her hematocrit was not dangerously
low. After patient complained of abdominal pain, she was
discovered by CT to have colitis. The patient later on also
developed a pneumonia. Decision was made by HCP and pt to be
made CMO. Pt was transferred to hospice.
Active issues:
# Goals of care: Initially unable to locate family for patient
and thus patient was Full code resulting in ICU transfer and
intubation. Patient was able to be extubated without event.
Family was located (see below for contact information) and they
expressed that patient would not want invasive heroic measures
and she was made DNR/DNI. It was also discussed that she would
not want HD if her kidney function were to worsen. Finally, in
the setting of severe pneumonia not improving on antibiotics,
decision was made to make patient comfort measures only and all
antibiotics were stopped. She was continued on nebs and morphine
PRN for discomfort. A scopolamine patch was also started to help
with secretions.
#C.diff colitis: Patient has had complaints of diarrhea since
she was placed on Augmentin after tooth extraction and incision
and drainage of submental and submandibular space. Lactate not
elevated and patient's abdominal pain did not appear to be
related to food intake. Patient found to be C.diff positive. Was
already being treated with flagyl so this was continued. Due to
acute respiratory compromise (see below) was also started on PO
Vancomycin. However, in conversation with patient and niece
(HCP) decision was made to make patient comfort measures only
(see below) and all antibiotics were stopped prior to discharge.
# Respiratory failure / Pneumonia: ___ be a component of volume
overload vs acidosis leading to compensatory respiratory
alkalosis. On the evening of ___, pt found to be satting in
the ___ with increased work of breathing while on RA and was
started on 2L NC with improvement in resp status. CXR showed
concern for mild volume overload. She was given 10mg IV lasix
and albuterol. The next morning her oxygen sat was up to the
mid-90s on 2L NC and she was breathing comfortably. On routine
check later that day (___) she was found to be satting 83% and
was placed on a non-rebreather. Her BP was in the ___ and soon
dropped to the ___. She was triggered and given significant
respiratory and hemodynamic compromise she was intubated and
transferred to the ICU. In the ICU she was able to eventually be
extubated without event and was transferred back to the floor.
Once on the floor she was found to have a large right-sided
pneumonia and was started on vanc/cefepime for HCAP. However,
despite these antibiotics, she continued to decline and the
decision was made to make patient DNR/DNI and comfort measures
only. Antibiotics were stopped prior to discharge. She was
maintained on nebs and morphine PRN for respiratory
distress/discomfort.
# CBD dilation, elevated alkaline phosphatase: Patient has not
been complaining of any right upper quadrant pain. No fever or
white count. Abdominal exam benign and improved with flagyl in
the setting of known C.diff (see above). RUQ U/S showed dilated
CBD with no evidence of obstruction. Given decision for comfort
measures only, further work-up was not pursued.
# Anemia: Patient has been worked up as outpatient and thought
to have anemia secondary to chronic kidney injury. She has
recently (___) receive Aranesp injection. On morning of
___ in the setting of transfer to ICU, patient received one
unit of red cells. Her Hct remained stable and when decision was
made to make patient comfort measures only, lab draws were
discontinued.
Chronic issues:
# Hypoalbuminemia: Likely secondary to poor nutrition. Patient
provided with Ensure supplementation with meals.
# Chronic kidney injury: Patient's baseline creatinine is
1.2-1.5. She has been receiving erythropoeitin injections as
outpatient. Her Cr was mildly elevated on admission and
increased in the setting of acute respiratory and hemodynamic
compromise. At time of discharge, her Cr was downtrending but
not yet back at baseline.
# Hypertension: Continue home regimen of labetalol, indapemide,
nifedipine, isosorbide mononitrate. These medications were
stopped in the setting of hemodynamic instability. They were not
restarted as patient was made comfort measures only.
# GERD: Continued home omeprazole initially. Stopped prior to
discharge as patient made comfort measures only. | 136 | 731 |
10043039-DS-9 | 24,987,075 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing right lower extremity in an unlocked
___
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40 mg 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.
-You may take down your Ace wrap once home. You may change your
dressing if saturated in place a new clean gauze if draining
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
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:
Touchdown weightbearing right lower extremity in an unlocked
___, range of motion as tolerated
Treatments Frequency:
Remove ace wrap once home
Change dressings if saturated, apply dry sterile dressing daily
if needed after primary dressing removed
if not draining leave open to air
wound checks
staple removal and replace with steri-strips at follow up visit
in clinic | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial plateau ORIF which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with home ___ was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the right lower extremity, and will
be discharged on Lovenox 40 mg daily for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 618 | 261 |
19415931-DS-15 | 23,218,963 | You were admitted for a acute on chronic heart failure
exacerbation. This is due to your poorly controlled blood
pressure and ongoing cocaine use which make it difficult for
your heart to work. Fortunately you did not have a heart attack,
but with continued cocaine use, it will not only worsen your leg
swelling but will dramatically increase your risk of having a
heart attack.
To improve your blood pressure and alleviate your lower
extremity swelling we have changed your medications to ***
Please weigh yourself every day. If you notice that you have
gained more than 3 lbs in less than 48 hours, please call your
PCP.
You have a kidney injury, likely also due to heart failure
exacerbation and should improve as more excess fluid is removed.
After talking with our social worker, in order to prevent
ongoing cocaine use, we have recommended the following
outpatient programs ***
Upon discussion with Dr. ___ recommends holding your
Gleevec medication until you seee him in clinic.
For your skin lesions, Dermatology was consulted and they do not
thing any of them are concerning and rather reflect chronic
changes of lower extremity swelling with possible component of
damage from cocaine use. We have prescribed some lotions to
help.
For your vision changes, you had no evidence of stroke, bleed or
mass on CT and MRI of your brain. You need ophthalmology
evaluation as outpatient.
It was a pleasure taking care of you
- Your ___ Team | Mr. ___ is a ___ yo man with CML on Gleevec, prior cocaine use
(last use <1 week prior to admission), uncontrolled HTN and
chronic ___ edema complicated by venous insufficiency, Hepatitis
B on lamivudine who presented with diffuse anasarca likely due
to HTN and cocaine use. TTE showed grade 1 diastolic dysfunction
and borderline LVEF of 58%. He had acute on chronic heart
failure, slow to improve with diuresis, with ___ on CKD that
significantly limited ongoing diuresis despite evidence of
volume overload. | 238 | 84 |
14823679-DS-20 | 20,802,961 | Dear ___,
___ were hospitalized due to symptoms of vertigo and
incoordination 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 ___ for
medical conditions that might raise your risk of having stroke.
___ also underwent a liver MRI which revealed 3 mm lesion on
your pancreas. Please discuss these findings with your primary
care physician and follow up this finding with MRI in one year.
We are changing your medications as follows:
Addition of Apixaban 5mg to be take TWICE A DAY
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ 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
___
- 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 | ___ with HTN, CVA ___ year ago (presented with L sided weakness
which resolves), and recent cerebellar stroke (discharge ___
who is admitted to the Neurology stroke service from rehab with
lethargy and nausea, and was found to have leukocytosis,
transaminitis, UA c/f UTI and confirmed new L cerebellar infarct
on neuroimaging. Her stroke was most likely secondary to
cardioembolic source, although ___ and ___ revealed no evidence
of arrhythmias or thrombus. Hypercoagulability was considered,
work up pending at time of discharge. Her exam was notable for
somnolence, inattention, worsened dysarthria, and new left-sided
dysmetria in addition to right-sided dysmetria. Her acute and
chronic issues where managed as follows. She will continue rehab
at a rehab center. | 257 | 117 |
18467693-DS-4 | 23,716,319 | Dear ___,
You were admitted to ___ for a
fall. You are recovering well and are now ready for discharge.
