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18686254-DS-12 | 27,440,517 | Dear Ms. ___,
It was a pleasure to participate in your care at ___. You were
admitted for nausea and vomiting. We found that you had no
evidence of large brain masses on CT to account for your
headaches and vomiting. You received medication for years in
your throat and your symptoms improved. We recommend that you
stop Xanax/alprazolam as a sleep aid since this has been known
to make you confused. You are being discharged to your rehab
facility. Please call ___ if you have any questions. We wish
you well!
Best Regards,
Your ___ Medicine Team | Ms. ___ is an ___ with a PMHx of CAD (STEMI in ___ sp
BMS to RCA), colitis (presumed ischemic), GERD, chronic
headaches, who presented from her rehab facility with nausea,
vomiting, cough and headaches.
# Nausea/Vomiting:
Symptoms were most likely due to ___ esophagitis. Pt had
dysphagia and odynophagia, previously relieved with fluconazole.
DDx included PUD and viral gastroenteritis. We also considered
the possibility of gastric malignancy and PNA leading to
symptoms. There were no intracranial masses on CTH to account
for sx. There was no evidence of ischemia (no EKG changes and CE
negative x 2). TFTs were wnl. Pt was evaluated by speech and
swallow and found no evidence of aspiration. Pt received
voriconazole 200mg po q12h (x2 doses) for empiric rx of cadida
esophagits; however given multiple drug interaction with
voriconazole and her other medications she was restarted on
fluconazole. Pantoprazole was increased from 40mg daily to bid.
Plan for fluconazole is to complete a 2-week course as patient
had been incompletely treated prior to admission with a 7-day
course.
# Cough
Pt presented with cough and CXR findings concerning for PNA. She
did not have leukocytosis, fever and exam was not impressive for
rhonchi/egophany. She did not recieve antibiotics as clinical
suispicion for PNA was low.
# Chronic Headache:
Patient continued to have severe, frontal headaches during this
admission. Headaches were similar to those she has had for many
years. Likely chronic tension headache. Neuro exam was wnl.
There was no evidence of head masses/bleed on NCCT.
# Normocytic Anemia:
HCT was close to last recent baseline. Pt did not have evidence
of active bleeding. Last ferritin WNL.
# CAD s/p STEMI on ___:
No evidence of ischemia on presentation. Pt was transferred
without aspirin, atorvastatin or lisinopril listed in her
outpatient medications. ASA, lisinopril and atorvastatin were
re-started and pt was continued on plavix and metoprolol.
# Depression: Continued sertraline. Stopped alprazolam as sleep
aid given daughter reports that medication makes pt confused.
Replaced alprazolam with trazodone.
TRANSITIONAL ISSUES
# CODE: Full Code (no mechanical ventilation, no NGT)
# CONTACT: Daughter ___ at ___
- Please obtain stool h. pylori antigen if symptoms persists
- Please consider outpatient EGD for further evaluation
- Please monitor QT interval on daily EKGs
- Please monitor LFTs every ___ days
- Please consider MRI for further evaluation of headache
- Please consider trial of amytriptiline in future
- Please continue to monitor HCT in outpatient setting and
consider further workup to establish etiology
- Please consider switching to ___ (from lisinopril) if pt
continues to have cough | 96 | 422 |
16546124-DS-16 | 27,752,991 | Dear Mr. ___,
It has been a pleasure taking care of you.
You were admitted to the neurology service at ___
because you had weakness on the left side of your body after you
fell down the stairs.
We have imaged your head to make sure you did not have a bleed
and the CT scan was normal. X-rays and MRI of your spine were
also normal, did not show any fractures or neurological
problems.
All the results were very reassuring. There is no evidence of
brain damage or spinal cord damage.
We believe your symptoms of weakness are most likely due to the
pain in your shoulder, and the high degree of stress your body
was under. We continued to watch you and your symptoms improved
markedly. We had our physical therapists come evaluate you to
make sure you were safe to walk.
Once you get the approval for free care, you can start getting
physical therapy if you still need it. But we believe that you
are safe to go home now. | Mr. ___ CT scan as well as spine MRIs were all
negative.
His examination continued to improve daily.
His weakness did not follow a characteristic upper motor or
lower motor neuron pattern, and when asked to perform a task, he
seemed to have normal strength. His left shoulder was painful
and therfore limited some of his upper extremity motion due to
pain but not to weakness.
Our diagnosis was that Mr. ___ has most likely a
conversion disorder, affecting the left side of his body.
His symptoms of left eye blurring as well as decreased hearing
on the left also do not fit within a specific central
distribution when we add the left sided weakness.
We had our social worker evalute him in order to identify any
stressors and make sure he has all the needed resources.
He was also seen by physical therapy in order to assess for gait
safety, and he managed to walk without imbalance, with the help
of a left AFO. He was deemed safe to be discharged home. He was
given the needed paper work to apply for health care coverage as
he did not have insurance, and can start seeing physical therapy
as outpatient if his symptoms persisted. | 168 | 199 |
19722227-DS-4 | 24,675,615 | Dear Ms. ___,
Thank you for the privilege of participating in your care.
You were admitted to the hospital due to rectal bleeding, which
caused a drop in your red blood cell levels. This bleeding was
due to your recent colonoscopy and polyp removal While in the
hospital, you received a transfusion of blood. You also
underwent a procedure called "flexible sigmoidoscopy," during
which the source of the rectal bleeding was identified, and the
bleeding was stopped.
Also during your admission, you developed high levels of fluid
in your lungs. This caused you to feel short of breath. This
fluid went away when you received medications to help you
urinate more (lasix).
Finally, during your hospitalization you developed a temporary
increase in your white blood cell counts, which can sometimes
indicate infection. However, you had no other signs of
infection, and your white blood cell counts have returned to a
normal level. A chest X-Ray was normal, urine studies normal and
your exam was reassuring.
No medication changes were made during this admission. Please
continue your regular home medications as usual. | Ms ___ is an ___ F with PMH of CHF, Afib on coumadin, CAD sp
CABG who was admitted for post-polypectomy bleed. Hospital
course complicated with acute on chronic diastolic heart
failure.
# Rectal Bleeding - The pt reported rectal bleeding with bowel
movements, beginning shortly after colonoscopy and triple snare
polypectomy. PCP noted ___ drop from 35 (baseline) to 28, and
referred pt to the ED. During hospitalization, the patient's Hct
dropped further to 26.6, and she was transfused 1u PRBC and 2u
FFP. She underwent a flexible sigmoidoscopy with thermal
coagulation of bleeding post-polypectomy ulcer site. Following
the procedure, the patient's hematocrit stabilized. She reported
no further rectal bleeding. The pt was re-started on her home
dose of coumadin prior to discharge.
# Leukocytosis - One day after flexible sigmoidoscopy, pt
developed a leukocytosis (WBC = 19). The patient remained
afebrile and asymptomatic. Infectious work-up (CXR, U/A) was
negative. Clinical exam reassuring. The patient's WBC count
spontaneously normalized within 24 hours.
# Pulmonary Edema/Acute on chronic diastolic heart failure - The
pt developed pulmonary edema during during her first night in
the hospital. She desatted to 83% on RA, and became tachycardic
to 141. CXR demonstrated diffuse pulmonary infiltrates. The
patient's symptoms responded to supplemental oxygen, metoprolol
25mg, and 40mg lasix IV. The pt subsequently resumed her home
dose of lasix. Repeat CXR demonstrated significant improvement.
Pulmonary edema was likely precipitated by a combination of
volume overload (pt's home furosemide had been "held" in the
setting of Gi bleed) and Afib with RVR. She had no further
episodes while inhouse nad was satting in high ___ on room air
at time of discharge. She was discharged on her home regimen of
lasix.
# Atrial fibrillation/Atrial flutter - the pt was in Afib for
much of her hospital stay. She was also found to be in A flutter
(3:1). She was effectively rate controlled on her home dose of
metoprolol, other than that incident above when she had afib
with RVR with acute pulmonary edema. In that setting, she was
given additional doses of metoprolol. Home dose of coumadin was
restarted after resolution of lower Gi bleed. | 178 | 357 |
11354555-DS-10 | 21,296,466 | Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
- At your rehab facility, they found that your blood counts were
lower.
WHAT HAPPENED WHILE I WAS HERE?
- You received some blood and some fluids, which helped your
blood counts and your kidney function.
- We found that you had an infection in your blood, so we gave
you an antibiotic to fight this infection called "vancomycin".
- You assigned your cousin ___ your health care proxy to
help you make medical decisions.
WHAT SHOULD I DO WHEN I GET TO REHAB?
- Please continue to take your medications as instructed.
- Please go to all follow up appointments with your doctors as
___.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ male with history of prostate cancer (suprapubic
catheter for obstruction since ___, on lupron), recent CVA,
chronic anemia, recent admission for proctitis (discharged
___, sent in from rehab due to declining hemoglobin and
suprapubic tenderness, found to have staph simulans bacteremia.
======================
ACTIVE ISSUES
======================
# Staph simulans bacteremia:
2 out of 2 sets of aerobic and anaerobic blood cultures from
___ growing staph simulans, resistant to oxacillin but
sensitive to vancomycin. Unclear source, but he remained
hemodynamically stable and afebrile. Could be related to skin
flora via his suprapubic catheter. Less likely gut
translocation from his proctitis given the speciated bug. No
known hardware. TTE without evidence of vegetations. Given that
he only met 1 minor Duke criteria, there was thought to be very
low likelihood of endocarditis. Therefore, ___ was not pursued
at this time. The ID team recommended a 2 week total course of
vancomycin from first negative blood culture (last day ___.
They recommended rechecking surveillance blood cultures 1 week
after completing course of vancomycin. If persistantly
positive, would readdress the need for TEE at that time. PICC
line was placed prior to discharge given ongoing need for
vancomycin.
# Metastatic Prostate Cancer:
# Illiteracy, poor health literacy:
# Poor social support:
Castration resistant. Sees BI oncology. On Lupron. Diffuse bony
mets identified on bone scan. Evaluated by ortho spine while
inpatient, who found no e/o spine instability that would
necessitate a brace. Of note, patient is illiterate with poor
health literacy and poor understanding of his overall disease
prognosis. His outpatient care has been complicated by poor
social support and difficulty making it to outpatient
appointments. At family meeting with cousin ___ on this
admission, ___ was officially made his HCP for medical
decision making. His code status was full code at time of
discharge, but he will need ongoing ___ discussions going
forward.
# Acute on Chronic Anemia:
Chronic normocytic anemia is most likely due to chronic disease
from known metastatic prostate cancer in addition to low EPO
from CKD. Iron studies c/w anemia of inflammation. No obvious
sources of bleeding, though could have slow oozing ___
worsening proctitis (likely chronic radiation induced). Acute
infection from bacteremia leading to marrow suppression is
possible. B12 wnl. No e/o hemolysis. After the initial
transfusion, his Hgb remained stable >7 for the rest of his
inpatient stay.
- DISCHARGE HGB: 7.7
# Pyuria, with likely colonization:
Suprapubic tenderness on admission in setting of suprapubic
tube plus UA with 32WBC and few bacteria initially c/f UTI.
Urine cultures growing multiple colonies c/w skin flora
contamination. Pyuria appears chronic, was noted at his prior
two admissions. Therefore, Cefepime was discontinued after a
single dose given low concern for UTI. | 123 | 437 |
13460025-DS-4 | 28,779,165 | It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital after presenting with blood in
your stool. You had a flexible sigmoidoscopy on ___, which
did not show any bleeding. You then underwent a colonoscopy on
___, which showed internal hemorrhoids but no other
abnormalities. These are the likely cause of your bleeding. We
have started you on medication to help treat your constipation,
and you should also use suppositories twice daily over the next
2 weeks to treat the hemorrhoids. While you were here, your
blood counts dropped slightly, but then remained stable and you
did not require any blood transfusions. We did treat you with
IV fluids. You should follow-up with your PCP and
gastroenterologist.
Some of your symptoms can occur with a condition called
endometriosis. For this reason, we have scheduled you for an
appointment with an Ob/Gyn doctor for further evaluation.
Also, the MRI of your pituitary shows a small 5 mm area of
abnormal signal in the pituitary. This could be an artifact of
the MRI, but it could also represent a microadenoma. We have
set you up with an appointment in Endocrinology for further
evaluation. | ___ with h/o depression and cyclic vomiting syndrome, presenting
with one month history of intermittent constipation and BRBPR,
in addition to chronic abdominal pain.
# Hemorrhoidal bleeding: Patient presented with BRBPR. While
sigmoidoscopy on ___ did not show evidence of bleeding, a
colonoscopy on ___ showed internal hemorroids which were
likely etiology of BRBPR. No other abnormalities noted on
colonoscopy. Patient's Hct dropped from 35 -> 29, but this was
in setting of IVF administration. Hct subsequently stabilized,
and was uptrending at time of discharge. Patient did not
require transfusion. Was tachycardic initially, but HR improved
with IVF and BP remained stable. Was not orthostatic. Was
started on bowel regimen and suppositories to treat hemorrhoids.
Will be discharged on Miralax given constipation, as well as
suppositories to use over next 2 weeks. Will follow-up in GI
clinic. Should have repeat CBC checked as outpatient. Of note,
some concern for endometriosis given chronic abdominal pain,
dysmenorrhea, constipation, fatigue, and low back pain, and this
can also cause rectal bleeding.
# Abdominal pain: Stable, and chronic in nature over past year.
While she had TTP on exam, overall her exam was reassuring with
normal bowel sounds, no masses, and no rebound tenderness. CT
abd/pelvis showed no acute pathology. UA negative. Colonoscopy
showed internal hemorrhoids but was otherwise normal. She
recently established care w/Dr. ___ Dr. ___ in ___
and is undergoing an outpatient work-up. Previous work-up has
included normal LFTs, amylase/lipase, B12, folate, ferritin,
TSH, CRP, and negative H. pylori testing. An abdominal
ultrasound in ___ showed a prominent right ovary with a
dominant simple appearing cyst. An EGD in ___ showed mild
chronic gastritis, and acute and chronic inflammation at the GE
junction. Per report, symptoms did improve somewhat with PPI.
She has had negative Lyme testing, as well as normal tTg and IgA
levels. Abdominal ultrasound in ___ showed trace sludge in
GB and 0.4cm GB polyp, as well as small pelvic free fluid,
likely physiologic. Had a normal gastric emptying study in
___. She has also had an extensive rheumatologic work-up,
with negative ___ 1:20, and negative Ro, La, ANCA, SM/RNP,
___, cardiolipin, and lupus anticoagulant per report.
Normal heavy metal screen, C1 esterase inhibitor, and ACTH
level. Per outpatient notes, patient may have a component of
pelvic floor dyssynergia +/- overflow diarrhea. Constellation
of chronic abdominal pain, dysmenorrhea, constipation, fatigue,
and low back pain suggestive of possible endometriosis, and
patient will see Ob/Gyn as an outpatient for further evaluation.
Will also undergo MRE on day of discharge, and follow-up in GI
clinic. While inpatient, continued PPI, amitriptyline, and
added oxycodone as needed for breakthrough pain, though
oxycodone not continued on discharge. She will continue on
Align and benefiber as outpatient. Also started Miralax for
constipation, as this may have been contributing to pain as
well.