Please follow the instructions below to continue your recovery:
* Your injury caused 5 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
If you have any questions or concerns, please call our office at
___. | The patient presented to the emergency department after a fall.
Upon trauma evaluation, she was found to have angulated L
midshaft humerus fracture, nondisplaced fractures of the lateral
left third and fourth
ribs, mildly displaced, comminuted fracture of the lateral left
fifth rib, and nondisplaced fractures of the lateral left sixth
and
seventh ribs. Her vital signs were stable at that time and she
was admitted for pain control and management of her humerus
fracture. She was started on a regular diet and home meds. For
pain control, she was given lidocaine patches and PO pain
medications.
An additional incidental finding of multiple pulmonary nodules
was found on her initial imaging. These findings were discussed
with the patient and a repeat CT scan was recommended in ___
months. A follow up appointment with her PCP was also scheduled
for ongoing management of this issue.
Orthopedic surgery was consulted for management of her L humerus
fracture. They elected for non-operative management with
coaptation splint and transition to ___ brace and
___.
At the time of discharge, the patient's pain was well controlled
on the PO pain medications and she tolerated a regular diet,
ambulation with walker and assist. She was voiding
spontaneously. She was not requiring supplemental oxygen and had
no increased work of breathing. She was discharged to home with
services and plans to follow up to the orthopedic surgery
outpatient clinic. The discharge plan was discussed with the
patient who expressed understanding and agreement. | 282 | 245 |
11934652-DS-9 | 29,913,039 | Dear Ms ___,
You were ___ because of your symptoms of word finding
difficulty and confusion. We believe that this is most likely
related to a degenerative disease such ___ body dementia
because of your waxing/waining difficulties, gait abnormailties
and cog-wheel rigidity. You were started on a medication for
dementia called Donepezil along with a medication for sleep
called seroquel. Because of your dizziness when standing we
discontinued one of your blood pressure medications -
amlodipine. You will have a follow up appointment in our
cognitive neurology clinic for ongoing evaluation. | Transition Issues:
[ ] Delirium: patient with sleep-wake cycle reversal and
agitation in the hospital suggestive of delirium. It responded
well to low dose seroquel. Given the possible diagnosis of
alpha-synucleopathy such as ___ Body Dementia, would try to
avoid use other antipsychotics although she did not demonstrate
any unfavorable responses to antipsychotics (olanzapine and
quetiapine) while in house.
[ ] Follow up with cognitive clinic. Patient was referred to
Cognitive Clinic for further evaluation as outpatient, but the
appointment should be confirmed at ___.
[ ] Orthostatic Hypotension: amlodipine stopped in the hospital.
Please have the patient sitting up during the day with
compression stocking (no compression stocking while IN BED) and
encourage plenty of fluid (fluid with electrolyte instead of
free water only) intake during the day.
Ms. ___ is an ___ year-old, right-handed woman with
significant for HTN, HLD, bilateral carotid stenosis,
orthostatic hypotension and a recent admition to ___ Neurology
for word-finding difficulty and gait instability (___) and
a negative stroke workup. The patient re-presented from rehab
with worsening word-findings difficulty, confusion and
tremulousness. She was admitted to the neurology service for
further workup. Her neurologic exam was notable for poor
5-minute recall, mild difficulty with complex commands,
bilateral intention/postural/action tremors of the arms and
apraxia. She continued to have significant gait instability.
There was no evidence of acute change, but rather, this appears
to be an ongoing relatively slow decline concerning for a
neurodegenerative disorder such as dementia with ___ body. The
patient underwent an EEG which showed no epileptiform activity.
She was started on donepezil. The patient's amlodipine was held
in the hopes of decreasing her symptomatic orthostatic
hypotension and allow her to better participate in ___. The
patient did become encephalopathic during her stay with reversal
of her day/night cycle so low dose seroquel was started QHS with
good effect. It can be used on a prn basis. | 90 | 315 |
12859844-DS-23 | 23,699,941 | Dear Mr. ___,
You were admitted to ___ for oral pain and abdominal pain with
diarrhea and difficulty eating and drinking after extraction of
teeth. You were also very dehydrated as the result.
As we discussed during your hospital stay, your CT scan showed
that a significant part of your pancrease has been damaged by
chronic inflammation. The pancrease is responsible for producing
digestive juices and certain hormones, including insulin.
Currently, you are on Creon, which acts like the digestive
juices produced by normal pancrease and help you digest the food
you eat. It is important for you to take Creon with meals to
help you absorb the nutrients you eat, prevent weight loss and
vitamine deficency.
While there is no effective way to cure your chronic
pancreatitis, it is important to prevent more damage. Avoiding
alcohol is the single MOST important treatment. We understand
that the alcohol helps you deal with chronic pain, however, it
is very bad for your pancreas and will cause you more pain in
the future. The pain of chronic pancreatitis may also be reduced
by eating small and low-fat meals. It is also very important for
you to drink plenty of water. Without enough water, you may
become dehydrated again and cause more damage to your pancrease
and other organs, such as your kidneys.
Stop drinking alcohol and eating smaller amount of food each
time may also help with your reflux and prevent damage to your
stomach. To avoid weight loss, you can eat the same amount of
food, just a little bit at a time.
Overall, please stop drinking alcohol all together, eat low fat
food, take Creon with food and drink plenty of water.
Thanks for letting us care for you,
- Your team at ___ | This is a ___ year old man with a PMHX of HTN, chronic
pancreatitis, chronic back pain, osteoporosis and EtOH abuse who
is S/P tooth extraction x5 approximately 2 weeks ago who
presents with the inability to eat/close the mouth secondary to
swelling and pain.
ACTIVE ISSUES
# ABDOMINAL PAIN: Mr. ___ endorses the onset of abdominal
pain 1 week ago accompanied by nausea, non-bloody vomiting and
diarrhea. Due to dental instrumentation 2 weeks ago, he's had
oral pain and difficulty maintaining po intake, including home
medications. He endorses feeling slightly more bloated than
usual. CT Abd/Pel showed sequelae of chronic pancreatitis,
without evidence of acute on chronic pancreatitis. Stool studies
for culture, O&P, C. difficile and guaiac were not able to be
sent since the patient had a few BMs while here and disposed of
them before RNs could send. Analgesia was achieved with
hydromorphone and MS ___. GI was consulted to see the patient
and felt conservative management, hydration, analgesia, stool
studies and follow up with GI as outpatient.
# ERYTHROCYTOSIS: Resolved. The patient reports a history with
some question of a red blood cell disorder, perhaps polycythemia
___, that was diagnosed at ___. Upon review of records, it
appears the patient has lupus anticoagulant. Heparin was used
for prophylaxis.
# GUM SWELLING: Mr. ___ had mild erythema of the upper
gums, without pus or discharge. He endorses pain over the area
as well, which has made po consumption difficult. He has been
afebrile, but does have a leucocytosis to 20.5, which could
indicate infection. He received Unasyn and was transitioned to
Augmentin. Dental saw him and requested that OMFS see him - they
recommended to obtain consultation with oral surgery to evaluate
maxillary anterior region. After discharge need to have upper
left bicuspid extracted and have full upper denture fabrication.
OMFS saw the patient and recommended full liquid diet, Peridex
rinse QID and encourage good Oral Hygiene.
# DEHYDRATION: In the setting of gum swelling and pain after
tooth extractions as well as nausea, vomiting and diarrhea for 1
week. On exam, the patient appears somewhat dry. He received IV
hydration and was slowly able to increase po intake on his own.
# HTN: Upon arrival to the floor, the patient was hypertensie
to 147/106, but appeared to be in pain. Analgesia and home
medications were continued and his BP normalised.
# CHRONIC PANCREATITIS: perhaps pain related to chronic
pancreatitis, although no evidence for this on CT abdomen.
Patient's symptomatology pointed to a possible pancreatitis
(epigastric pain, radiating to back, nausea, pain relieved in
prone position). Home Creon was continued. Will follow up with
GI as outpatient.
INACTIVE ISSUES
# OSTEOPOROSIS: continue weekly alendronate at home. No
bisphosphonate was given during hospitalisation for concerns of
refractory GERD.
# CHRONIC BACK PAIN: At home, the patient reports taking
hydromorphone 4 mg po qAM and qPM, as well as MS ___ 100 mg
po once daily, despite being prescribed for MS ___ 100 mg
bid. He reports attempting to cut back on the amount of opiates
he's taking, in conjunction with his PCP. Analgesia was
provided.
TRANSITIONAL ISSUES
- Should see Cognitive Neurology - concerned about decreases in
memory
- Sleep study for ? history of OSA
- Follow up with GI for EGD/H. pylori testing
- Follow up with dentistry at ___ - will be contacted for
appointment, if not, please call ___ | 291 | 564 |
19311221-DS-11 | 28,788,472 | Ms. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
- You were admitted to the hospital because you had severe back
pain.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were given medications to treat your pain and you felt
better
- You were seen by the neurosurgeons, who did not think you
needed surgery during your hospital stay
- You were treated for constipation and retaining urine
WHAT SHOULD I DO WHEN I GET HOME?
- Take you medications as prescribed
- Follow up with your doctors
___ the best!
Your ___ Care Team | Ms. ___ is a ___ woman with history of lumbar
stenosis, cardiomyopathy, COPD who presented as an outside
hospital transfer with acute on chronic back pain.
==================
ACUTE ISSUES
==================
# Acute on chronic back pain: Patient presented as a transfer
from outside hospital for back pain. She has a history of spinal
stenosis with multiple epidural steroid injections (most recent
2 weeks before admission), MRI showing spinal cord involvement
at T3 and multi-level disc bulging. Presented here upon transfer
with back pain and left buttock pain. MRI spine from outside
hospital reassuring against cord compression, epidural abscess,
or other acute pathology. Neurosurgery was consulted and
recommended non-surgical intervention. Pain was managed on
Tylenol, oxycodone, diazepam, and gabapentin. Bilateral hip
xrays showed degenerative changes without other acute process.
Neurosurgery recommends follow up in clinic in ___ weeks after
physical therapy and rehabilitation.
# Urinary retention: Likely secondary to narcotic use. Foley
catheter was placed initially and subsequently discontinued.
Patient was able to void.
# Constipation: Developed secondary to narcotic medications.
Initiated on bowel regimen to good effect.
# Catheter-associated urinary tract infection: On day of
discharge, less than 24 hours after removal of Foley, the
patient report dysuria. Urinalysis was pending at time of
discharge but was subsequently found to be positive for
infection. These results will be communicated with her rehab.
==================
CHRONIC ISSUES
==================
# Cardiomyopathy: Unknown LVEF. Reportedly nonischemic as
patient has had cardiac catherization and reports this showed no
obstruction. Continued aspirin, statin, BB.
# HTN: Continued lisinopril, BB.
# Hypothyroidism: Continued levothyroxine.
# COPD: Continued home Spiriva, albuterol nebs as needed.
# HLD: Continued home simvastatin
# ___ esophagus: Continued home omeprazole.
========================
TRANSITIONAL ISSUES
========================
- Patient given Tylenol, oxycodone, diazepam, gabapentin,
Lidocaine patch for back pain; please downtitrate and
discontinue narcotics as pain improves
- Please engage patient in physical therapy
- Patient complained of dysuria after discontinuation of Foley
catheter and urinalysis was positive for infection; this result
will be communicated to her rehab.
- Please refer patient to a local neurosurgeon for consideration
of laminectomy
I certify that 35 minutes were spent on coordination of care &
discharge planning. | 97 | 341 |
19123301-DS-18 | 26,006,986 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You had to stay in the hospital because of a heart
failure exacerbation and pneumonia (aka lung infection).
You had a CT scan of your chest that showed an infection of your
lungs and also fluid in your lungs. We gave you antibiotics for
the lung infection, and drained some of the fluid from your
right lung. We also gave you diuretics for the extra fluid in
your body. You improved with this regimen.
As we discussed in the hospital, you are scheduled for a biopsy
of the lung with interventional pulmonology to rule out lung
cancer. This will be ___.
You should follow up with your regular doctor, as well as your
cardiologist.
You should return to the hospital for fevers > 100.4F, worsening
shortness of breath, chest pain, pain on urination, or more
blood in your urine.
Sincerely,
Your ___ Team | ___ male with a complex history including MI and
congestive heart failure with an EF of 40% in ___ who
presents with shortness of breath and cough c/f HF exacerbation
& PNA, with imaging findings concerning for lung cancer.
#Acute on chronic systolic heart failure:
Trops mildly elevated but did not uptrend and TTE did not show
evidence of new ischemic events. His diuresis was uptitrated
with cardiology involvement, at one point requiring 160 mg iv
Lasix tid + metolazone 5 mg qd for net I/O -1.3L. Once he was
euvolemic he was transitioned to oral torsemide on ___. Beta
blockade also started with carvedilol 6.25 mg po bid. ___ also
saw the patient and recommended dc to rehab.
#PNA
#Pleural Effusion:
Per CT read may have lung mass, which may predispose him to PNA.
Concurrent rib Fx also put him at risk for worsening pna.
Initially started on vanc/cefepime/azithro on ___. Vanc was
discontinued when MRSA became negative on ___. He completed
cefpodoxime for total 8 day course on ___. On ___ pt had
diagnostic and therapeutic R thoracentesis by IP for 2L and
studies were consistent with a transudative etiology. Plavix was
held starting on ___ for post-discharge IP lung biopsy planned
for ___.
#Hematuria:
Hematuria while in-house may be related to foley placement,
however pt has h/o sporadic hematuria at home c/f malignancy
given smoking history. Has not been worked up. Has enterococcus
in his urine but not likely to be pathogenic as he is otherwise
asymptomatic. He should have outpatient urine cytology and
cystoscopy.
#Lymphopenia:
ALC 280, previously about 320 in ___. Per outpt heme note
would do bone marrow biopsy if not improving. In setting of
infxn, held off on bone marrow biopsy while inpatient. Pt should
follow up with hematology as an outpatient.
#Rib fx: minimally displaced ___ L rib fx. Pain was well
controlled while in-house.
#Psych: Continued citalopram. No active SI but depression seemed
to be worsening. Social work was consulted for support.
TRANSITIONAL ISSUES
===================
- Dr. ___ to perform transbronchial biopsy of lung mass on
___ @ 1pm (arrival 11:30am) NPO midnight night
prior. OK to resume Plavix afterwards (held starting ___ in
anticipation of procedure)
- Please weigh patient daily. If weight goes up 3 lbs or more in
one day, please consider increasing torsemide dose by ___ mg.
If weight increases by 5lbs or more over the course of 1 week,
would also consider increasing torsemide dose by ___ mg.
- Recommend re-checking Chem 7 on ___. Discharge Creatinine
1.8, which is baseline for pt. If adjusting torsemide dose,
please monitor Chem7.
- Has had chronic hematuria. Consider outpatient cystoscopy
- Pt is lymphopenic, should discuss potential bone marrow biopsy
and/or heme f/u
- Started carvedilol 6.25mg BID while in-house given h/o CHF,
will need outpatient Cardiology followup
- Added Ramelteon to help with sleep (took Melatonin as
outpatient but wasn't available on ___ formulary), and
Benzonatate as needed for cough
- Full code
- EMERGENCY CONTACT HCP: ___ (Law partner/friend)
___ | 153 | 488 |
17412466-DS-13 | 28,323,671 | Dear Mr. ___,
It was a pleasure taking part in your care at ___
___ ___! You were admitted because of increased
confusion and difficulty taking care of yourself at home.