# Possible pituitary lesion: Patient with history of
intermittent headaches, galactorrhea and irregular periods.
Previous testing of TSH, prolactin, cortisol, and ACTH normal.
Underwent MRI pituitary on day of admission, which showed an
equivocal lesion in the pituitary gland, about 5 mm, which could
represent a microadenoma. Will need outpatient Endocrine
follow-up, which has been scheduled.
# Cyclical vomiting syndrome: Chronic. Continued PPI,
amitriptyline, zofran prn nausea.
# Depression: Continued home escitalopram, methylphenidate. | 213 | 576 |
18477790-DS-10 | 25,632,784 | Mr. ___,
It was a pleasure caring for ___ during your stay at ___
___ were admitted for back pain. ___
had an MRI that showed that your cancer is in many of the bones
of your back, which is likely causing your pain. ___ were
evaluated by our Radiation Oncologists, who recommended
radiation therapy to help control your pain. Our oncologists
also reviewed your imaging and recommended a procedure called a
"bronchoscopy" so that we can make sure ___ don't also have lung
cancer.
Please follow-up with your doctors as ___ below. Please be
sure to bring your CD with the images to your appointment with
___
___ care,
Your ___ Team | Mr. ___ is a ___ man with a history of presumed esophageal
cancer with extensive metastatic disease to lung, liver, and
spine who presents with acute on chronic lower back pain and
constipation.
# Lower back pain likely secondary to metastatic disease
There is no neurologic compromise or evidence of cord
compression by physical exam. MRI L spine shows significant
diffuse metastatic disease without any evidence of acute
fracture. Patient's pain initially controlled with IV dilaudid,
which was transitioned to PO oxycodone. Patient found that a
dose of 20mg q3h improved the pain. Radiation oncology was
consulted and recommended outpatient radiation and patient was
referred to ___ in ___ and appropriate close follow-up
was scheduled.
# Presumed esophageal adenocarcinoma
# Possible synchronous lung cancer
# metastatic cancer to the liver, bone (spine) and numerous
lymph nodes including mediastinal, hilar, and cervical
Patient with significant esophageal disease (30cm in length)
seen on both outpatient CT and EGD with pathology at ___
showing poorly differentiated adenocarcinoma. He also has large
RUL lung lesion, which could be a second primary or metastatic
lesion. Heme/onc was consulted and recommended IP consultation
for bronchoscopy. IP recommended a CT chest prior to discharge,
which showed interval progression of mediastinal disease with
pulmonary artery invasion. These results were discussed with IP
who recommended bronchoscopy on ___ after discharge. Patient
was stable at discharge with small volume hemoptysis with a
stable h/h.
# Constipation
Likely opiate induced as patient recently started on oxycodone
for pain control. No evidence of cord involvement on MRI.
Patient started on aggressive bowel regimen with standing
senna/colace BID. He required lactulose and an enema in order to
produce bowel movement. | 110 | 278 |
16296962-DS-9 | 29,416,427 | You were admitted to the hospital because of abdominal pain
caused by bleeding liver masses.
Your blood levels (hematocrit) were closely monitored while in
the ICU and on the floor and you were transfused as needed. Your
hematocrit has been stable for several days and you have
required no further blood transfusions since ___.
You underwent a procedure, an angiogram with right hepatic
artery embolization, on ___ to help stop the bleeding
within one of your liver masses.
You may continue to eat a regular diet.
You may continue to do aerobic exercises such as walking or
riding on a stationary bike. You should not do exercises which
work your core/abdominal muscles such as yoga or lifting heavy
objects.
You may continue with light massage as you inquired about. No
deep massage to your abdomen, however.
You should refrain from taking over the counter
medications/natural supplements. Take only the medications
prescribed to you by your doctor until cleared by Dr. ___.
You should continue to drink plenty of fluids.
You should not drive or operate heavy machinery while taking
narcotic pain medications such as dilaudid.
You may take up to 2g of tylenol a day. Do not take more than
this as it may damage your liver.
You should continue to take senna and colace while on narcotic
pain medications to avoid constipation.
You should call Dr. ___, ___, if you
develop fevers, chills, worsening abdominal pain, inability to
take in food or water, nausea/vomiting, worsening abdominal
distention, feeling dizzy, changes in vision, lightheadedness,
chest pain, shortness of breath, or any other symptom which
concerns you. | Mr. ___ was admitted to the Hepatobiliary (___) surgical
service on ___ for management and evaluation of a bleeding
hepatic mass. He was triaged in the ___ ED s/p transfer from
___. While in the ED he was aggressively fluid resuscitated
given his tachycardia to 115, and was noted to be responsive to
this hydration. A foley was placed for urine output monitoring,
which remained more than adequate throughout his hospital stay.
Labs were drawn on presentation and were notable for a Hct of
32. Following stabilization in the ED, Mr. ___ was
immediately taken to the interventional radiology suite where he
underwent embolization of his R hepatic artery (reader referred
to radiology note from ___ for further details). He
tolerated this procedure well. Nonetheless, given concern over
his potential for rebleeding as well as his persistent
tachycardia, Mr. ___ was transferred to the surgical ICU
following his procedure for closer monitoring.
Neuro: The patient received IV Dilaudid initially while NPO. He
achieved good pain control with this medication. He was
transitioned to oral pain medication (oxycodone and later
dilaudid) when his bowel function returned and endorsed he
adequate pain control with this medication.
CV: The patient was tachycardic with HR 110s on admission and
immediately post ___ embolization of his R hepatic artery. Mr.
___ was aggressively fluid resuscitated with both
crystalloid and blood product (receiving 6u PRBCs in total). He
gradually responded to this therapy, and by HD#2, consistently
had heart rates in the 60-80 range. Mr. ___ otherwise
remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: No issues.
GI: Immediately post-procedure, Mr. ___ was kept NPO. He was
gradually transitioned from sips to clears and eventually to
regular diet as he endorsed return of bowel function and
adequate pain control. On HD#3, he was noted to be very
distended and tympanic on physical exam, prompting a KUB. The
results of this study were notable for dilated loops of bowel
without air-fluid levels or distinct transition point. Mr.
___ subsequently endorsed positive flatus and alleviation of
his crampy abdominal pain and distention. He had no further
issues re: GI function following this episode and was tolerating
a regular diet by the time of discharge.
ID: No issues.
Hematology: The patient's complete blood count was examined
every ___ hours during HD1-2. In total, Mr. ___ received 6
units of PRBCs for downtrending Hct. His last transfusion was on
___, and Mr. ___ was noted to remain stable in the
___ range on the ensuing days.
Prophylaxis: The patient did not receive subcutaneous heparin
given his risk of recurrent bleeding. As such, venodyne boots
were used during this stay; he was encouraged to get up and
ambulate as early as possible.
At the time of discharge, the patient was doing well, with
stable vital signs. Mr. ___ 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. | 260 | 501 |
18542094-DS-18 | 22,489,373 | Dear Ms. ___,
You were admitted to the hospital with abdominal pain and found
to have acute appendicitis. You were taken to the operating room
and had your appendix removed in a laparoscopic converted to
open surgery. You tolerated the procedure well and are now being
discharged home to continue your recovery with the following
instructions.
While in the hospital you developed a diffuse red, non-pruritic
rash consistent with a medication allergy. Please follow up with
your primary care provider if your rash persists or worsens.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ is a ___ F who presented to the emergency department
on ___ with right lower quadrant abdominal pain x4 days. CT
scan concerning for significant inflammation of the appendix.
Informed consent was obtained and she was taken to the operating
room on ___ for laparoscopic converted to open appendectomy
with extensive lysis of adhesions and placement of an incisional
vac. Post operatively she was extubated and taken to the PACU in
stable condition then transferred to the floor once recovered
from anesthesia.
On POD0 she was kept NPO with IV fluids and IV pain medications.
On POD1 diet was advanced with good tolerability. She voided
spontaneously without difficulty and pain continued to be well
controlled. On POD4 patient had increased abdominal distension,
pain, and emesis. Abdominal xray concerning for post operative
ileus. She was made NPO with IV fluids and nasogastric tube.
Narcotic pain medications were minimized and the patient was
encouraged to mobilize. On POD6 the nasogastric tube was removed
and she tolerated sips of clear liquids. On POD7 diet was
advanced to regular with good tolerability. Once taking adequate
PO, IV fluids were discontinued.
On POD7 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. | 773 | 240 |
15763204-DS-7 | 22,664,139 | You were admitted with abdominal pain and you were found to have
pancreatitis and bacteria (EColi) in the blood. This was likely
due to sludge/stone from the gallbladder leading to transient
obstruction in the biliary tract. You also had a small
pneumonia with bronchitis. You were treated with antibiotics and
pain medications and were withheld from eating for several days.
You should continue the antibiotics for another 5 days. You
were also started on metoprolol for blood pressure control. The
hydrochlorothiazide was discontinued given its association with
pancreatitis.
You should follow up with general surgery for eventual
removal of the gall bladder | ASSESSEMENT & PLAN: ___ with h/o STEMI complains of chest pain
and abdominal pain.
#) Abd pain, fever: Mr. ___ presented with ___
pain, WBC 14, mildly elevated lipase, and significant
dehydration. RUQ U/S revealing GB sludge, no evidence of
cholestasis, or cholecystitis. He was presumed to have
pancreatitis and kept NPO, however given the development of
fever and diffuse abd tenderness, and Abd/pelvic CT was
performed. It revealed no acute pathology.
On hospital day 2, Mr. ___ developed fever to 101 with + GNR in
blood, and contd to have significant abd pain requiring iv
dilaudid. Initially, UTI was considered a possibility with
evidence of mild-mod R sided hydronephrosis and recent
nephrolithiasis. However, U/A and urine cx were negative.
There was some blood in urine, but evidence of stone in abd CT.
He was treated with unasyn.
Blood cx eventually returned with Ecoli. Chest CT scan on
___ (to eval for PNA - see below) incidently showed
stone/sludge in GB head and inflammation of pancreatic head. He
was kept NPO, given iv fluids, and surgery was consulted for
eval of cholecyst given significant RUQ tenderness at the time.
No acute intervention was considered necessary and the
recommendation was to refer him to outpt surgery for
consideration of interval cholecystectomy. He was treated with
ceftriaxone and flagyl (cover RUL pneumonia and GNR in blood not
___ to cipro). Over time, his symptoms improved, he was
afebrile, had normalization of WBC, and able to tolerate PO. He
required no opiates upon the day of discharge. Serial blood
culture were negative - and the source of infection was presumed
to be from transient cholangitis vs. cholecystitis (less likely)
with GB stone/sludge.
He will be discharged on cefpodoxime/flagyl to complete a 10
day course. Plan for interval cholecystecomy f/u outpt gen
surgery
#) Pulm: NP cough, SOB. history: CXR with some atelectasis but
otherwise relatively unremarkable. Has nl sats aside from
hypoxia at night attributed to OSA. Chest CT with mild RUL
pneumonia and bronchitis. He was treated with iv ceftriaxone
with significant improvement in cough, SOB. Of note, he was
observed to desat overnight likely consistent with OSA. This
should be f/u as an outpt.
#) Transaminitis: Possibly Etoh related although, ALT/AST ratio
elevated - more consistent with NASH with possible overlying
transient cholestasis from gallstones. Hepatitis serologies
negative. Low suspicion for other etiologies and will hold off
on sending other screening labs (chronic for years)
#) CV: HTN, 2v CAD s/p STEMI ___ s/p mRCA DES. Last stress
test on ___ - no inducible ischemia. Ruled out for MI
- On ASA, statin
- Some evidence of hypertension during the hospitalization with
SBP 140-150s. Considered restarting HCTZ but given recent
pancreatitis opted for BBlockers. On metoprolol 12.5 mg BID
with significant improvement of BP to 120-130 systolics.
#) BPH - some evidence of enlarged on prior CT scans. PVR 48 -
no evidence of urinary retention
- follow up as outpt
.
# OTHER ISSUES AS OUTLINED.
.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: []heparin sc []SCDs
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: [] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#COMMUNICATION: ___ (dtr) ___
#CONSULTS: Possibly GI pending final abd CT read
#CODE STATUS: [X]full code []DNR/DNI | 113 | 596 |
14286519-DS-18 | 24,967,783 | Dear Mr. ___,
It was a pleasure to care for you at ___. You came to the
hospital because you developed worsening shortness of breath at
home. You also felt weak and had symptoms of an upper
respiratory infection such as runny nose. In the hospital, we
found that you had extra fluid in your body and gave you
medication to remove that flid ("Lasix"). We also gave you one
dose of antibiotics for a urinary tract infection for which you
did not have any symptoms.
Please continue to take your home medications as prescribed and
follow-up with your doctors as ___.
We wish you all the ___,
Your ___ care team | ___ PMH HFpEF, NIDDM, HTN, HLD, atrial fibrillation, CAD, COPD,
CKD (bl Cr 1.2-1.4), BPH, carotid stenosis, presents with
progressively increased weakness, SOB and chills, found to have
a UA positive for nitrites, increased weight. Problems addressed
during his hospitalization are as follows:
# Acute on chronic HFpEF exacerbation (LVEF 55% ___
Most likely acute on chronic HFpEF exacerbation, may have been
triggered by recent URI. Flu negative. Weight increased from
last admission (143 lbs presentation vs 138 lbs ___, proBMP
elevated, SOB, euvolemic on exam, CXR unremarkable. Troponins
negative. Received IV Lasix PRN (20 mg), transitioned back to PO
torsemide 20 QD. Continued home metoprolol, fractionated home
isosorbide. Euvolemic with improvement in SOB at time of
discharge. Of note, admitted ___ for HF exacerbation
improved with IV Lasix.
#Asymptomatic bacteruria
UA positive for nitrites and few bacteria, asymptomatic. Chronic
foley in place, last changed ___. Received 1 dose of IV
levofloxacin in the ED. Did not treat with additional
antibiotics.
# Urinary Retention
Has incomplete bladder emptying and overactive bladder and is
followed by BI urology. Patient experienced urinary retention
during last admission (___) requiring straight
catheterization. Foley was placed by urology, last exchanged
___. He has had no problems with catheter and no UTIs since
placement. Scheduled for outpatient foley exchange ___.
Continued home oxybutynin.
CHRONIC ISSUES
===============
# Atrial fibrillation:
CHADS2VASC6. Continued home metoprolol, continued home
dabigatran.
# COPD:
Remained on room air. Continued home montelukast, held
ipratropium nebs as states has not been taking.
# DM2: Held home glimepiride. ISS in-house.
# CAD: Continued home Simvastatin
# HTN: Continued home Isosorbide as above
# Glaucoma: Continued home timolol, latanoprost
# Diarrhea: Continued PRN loperamide
# Insomnia: Held home zolpidem
# GERD: Continued home Omeprazole | 108 | 275 |
16187793-DS-11 | 25,380,381 | Dear Mr. ___,
It was a pleasure participating in your care at the ___. ___
were admitted with chest pain and diarrhea with concern for
another heart attach after your recent admission in ___. We
maximized your medical therapy for coronary artery disease since
there were some issues with the outpatient regimen due to
frequency of administration and GI upset. ___ were treated for a
heart failure exacerbation from which ___ recovered quickly.