Imaging done during your admission showed that your cancer has
spread to your liver. This was the most likely cause of your
confusion. Because of the extent of and prognosis your disease,
you decided to pursue care to become more comfortable. You were
discharged to an extended care facility with hospice services.
.
While you were here, some changes were made to your medications.
Please see the medication sheet for changes. | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ year old gentleman with a history of
HCV/alcoholic cirrhosis and cholangiocarcinoma who presented
from clinic a day after OSH discharge with persistent confusion
and hyponatremia. He underwent imaging and was noted to have
several hepatic metastases. Given his prognosis, family meeting
was held and patient agreed to be DNR/DNI, and transition care
towards rehab with hospice. His goal is to be closer to home.
ACTIVE ISSUES
=============
# Confusion attributed to hepatic encephalopathy: Intially there
was concern for hepatic encephalopathy vs infection as he
appeared mildly confused and lethargic, with mild asterixis on
exam. He was started on lactulose and his mental status
improved. Infectious work-up including UA, CXR, urine and blood
cultures was unremarkable. He was evaluated by ___ on ___ and
due they felt he was deconditioned and was not steady enough to
go home. They recommended discharge to rehab facility; patient's
goal was to be as close to home as possible. At time of
discharge he was orientedx3, though had a flat affect and was
not very interactive, which was attributed to difficulty with
coping and distress from bad news. He was visited by both social
work and palliative care.
# Hyponatremia: Per OSH records he was treated with a vaptan and
salt tablets. At admission his Na was 128, which is stable from
his discharge sodium (127-129). In the following days he was
placed on a fluid restriction and his Na ranged from 128-130. As
his goals changed, his fluid restriction was liberalized.
# Cholangiocarcinoma: He presented with profound recent clinical
decompensation. An Oncology consult was called and though plans
were made for the patient to be seen by Oncology as an
outpatient for possible chemotherapy in the future, he had
several hepatic metastases and was very depressed, with
vegetative symptoms. He was seen by pallative care in order to
help facilitate his goals of being closer to home. Family
meeting was held and he decided to change his code status to
DNR/DNI, and planned to go to rehab with hospice services.
# History of Varices: Underwent EGD on ___ which did not show
any varices. As such his nadolol was stopped.
# Nutrition: Patient was initially kept on a low sodium diet and
1500mL fluid restriction. Patient appeared to have poor PO
intake based on his body habitus so he was seen by Nutrition.
Nutrition recommended supplementing his diet with Ensure plus
BID. He was started on calorie counts on ___ as ___ felt that he
was very deconditioned, but this was discontinued because POs
were not recorded. However, he was noted to have poor intake.
Regardless, he was encouraged to eat and his diet and fluid
restriction were liberalized.
# HCV/EtOH CIRRHOSIS: MELDS on admission was 24. Not on
transplant list because actively drinking until recently. He is
now transitioning his care towards being more comfortable.
# Coagulopathy: Patient with INR of 2.7 - 3.0, likely due to
liver disease. Platelets were stable. | 99 | 499 |
14263401-DS-25 | 28,855,130 | Dear ___,
You were admitted to ___
because you were having back pain and right arm/leg pain. You
were also found to have a kidney injury.
What happened while I was here?
- We gave you medications to help with your pain
- We gave fluids which improved your kidney function
- You had a cat scan of your abdomen which was fairly normal.
You also has an X-ray of your right foot which showed some mild
swelling but nothing else concerning.
What should you do when you get back to rehab?
- Please take your medications as prescribed
- Please follow up with your neurologist
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely,
The team at ___ | SUMMARY:
==================
___ with a history of dementia, CVA c/b R-sided deficits
currently admitted for ___ in addition to pain control likely
secondary to post-stroke neuropathic pain. | 119 | 25 |
19438541-DS-7 | 22,664,044 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___! You came in after losing consciousness which was
likely due to a heart arrythmia called ventricular tachycardia.
You were having these episodes because of a scar in the base of
your heart. In order to prevent these episodes in the future,
you have been started on a medication called dofetilide. You
should also take the remainder of your antibiotics which will be
2 pills of keflex to be taken on the day of discharge. | #NSVT: Mr. ___ had a syncopal episode preceeded by chest
pain, shortness of breath, diaphoresis, and lightheadedness. He
lost consciousness shortly before EMS arrived and was found to
be in V-tach. He came out of the arrythmia before rescuscitation
could be attempted and returned to consciousness. On arrival to
the ED, he was in normal sinus rhythm. He was monitored on
telemetry and had several PVC's with some NSVT but no more than
12 beats and without symptoms. To prevent future episodes, he
was treated with dofetilide. He was monitored for 6 doses of
dofetilide and was sent home on 250mg twice daily. An ICD was
implanted as well. The patient will complete his antibiotics for
prophylaxis after the procedure on the day of discharge, he will
take 2 more doses of keflex. An EP study was performed at the
time of ICD implantation and the patient was found to have an
inducible V-tach at around 200 BMP which seemed to be
originating from area of scarring at the base of his heart. This
area is thought to have come from the mitral valve repair he had
in ___. He has a small area of aneurysm/balooning of the
ventricle as well, and his EF by echo is 45%.
#Transitional issues-please ensure the patient is tolerating his
medications
*Consider starting ACE-inhibitor for depressed EF. | 87 | 222 |
12645629-DS-6 | 24,000,070 | Please ___ with the Allergy Clinic. They will call you
with an appointment for Dr. ___.
Please also ___ with your PCP in the next 1month. | Mr. ___ is a ___ year old man with HTN and alcohol use, who
presented with throat swelling concerning for angioedema. His
hospital course included ICU admission for intubation.
#Angioedema:
Patient presented with angioedema, requiring intubation. He was
extubated within 24 hours. The presumed trigger was lisinopril
as there were no other identifiable triggers. Patient did well
___. Allergy ___ has been arranged w/ Dr. ___.
#Fever:
The morning ___ the patient had a fever to 102.
Blood and urine cultures were sent. He had no other localizing
symptoms, and the fever did not recur. On ___, after 24hrs
___ observation, he was sent home to f/u w/ allergy and
PCP.
#HTN:
Lisinopril was stopped due to concern for being the trigger of
angioedema. His BPs were ___ while off
lisinopril. He was started on metop 25 XL and tolerated the
first dose well.
#Alcohol use disorder:
On the second day of hospitalization the patient disclosed that
he drinks 1 bottle of vodka per day. CIWA scores were low during
admission, he did not require any Ativan. SW was consulted for
addiction counseling support. | 26 | 180 |
12468016-DS-66 | 23,904,259 | Dear Mr. ___,
Thank you for allowing us to care for you at ___
___.
WHY YOU WERE ADMITTED:
-You had very high potassium in your blood.
-You had worse swelling and redness in your legs.
WHAT HAPPENED WHEN YOU WERE HERE:
-We checked your blood to make sure your potassium returned to a
normal level.
-We restarted your torsemide.
-We wrapped your legs to help make them feel better.
WHAT YOU SHOULD DO WHEN YOU GO HOME:
-Please take 7.5mg of warfarin tonight ___. You should have
your INR checked by the visiting nurse service on ___ to make
sure it is going in the right direction and to adjust the dose
if needed.
-You should have your electrolytes and kidney function checked
by your ___ on ___. These results should be sent to your
primary doctor or your cardiologist to make sure your kidneys
and electrolytes are continuing to normalize.
-Please return to the hospital with any chest pain, shortness of
breath, palpitations, fevers, chills, pain with urination,
feeling like you have to urinate more frequently, or any other
symptoms that concern you.
-You should weigh yourself daily. If you ever gain more than
___ pounds in one day you should call your Cardiologist @
___ because this might mean that you are gaining too
much fluid in your body.
-Please continue to take all of your medications as you were at
home.
-Please go to all of your appointments as listed below.
We wish you the ___!
Sincerely,
Your ___ Care Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ w/ Crohn's disease s/p total
colectomy & splenectomy w/ ileo-rectal anastomosis now w/
colostomy, not on immunomodulatory therapy due to recurrent
infections, HFpEF (LVEF 55% ___, CKD (baseline unclear,
1.0-1.5), COPD (no PFTs on file), adrenal insufficiency, OSA on
CPAP, obesity, HTN, HLD & chronic b/l leg venous stasis changes,
presenting after being referred by his Cardiologist for K 6.3,
found to have +UA & worsening b/l leg edema & erythema.
His ___ reported his hyperkalemia 6.6 ___ to his Cardiologist
___ who instructed him to take torsemide 40mg QD &
Kayexalate and present to the ___ ED immediately. He wanted to
wait to present so he did not go to the ED until ___.
On admission, his potassium had improved to 5.5. He had no
physical complaints other than worsening of his b/l extremity
swelling and edema. He specifically denied fevers, chills, HA,
CP, palpitations, SOB, cough, rash. | 242 | 153 |
19539625-DS-22 | 22,739,156 | Dear ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital for
a rash and fever that was concerning for chickenpox. You had a
skin test that showed that you did have a chickenpox infection.
You were started on antiviral medication to help treat the
infection. While you were in the hospital you developed severe
headaches. You had a lumbar puncture and a MRI of your brain,
both of which showed no infection. You were continued on
antiviral medication with a plan to complete a total of 14 days.
All the best,
Your ___ Team | ___ year old female with interstitial cystitis, IBS, and
endometriosis receiving monthly leuprolide injections who has
developed fevers, sweats and rash following last leuprolide
injection on ___ with interval development of lesions over
face, back and arms concerning for varicella.
ACTIVE ISSUES
# Varicella Zoster, primary infection
Patient presented with disseminated rash involving multiple
dermatomes with different stages of vesicular lesions on an
erythematous base and others crusting suggestive of varicella.
DFA of from scraping of lesions was positive for Varicella. She
had a negative varicella IgG which suggested primary varicella
exposure. She was started on oral acyclovir five times daily
for treatment. While receiving acyclovir she developed severe
headaches of which she never had prior to admission. Infectious
Disease was consulted who recommended obtaining LP and MRI brain
as well as switching to IV acyclovir. Her LP was obtained under
fluroscopic guidance and showed no concern for infection. Her
MRI brain was normal without signs of infection. She was then
transitioned back to oral acyclovir and she tolerated the
medication well. She was discharged with a plan for a total of
14 days of acyclovir.
# Neutropenia
Patient meets neutropenic criteria with an ANC of 1323 on
admission. HIV was repeated and was negative. Also, an
immunoglobulin panel was performed which showed normal levels.
Her ANC initially trended down and a blood smear was not
concerning for blasts. Discussed with ___ who noted that
this was most likely secondary to her current viral infection.
She was no longer neutropenic at the time of discharge.
# Headache
Acute R-sided throbbing headache overnight associated with R eye
tearing/blurry vision, photophobia, phonophobia, n/v and
resolved with toradol. Her headaches were controlled with
toradol, oxycodone, and fioricet. As above, LP and MRI brain
were obtained to evaluate for cause of headache and were
negative. Her headaches improved at the time of discharge.
# Transaminitis
This was thought to be secondary to viral infection and was
trending down at time of discharge.
CHRONIC ISSUES
# Intersitial Cystitis
Her pain was controlled with oxycodone and toradol. Her home
dose of tizandine was continued.
# Depression
Her home dose escitalopram was continued. | 109 | 368 |
15866635-DS-18 | 23,977,865 | Dear Ms. ___,
It was a pleasure caring for you at ___.
You were admitted with increased cough and SOB. You were found
to have an asthma exacerbation. You were treated with inhaled
medications and steroids, which helped. You should continue your
steroids until ___.
Please follow-up at your appointments listed below. | Ms. ___ is ___ year-old woman with a PMH of asthma, OSA, and
hyperlipidemia presenting with shortness of breath, wheezing,
cough and chills, concerning for an acute exacerbation of her
asthma.
ACUTE ISSUES
# Acute asthma exacerbation: Acute onset of cough, SOB, and
wheezing is most concerning for an asthma exacerbation, likely
with underlying viral etiology. Patient appeared comfortable on
RA at the time of admission. Given that she did not receive the
flu shot this year and she has reported chills, there was some
concern for constellation of symptoms representing influenza
infection, but influenza swab negative. Patient was maintained
on neb treatments + prednisone throughout stay with improvement
in her symptoms prior to discharge. Patient will be discharged
with nebulized albuterol and ipratropium plus a prednisone
taper. Patient's most recent PFTs from ___, which were wnl.
Consider repeat testing following improvement from current
exacerbation.
# OSA: Previously on CPAP at night, but according to Sleep note
from ___, patient no longer uses CPAP. Consider follow-up
sleep study as an outpatient.
CHRONIC ISSUES
# Low back pain: Stable. Secondary to lumbar radiculopathy.
Continued Tylenol as needed for pain.
# Right eye corneal ulcer: Stable. Followed by ophthalmology.
Continued home eye drops.
# Eczema: Stable. Continue home betamethasone ointment and
triamcinolone cream to affected areas.
TRANSITIONAL ISSUES
- Continue prednisone 60 mg PO QD through ___. On ___
patient should taper prednisone as follows: 40 mg PO x 2 days,
30 mg PO x 2 days, 20 mg PO x 2 days, 10 mg PO x 2 days, then 5
mg PO QD x 2 days through ___.
- Patient has OSA and per Sleep note on ___ she was using
CPAP at home. Note from ___ states that CPAP no longer
needed, but does not explain reasoning. Please clarify this as
an outpatient and consider outpatient sleep study. | 50 | 314 |
18067813-DS-21 | 24,768,497 | You came to the hospital on ___ from an outside hospital
for further evaluation and treatment of right upper quadrant
abdominal pain, fevers of 102.5 and elevated LFTs including
total bilirubin.
You had a right upper quadrant ultrasound which showed signs for
gangrenous gallbladder with possible perforation. At ___
___, you were taken to Interventional Radiology for an ERCP
and had a drain placed. You are feeling better and are
tolerating a regular diet. You are ready to be discharged home
and will follow up in clinic in two weeks to have the drain
looked at and to schedule an interval cholecystectomy. Please
adhere to 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.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:You will have a visiting nurse help you at
home with your drain.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | The patient was transferred to ___ from an outside
hospital complaining of right upper quadrant abdominal pain. The
patient had an ultra sound at the outside hospital as well as
labs that showed acute abnormalities. The patient was given
zosyn and transferred here for ERCP and surgery. The patient had
the ERCP and a drain was placed. The patient was then
transferred to the floor on an NPO diet and IV fluids.
Neuro: The patient was alert and oriented throughout
hospitalization;
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient will be seen in
___ clinic for drain assessment and scheduling of interval
cholecystectomy. | 453 | 249 |
17517983-DS-94 | 22,900,096 | Dear Ms. ___,
You were admitted with chest pain and fluid in your lungs. You
had dialysis which improved your pain and volume overload. You
will follow-up with your nephrologist next week. Please make an
appointment with your PCP in the next ___ weeks. It is EXTREMELY
important to follow a low sodium diet (no salt added to food, no
take out food, no canned food) to prevent these episodes from
happening in the future. It is also important to take your
medications regularly each day. | ___ with T1DM, ESRD on HD, depression who presents with chest
pain.
#Chest pain: Likely due to volume overload at admission. Pain
improved when 3.4L were removed at HD on the day of admission.
She was hypertensive to the 190s systolic in the ED, resolved to
the 130-150s in after dialysis. Was ruled out for MI, but low
suspicion for ACS. She also had LENIs to look for a DVT which
was negative. Suspect poor adherence to low Na diet as
potential cause for her recurrent volume overload. She was
counseled on the importance of following a low sodium diet and
taking her medicines as prescribed.