Since ___ came in with a cough productive of red sputum, we
started antibiotics for pneumonia to which ___ responded well.
We also treated your facial and scalp rash with antifungal and
steroid creams.
It is very important that ___ do not miss ___ dose of aspirin or
Plavix for any reason because your recent stent (___) could
become blocked and cause a major heart attack. If ___ have any
issues with the medication regimen, please call your PCP or
cardiologist immediately but do not stop taking the medication
unless told to do so. We are lowering the frequency of your
medications so it is easier to take them with your normal
schedule.
For your heart failure we are starting a small dose of diuretic.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
For your rash, we started ketoconazole cream and hydrocortisone
cream. The ketoconazole can be used as needed if the rash
returns but Do NOT use the hydrocortisone cream for more than
seven days because it is meant to control severe outbreaks of
the rash. If ___ use it long term it may cause skin problems on
your face.
Follow up with your PCP within one week to follow the details of
this admission
Follow up previous findings of left lower lobe spiculated nodule
with a CT Chest - confer with your PCP.
Follow up with your cardiologist within 2 weeks to follow the
details of this admission
Follow up with Dr. ___ the previous heart attack and
stent placement) as scheduled ___
We are working on getting ___ an appointment with Dr. ___ to
complete your aortic valve replacement workup and have provided
___ with a phone number if we do not get back to ___.
It was a pleasure treating ___ and we wish ___ the best in
health.
Sincerely,
-Your ___ team | ___ yo M with a h/o severe calcific aortic stenosis ___ 0.5),
CAD s/p CABG (SVG-LAD, SVG-OM with Y to RV branch of RCA), PAD
with RFA and RSFA occlusion, AAA (3.6 cm), infarct related
cardiomyopathy (EF 35%), hyperlipidemia, COPD on ___ Lpm home
___, squamous cell carcinoma of the throat s/p XRT and G-tube ___
years ago), right renal artery stenosis, hypothyroidism, LV
systolic heart failure (HFrEF with LVEF 30%), with recent
admission for NSTEMI ___ now s/p PCI with bare metal stent to
SVG-OM ___ with plans for TAVR in ___ weeks who presented with
an episode of chest pain, elevated troponin and non-bloody
diarrhea.
Patient had been taking BID metoprolol instead of QID regimen
due (G tube dependent - succinate cannot be crushed) and had an
episode of diarrhea 2 days PTA which made him skip all
medications (due to GI distress) on the day PTA, including
ASA/Plavix. He had one episode of chest pain that was self
limited and his troponinemia and CK-MB were both downtrending.
We elected to maximize medical therapy due to question of
possible non-adherence to regimen s/p BMS ___.
-Patient received IV diuresis during acute presentation as he
had increased O2 requirement with CXR findings of pulmonary
edema and a BNP of >15000. He responded well but only required
minimal PO (G-tube) furosemide subsequently. He did not have
peripheral evidence of volume overloaded and presented 3 kg
below discharge weight on ___. We suspected that his chest pain
pain led to elevated BP, exacerbating severe AS causing flash
pulmonary edema and CHF exacerbation. Digoxin levels were stable
throughout admission and patient discharged on home dose of
this.
-Patient had no further chest pain but did have increased oxygen
requirement from baseline and cough productive of red sputum. He
was treated for HCAP with an 8 day course of vancomycin+Zosyn
due to multiple risk factors for MDR pathogens. Cultures
speciated commensal flora and Stentotrophomonas maltophilia,
likely commensal since patient did well without TMP-SMX (drug of
choice for this pathogen).
-Unlikely COPD exacerbation due to lack of wheezes, and
pneumonia being more likely. Required minimal PRN Nebs
(levalbuterol/ipratropium) and no steroids.
-Managed CAD/NSTEMI medically by continuing ASA, clopidogrel,
atorvastatin, and metoprolol with adjustment to BID tartrate
regimen. Dose reduction prior to discharge to 12.5 mg BID due to
an episode of asymptomatic hypotension to 80/60.
-Patient also had a facial and scalp rash consistent with
seborrheic dermatitis which responded well to ketoconazole 2%
mixed 1:1 with hydrocortisone 2.5% cream. Ketoconazole can be
ongoing but recommend shorter course of HC cream (started ___
for ~ 7 days, as higher potency on facial region, discharging
with one tube without refills.
-Patient had a stage II coccyx ulcer which was healed at
discharged.
-Patient had a mild transaminitis (AST 207, ALT 284, ALP 158) on
admission, thought to be due to recent NSTEMI and passive
congestion from heart failure exacerbation. He had no history of
liver disease, denied alcohol use, platelets normal, no HSM,
synthetic function with INR 1.1, normal albumin. Hepatitis
serologies negative; elevated LFT resolving at discharge (ALT 69
AST 39 ALP 120)
-Although patient did not have severe diarrhea while admitted,
history and risk factors prompted C Diff screen which was
negative.
-TAVR workup for severe AS to be completed with structural heart
CT as outpatient, appointment with Dr. ___ scheduling.
Determined at most recent hospitalization to be at extreme risk
for SAVR.
TRANSITIONAL ISSUES
-F/U with cardiologist Dr. ___ 2 weeks
-F/U CT/CXR findings of LLL speculated nodule warrants repeat CT
-TAVR appt with Dr. ___, patient has phone number to
schedule appt
-Started furosemide 10 mg po daily
-Changed metoprolol to 12.5 mg BID regimen
-Started ketoconazole 2% cream (can be PRN)
-Started hydrocortisone 2.5% cream (UP TO 7 Days course) | 376 | 612 |
15170418-DS-4 | 23,793,885 | Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted because you were in diabetic ketoacidosis, which
resolved with an insulin drip. You are now doing well with a
humalog insulin sliding scale and lantus at night. You will be
transferred to an inpatient psychiatric unit for support and
treatment of your bipolar disorder. | Mr. ___ is a ___ year old gentleman with history of
ketosis-prone T1DM, Addison's disease, bipolar d/o, and seizure
disorder who presented to the hospital with 3 days of nausea and
vomiting. He was found to be in DKA, have low levels of
cortisol, and with bloody emesis. He was treated in the ICU for
DKA which resolved, SI/HI in the unit, now with 1:1 sitter and
psychiatry following. He is at his baseline. Patient is
medically stable for discharge.
ACTIVE ISSUES
==============
# Type 1 diabetes, presenting with diabetic ketoacidosis:
Unclear precipitant but may have been gastroenteritis or
non-compliance with fludrocortisone (given undetectable cortisol
levels) causing nausea and vomiting, or diabetic ketoacidosis
itself. Regardless, symptoms have resolved and anion gap closed
with insulin infusion and he was transitioned to home dose of
Lantus 40 units daily.
- He will be followed by ___ when transferred to Deaconess 4
(inpatient psych unit). He can continue on his Lantus and
humalog sliding scale with fingersticks QACHS (meals and
bedtime).
# Mild hematemesis: consistent with ___ tear, blood
only evident after persistent retching. Hematocrit stable, and
patient had no further emesis or bleeding since admission. ___
be some component of gastroparesis causing nausea / vomiting, vs
gastroenteritis, hypocortisolism.
- No need to monitor further. He can take PO ondansetron for any
nausea.
CHRONIC ISSUES
===============
#Addison's disease: On prednisone and fludrocortisone at home,
normotensive at arrival. Cortisol level checked in the ED was
undetectable, and prednisone should cross-react with the
cortisol assay so medication compliance likely poor. He may also
have been vomiting his PO medications prior to admission. No
evidence of adrenal crisis, so home prednisone and
fludricortisone were continued without need for stress-dose
steroids.
#Depression and ? bipolar disorder: Patient self-discontinued
Effexor and Abilify because of "paranoia." Recent admission for
active SI and will need to discuss medication changes with his
psychiatrist. Depakote level undetectable, medication compliance
likely poor. In discussion with social work, patient endorsed
active SI / HI. He was evaluated by psychiatry, who recommended
1:1 sitter and psych admission once acute medical issues
stabilized.
# Likely seizure disorder: Had complex partial seizures with
secondary generalization, seen in house by Neurology, in the
setting of DKA, but AED levels were normal. Has not yet f/u with
Neurology as an outpatient.
- Continue depakote
TRANSITIONAL ISSUES
===================
- Code status: Full code.
- Emergency contact: ONLY TO BE USED IN EXTREME MEDICAL
CIRCUMSTANCES: Aunt ___, ___.
- Studies pending on discharge: None.
- Consider rechecking a cortisol level at follow up appointment.
- Consider uptitrating lantus as outpatient.
- Please help patient to make ___ and PCP appointments at
discharge from Deac4.
- Please check chem-7 on ___ and replete potassium to 4.0
with PO potassium. If potassium is 4.0 or greater on ___,
there is no need to check a chem-7 again. If potassium needs to
be repleted (ie is less than 4.0), please replete and check next
chem-7 on ___. If chem-7 on ___ has a normal
potassium, then there is no need to replete or check another
chem-7. If it continues to be <4.0, then please replete with PO
potassium and recheck on ___.
- He will be followed by ___ when transferred to ___
(inpatient psych unit). He can continue on his lantus (45 units
at bedtime) and humalog sliding scale (QACHS) with fingersticks
QACHS (ie, meals and bedtime). | 60 | 547 |
17583229-DS-12 | 22,624,097 | You were admitted to the hospital after a fall in which you
sustained hip and pelvic fractures. There was no repair of her
pelvic fracture. She has been enrolled in a Palliative care
program. Her code status as been DNR/DNI. Per family request
that patient return to the Palliative care program for care. | Ms. ___ is an ___ yo female with a history of dementia,
___ disease,
and dementia who presents after an unwitnessed fall. Her son
responded immediately and she was transported by EMS to the
___
ED. Here she was initially conversant, but later was no longer
responding to commands or answering questions.
Her son noted that at baseline she ambulates very little and
mostly transfers from bed to chair. Further history was not
possible given the patient's unwillingness to
communicate. Of note, patient's son notes that she is CMO and is
hesitant to agree to surgical intervention. The patient was
admitted to the intensive care unit for monitoring and
completion of imaging.
The patient was made NPO, given intravenous fluids, and
underwent imaging. Cat scan imaging of the pelvis showed
numerous pelvic fractures identified involving the left inferior
pubic ramus, anterior column of the left acetabulum, left
femoral neck and left sacrum. A 4.2 cm gallstone was seen at
the gallbladder fundus. The orthopedic service was consulted for
evaluation of the pelvic fracture. After discussion with the
family, the plan was for closed non-operative management.
The patient was discharged to the Season's Hospice and
Palliative Care on HD # 3 in stable condition. Her vital signs
were stable and she was afebrile. She had a foley catheter in
place for monitoring of urine output. She was NPO and receiving
intravenous fluids. At the time of discharge, her IV line was
discontinued per request of Season's Hospice. | 57 | 255 |
12757493-DS-8 | 29,525,074 | Dear Ms. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were not eating and felt dizzy
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We worked to figure out why you had a poor appetite.
- We trialed a medication for your mood and energy however you
started seeing things in the room (visual hallucinations) that
were not there. While we do not think this was a direct side
effect of the medication we discontinued them.
- Your MRI showed that you had decreased brain volume.
- The EEG revealed that you were not having any seizures.
- We started dronabinol to increase your appetite, to good
effect.
- You were started on low-dose prednisone, as you had mild
adrenal insufficiency.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below .
- Seek medical attention if you have new or concerning symptoms.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team | TRANSITIONAL ISSUES:
==================
[] Discharge weight: 70.1 kg (154.54 lb)
[] Discharge Cr: 0.7
[] Consider restarting torsemide for volume control and
management ___ edema
[] F/u with concussion clinic, given that we expect that her
symptoms were related to TBI/post-concussive syndrome.
[] F/u with endocrinology to determine taper of prednisone going
forward, for her secondary adrenal insufficiency.
[] Recommendations for Marinol dosing: after 2 weeks, consider
decrease to BID and see if she still maintains appetite, then
after another 2 weeks try another taper
to QDaily
- We anticipate rehab stay to be < 30 days
ENDOCRINOLOGY RECOMMENDATIONS FOR DISCHARGE, regarding her
diagnosis of secondary adrenal insufficiency:
[ ] Patient will need education about sick day rules, as below
[ ] Sick Day Rules - patient should take double steroid dose for
two
days if they feel sick or have a cold. Furthermore, should
triple
dose for three days if sicker
[ ] Please ensure pt gets Solu-cortef 100mg 1 vial IM
prescription
(ACT-O-VIAL)at discharge with rx for BD ___ Syringe 3ml 23
gauge with instructions to use in emergency to prevent adrenal
crisis--> SYMPTOMS: Nausea, vomiting, unable to take PO and
feels extremely ill- should be given ___ doses upon discharge as
a prn prescription. Patient and his family member should receive
education by the inpatient nurse about administering it
[ ] Patient needs a medical bracelet indicating she has adrenal
insufficiency
Ms. ___ is a ___ woman with COPD, Atrial fibrillation
(on apixaban), history of Squamous cell Ca of the RL Lung (s/p
RLL Resection), who presented from cardiology clinic for rapid
atrial fibrillation and is admitted to medicine for failure to
thrive.
# Failure to thrive
# Anorexia
# Severe protein calorie malnutrition
# Medication non-adherence
# dyspepsia
# Possible post-concussive/TBI s/p fall in ___
The patient has had multiple admissions for failure to thrive.
This is likely related to her symptoms of nausea, anorexia that
lead to her not taking her medications. Clinically she does not
appear to have any organic causes of her anorexia. Most likely
mood/motivation/behavior is likely sequela of fall in ___.
Geriatrics consulted. Psych consulted. Palliative care
consulted. MRI with global atrophy and chronic microangiopathy
changes, thought to represent early stages of vascular dementia;
no acute processes that could explain he recent decline were
identified. Labs reassuring. Treponemal Ab and HIV negative. EEG
showed mild encephalopathy and/or intermittent midline
dysfunction, nonspecific with regards to etiology. There were no
epileptiform discharges or electrographic seizures. Patient
ultimately started on Marinol 5mg TID, to very good effect, and
her appetite increased dramatically afterward. She was also
started on mirtazapine, final dose was 15mg QHS (did not
tolerate 30mg dose due to orthostasis). Patient will need follow
up with concussion clinic as an outpatient.
# Dizziness
# Orthostatic Hypotension
# Possible vertigo
# Secondary Adrenal Insufficiency
Based on history, appears to be orthostasis, given poor PO
intake over several weeks. Had ___ stim test on ___ that was
mildly abnormal, suggesting that patient had mild secondary
adrenal insufficiency that was contributing to her orthostasis;
she had been on high-dose steroids from ___
for pain control, and these were then abruptly stopped after
fall in ___. Endocrine was consulted, and recommended
starting 5mg prednisone daily, with plans for outpatient
endocrinology follow-up to determine when safe to discontinue
prednisone going forward. Please see transitional issues section
above, for sick day rules, need for Solu-cortef 100mg 1 vial IM
prescription, and need for medical bracelet indicating she has
adrenal insufficiency.
#UTI
Urine culture speciated enterococcus, completed a 5-day course
of MacroBid (___).
# Visual hallucinations
# Hypoactive delirium
Pt wil hx of VH prior to admission. Likely multifactorial with
new medications, possible sequela from TBI, and hypoactive
delirium. Pt has had VH during prior hospital admissions,
attributed in past to stopping SNRI/Ritalin.