#ESRD on HD: Volume status improved with 3.4L of
ultrafiltration. Will follow-up with outpatient nephrologist.
#T1DM: Hyperglycemic on arrival. Compliance with meds at home
appears poor, blood sugar improved when she was restarted on
home doses of insulin.
#CODE: Full
#EMERGENCY CONTACT HCP: ___ (___)
#Transitional issues:
-Continue to amphasize importance of low sodium diet and
medication compliance | 85 | 162 |
18206392-DS-9 | 23,712,560 | Dear Mr. ___,
You were admitted to the Neurology service due to concern for
transient vision loss and incoordination that improved. You had
a head CT that did not show a stroke. You could not have an MRI
due to your spinal stimulator. You likely had low blood flow to
the brain causing these symptoms (vertebrobasilar
insufficiency). You will have outpatient follow-up with
Neurology and Ophthalmology. | Mr. ___ is an ___ year old gentleman with HTN, HLD, DM, PVD,
CAD who presented with 45 minutes of transient bilateral visual
loss. He was admitted to the stroke service where his CT
angiogram revealed atherosclerosis most pronounced in his
posterior circulation. There was no evidence of acute infarct,
though MRI could not be obtained due to a spinal stimulator. He
underwent echocardiogram that showed mild LVH with preserved
regional and global biventricular systolic function (LVEF = 58%)
and a mildly diated thoracic aorta. No definite structural
cardiac source of embolism identified. He was continued on ASA
and Plavix and his atorvastatin was increased. His symptoms were
thought to most likely be secondary to vertebrobasilar
insufficiency vs. less likely TIA or migraine aura without the
headache. Primary ocular etiologies were also considered, but
the bilateral vision changes without eye pain did not seem to
fit. He was observed to have no residual deficits on his
examination following this episode, therefore he was cleared for
discharge home with outpatient follow-up with Neurology and
Ophthalmology. | 66 | 176 |
17607781-DS-15 | 26,669,284 | 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 severe rectal pain
and bloody bowel movements.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received medications to manage your pain.
- You received a port placement for chemotherapy. You started
chemotherapy in the hospital.
- You underwent radiation mapping prior to starting radiation
sessions in the hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Weigh yourself every morning, call your doctor 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:
====================
[ ] Patient is discharged on new pain regimen: oxycontin 160mg
Q8H + oxycodone 45mg Q3H:PRN.
[ ] Discharged with a prescription for intranasal Narcan given
large opiate doses: Did not demonstrate any signs of
oversedation on this regimen
[ ] PO intake was suboptimal throughout her admission: Please
follow up weights and if having decreasing weights with
continued decreased PO intake may need to discuss options to
increase caloric intake
[ ] Patient will complete the remainder of her radiation and
chemo as an outpatient per the ___ protocol
[ ] Discharged with ___ pump from ___ clinic: Will follow up in
___ for pump disconnect appointment on ___
[ ] Insulin requirements substantially decreased while inpatient
due to hypoglycemia, with discharge regimen as follows:
- Glargine 12 units daily, no standing mealtime Humalog
- Follow up fasting blood sugars and uptitrate if PO intake
increases
CODE STATUS: Full (presumed)
CONTACT: ___, husband (___) | 161 | 147 |
15986929-DS-4 | 21,766,016 | You were admitted and treated for poorly controlled diabetes
caused by blood stream infection and urinary tract infection.
You improved with antibiotics which will need to be continued
for a 2 week total course. You were put back on your home
diabetes medications. You will need to come back to the BI
infusion clinic to get your antibiotics.
You have a pulmonary nodule that was seen on imaging. Because
of its size and you have not smoked, no follow up is needed
2 mm right lower lobe pulmonary nodule. For incidentally
detected single
solid pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a
low-risk patient, and an optional CT in 12 months is recommended
in a
high-risk patient. If the patient is at high risk, a complete
chest CT at
this time should also be given consideration.
See the ___ ___ Guidelines for the Management
of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___ | The patient is a ___ yo woman visiting family from ___ w/
PMH of HTN, T2DM presenting with DKA and sepsis due to ecoli BSI
and pyelonephritis, now clinically improved. | 158 | 30 |
18664844-DS-21 | 22,547,825 | Dear Ms. ___,
You were admitted after a mechanical fall and am now ready for
discharge to a rehabilitation ___.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o As recommended by your physical therapist at ___.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
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.
Thank you for letting us participate in your care! | Ms. ___ was admitted to ___
after mechanical fall with headache and right hip/flank pain.
She was admitted for work up and treatment. She was managed
conservatively with pain medicine and physical therapy and
occupational therapy. Orthopedic surgery recommended weight
bearing as tolerated and physical therapy with repeat imaging in
___ days. Neuro recommended Keppra 1gm IV BID for 7 days and
to keep blood pressure <160. She was discharged in stable
condition with appropriate follow-up. | 431 | 78 |
11253475-DS-20 | 21,411,273 | You were admitted for worsening headaches, neck pain, nausea and
shaking activity. Neurology and psychiatry were consulted. You
had an EEG placed which captured one of these shaking episodes
and they were found to not be epileptic seizures. A lumbar
puncture was performed which showed normal pressures and no
evidence of infection. Your headaches are likely a combination
of tension headache and medication overuse headaches. We
strongly recommend that you stop taking fioricet, tylenol,
ibuprofen or opiod medications for your headaches. You were
started on nortriptyline to help prevent migraines. You should
follow up closely with your primary care, neurologist and
psychiatrist as scheduled. | ___ y/o female with PMHx of gastroparesis, s/p cholecystectomy,
hysterectomy and USO w/ complex L ovarian cyst, bipolar d/o,
pseudoseizures who presented with several days of abdominal
pain, nausea, and poor PO intake fevers, worsening
headaches and neck pain.
.
Neuro/psych: Psychogenic non-epileptiform seizures
(pseudo-seizures), medication overuse headache, likely
somatization disorder. Neurology and psychiatry were consulted.
No clear documentation of any epileptiform activity on prior
admissions to ___. Event in ED and
event on floor appears to be pseudoseizure. She was placed on
continuous EEG and had another event on monitor that was not a
seizure, consistent with her prior diagnosis of psychogenic
non-epileptiform seizures (pseudo-seizures). Her chronic
headaches are likely due to chronic use of opiods and fioricet
causing medication over-use headache along with possible tension
headache. Her fioricet was discontinued, she was not given any
opiods and her dilantin was discontinued. Her keppra can also
be discontinued on outpatient neurology follow-up. She was
started on nortriptyline for chronic migranie prevention. She
reports having a prior lumbar puncture which improved her
headaches concerning for possible pseudotumor cerebri. A lumbar
puncture was performed which showed a normal opening pressure of
12 with no signs of inflammation.
-Can titrate up nortriptyline as tolerated as an outpatient
-Continue keppra, gabapentin, klonopin for now
-Continue Celexa, trazodone.
-Has follow-up at ___ with PCP, neurology and
psychiatry
.
ABDOMINAL PAIN/N/V/: Possibly migraines contributing to nausea.
Had EGD in ___ showing gastritis with plan for repeat EGD later
this year
- Continue PPI, simethicone and carafate
- F/u with outpatient GI
.
# Subclinical hyperthyroidism:
Continue methimazole
#Access: Femoral TLC placed in ED as unable to obtain peripheral
IV, this was removed prior to discharge.
FEN: [x]Oral [ ]Tube feeds [ ]Parenteral [] NPO
DVT PROPHYLAXIS: [X ]Pharmacological [] Mechanical []
Ambulation
Lines and drains: [ ]Periphera [x ]CVL _1____ days(s) [ ]PICC
____day(s) []Foley day(s)
PRECAUTIONS: [X] None [ ]Fall [] Aspiration []
MRSA/VRE/C
diff/ESBL/Droplet/Neutropenic/Airbourne [ ]Restraints
DISPOSITION: [ X] Home [ ] Rehab [ ] SNF [] Hospice
Code Status: FULL CODE | 110 | 353 |
18277506-DS-14 | 25,676,879 | Dear ___,
It was a privilege to care for you at the ___
___. You were admitted with worsening of your MS
symptoms in the setting of a bad viral illness. You were
evaluated by the Neurologist who did not feel that steroids or
any other new treatments were required for your MS and expect
that your symptoms will improve as your infection subsides.
We encourage you to stay hydrated and get plenty of rest as you
recover from your viral illness. Please take all medications as
prescribed and follow up with all appointments as detailed
below.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with a history of MS
and PTSD who presented to the emergency department with 2 weeks
of upper respiratory symptoms as well as increasing MS symptoms
from her baseline.
#URI #Myalgias
#Vertigo #Multiple Sclerosis ___:
Patient with MS ___ in the setting of viral illness. CXR
w/o evidence of pneumonia. Flu negative. Seen by neurology who
reports that she has no new neurological symptoms to suggest an
active demyelinating lesion, but rather has worsening of her
baseline symptoms in the setting of a viral trigger. No
indication for steroids or other new MS therapy. Treated with
supportive care including IV hydration and analgesia. Patient
seen by ___ prior to discharge.
#PTSD #Domestic Violence:
Currently in domestic violence shelter. Seen by SW this
admission and is coping well. | 104 | 133 |
18309296-DS-19 | 29,747,640 | Dear Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted because you fell, but after a night of observation and
IV fluids, it does not appear that there is anything acutely
wrong with your heart, brain, or spine that may have caused
this. Since you were found to have a very small bleed in your
head, please take your new seizure medication, dilantin, three
times a day for 9 more days (10 days total), and follow up with
Dr. ___ a CT scan in ___ weeks. | ___ native ___ speaker with h/o lupus and chronic back pain
presents to ED with fall on day of admission, likely mechanical,
admitted for syncope workup.
# Fall: likely mechanical, as family reports progressively
unsteady gait and a patch of ice where she fell, but because the
actual mechanism of the fall was not fully witnessed, we will
perform syncope workup overnight. ___ have also been
orthostatic given tachycardia when standing (though no
hypotension), and orthostatis improved after 1L bolus. No signs
of infection, and ? small SAH unlikely to have caused this given
lack of clinical symptoms. Telemetry and EKG revealed no
remarkable findings. ___ recommended ___ services at home.
Headache improved and patient showed no significant neurologic
or other symptoms/signs, and was discharged home in stable
medical condition.
# ? small SAH: operation not indicated per neurosurgery recs in
ED. Unclear if this is new or old, given that son reports that
___ started a 10-day course of keppra after a similar fall ___
years ago at ___. She will need dilantin 100mg TID x 10 days
(starting ___, ending ___, per neurosurgery consult
in ED. She will follow up with her neurologist Dr. ___
___ at ___ on ___ for a repeat head CT
and evaluation.
# hypothyroidism: stable, on levothyroxine. ___ checked here
within normal limits. | 93 | 226 |
16425310-DS-14 | 27,352,897 | Dear Ms. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had whole body itchiness
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have acute liver injury
- Blood tests were performed and did not reveal an infection
causing this
- ___ imaging showed no evidence of bile duct obstruction
- The most likely cause of the liver injury was determined to be
augmentin. This can happen days or weeks after taking your last
dose.
- Your liver tests were improving at the time of discharge.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your appointments
-Avoid augmentin in the future. While it is not an allergy,
you're at increased risk for having a similar bad reaction in
the future.
We wish you the best.
Sincerely,
Your ___ Team | SUMMARY OF HOSPITALIZATION
============================
Ms. ___ is a ___ woman with history of CKD stage V, central
retinal artery occlusion, and hypertension who presented to the
ED with whole body pruritus, found to have acute hepatocellular
and cholestatic liver injury, with CKD within baseline and a
very mild hyperkalemia that resolved after single dose of lasix.
Workup for obstructive cause by right upper quadrant ultrasound
showed stones but no obstruction or biliary dilation, MRCP
showed also do NOT show biliary dilation or
obstruction. Serologic workup was negative for infectious cause,
toxin ingestion. Recent exposure to amoxicillin-clavulanate was
thought to be the most likely cause. LFTs downtrended. Amox-clav
was added to allergies and patient was discharged.
ACUTE ISSUES ADDRESSED
========================
# Mixed hepatocellular/cholestatic injury
Presentation of pruritis found with transaminitis, elevated alk
phos, and tbili that peaked at 2.8. Right upper quadrant
ultrasound showed coarsened hepatic parenchyma, no focal lesion,
though with cholelithiasis. MRCP showed no evidence of biliary
dilation or obstruction within the limits of the study. Patient
with recent amox-clav use for sinusitis, otherwise, no recent
start of culprit meds, no toxins, no supplements. Hepatitis B
immune and Hep C antibody testing negative. Hep A Ig testing was
positive with IgM pending at time of discharge. Thyroid function
within normal limits. Normal iron saturation. Autoimmune workup
not pursued. LFTs downtrending during discharge. Amox-clav was
added to allergies and patient was discharged.
# Pruritis
Underlying CKD 5 (stable, no e/o uremia) with acute
hepatocellular/cholestatic injury; while the bili wasn't
particularly high, may have tipped over the edge. Very mild
peripheral eosinophilia, no rash, reassuring against DRESS.
Cetirizine, Sarna was started with improvement of pruritis.
Received 1x gabapentin with improvement, but was unlikely the
agent to have helped. Hydrocerin ordered and never applied.
Cholestyramine was considered but not given because of risk of
hyperchloremic acidosis in renal impairment. Her pruritis was
improved at time of discharge.
# CKD stage V
On admission, at her baseline Cr. CKD likely due to secondary
focal glomerulosclerosis ___ pre-eclampsia in ___. Also with
contribution from hypertension. Labs stable over several months,
with intermittent metabolic acidosis and mild hyperkalemia.
Sodium bicarbonate dosing was recently increased. Renal
consulted in the ED, recommended outpatient follow-up with Dr.
___ as planned and compliance with sodium bicarb and low K
diet. Already has mature AVF.
# Hyperkalemia
Related to CKD, diet non-adherence. No EKG changes at K5.8,
which normalized. She received 1 dose of lasix.
# Borderline Macrocytic Anemia
Chronic, stable, secondary to CKD. On aranesp as outpt.
CHRONIC ISSUES ADDRESSED
==========================
# HTN
Continued home amlodipine and metoprolol.
# Gout
Held home allopurinol initially with concern for contribution to
transaminitis, then resumed prior to discharge.
# Hx central retinal artery occlusion ___
Felt embolic, carotid u/s neg, hypercoagulable work up negative,
though ___ 1:160 without other e/o autoimmune phenomenon.
Treated
with DAPT for 3 months(?) and maintained on aspirin thereafter.
Continued aspirin.
TRANSITIONAL ISSUES
===================
[] repeat LFTs to ensure they continue to downtrend.
[] Pravastatin was held on admission given elevated LFTs. Would
restart when LFTs normalized.
[] Found to have multiple tiny pancreas cysts (largest 7mm).
RECOMMENDATION(S): For management of pancreatic cyst(s) between
6-15 mm in patients between 65- ___ years at presentation,
recommend non-contrast MRCP follow-up every other year up to a
total of ___ years.
[] Received 1 dose of gabapentin with improvement of itching.