Pt placed on delirium precautions, and Psych consulted.
Mrirtazapine initiated as above, and other medications minimized
as much as possible, to reduce burden of polypharmacy. Her
hallucinations resolved on their own.
# Chest pressure
Patient had episode of chest pressure on ___, unclear etiology,
occurred with dizziness. EKG unchanged from prior. Did not occur
with exertion, so less likely angina-equivalent. Recently had
unrevealing TTE in ___. Troponins elevated but decreased from
prior (has chronic elevation), CK-MB flat.
# Afib
Presented with rates in 150s. Likely due to dehydration and med
non-adherence. Continued home metoprolol and apixaban, with
improvement in heart rates. Held diltiazem as above, secondary
to likely orthostasis; her heart rates remained normal even off
this medication. | 219 | 735 |
10683330-DS-6 | 20,081,852 | Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were feeling fatigued
- You reported that you were loosing weight
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You received a blood transfusion because your blood levels
were low. This increased your blood levels
- A gastroenterologist looked in your esophagus, stomach, and
colon for any signs of bleeding
- They found a polyp in your stomach and rectum, but no evidence
of bleeding
- You began to feel better and were ready to go home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- We prescribed you a new medication to help keep your iron
levels up. Please take this pill every other day.
We wish you all the best!
Sincerely,
Your ___ Care Team | PATIENT SUMMARY
===============
___ year old female with no significant PMH presented to outside
provider with fatigue, dyspnea, and weight loss, found to have
hgb of 6.0 and referred to ___ for blood transfusion with
appropriate rise in Hgb, now s/p unrevealing EGD and colonoscopy
discharged with plan for pill endsoscopy with GI in outpatient
setting and PCP follow up for iron deficiency anemia of unknown
etiology.
TRANSITIONAL ISSUES
===================
[ ] f/u stomach and rectal polyp biopsy results
[ ] will need pill endoscopy in outpatient setting with GI
[ ] consider fibroscan to assess for cirrhosis
[ ] f/u H pylori stool antigen, HBV and HCV serologies
[ ] will need HLA DQ2 and DQ8
[ ] colonoscopy here was inadequate for screening, she will need
a repeat colonoscopy in ___ year (___)
ACUTE ISSUES
============
#Iron deficiency anemia
Found to have hgb of 6 in outpatient setting after a few months
of fatigue. She denies any further menstrual bleeds or abnormal
uterine bleeding. She had appropriate increase in Hct to 8.6 in
the setting of pRBC transfusion and IV iron x3d. Patient
underwent EGD and colonoscopy that were not revealing for any
source of bleed or malignancy, however prep was moderate and
will require pill endoscopy in outpatient setting. IgA 475 and
tTG-IgA 16. H pylori stool antigen pending at time of discharge.
Current etiology remains unknown at this time. Discharged with
PO ferrous sulfate to take every other day.
#Transaminitis
#Elevated INR
#Hepatic Steatosis
AST 50 and ALT 27 on admission, INR of 1.2. RUQUS during
admission with steatosis but cannot exclude cirrhosis. Hemolysis
labs and CK unremarkable. No known risk factors for cirrhosis at
this time. Will need fibroscan in outpatient setting to rule out
cirrhosis. | 153 | 273 |
15149380-DS-10 | 24,328,886 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
*** You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your staples along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | #___
Mrs. ___ presented to the ED with concerns for lethargy,
confusion and worsened left sided weakness. Patient was found to
have a large right sided SDH with brain compression and was
emergently taken to the OR on ___ for a right craniotomy for
evacuation of the ___. Please see separately dictated operative
report in OMR for more specific details of the procedure. A JP
drain was left in place intra-operatively. Patient was taken to
the PACU for close monitoring, however was slow to wake and very
lethargic on exam post-operatively. STAT CTH post-op revealed
improved MLS and SDH wit the JP catheter in good position.
Patient was further transferred to the SICU for close
neurological monitoring. Patient was on Keppra 500mg BID for a
total of 7 days for seizure prophylaxis. Patient remained stable
and on POD #1 improved to her baseline. Patient was evaluated by
the neurovascular team and was consented for a cerebral
angiogram for MMA embolization. Patient was taken in the evening
of ___ for cerebral angio for MMA embo and tolerated the
procedure well. For more specific details of this procedure
please see separately dictated report in OMR. Patient was on
bedrest for 4 hours post-procedure to allow her right groin to
seal. Patient was transferred to the PACU post-procedure and
then to the ___ for continued neurological monitoring. She had
a NCHCT on ___ that was slightly improved, but the decision
was made to keep in her subdural JP drain for another day. She
was ordered for Ancef 2g Q12 while the drain was in place. She
was kept NIMU status and ___ was held due to risk of recurrent
hemorrhage or interval worsening. A repeat NCHCT was scheduled
for the morning of ___ that was stable. Her subdural JP drain
was removed on ___ without complication and her antibiotics
were discontinued. Post-pull NCHCT showed stable bleed with
increased pneumocephalus. She was put on a non-rebreather for
24-hours. She was cleared to start ___ BID for DVT prophylaxis
on ___. On ___ patient became acutely confused and
disoriented in the afternoon and a CTH was ordered to re-assess
SDH. CTH obtained and revealed stable bleed without significant
interval changes.
___ Disease
Patient remained on her ___ meds while inpatient.
#DMII; Episodes of hypoglycemia prior admission
The patient's home diabetic medications (lantus, glimepiride)
were held while she was NPO. The patient's blood sugars were
closely monitored via regular finger sticks and she was covered
with sliding scale insulin. Patient's home lantus was restarted
on ___ at half dose with plans to continued to uptitrate while
at rehab.
#Disposition
Patient was evaluated by ___ and OT who recommended acute
___ rehab. Patient was discharged to rehab on ___,
patient and family in agreement with plan. | 560 | 456 |
10828230-DS-16 | 29,506,558 | Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with dizziness, nauease and
cough. You were found to have a pneumonia. You were treated with
antibiotics, cefpodoxime and azithromycin. You should continue
your azithromycin through ___. You should continue your
cefpodoxime through ___. These antibiotics may interact with
your birth control medication. They may make your birth control
medication less effective. You should use alternative forms of
contraception, if needed, while you are on these antibiotics and
for 1 week after you finish your antibiotics.
After discharge, please continue to follow up with your primary
care provider for further management of your hypothyroidism,
migraines, and exercise induced asthma.
We wish you the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old female with a past medical history
of hashimotos thyroiditis, exercise induced asthma and chronic
migraines presents with dizziness, nausea and cough found to
have right lower lobe pneumonia
# Community acquired pneumonia: Patient presented with nausea,
dizziness, cough and decreased oxygen saturation on ambulation,
found to have right lower lobe consolidation on CXR. The patient
was initially treated in the ED with levofloxacin, will
transition to cefpodoxime and azithromycin given the patient's
hx of playing soccer given risk for tendon injury on medication.
The patient's ambulatory oxygen saturation improved on this
regimen. She will continue this course of cefpodoxime 200mg PO
q12hrs through ___ and azithromycin 250mg PO qday through
___. She was treated symptomatically with benzonatate 100mg
TID PRN cough and acetaminophen 650mg PO q6hrs PRN pain and
ibuprofen 400mg PO q8hrs PRN pain. The patient was instructed to
refrain from sports for 2 weeks (until completion of her
antibiotic regimen).
# Hashimotos Thyroiditis: The patient's TSH and T4 were found to
be within normal limits. She was continued on her home
levothyroxine 68mcg PO qday
# Exercise induced asthma: continued proair
# Chronic Migraine: continued tompiramate 50mg PO BID
Transitional Issues:
- Continue cefpodoxime 200mg PO q12hrs through ___
- Continue azithromycin 250mg PO qday through ___
- f/u with PCP regarding further management of chronic medical
conditions including hypothyroidism and chronic migraines | 129 | 232 |
12993146-DS-33 | 20,497,010 | Ms. ___,
You were admitted to ___ for confusion. This was concerning
for a urinary tract infection; however, analysis of your urine
was not suggestive of an infection. You change in mental status
may have been related to problems with your blood sugar. You did
well with good control of your blood sugar in the hospital. | ___ ___ speaking woman with history of Alzheimer's
and vascular dementia with sleep and mood disturbances,
afib/aflutter, DM2 and multiple presentations with altered
mental state usually in the setting of recurrent UTIs, who
presents with reportedly increased confusion. | 55 | 38 |
10229302-DS-19 | 26,194,242 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized because you lost your balance and
tripped, followed by weakness which was concerning from a
potential stroke.
What was done while I was in the hospital?
- You were found to have very high blood pressure, which could
have caused fluid to back up into your lungs making it difficult
to breathe. This is more likely since pictures of your heart
showed valves which did not completely block flow from going in
the wrong direction.
- You were intubated and started on mechanical ventilation in
the intensive care unit to protect your airway.
- Pictures were taken that showed that you did not have new
changes in your brain which would have been concerning for a
stroke. Signs of wear and tear were shown in your spinal at the
level of your neck.
- Other pictures later demonstrated signs of an infection in
your lungs. This may have been from materials passing down the
wrong tube instead of into your stomach or from infectious
bacteria gaining access to your lungs from the ventilator tube.
- You were started on medications to target the infection in
your lungs and to keep your blood pressure controlled, in
addition to help clear fluid from your lungs.
- You were treated with oxygen and clearance of your lung
secretions.
- You were transferred to a hospital near your home for better
family access.
Best wishes,
Your ___ team | ___ with a background history ___ Body dementia, HLD, DM,
HTN, carotid artery stenosis and multiple syncopal episodes, who
originally presented to the ED after a self limited episode of
syncope, followed by unilateral weakness concerning for stroke
and requiring intubation for airway protection, now status post
extubation and normal brain imaging, and second MICU admission
for respiratory distress. | 264 | 59 |
19322986-DS-9 | 25,056,627 | You were evaluated for your injury after your motorcycle
accident. You had CT scan which did not show major injury except
for a nose fracture. Plastic surgery team repaired this and the
sutures will need to be removed in ___ days. Apply bacitracin
ointment twice a day and take your antibiotics as prescribed.
You may wash your face in 2 days.
START AUGMENTIN 825mg twice a day for 7 days.
Incision Care:
*Please ___ your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry. | ___ s/p dirtbike collision into tree, intubated at OSH for
altered mental status, transferred for further evaluation.
During evaluation in the emergency department patient did not
reveal other injuries besides nasal fracture/laceration. CT scan
of head, C-spine, and torso did not show any acute injuries. A
Maxillofacial CT scan showed a comminuted nasal bone fracture
with minimal displacement. Plastic surgery was consulted for the
facial lacerations and nasal bone fractures. The lacerations
were repaired. The fractures did not require emergent treatment.
Patient was extubated in the emergency department and admitted
for observation. At the time of discharge patient was alert and
oriented x3. On tertiary survey patient complained of right arm
swelling, a chest x ray was obtained without evidence of injury
or foreign body, and a ultrasound was negative for DVT.
Patient is to follow-up in Plastic Surgery clinic for further
evaluation of nasal fracture. He was discharged with 1 week
course of augmentin for infection prophylaxis. A social work
consult was placed and patient was provided with options for
mental health counseling, given recent drug use relapse, as well
as supportive counseling and encouragementto continue to use his
father and father's girlfriend help to pursue welfare benefits. | 118 | 203 |
18830695-DS-3 | 25,124,186 | Why did I come to the hospital?
-You had a headache with vomiting
What happened while I was in the hospital?
-You were found to have a bleed in your brain
- You had a cerebral angiogram (brain study) to coil the
aneurysm (to help control the bleeding).
- You also developed seizures after the bleed and you were
started on medications to prevent seizures
- You also developed a clot in your arm and lungs, which
required using a blood thinning medication. You will need to
take warfarin for ___ months after leaving the hospital.
What should I do when I leave the hospital?
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You may take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much all at once.
- You make take a shower.
- Because you had a seizure while admitted, you must refrain
from driving.
-Please take all of your medications as prescribed.
Best,
Your ___ team | ***SURGICAL ICU COURSE***
Ms. ___ was admitted to ___ on ___ with diffuse SAH
and left frontal IPH secondary to ruptured left supraclinoid ICA
aneurysm. She was started on Keppra and Nimodipine. She was
taken directly to INR for successful coil-embolization of the
aneurysm without complication. She was extubated post-procedure
and transferred to the ICU for close neurological monitoring.
Her exam remained at baseline, with right lower extremity
weakness. CT Head showed no evidence of hydrocephalus. Her blood
pressure goals were liberalized to SBP<200.
On ___ neuro exam is stable and her RLE weakness was slightly
improved. Her left eye was noted to have continued vision loss
and Ophtho felt she would be unlikely to have any vision in the
eye return. An MRI was done which showed a left caudate infarct
secondary to likely spasm during the procedure. Ophtho thought
her vision loss was a posterior optic neuritis, either due to
ischemia with posterior ischemic optic neuritis (PION) vs due to
compression / trauma from coil placement.
On ___ her exam was stable with RLE weakness, left vision loss,
and was otherwise intact. She underwent TCDs.
On ___ at approximately 0100 she was found to have distal LLE
weakness with ___ in Left ___. She udnerwent emergent
CTA which showed preliminarily left A1 and M1 vasospasm. She was
consented for angio and subsequently on AM rounds her exam was
improved. In the early afternoon she was noted to have an
episode of somnolence and BLE ___ in addition to tachycardia.
She was evaluated at bedside by the fellow and her exam had
begun to improve at that time. Decision was made to press SBP >
180 and angio was scheduled for later in the day. She went to
angio in the evening and was noted to have significant vasospasm
and she was given intra-arterial verapamil and nitroglycerin.
Plan was made to have her return to angio on ___ at 1300.
On ___ Around 0005 had witnessed clonic seizure activity and she
received 4mg Ativan. Stat CT stable, Loaded 1g keppra, Loaded 1g
phenytoin, started phenytoin 100mg TID. EEG ordered and was
showing diffuse background slowing, no seizures, no epileptiform
activity. Very mildly attenuated on the left, possibly mild
focal dysfunction or possibly post-ictal. on AM rounds no
movement to Bilateral ___, sleepy but oriented,
awaiting angio at 1300, angio showed moderate bilateral ICA and
L MCA vasospasm and verapamil, nitro, and integrilin were
instilled.
On ___, Ms. ___ underwent another cerebral angiogram that
showed severe vasospasm in her right A1, and less severe in the
left A1. Intra-procedure the patient received intra-arterial
nitro and verapamil. Systolic blood pressure goals were
increased to 170-190. EEG continued to be negative for seizure
activity and was stopped. The patient continued to be non
cooperative with exam, eye opening to noxious stimuli,
localizing with right upper extremity, withdrawing left upper
extremity and minimally withdrawing bilateral lower extremities.
Plan for patient to have another cerebral angiogram tomorrow ___
with possible intra arterial ballooning for treatment of
vasospasm.
On ___, the patient was febrile overnight, and was therefore
re-cultured for her fever of 101.8. Her WBC was 33. Her
neurological exam remained stable. She again underwent an angio
with intra-arterial verapamil and nitro to her L ICA. Her left
groin was angiosealed.
On ___, the patient's neurological exam improved. Nursing was
concerned for possible decreased palpable pulses to LLE, in the
setting of angio groin site being slightly firm to palpation. A
left groin US was obtained and revealed no pseudoaneurysm or
hematoma. The patient's afternoon serum sodium was 139, with
hypertonic 3% saline @ 45 ml/hr.
On ___, the patient was not following commands as briskly,
therefore a CT/CTA was performed and was stable (reviewed by Dr.
___. Her 3% increased to 50cc/hr, and she was started on
salt tabs as her sodium was still 136, out of the goal of
140-145.
On ___, the patient is not follow commands otherwise is stable.
Patient's blood pressure is being managed on neo/levo to
maintain 180-200. Current sodium is 144 on 3% drip. WBC is 43.9,
is on ceftriaxone for positive UTI; C-diff is pending.
On ___, Exam improved, follows simple commands; said "hi". Na at
138 @50cc/hr, continuing with q 6 hour Na checks. TCDs with R
MCA mild vasospasm. CT head is stable. ___ is working with
patient.
On ___, The transcranial Doppler study was performed and
consistent with mild vasospasm of R MCA which was stable from
the day prior. The patients serum sodium was 140. The 3% serum
sodium was at 40 cc hr. A speech and swallow consult was placed
as the patient was NPO, tube feedings continued. The vancomycin
level was 4.3. And the Vancomycin 1000 mg IV Q 12H was changed
to Vancomycin 1250 mg IV Q 8H. The patient fluid volume status
was maintained fluid even to positive throughout the day.
On ___, Ms. ___ remained neurologically and
hemodynamically stable. She was awake and alert, oriented to
self and answering her last name. She was moving bilateral upper
extremities anti-gravity and purposefully. She was able to lift
lower extremities antigravity to command. Continues to have
little to no plantar flexion or extension. A 3% hypertonic drip
continued at 30ml/hr for a goal sodium of 140-154. Serum sodium
today was 144. She remained on vancomycin and ceftriaxone for
positive blood and urine cultures.
On ___, the patient was febrile overnight. Hematology was
consulted for work-up of HIT. Patient is HIT + and hematology
has made recommendations to start argatroban. Blood cultures
ordered. She had RUE swelling. US+ for DVT.
On ___, the patient remained neurologically stable. Sodium was
146. The right upper extremity was wrapped in compressive
dressing for DVT. The patient was continued on vancomycin and
cefepime.
On ___, the patient's neuro exams were spaced out every 3
hours. A head CT was stable. Sodium was low at 133 so 3%
hypertonic saline was started as well as satl tabs. A CTA chest
was ordered, which showed a PE. Argatroban drip continued for PE
and DVT. Tube feeds were held due to abdominal distension.
On ___, the patient was no longer withdrawing in RLE. A CTA was
ordered and was stable in comparison to priors. The patient was
also intermittently febrile throughout the day.
On ___, neurologically patient improving; antigravity in all 4,
delay in ride side; patient verbalized "hi" and ___ with
prompting. Blood pressure goals changed to SBP 120-160.
Discussed with ___ plan for transition off of
Argatroban. Patient continues to work with physical therapy,
patient out of bed to chair.
On ___, patient is neurologically stable. Patient is becoming
more vocal with staff. Continues to be anti-gravity in all
extremities, left stronger than right.
On ___, the patient was noted to be less verbal in the morning.
Otherwise she remained stable on examination. She waxes and
wanes. TCDs were ordered and showed Vasospasm L ACA, Hyperemia L
proximal & distal MCA. Na+ dropped 154-148. Overall 11L
positive, 800cc negative today. Do not ___ urine per Dr.
___.
On ___, the patient was noted to have up-trending LFTs. A liver
ultrasound was ordered. She was also noted to have a tense
abdomen and her bowel regimen was increased. TCDs were performed
and negative for vasospasm. Started to wean Fosphenytoin per
Neurology recommendations as she has been subtherapeutic on this
medication.
On ___, the patient's neurologic examination remained stable.
IV fluids were discontinued and her Nimodipine stopped. Given
her complex medical conditions, it was determined she would be
transferred to medicine. She was accepted to the Medicine
service.
**********MEDICAL FLOOR COURSE************
___ w/ PMHx significant for HTN and HLD who presented to ___
with a ___ ___ ruptured left supraclinoid carotid ophthalmic
aneurysm on ___ s/p angio-embolization and coiling. Her
early postoperative course was complicated by posterior optic
neuritis, with evolving strokes and persistent vasospasm, HIT
and extensive RUE DVT and PE treated with argatroban and now
bridged to warfarin.
#___ s/p angio embolization c/b left optic neuritic with
complete left eye vision loss, vasospasm, seizure and aphasia
Pt treated in neurosurgical ICU as described in detail above.
In brief, she had coiling of aneurysm on admission. She was on
pressors to maintain perfusion pressures. She had several angio
studies with intra-arterial verapamil and nitroglycerin
injection to treat spasm. She was monitored with serial
transcranial Doppler's. Upon transfer to medical floor, pt was
continued on Keppra BID. Fosphenytoin was weaned and
discontinued. Hypertonic sodium was also weaned and Na remained
at goal (135-145). BP remained at goal, < sbp 200. Her home
lisinopril was stopped to prevent relative hypotension and
hypoperfusion. She was placed on full dose ASA for her coil per
NeuroSurgery recommendations. She was seen by Speech/Swallow
and was deemed safe for an oral diet. She was seen by ___ and
will need ___ rehab. Her home statin was held due to
transaminitis, but should be considered for re-initiation as an
outpatient pending improvement in LFT's, for treatment of
hyperlipidemia in secondary prevention. She will also need to
follow-up with Neuro-Ophthalmology and NeuroSurgery.
#THROMBOCYTOPENIA ___ HIT and complicated by UE DVT as well as
PE
Found to have thrombocytopenia. HITT studies positive. RUE
swelling noted. Found to have occlusive thrombus in the R
axillary and subclavian vein with other non occlusive thrombi as
well. Also with segmental and subsegmental pulmonary emboli in
the right posterior lower lobe. Hematology was consulted and
recommended argatroban drip followed by warfarin treatment for
three to six months. Pt was initiated on argatroban drip and was
then transitioned to warfarin. INR upon discharge was 2.4. INR
goal is between ___. Pt should have f/u with Hematology this
month, which has been scheduled (___). Pt should have INR
checked 2 times per week and warfarin should be adjusted for
goal. Arixtra was not chosen for anticoagulation due to lack of
reversibility in setting of recent intracranial bleed.
#NUTRITION
Course c/b minimal PO intake and very little tube feeds since
___ in setting of potential ileus. NGT tube placed for ileus.
Then used for tube feeds but patient pulled. ___ placed
several times but was unfortunately pulled out by patient.
Speech and swallow as well as nutrition evaluated the patient.
She tolerated thin liquid and soft dysphagie diet with
supplements during meals. Nutrition evaluated and added
supplements to the patient's diet. Upon discharge, it was
determined that patient did not require tube feeds for adequate
caloric intake.
#EOSINOPHILIA, TRANSAMINITIS
Likely ___ reaction to fosphenytoin, ALT/AST stable. RUQ US with
mildly coarsened hepatic parenchyma without focal liver lesions.
There was no evidence of ascites. Fosphenytoin was weaned and
LFTs upon discharge were stable/ Her home statin medication was
stopped due to transaminitis.
#SINUS TACHYCARDIA
Etiology unclear. HR in ___ be related to discomfort.
No evidence of current infection. Pt was initially treated with
metoprolol in the SICU but this was discontinued on the medical
floor and remained stable.
#CYSTITIS / Catheter-related UTI
Patient treated with ceftriaxone and cefepime for total of seven
days for complex urinary tract infection in setting of Foley
catheter.
#BACTEREMIA - Gemella and Strep viridans were isolated from
blood cultures. Pt was seen by Infectious Disease and these
positive blood cultures were felt to be contaminants. Two TTE's
were obtained and without evidence of obvious valvular
vegetation.
#ANEMIA
Likely related to frequent blood draws and inflammatory state.
Iron 50. Ferritin of 811. TIBC 168 (low). TRF 129. C/w anemia of
chronic disease in setting of inflammation. Received 1 unit
PRBC on ___.
#LEUKOCYTOSIS
Likely related to acute illness. Significantly improved upon d/c
and wnl. | 168 | 1,918 |
13249136-DS-18 | 26,166,798 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weight-bearing as tolerated and range of motion as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Aspirin 325mg 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.
- Your dressing should remain in place until post-operative day
5 (___)
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 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have fractures of the right tibial -fibular shaft, and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for suprapatellar nail,
and was found to have evidence concerning for compartment
syndrome. She received 4-compartment fasciotomies of the right
leg. For full details of the procedure please see the separately
dictated operative report.
The patient was taken back to operating room on ___ for
right leg I&D and primary closure of fasciotomy.
After each procedure 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. The patient
was given ___ antibiotics and anticoagulation per
routine. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight-bearing as tolerated in the right lower extremity, and
will be discharged on Aspirin 325mg 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. | 254 | 267 |
18404869-DS-20 | 20,671,912 | Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
evaluated for back pain. Your imaging studies and laboratory
studies were reassuring and we found no fracture. You were also
evaluated for episodic confusion. This is most consistent with
dementia. In order to evaluate this further, a followup
appointment with neurology has been scheduled for you. Please
refer to the appointment section below.
You were also evaluated by endocrinologists, who determined that
you needed some additional titration of your thyroid
medications. You will need your thyroid function tests to be
followed by Dr. ___. In consultation with the endocrine
specialists, we changed your thyroid medication dose.
In addition, you were also found to be dehydrated. You were
given fluids through your IV line. However, it is imperative
that you drink at least 8 full glasses of water per day.
Dehydration has also shown to make dementia significantly worse.
Please try to stick to a normal, repeated pattern every day. Go
to sleep and wake up at the same time. Try to get as much sleep
as possible at night. Excercise regularly. Consume 3 meals per
day.
On this admission, we stopped your Torsemide because you were
dehydrated. Please discuss this with Dr ___ at your upcoming
appointment. | ___ with PMH prostate and colon CA, CABG s/p pacemaker ___,
hearing loss s/p internal hearing aide implants, presents with
CC of low back pain x2 days.
# back pain/urinary retention: atraumatic back pain, which
appears to be slowly resolving. At this time, unclear etiology.
However, concern for osteolytic process secondary to primary or
metastatic disease. A CT of the L/S spine was negative for any
acute process. Given an episode of bladder incontinence, the
spine service was consulted. However, his neurological
examination remained nonfocal. The spine consulting service
therefore recommended no acute intervention aside from ___
therapy
# hypothyroidism: TSH 34. HOwever it is unclear whether this may
be underlying his altered mental status in the absence of other
physical findings of hypothyroidism, including hypothermia,
bradycardia, hypotension, constipation, cold intolerance etc.
Endocrinology was consulted and recommended this is not
consistent w/ myxedema given physical exam (no ___ edema, no
brittle nails, no hypothermia, hypotension, or somnolence). They
recommneded to continue with thyroid hormone supplementation,
BUT change to 25 mcg daily ofr the next 2 weeks, with repeat TSH
and FT4 before
dosage change. Likely, higher dose will be required yet the h/o
CAD and age suggests extra caution in escalating the dose.
Tindex and T3 uptake as well as anti-TPO and anti-Tg antibodies
were within normal range, arguing against acute thyroiditis.
# altered mental status: head CT normal. unclear if this
represents delirium vs. dementia. Stroke, seizure unlikely given
no overt weakness of exam and temporal profile. Less likley
infectious given absence of fever, leukocytosis. This most
likley is consistent with dementia, given timecourse, imaging
findings and lack of other toxic/metabolic significant findings.
We therefore deferred cognitive testing to the outpatient
setting, given the patient had significantly improved on his
own. | 218 | 292 |
16766035-DS-5 | 29,714,962 | Dear Ms. ___,
You were admitted to the hospital for numbness in your right
lower extremity. This was though to be due to a blockage to the
normal blood supply to the leg. Because of this you required an
above the knee amputation of your knee. Please follow the
instructions below regarding your amputation:
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Sincerely,
Your ___ Team | ___ yo female with significant PVD, aortobifem graft, presents
with severe right lower leg pain and a cold leg with
leukocytosis and tachycardia found to have occlusion of R-aorto
femoral bypass requiring above the knee amputation.
# Ischemic RLE
Ms. ___ presented from outside hospital with cold right
lower extremity thought to be secondary to complete right
aorto-femoral bypass graft occlsusion. He was urgently evaluated
by vascular surgery who felt that the limb was non-salvagable
and would require above the knee amputation. Patient started on
Vanc/Zosyn per vascular surgery as prophylaxis and in the
setting of leukocytosis on admission. Pain controlled initially
with PRN dilaudid bolus, however initiated dilauded PCA which
improved patient's pain. CTA confirmed occlusion of the right
illiac graft limb. The patient underwent above the knee
amputation on ___. Pain control post-operatively was
achieved with a dilaudid PCA. The patient complained of phantom
limb pain and shooting pain down her leg, so gabapentin was
added to her pain regimen. She was transitioned to PO dilaudid
with IV for breakthrough pain with good results.
# ___
Ms. ___ was found to have ___ on admission thought to be
pre-renal in nature given BUN/Cr > 20 and improvement with IV
fluids. CK was also noted to be elevated and trended daily until
it peaked. IV fluids were continued at 100 cc/hr given elevated
CK and risk for rhabd. Post-operatively, her IV fluids were
discontinued as her creatinine had returned to baseline.
# Leukocytosis
Ms. ___ was found to have leukocytosis at time of
admission thought to be secondary to RLE ischemia. Other
etilogies of infection ruled out with normal CXR. In addition UA
obtained with positive WBC's though patient denied urinary
symptoms including dysuria. She was treated empirically with
vanc/zosyn per vascular recs because of ischemic limb (see
above). Leukocytosis downtrended. The antibiotics were continued
throughout the perioperative period and for 24 hours
post-operatively prior to being discontinued.
# Coping:
Patient with extreme emotional and physical distress in setting
of known pyschiatric history and substance abuse in the past
during hospital course. She initially refused surgery though
with time accepted the procedure and was consented with full
capacity as she was able to relay to the team that lack of
surgery would result in life threatening infection and likely
death. Social work was consulted for coping given need for above
the knee amputation.
#Tobacco Abuse
Ms. ___ was counseled extensively about smoking cessation
given her severe PVD resulting in amputation this hospital
course. She noted understanding and confirmed that she would
quit smoking. She was discharged with nicotine patches. | 314 | 428 |
13242049-DS-12 | 26,186,504 | You were admitted with E Coli sepsis; we found the bacteria E
coli in your blood, and this appears to have occurred after your
colonoscopy in which a polyp was removed.
You should remain on the antibiotic ciprofloxacin for a total of
two weeks this will end on ___
While you were in the hospital, you developed an irregular heart
rhythm known as atrial fibrillation. This occurred because of
the stress of your medical illness. Your heart rhythm
normalized over the course of your hospital stay. You decided
not to take coumadin for this, but to take aspirin. Please
discuss further with Dr ___.