Unlikely to have helped. Consider restarting gabapentin 100mg
daily if itching restarts vs cholestyramine
[] amoxicillin-clavulanate added to allergy/adverse reaction
list
[] f/u ___ IgM, pending at time of discharge
[] f/u blood cx, no growth at time of discharge
#CODE: Full
#CONTACT:
Name of health care proxy: ___: husband
Phone number: ___ | 153 | 583 |
17556194-DS-8 | 28,381,484 | Dear Ms ___,
It was a pleasure caring for you at the ___
___. You were admitted for worsening wound on your
sacrum. You were treated with debridement and wound care with
the surgery team. You were continued on your home medications
and were otherwise stable. You will continue your care at your
rehab center.
Best wishes,
Your ___ Care Team | ___ is a ___ y/o woman with a PMH of TB meningoencephalitis,
chronic stage IV decubitus ulcer, and severe, complicated CDI,
who presented with worsening of her sacral wound and concern for
osteomyelitis.
# Sacral wound. Chronic stage IV decubitus ulcer; followed by
___ wound clinic and ___ ID. Has been packed with Dakin's
gauze at rehab. Wound probes to bone, and MRI with high
suspicion of abscess/osteomyelitis. Wound cultures have
previously grown GNR, and she hasa history of MDR Pseudomonas
(sensitive to aminoglycosides). Debrided by surgery in ED who
recommended BID wtd dressing changes, wound care nurse to
follow, frequent turns, air mattress, optimize nutrition.
Continued home ceftolozane-tazobactam 1.5 g q8h, vancomycin 1250
mg q12h. Review of outside ID records (Dr. ___ ___
___, who in ___ clinic note is determining antibiotic
regimen and duration) showed planned last day of IV antibiotics
___ which was completed prior to discharge. She remained
afebrile during her stay.
#Hyponatremia- likely hypervolemic hyponatremia with
hypochloremia in setting of large quantities of free water and
fluid intake due to frequent flushes with medications and tube
feeding with contribution from SIADH. Inappropriately
concentrated urine. Improved with fluid restriction.
#Emesis - Patient had an episode of emesis following
administration of her usual liquid potassium medication. Small
aspiration that was suctioned with no desaturation.
Interventional radiology was consulted to advance G tube to G-J
tube. This should be reevaluated in 3 months for potential
exchange.
# TB meningoencephalitis. Had positive TB culture from brain
biopsy, and has had a complicated antibiotic course, and
developed severe, complicated C. difficile infection, pneumonia,
and sacral wound infection, as above. Will have 12 month course
of rifamipin and isoniazid (day 1: ___. Minimally
responsive mental status at baseline. Continued isoniazid and
rifampin. Continued keppra, lacosamide, prednisone 10mg,
omeprazole.
# C. difficile infection.
- continued PO vancomycin 125 mg q6h and PO flagyl. This should
be continued for 2 weeks after discontinuation other IV
antibiotics. (___)
# Med rec - IV fluconazole was not on medication list from our
ID doctors but on review of Rehab notes seems that this was
started because patient had Fevers of unknown etiology. Patient
remained afebrile and without increased leukocytosis.
# Goals of care. Has been DNR/DNI, and numerous goals of care
discussions have been held with the family, with the family
desiring ongoing maximally intensive care with understanding
that patient is DNR though acceptable for ventilation if needed
given tracheostomy.
# Hypothyroidism
- continued levothyroxine 50 mcg daily | 58 | 407 |
11373442-DS-19 | 24,354,811 | Mr. ___,
You were admitted to the surgery service at ___ with symptoms
of sepsis. You underwent perihepatic abscess drainage, I&D right
flank necrotic tissue, and right groin abscess. You required ICU
admission for pressure support, broad-spectrum antibiotics and
IV anticoagulation. You underwent cholangiogram with biliary
stent placement, and your PTBD was discontinued. You are now
safe to return home to complete your recovery with the following
instructions:
.
Please ___ Dr. ___ office at ___ or Office RNs at
___ if you have any questions or concerns.
.
Please ___ 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 ___ your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. ___ 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 ___ your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Right flank and right groin wound VAC will be changed every 72
hours by ___ nurses.
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
.
Anterior drain: cholecystostomy tube. Please keep capped.
Cleanse insertion site with ___ strength hydrogen peroxide and
rinse with saline moistened q-tip or with mild soap and water.
Apply a drain sponge if needed. Change dressing daily and as
needed. Monitor for s/s infection or dislocation.
.
Peripancreatic drain (LUQ) to gravity drainage ___ ostomy bag:
To gravity drainage. Monitor for s/s infection or dislocation.
Monitor and record quality and quantity of output.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE ___ THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions. | The patient well known to biliary-pancreatic surgery service was
admitted for evaluation of hypotension, right frank and right
groin pain. Admission labs were noticeable for ___ 30.7, lactate
5.3, he was hypotensive with BP 89/50. Patient underwent CT
scan, which demonstrated new subhepatic abscess, new extensive
right abdominal wall fluid and gas collection concerning for
necrotizing fasciitis. Patient was admitted on ICU, he was
started on pressors support and broad spectrum antibiotics.
Acute surgery team and ___ team were consulted. Patient underwent
US-guided drainage of intaabdominal abscess on ___. He went ___
OR, where he underwent I&D of right upper quadrant necrotizing
soft tissue infection. Post operative patient was transferred to
the ICU, intubated and sedated, on IV fluids and antibiotics,
Foley catheter to monitor UOP, PTBD and PTC to gravity drainage,
right flank drain to bulb suction. On ___, patient was
extubated, he remained on Levophed for pressure support, he was
noticed to have biliary drainage around right PTBD catheter, ___
was consulted for cholangiogram. On ___ patient underwent
cholangiogram and PTBD catheter was upsized to ___. Patient,
also underwent NJ tube placement and was started on tubefeeds.
On ___ patient's tube feed was advanced to goal, he continued
on broad spectrum antibiotics, ID was consulted for long-term
treatment plan. On ___ patient was started on heparin drip
secondary to chronic A. fib. Patient was transferred to the
floor. He was continued on TF, ___ and heparin gtt. On
___, patient underwent non contrast CT scan, which demonstrated
increased soft tissue stranding ___ the subcutaneous tissues
anterior to the
right groin, which is concerning for progression of infection.
On ___ patient was taken ___ OR by ___ team, where he underwent
incision and drainage of multiloculated right groin abscess. ___
was consulted for possible CBD stent placement. Patient was
transitioned to Daptomycin secondary to VRE. On ___, patient
underwent cholangiogram, his PTBD was removed and CBD stent was
placed, external biliary catheter was placed as well and was
capped. On ___ patient's LFTs were normal, wound VAC was placed
into right groin wound. Patient was afebrile and tolerated
regular diet. He remained on IV Meropenem and Daptomycin, and
his WBC remained normal. On ___, patient was noticed to have
neutropenia with WBC 3.0. On ___ patient underwent cholangiogram
and his external biliary catheter was removed, tract was
embolized with GelFoam. On ___, wound VAC was placed into right
flank. Patient remained neutropenic, ID was contacted and
patient was transitioned to Cipro/Flagyl instead Meropenem. On
___ patient's heparin gtt was discontinued and he was restarted
on home dose Pradaxa. On ___ patient was discharged home with
services with wound VAC x 2, IV Daptomycin and PTC/JP drain
care. Patient was stable prior to discharge. He will have repeat
labs on ___ to follow up on his neutropenia.
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. | 544 | 518 |
13960889-DS-5 | 27,432,520 | Ms. ___, it was a pleasure taking care of you here at
___. You were admitted to the hospital because of pain in your
chest. You did NOT have a heart attack. It appears that the pain
in your chest is because of spasm in the arteries of your heart
(the coronary arteries). You were started on medications that
help to reduce spasm.
Several changes were made to your medications. Please see the
attached list for the details. | PRIMARY REASON FOR HOSPITALIZATION:
=====================================
Ms. ___ is a ___ with a history of coronary dissection in
___ (s/p stents X 10) as well as coronary vasospasm who
presented with chest pain. | 78 | 31 |
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