We have stopped your nadolol, and substituted metoprolol
instead. Also, do not take lisinopril as your kidney function
has not yet normalized (we expect that it will) | Ms. ___ is an ___ with a history of CAD s/p stenting in
___, and adenocarcinoma of the transverse colon who presents
with diarrhea s/p colonoscopy, hypotension, and GNR septicemia.
ACTIVE ISSUES
# Septic shock: Thought to be secondary to GNR septicemia with
most likely source being colonic (s/p colonoscopy with
polypectomy). Pt was started on multiple antibiotics, pressors,
and fluids. In the FICU, vanc and zosyn were continued. Pressors
were weaned by the morning of admission. Blood cultures ___
positive for E. coli, and the pt's antibiotics were changed to
ceftriaxone (14d course) based on sensitivities, and then to
ciprofloxacin as there is equivalent oral and IV
bioavailability. He was started on oral ciprofloxacin on
___, and will complete a two work course of antibiotics on
___. F/u Blood cultures showed clearance of E Coli. As a
complication of his sepsis, the pt was both altered and
developed DIC. He did not require transfusion of FFP or
fibrinogen, and both resolved with treatment of his sepsis.
# Respiratory distress: Pt appeared to have increased work of
breathing durnig the period of his septic shock. He appeared to
be belly breathing on exam. ABGs showed good oxygenation and
some respiratory acidosis. Serial ABGs showed improvement. He
did not require mechanical ventilation.
# Atrial fibrillation: Patient was intermittently in Afib this
admission. He was started low dose metoprolol 12.5 mg PO TID,
which was increased to25 mg po QID with good control. This was a
first time occurence. With CHADS score of 2 and currently in
DIC, anticoagulation with coumadin was not initiated. Patient
preferred to take aspirin 81 mg daily. He reverted to sinus
rhythm during his hospitalization. We
did not restart nadolol, and continued him on metoprolol
# Hypertension: He was put on metoprolol xl 100 mg, but then
blood pressure dropped to 110/50, so this was cut back to
metoprolol tartrate 25 mg po bid. Nadolol discontinued as
metoprolol more studied for use in patients with CAD/paroxysmal
atrial fibrillation. Patient will resume his nifedipine xl 90
mg.
# DIC: In the setting of sepsis. Did not require factor/product.
He had one episode of hematuria s/p Foley placement but did not
show other signs of bleeding, and hematuria resolved. Did have
anemia and thrombocytopenia. Thrombocytopenia resolved, but
hematocrit remained at 33. Should be followed up as outpatient.
# AMS: This was abrupt in onset and thought to be due to
sepsis/DIC. A CT head showed no acute abnormality. Secondarily
there was a question of alcohol withdrawal, although initially
did not respond to benzos. He was managed briefly with prn
haldol and ativan. Resolved spontaneously by third day of
admission. He was seen by occupational therapy and found to
have some minor short term memory deficits on day of discharge
(their detailed note is in OMR). PCP can consider administering
MOCA test in f/u to see if those have resolved.
# Acute kidney injury: Cr on admission elevated above baseline
with hematuria. Likely prerenal or ATN in the setting of septic
shock. This improved with administration of IVF and with
treatment of DIC. LIsinopril held; creatinine was 1.5 at
discharge, and is .6 at baseline, so creatinine should be
closely monitored as outpatient and lisinopril restarted when
creatinine normalizes.
# Transaminitis: Likely due to sepsis. Statin restarted as
transaminitis resolved.
.
# Hypoglycemia: Seems c/w increased metabolic demand in setting
of sepsis, DIC. Was on D10 gtt briefly which improved his BGs.
# Diarrhea: C diff negative, likely abx associated. Did have
one episode of fecal incontinence in the hospital.
CHRONIC ISSUES
# Adenocarcinoma of the colon (s/p right colectomy): Patient was
followed by colorectal surgery during his admission. No
additional management was indicated.
# CAD: s/p stent ___. troponins negative.
TRANSITIONAL ISSUES
- Cr still remains above baseline. Would continue to monitor
frequently as outpatient.
- Would also trend hematocrit
- ELevated alkaline phosphatase elevation | 135 | 665 |
18136887-DS-80 | 27,898,886 | Dear Ms. ___,
It was a pleasure to participate in your care during your recent
stay at ___. You were hospitalized for weakness, muscle
soreness, high potassium and low blood pressure.
Your high potassium and low blood pressure was thought to be the
result of an infection in the setting of your Addison's disease.
You had no evidence of a urinary tract infection. Your chest
x-ray showed a possible pneumonia, and so you were given a
course of 5 days of an antibiotic, azithromycin, to treat the
infection. Your steroid dose was increased while you were in the
hospital from your normal dose of 5 mg daily to 20 mg for one
day. Today, the day of your discharge (___), you will receive 15
mg for one day, followed by 10 mg for two days (___), after
which time you will continue taking your normal dose of 5mg
daily.
It is important that you follow up with your primary care doctor
and continue to take all prescribed medications.
Once again, thank you for allowing us to participate in your
care. We wish you the best!
Your ___ Team | This patient is a ___ year old female with a history of Addison's
for over ___ years and rheumatoid arthritis who presented to the
ED with weakness/fatigue/lethargy which began yesterday and
diffuse bilateral lower extremity cramping. The patient stated
that these symptoms were similar to prior Addison's crises, for
which she is often admitted with prednisone.
In the ED, she was found to be hyperkalemic to 6.0 with no T
wave or other abnormalities noted on EKG. She received 20 mg of
prednisone, insulin and glucose, and 3L of IV fluids. Her course
by problem after admission is as follows:
#Hyperkalemia - No T wave or other abnormalities noted on EKG.
Received one dose of kayexalate on hospital day 1, which she
tolerated well. K normalized to 4.9 shortly after admission, 4.2
on second hospital day. Her leg cramping and weakness was
improved by discharge.
#Addisonian crisis - Felt likely secondary to L lung pneumonia
seen on chest x-ray without stress dosing of steroids. She was
prescribed a 5 day outpatient course of azithromycin for
treatment of possible CAP. Orthostatic on ___ evening
(tachycardic to 126 on standing). Vitals otherwise stable. The
endocrine team was consulted for management of her steroid
stress dosing. She was treated with 20mg prednisone on hospital
day 1, 15 mg on hospital day 2, and was told to take 10 mg
prednisone for 2 days after discharged before returning to her
normal dose of 5mg qd. Her fludrocortisone was continued at
0.1mg qd.
# Back pain - Tender to palpation at left upper back over
inferior medial wing of scapula. Per patient, pain quality and
location identical to rhomboid bursitis pain diagnosed by sports
medicine physician on several previous occasions. ___ consider
intramuscular steroid injection as outpatient.
# Transaminitis: Mildly elevated AST 51, ALT 52. Sent hepatitis
serologies, given no clear etiology and appeared increased above
baseline. No RUQ abdominal pain on exam, negative ___.
Tbili and alk phos wnl. Hepatitis serologies pending at time of
discharge.
# Eosinophilia: Increased to 4.3%; felt most likely secondary to
adrenal insufficiency.
# Rheumatoid arthritis. Not recently on methotrexate. Managed
with prednisone and transdermal NSAIDs. Recent flare, perhaps in
setting of increased stress associated with illness. Continued
home prednisone
# Insomnia Continued home trazodone 50mg QHS
# Hypertension: continued home metoprolol
# Hypothyroidism: continued home levothyroxine | 186 | 377 |
12190654-DS-18 | 24,354,390 | Dear Mr. ___,
You were admitted because you fainted. We found that you were
dehydrated and also that you have a urinary tract infection. We
treated you with IV fluids and antibiotics. You will complete
the IV antibiotics on ___. You fainting is probably due to
you low blood pressure, which improved when we gave you IV
fluids, but still drops low at times. It is important that you
take your time getting out of bed and standing up. Please stand
near your bed/chair for several minutes to make sure you do not
feel lightheaded befor you start walking so that you do not
faint or fall. | The patient is a ___ with stage IIIB (pT3pN1M0) colon
adenocarcinoma c/b malignant ascites and peritoneal
carcinomatosis on palliative chemotherapy with Irinotecan who
presented with syncopal episodes. He was treated for a UTI and
given IV fluids as well as drainage of his ascites. His symptoms
resolved by day of discharge, but was noted to still have
borderline orthostatic changes on standing (asymptomatic), which
may be chronic for him. | 109 | 69 |
11053554-DS-10 | 29,440,764 | You were admitted because of difficulty breathing. We think
this is likely due to a COPD exacerbation. You were being
treated with steriods and antibiotics, however you wanted to
leave against medical advice before we felt you were ready. You
were advised of the risks of leaving Against Medical Advice
including worsening trouble breathing, worsening cough,
development of severe infection, or death.
We were also checking you for tuberculosis - we were only able
to get 2 of the needed 3 samples to rule this out. If you
develop worsening cough or blood in your sputum, or worse
trouble breathing - please report to an emergency room.
You left the hospital against our medical recommendation. We
did not feel that it was safe for you to go, especially since we
wanted to make sure you did not have tuberculosis and that your
breathing was improving. | Mr. ___ is a ___ yo gentleman with HIV on HAART ___ CD4 586,
undetectable viral load), HCV, COPD on 2L O2, asthma,
sarcoidosis, ?TB partially treated, bronchiectasis, who presents
with a 16 day history of increased SOB and nonproductive cough.
Of note, on the day his symptoms began, he had moved from ___
___ to ___ and attributes his SOB
and cough to the mold, AC and bleach used in the facility.
# SOB/cough - likely ___ COPD flair given COPD history,
scattered crackles on exam, hyperinflation on CXR and
environmental trigger (mold, AC, cleaning products). Most likely
not pna given no fevers, no considlation on cxr or exam. ___ be
a component of bronchiectasis, though no known preceding
infection. Less likely to be an asthma flair since he did not
have wheezes on exam and was not tachypnic. Unlikely TB, but
ruling out due to subjective fevers, cough, night sweats in
addition to possible h/o TB and his stays at multiple
facilities. He received 4L O2NC, albuterol nebs Q4H standing
with additional Q2H prn, and Tiotroprium. He was also given Vanc
and Cefepime in the ED and switched to Vanc and Ceftazedime
given a history of ?mrsa and intermed cipro sensitive
pseudomonas pna. He improved clinically on day two and was even
able to have 98% O2sat on room air during parts of the night. He
continued to be afebrile. Since it seemed most likely to be a
copd flair, we started him on the prednisone and continued his
nebs, tiotroium and decreased O2 to 2LNC. Sputum cultures were
sent and was negative for acid-fast bacteria. The patient left
AMA before the rest of his labwork returned.
# Fevers (subjective) - afebrile while inpt. ___ have had a URI,
but no longer present by the end of the hospitalization. Left
AMA prior to full workup.
# Polysubstance abuse - Pt most recently used cocaine and heroin
on ___. EKG on ___ normal but had a h/o of MIx2 after cocaine
use. Much more agitated today, restless, crampy abdominal pain.
Was withdrawing from heroin. Did not give him pre-admit
oxycodone for pain, and he was very agitated about this. After
confirming dose with original providor, decided to restart
oxycodone. Gave valium prn. Asked for social work consult. Blood
cx negative.
# Diarrhea - started yesterday, ___ x ?a few times. Possible
c.diff given his recent living situation in multiple different
facilities including a nursing home as well as being homeless.
Also possible that it is part of his withdrawal symptom or just
from eating a normal diet again. Planned to send for c. ___ but
patient left ama.
# HIV - on HAART, followed by Dr. ___. In ___, CD4 586
and undetectable viral load. However, had not taken his HAART
meds since he was homeless around 12 days ago because he did not
have any left. Restarted HAART meds. Will f/u on CD4 count and
HIV viral load.
Stable Issues
# Foot pain - likely ___ HIV neuropathy with a possible
component of plantar fascitis. Gave gabapentin and tylenol on
first day but pt complained that pain was not well controlled.
Restarted his prescribed oxycodone of 10mg QID. Recommend
followup as outpatient.
# Lower back pain - chronic. Unknown etiology. Continued
gabapentin and tylenol on first day. Pt becmae very irritated by
lack of oxycodone so after checking with initial prescriber,
restarted the oxycodone. | 151 | 562 |
19179292-DS-17 | 27,635,137 | Ms. ___,
You have sustained a very serious trauma injury. You have many
fractures in your face, ribs, right hand and left leg. You had
several operations to fix this serious injuries. You are doing
much better now and are ready to be dishcarged from the
hospital.
The follow instructions are very important. Please read them
carefully:
* Your injury caused many 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).
Activity
- Your weight-bearing restrictions are: non weight bearing in
the left lower extremity until follow up. Non weight bearing
right hand until follow up.
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.
SINUS PRECAUTIONS
Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved. | ___ with PMH L femur fracture and cdiff admitted to ___ as
unrestrained driver s/p MVC. Patient initially evaluated in ED
and subsequently TSICU; injury burden includes multiple facial
fractures as well as multiple rib fractures and pericardial
effusion. On tertiary survey, patient noted to have R hand pain
and L ankle pain; orthopaedics consulted once patient
transferred to floor. Of note, patient is s/p L distal femur
ORIF (___) and subsequent removal of hardware last month (Dr.
___.
The patient presented to Emergency Department on ___. Pt was
evaluated by the trauma surgery team arrival to ED. Given
findings, OMFS and orthopedic surgery were consulted. The
patient was admitted to the trauma ICU for close monitoring. She
was subsequently transferred to the hospital floor and then
taken to the operating room with OMFS and orthopedic surgery
___. There were no adverse events in the operating room;
please see the operative note for details. Pt kept intubated
overnight in the trauma ICU for significant facial edema and
concern for airway patency, and then extubated the next morning
uneventfully. She was then taken back to the operating room
___ with orthopedic surgery for open reduction and
percutaneous pinning of her left talonavicular dislocation.
Postoperatively, she was taken to the PACU until stable, then
transferred to the ward for observation.
Nasal packing was removed on ___ by OMFS; the patient
experienced ongoing epistasis. On ___, merocel nasal packings
with bacitracin ointment placed by OMFS and removed 24 hours
later. The patient was observed overnight and no further
nosebleeds. She was seen and evaluated by Physical therapy, who
recommended rehab at the time of discharge.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a dilaudid PCA
and then transitioned to oral oxycodone once tolerating a diet.
.
CV: Ms. ___ was found to have a moderate pericardial effusion,
but was asymptomatic. She was initially monitored in the trauma
ICU for this, and then transferred to the floor after vital
signs remained stable for 24 hours. She will need follow up
with cardiology for this. Ms. ___ remained stable from a
cardiovascular standpoint on the hospital floor; vital signs
were routinely monitored.
.
Pulmonary: The patient intermittently had an oxygen requirement
during the first few days of her hospitalization. She remained
stable from a pulmonary standpoint and was able to be weaned to
room air without a problem; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
.
GI/GU/FEN: The patient was initially kept NPO. Her diet was
advanced sequentially to full liquids with supplements, which
was well tolerated. Patient's intake and output were closely
monitored and she was followed by nutrition.
.
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 be
active as early as possible.
.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
OOB to chair with assistance, 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
has scheduled follow-up with Orthopedics, Ortho Hand, OMFS, and
ACS. She was instructed to see her PCP and ___ within
a month of discharge. | 738 | 595 |
11342314-DS-16 | 29,217,249 | Dear Mr ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital for cardioversion for atrial
fibrillation
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent cardioversion successfully
- We monitored you heart rhythm and followed your kidney
function, which was slightly elevated
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is an ___ with history of atrial fibrillation (on
warfarin) s/p cardioversion and ablation, hypothyroidism, and
CKD
Stage III (baseline Cr 1.1-1.3) who presents with symptomatic
atrial fibrillation with RVR. He was successfully cardioverted
on ___. He also had a small ___ in the setting of likely
overdiuresis, and torsemide was ___. | 90 | 52 |
11332461-DS-8 | 27,092,363 | 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:
- 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 a doctor's office in 2 weeks.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Non-weight-bearing right upper extremity in splint
Physical Therapy:
Non-weight-bearing right upper extremity in splint
Treatments Frequency:
Please assess wound daily for erythema, drainage, skin
breakdown, or other signs of infection. | Ms. ___ presented to the ___ emergency department on
___ and was evaluated by the orthopedic surgery team. The
patient was found to have a deep right elbow laceration and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for repair of the wound,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home under the care of her niece
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non-weight-bearing in the right
upper extremity in a splint. The patient will follow up in two
weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge. | 148 | 237 |
14260773-DS-13 | 20,736,466 | You were admitted to the hospital for constipation. You had and
xray which was normal. You have recovered from this procedure
well and you are now ready to return home. Samples from your
colon were taken and this tissue has been sent to the pathology
department for analysis. If there is an urgent need for the
surgeon to contact you regarding these results they will contact
you before this time. You have tolerated a regular diet, passing
gas and you have minimal pain. You may return home to finish
your recovery.
Please monitor your bowel function closely. You must take colace
100mg twice dialy everyday and miralax daily. If you have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonged loose stool, or
constipation. You may also need to us an enema or suppository
however call the office with questions related to this.
You have a UTI that you should take one additional day of
Ciprofloxacin to treat. Please moniotr yourself for continued
UTI symptoms: burning with urination, lower abdominal pain, foul
smelling urine, or fever. | The patient was admitted to the inpatient colorectal surgery
service with abdominal pain. Abdominal film on ___ showed
dilated small bowel with air-fluid levels in the ___. A
nasogastric tube and Foley catheter were placed. Soap suds enema
was administered with minimal stool return and no flatus. On the
morning of ___, the patient reported passing flatus, the
nasogastric tube and Foley catheter were removed. It was
determined that the issue of the possible obstruction was most
likely in the colon and a Gastrografin enema was preformed to
evaluate for possible stricture or other cause of obstruction
and dilation of the colon. The Gastrografin enema was negative.
The patient passed a medium semi-formed stool on the morning of
___. A urinalysis/culture sent on ___ was positive and the
patient was given a three day course of Ciprofloxacin. The
patient was given clear liquids in the afternoon of ___ which
was tolerated well and her diet was advanced to regular on the
morning of ___. It was determined that the patients symptoms
were likely related to constipation and her home bowel regimen
was increased as described in the discharge instructions. The
patient was discharged home with appropriate discharge
instruction. | 202 | 199 |
11159299-DS-6 | 25,737,628 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for a fall.
WHAT HAPPENED IN THE HOSPITAL?
-You had a CT scan of your head which did not reveal a head
bleed.
-You were found to have a urinary tract infection and treated
with antibiotics.
WHAT SHOULD YOU DO AT HOME?
-You should continue to take your medications as prescribed.
-You should follow-up with your doctors' appointments as
indicated below.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | SUMMARY STATEMENT
=================
___ yo woman w/ history of dementia from ___ who
presented one day after
a fall with head strike who was found to have a UTI. | 94 | 28 |
11966699-DS-36 | 27,068,288 | It was a pleasure taking care of you while you were admitted to
___. You were admitted to the hospital with
chest pain. We sent off labwork that showed you were not having
a heart attack. Your pain went away and did not return while
you were here. We do not think that you need a stress test and
we think it is safe for you to go home. We made some mild
changes to your medication. You should also follow up with Dr.
___ one of his nurse practitioners in the next week.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is an ___ year-old gentleman with a PMH of sCHF ___
ischemic cardiomyopathy with EF 20% s/p BiV pacer/AICD, CAD s/p
CABG in ___, HTN, HLD now presenting with chest pain.
# Chest pain: pain more severe than over the last few months.
Troponins mildly elevated to 0.02 x2 with flat CK-MB and ECG
v-paced. Also of note, his pMIBI from last month showed
extensive fixed perfusion defects. Given his extensive perfusion
defects, unlikely that he will benefit from cardiac cath or
another stress test. We optimized his medical management. His
lisinopril was doubled to 5mg daily and diuresed as per below.
He was continued on aspirin 81mg, pravastatin, metoprolol,
digoxin. On arrival to the floor, he was pain free and remained
asymptomatic for the remainder of his hospitalization.
# acute on chronic sCHF: Mild vascular congestion seen on CXR
with elevated JVP.
He was continued on his home dose of metoprolol, artorvastatin,
aspirin, and digoxin. Lisinopril was increased as per above. His
lasix dose was also doubled to 40mg daily with close follow up
with Dr. ___.
# History of LV thrombus: anticoagulated with warfarin for goal
INR 2.0-3.0. INR was 2.8 and he was continued on his home
warfarin
.
# HTN: doubled dose of lisinopril for better blood pressure
control.
# BPH: continued on tamsulosin and finasteride
# PVD: hx of multiple percutenous interventions and followed by
Dr. ___. Pedal pulses present with dopplers.
#TRANSITIONAL ISSUES
-___ medical management by increasing lisinopril to 5mg
daily and lasix to 40mg daily.
HEALTH CARE PROXY: ___ (wife) ___
CODE STATUS: FULL CODE | 115 | 276 |
19682438-DS-12 | 27,400,389 | You were admitted to ___ after a fall. You were found to have
a fractured jaw. You were taken to the operating room with the
Oral Maxillary Facial Surgeons for repair of the fracture. You
tolerated this procedure well and are now medically cleared for
discharge. You should continue the full liquid diet for the next
4 weeks until your ___ follow-up. Please note the following
instructions:
Chin laceration: Continue bacitracin BID
Jaw fracture: Ice packs for pain, chlorhexidine mouth rinse BID,
full liquid diet, wire cutters at bedside.
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 | ___ male with no known past medical history who
sustained a complicated mandibular fracture after a fall from
standing when he was tasered by the
police the context of a domestic dispute. He does not have any
other apparent injuries and is hemodynamically stable. ___ is
consulted and the patient was taken to the OR for ORIF of
bilateral mandibular fractures. In the PACU the patient was
agitated and started on a phenobarb taper for ETOH withdrawal
with good effect.
Post-operatively, pain was well controlled. Diet was
progressively advanced as tolerated to a full liquid diet with
good tolerability. The patient voided without problem. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. Antibiotics were switched to oral form to
complete a 5-day course of Keflex.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged to prison. The
___ team would be in contact with the facility to schedule
follow-up. The patient had instructions to continue the full
liquid diet and chlorhexidine mouth rinses. He was sent with a
small prescription for oxycodone to be taken as needed for the
next ___ days and has been instructed to wean off narcotics and
use only Tylenol or ibuoprofen for pain along with ice packs.
The chin laceration would require bacitracin twice a day until
healed. | 283 | 245 |
17628952-DS-9 | 29,461,318 | Dear ___ were admitted because ___ fell and had hip pain. ___ were
found to have a fracture of your pelvis. ___ pain was treated
with medications as needed. ___ were offered physical therpay,
which ___ refused.
___ were assigned a legal guardian to help make medical
decisions for ___ in the future.
The following changes were made to your medication regimen
- START olanzapine daily
- START calcium carbonate three times a day with meals
- START nephrocaps daily
- START tylenol as needed for pain
- START lidocaine patch to hip for pain | ___ yo F with a history of schizoaffective disorder, CKD stage V,
and ruptured right breast implant with chronic drainage
presenting s/p traumatic fall with right pubic ramus fracture.
.
# Right pubic ramus fracture- Patient seen by orthopedics in the
ER who recommended pain control, physical therapy and weight
bearing as tolerated with close follow-up. Patient's pain was
initially controlled with opiates, then transitioned to tylenol
and lidocaine patch. Patient had intermittent pain in hip,
however, was persistently resistant to fully standing. She
would intermittently work with physical therapy in bed.
Follow-up x-ray showed healing pubic ramus fracture. Ortho
recommended continuing physical therapy as patient was willing.
Patient discharged on tylenol and lidocaine patch.
.
# Right breast drainage- Patient was seen at ___ prior to
discharge regarding chronic drainage from skin defect in right
lower outer quadrant of breast. Imaging from ___ confirmed a
ruptured implant with silicone granuloma and tract formation to
the skin. Patient refused surgical intervention at ___ and on
admission to ___. There was no sign of infection on
admission, with only mild erythema of surrounding skin, no fever
and no leukocytosis. Throughout admission, skin defect was
closely monitored for signs of infection. She was afebrile
throughout admission and there was no purulent drainage from
skin defect, nor evidence of cellulitis. Patient would benefit
from having implant removed, however she refuses. At this time,
there is no emergent need for guardian to press for surgical
intervention, however, if patient develops infection in the
future this will be necessary.
.
# Chronic kidney disease- Patient's creatinine on admission was
close to her baseline. She has stage V chronic kidney disease.
Electrolytes were monitored closely and were notable for low
bicarbonate, elevated phosphate and low calcium. Patient was
started on calcium carbonate and was given IV bicarbonate as
needed during admission. She was also started on nephrocaps.
Patient's creatinine and electrolytes remained stable and she
did not require dialysis. However, she will likely require
renal replacement therapy in the near future, and options should
be discussed at length with patient and guardian. She should
have care established with nephrologist. Creatinine and
electrolytes will need close monitoring, weekly lab draws.
.
# Decubitus ulcers- Secondary to patient's refusal to get out
of bed into a chair or walk, she developed decubitus ulcers
during her admission. They were covered with duoderm and
cleaned daily by nursing. These are at risk of becoming
infected. Patient requires continued encouragement to get out
of bed and into a chair and to walk to prevent ulcers from
worsening.
.
# Schizoaffective disorder- Patient has a history of
schizoaffective disorder. She has been on antipsychotics in the
past, and has evidence of tardive dyskinesia. During admission,
she was started on sublingual olanzapine 5mg daily. This
medication should be continued. If patient refuses this
medication, she will require 5mg of olanzapine intramuscularly.
Patient was followed closely by psychiatry throughout admission,
who added several other potential medication options to the
___ guardianship to control psychosis in the future should
olanzapine not control her symptoms.
.
# Urinary tract infection- Patient had enterococcus UTI on
admission. She was treated with vancomycin for one week.
.
# Hypertension- Patient has history of elevated pressures but
has not been on medication. She was transiently on labetolol
but refused this medication. Blood pressure was well controlled
off of labetolol, and increases were largely related to pain.
.
# Difficulty swallowing- Patient reported difficulty swallowing,
liquids more than solids. She was evaluated by speech and
swallow who found no mechanical issues with her swallowing. She
was offered thickener for fluids, and pureed food options but
refused.
.
# Capacity- Patient found to not have capacity to make medical
decisions on admission per psychiatry. She had no appropriate
family members to serve as guardian and so a court appointed
guardian was found. Legal guardian will need to make further
medical decisions for patient.
.
# Transitional issue-
- patient will need to establish care with a nephrologist:
___
- weekly electrolytes to evaluate creatinine, potassium
- decubitus ulcer care- duoderm daily
- ongoing physical therapy
- please touch base with legal guardian ___
- will need permission from legal guardian to give additional
psychiatric medications other than those listed in medication
reconciliation | 93 | 729 |
16119588-DS-26 | 27,896,043 | Dear Ms. ___,
It was a pleasure taking care of you.
You were hospitalized because of a COPD exacerbation and ongoing
difficulty with controlling your symptoms, including breathing
discomfort and pain.
We treated you for a COPD exacerbation and helped arrange for
you to be discharged to an inpatient hospice unit, where your
care will focus on comfort.
If you feel the need to see any of your normal providers,
including your pulmonologist or your PCP, you can make an
appointment with them at any time.
We wish you the best.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman with severe COPD (FEV1
21%, on 3L) and HFpEF, with recent hospitalization and discharge
on ___ and ___ for COPD exacerbation and hospice placement.
She returns with continued SOB and a desire to return back to
inpatient hospice.
>> ACTIVE ISSUES:
# End Stage COPD
# COPD Exacerbation: Patient initially presented with worsening
SOB from home, reportedly attributed to not receiving enough
support with home hospice, became acutely more dyspneic and
presented to ED. Respiratory status had been stable since her
last discharge up until that point. After last admission
discharged to inpatient hospice, medically and symptomatically
stabilized and was then transitioned to home hospice. However,
husband and patient had difficulty managing this at home and she
became more and more dyspneic. Her dyspnea quickly resolved
after admission and reinstitution of her regimen. While in the
hospital, we continued her on 10 mg of prednisone, duonebs,
albuterol PRN, and her dyspnea resolved. She was on her baseline
3 L in the hospital. OxyContin was started for management of
baseline dyspnea in addition to prn oxycodone ___, and morphine
liquid in case of acute dyspnea or pain.
# Goals of care: Patient expressed very clearly that she wants
to pursue inpatient hospice care and does not wish to be at home
due to lack of support. She is DNR/DNI and does not want to go
to the ICU if she decompensates.
# Chronic Pulmonary Embolism: Continued apixaban.
# Thoracic Back Pain ___ Compression Fractures: Escalation of
her home breakthrough oxycodone to oxycontin with oxycodone ___
mg for break through. Also received standing Tylenol.
# Chronic Diastolic Heart Failure: Continue home lasix
# Hypothyroidism: continue home Levothyroxine
# Anxiety: Transitioned to clonazepam for longer action over
diazepam. Lorazepam PRN. | 89 | 291 |
16797123-DS-8 | 23,901,508 | Dear Mr. ___,
It was a pleasure taking care of you during your recent
hospitalization. You were admitted on ___ because you were
feeling weak and had diarrhea. While you were in the hospital,
we ran multiple tests looking for an infectious cause for your
diarrhea, and found none. Your diarrhea improved with the drug
loperamide. You also had a cough and shortness of breath, which
was likely due to a partial collapse of your left lung found on
a CT scan of your lung. This lung collapse improved with
breathing exercises. We also treated you with antibiotics for
pneumonia because of your concerning symptoms. You completed a
full course of antibiotics for pneumonia. All of your symptoms
and lab values improved, and you were discharged back to your
living facility on ___.
Please continue to take all your medications as prescribed. You
have a follow up appointment with Dr. ___ month.
Sincerely,
-Your ___ Team | ___ ___ of AIDS (CD4 count 182 on ___ who presents with
3-week history of watery diarrhea and progressive weakness,
found to have productive cough and rising WBC. | 156 | 30 |
11396991-DS-11 | 22,454,600 | Discharge Instructions
Traumatic Brain Injury
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You may resume Aspirin in 5 days, on ___. Please do NOT
take any blood thinning medication (Aspirin, Ibuprofen, Plavix,
Coumadin) until that time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ who presented s/p with intermittent facial droops, and
frequent falls over the past two weeks. CT head showed acute
parafalcine, right tentorial, and left convexity SDH with an
acute small volume left frontal SAH. He was admitted for further
workup. His home Aspirin dose of 325mg was held. Due to the
patient's history and un-witnessed nature of the fall, CTA head
and neck and carotid ultrasound were done. CTA head and neck was
negative. Carotid ultrasound showed less than 40% carotid
stenosis bilaterally. He remained neurologically intact and had
no additional episodes of aphasia or facial droop. He was
discharged to home on ___.
#Elevated WBC
Morning of ___ his WBC was elevated at 12.4, he remained
afebrile and asymptomatic. UA was negative. Patient refused CXR.
Lungs were clear to auscultation and the patient was instructed
to follow up with PCP should he develop any symptoms such as
wheezing, cough, or SOB.
#Elevated BUN/Cr
On arrival, BUN and Cr were elevated and he was started on IV
fluids. Cr was elevated again on the morning of ___, and a 250cc
bolus was given. He was instructed to follow up with his PCP
regarding creatinine. | 454 | 192 |
15032609-DS-20 | 22,689,967 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were brought to the hospital because you
were found unresponsive due to overdose. In the hospital, you
received medications to reverse the overdose effect and you were
able to wake up.
We strongly recommend that you see your psychiatrist early next
week. We stopped the nortriptyline and diazepam due to the risk
of future overdose. You can continue taking Gabapentin as
scheduled until your see your psychiatrist who might adjust your
medications further. For your anxiety you may take hydroxyzine
as prescribed.
Best regards,
Your ___ team | ___ with history of depression, anxiety, and chronic neck/back
pain, who was transferred to ___ with hypotension and AMS in
setting of polysubstance ingestion (heroin, alprazolam,
gabapentin, alcohol).
# Polysubstance Overdose: Patient overdosed on heroin,
gabapentin, alprazolam, and alcohol. Patient was obtunded at OSH
and upon arrival to ___, resolved after pressor support and
narcan. The patient was hypotensive and briefly maintained on
dopamine gtt for low EF (see below), which improved during his
time in the ICU.
# NSTEMI/Demand Ischemia: By report from OSH, EF was found to be
markedly reduced to 15%, improved to 50% with dopamine gtt.
There was evidence of end-organ ischemia on ___. Exam was not
consistent with cardiogenic shock, and bedside echo in ED showed
low-normal LV function, mild TR without significant valvular
disease. Elevated troponin likely represented demand ischemia in
the setting of hypotension, as patient is young without cardiac
risk factors; cocaine-induced ischemia was possible though
patient denied cocaine use. TTE showed no evidence of
endocarditis, LVEF 50-55%. Troponins peaked on ___, and
pressures improved.
# Rhabdomyolysis: Patient was also found to have elevated CK
with ___ consistent with rhabdomyolysis, likely in setting of
prolonged time down. His CK and creatinine decreased with fluid
resuscitation. Patient had left leg pain raising concerns for
compartment syndrome; however, pulses, sensation, and motor
strength were intact on exam and leg symptoms improved.
# Depression: Psychiatry evaluated the patient and recommended
1:1 sitter during his hospital stay. He denied suicidal
ideation. Anxiolytics and antidepressants were held in the
setting of concern for overdose. Upon discharge, he received
scripts for 5 days supple of gabapentin for his chronic pain and
hydroxyzine for anxiety.
# Transaminitis: He had elevated transaminitis, likely secondary
to shock liver due to hypotension, overdose, or alcohol abuse,
which down-trended.
***TRANSITIONAL ISSUES:***
- Patient needs to follow up with his psychiatrist on ___
___
- We stopped nortriptyline due to risk of future overdose;
patient was discharged on 5 days supply of hydroxyzine 25 mg Q6H
PRN for anxiety
- We held Gabapentin during his hospitalization; after
discussion with psychiatry, we discharged patient on 5 days
supply of Gabapentin 300 mg TID for chronic neck and back pain
- Check LFT, creatinine, and CK during next visit
- Intranasal naloxone prescription and instructions were
provided to patient and patient's mother
# Communication: HCP Mother, ___ ___
# Code: Full | 100 | 389 |
10325255-DS-19 | 24,449,325 | Dear Mr ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with fever, headache, vision
changes concerning for meningitis. A CT scan of your head
showed no acute process that could be causing your symptoms. A
spinal tap was done that suggested you likely do not have
meningitis, and if so it is due to a virus that will improve
over time. On the day of discharge you did not have any further
fevers and your neck pain and headaches were improving. | ___ M w/ DM2 who presented with sudden onset headache, blurry
vision, neck pain, nausea and vomiting following 1 day of fever
prompting concern for meningitis.
# Viral Illness Vs Aseptic Meningitis: Patient had LP which was
traumatic and showed 50WBC on tube 1 and 5WBC on tube 5. He
also had CT head which did not show any acute bleed. He received
IV Ceftriaxone and vancomycin x 1 empirically in the ED which
was discontinued on the floor following LP results. He was also
started on empiric treatment with acyclovir which was also
discontinued given rapid improvement in clinical status and low
suspicion for HSV meningitis. His CSF culture remained
negative. He was observed off of antibiotics for more than 24
hours and he remained afebrile with no symptom recurrence. He
most likely had aseptic meningitis vs self limited viral
illness. He will follow up with PCP for ___.
.
# Diabetes Mellitus, type II: Poorly controlled with
microalbuminuria. Last HgbA1c 9.6% in ___. Lisinopril and
Humalog SS was given in house. Home oral metformin and glipizide
were held in house but restarted at time of discharge.
. | 94 | 194 |
19626923-DS-10 | 28,933,569 | Mr ___,
It was a pleasure participating in your care at ___. You were
admitted because you had chest and leg pain. We found that you
have blood clot in your lungs. We are treating you with Lovenox
(injection blood thinner). You will continue to take Lovenox
until your coumadin level builds up in your blood.
We made the following changes to your medications:
STARTED Lovenox (you will stop once your coumadin level is at
goal)
RESTARTED Coumadin
STARTED Oxycodone as needed for pain | ___ y/o M with PMHx of DVT, recently off coumadin, presenting
with left leg pain, chest pain, CTA c/w b/l subsegmental PE.
# PE/Chest pain: Patient presented with chest pain and leg pain.
CTA showing bilateral subsegmental PEs. EKG with S1Q3T3.
Patient with h/o recurrent DVT/PE x2, on life-long
anticoagulation. These DVT/PEs did not seem provoked. Unclear
whether he had hypercoagulable workup as outpatient. Per outpt
records, last time INR within goal was ___, on coumadin 5mg
daily. Patient with med non-compliance due to social reasons.
Will continue to require lifelong anticoagulation given this is
his third episode. On admission, patient mildly tachycardic,
but not hypotension and had no O2 requirement. Chest/leg pain
controlled with oxycodone 5mg BID prn. Will likely be able to
wean off as PE/DVT resolves. Started Lovenox ___ bid (1mg/kg
bid) and coumadin 5mg daiy on ___. INR on ___ was 1.1.
Patient will go to ___ for Lovenox/coumadin bridging
and continued monitoring. Once INR ___, can discontinue
lovenox. Please arrange follow up and INR monitoring with
patient's PCP- ___.
# COPD: Patient only with ___ year smoking history, but recently
diagnosed with COPD. Uses rescue inhalers every few days.
Continue tiotropium and albuterol prn.
# Depression: Continued celexa daily.
# Transitional issues:
- code status: full code
- pending labs: none
- follow up issues: INR check, Lovenox- coumadin bridging;
Please arrange follow up and INR monitoring with patient's PCP-
___ prior to discharge from ___ | 83 | 252 |
14581261-DS-10 | 28,296,393 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted for shortness of breath, you were found
to have a heart failure exacerbation, for which you were given
IV lasix to remove fluid from your body. You underwent a right
heart catheterization to evaluate your fluid level and it showed
your fluid level was down appropriately. You had a cough and
underwent a CT scan which was normal. Your cough was probably
from allergies.
You are being discharged with several new medications. You have
a new inhaler, called fluticasone to help your allergies. You
are also being discharged with loratidine to help control your
allergies. Finally, you are being discharged with several cough
medications.
We discontinued your valsartan, hydralazine and torsemide this
hospitalization because your kidneys were not working as well as
they were before you came in. You should speak with your
cardiologist about restarting these medications.
During your hospitalization, you were also found to have anemia.
You received a blood transfusion, and your anemia improved.
It was a pleasure to help care for you during this
hospitalization, and we wish you all the best in the future.
Sincerely,
Your ___ Team | Ms. ___ is an ___ w/PMHx notable for colon CA s/p
sigmoidectomy, most recent colonoscopy ___ years PTA, dCHF (EF
70-75% ___, CKD stage IV, refactory HTN (baseline elevated
BPs,), HLD, and chronic anemia (baseline hct ___ who
presented with exertional dyspnea and worsening leg swelling.
# Acute decompensated dCHF:She was admitted to the cardiology
service for dCHF exacerbation. Presented with proBNP elevated >
3000, worsening dyspnea on exertion, and clinical evidence of
volume overload. Admission weight was 111 (Baseline 108-110).
She was started on IV lasix ggt which was uptitrated to 20mg/hr
and given boluses of 80-120mg. She also required one dose of
metolazone. Repeat cardiac enzymes reassuring, no evidence of
ischemia. She underwent a right heart cath that showed low right
atrial pressures and low wedge pressure. She was discharged
without torsemide, given that she appeared slightly dry and had
ATN (see below).
Patients discharge weight was 47.6kg.
#Acute on chronic kidney disease: Pt developed worsening renal
function in the setting of aggressive diuresis. Creatinine
peaked at 3.2 and downtrended. Pt was otherwise not oliguric.
Urine showed muddy brown casts, and pt was felt to have ATN from
overdiuresis. Pt's valsartan was held in the setting of her
kidney function, and she was discharged with a plan to consider
resuming this medication after her AOCKD had resolved.
#Cough- patient developed a cough with sputum production. No
evidence of leukocytosis or fever. CXR concerning for RUL
opacity. She underwent a CT scan that showed no evidence of
pneumonia. She was empirically started on vancomycin and
levofloxacin, which was discontinued on ___. Pt was noted to
have some wheezing, and she was thought to have a non-bacterial
bronchitis with subsequent possible reactive airway disease. She
was started on cetirazine and a fluticasone inhaler, in addition
to several cough medications. In addition, she was started on a
5-day course of azithromycin (d1 = ___. She refused to
take oral steroids.
# Anemia: H/H on admission of 7.___.3, improved to ___ during
hospital stay and after 1 unit of PRBC. Patient had no signs or
symptoms of bleeding, Guaiac negative in ED. Her baseline H/H is
approx ___. Notably, during her last hospital stay, she
presented with a GIB with Hct drop to 17, which did correct with
2u PRBC transfusion. She was offered colonoscopy given her
history of colon cancer, which she declined during her last
hospital stay. We touched base with Dr. ___
nephrologist, who reports she will likely receive EPO upon
discharge.
# Acute on Chronic Kidney Injury: Creatinine on admission to
2.3, consistent with recent baseline of 2.0-2.5. Her home
valsartan 320 mg daily was held while actively diuresing. Pt's
creatinine increased to 3.2 during this admission in the setting
of aggressive diuresis. After holding diuresis, her Cr decreased
to 2.8. This should be trended until she returns fully to
baseline.
# HTN: Longstanding issue. Per last discharge summary, she gets
symptomatic with SBPs < 160. Her outpatient cardiologist is
considering pseudohypertension as the cause of her refractory
elevated pressures, and/or sleep apnea. However, the patient was
not symptomatic during this hospital stay with blood pressure
often dipping to 130s and 140s systolic. She was continued on
her carvedilol, but hydralazine and valsartan were held.
# HLD: Continued home pravastatin.
# GERD: Omeprazole dose was increased during this
hospitalization.
# Macular degeneration: stable.
# CODE: DNR/DNI confirmed
# EMERGENCY CONTACT: ___ (son) ___
TRANSITIONAL ISSUES
==================================
-Hold home torsemide
-Recheck Chem-7 on ___
-Check weekly creatinine until stable
-Avoid nephrotoxic medications until ATN resolves
-Consider restarting valsartan when creatinine improves
-Consider restarting hydralazine if blood pressure tolerates
-Daily weights. Please start Torsemide 20mg/d if greater than 3
pound weight gain
-5-day course of azithromycin (d1 = ___
-Continue fluticasone inhaler
-Continue albuterol inhaler
-Follow up with cardiology
-Follow up with nephrology
-Consider outpatient EPO | 196 | 625 |
10890576-DS-3 | 28,264,621 | Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted with some confusion and low blood pressures. We think
you may have been dehydrated. You should be sure to eat and
drink enough at home. Your electrolytes were also slightly
abnormal on admission. They improved with some fluids and we
think this was due to dehydration.
We hope you continue to feel well.
-Your ___ team | ___ year old male hx. HTN, CHF, afib, CHB s/p pacemaker,
rheumatic heart disease s/p AV replacement, ILD thought due to
amiodarone toxicity, CKD, dementia presenting with c/o AMS and
hypotension.
# Hypotension: Resolved. Likely related to poor PO intake given
family reported patient with chronically poor PO intake, likely
related to his dementia. Less likely was adrenal insufficiency
given patient was on slow prednisone taper and was still on 30
mg prednisone daily. SBPs improved with fluids and 100mg IV
hydrocort in ED. Elevated lactate suggested some hypoperfusion,
trended down with IVF. There were no signs of infection during
admission and U/A was negative. TSH was within normal limits.
Orthostatics were checked on the medical ward and were normal.
He was discharged on his home dose of prednisone to continue his
taper as directed by his pulmonologist and PCP.
# AMS, suspect toxic-metabolic encephalopathy: episode of
confusion on admission but patient returned back to baseline
mental status as per son. No syncope. Head CT negative for acute
process. Patient does have baseline dementia. Likely related to
hypoperfusion in setting of poor PO intake and underlying
dementia. Family was advised to assist patient in maintaining
good PO intake to help prevent hypotension and subsequent
hypoperfusion.
# Hyponatremia: Resolved. sodium 130 on admission, 138 with IVF
and steroids. Likely hypovolemic hyponatremia given
hypotension, improvement with IVF.
# ILD: Thought due to amiodarone toxicity, on intermittent home
02. Was comfortable on room air during hospitalization.
Discharged on home prednisone taper.
# afib s/p pacemaker: V paced on admission. Continued on his
home digoxin. Digoxin level was checked, was low at 0.4.
Recommend titrating dose as indicated.
# s/dCHF: last ECHO ___ with normal EF but mild MR and moderate
TR, stays post AV replacement for rheumatic heart disease. No
specific intervention during his admission for this issue.
# CKD: Creatinine at baseline on admission.
# s/p CVA: continued home plavix
# GERD: continued home omeprazole
# Dementia/Psych: continued home wellbutrin, memantine | 75 | 345 |
16584374-DS-10 | 28,652,781 | It was a pleasure taking care of you during your stay at ___
___. You were admitted after passing out
and found to have a very slow heart rate. We suspect this may
have been related to your medication and switched your atenolol
to metoprolol. Your heart rate varies from too slow to too fast,
and you may need a pacemaker for this. However, we would like to
evaluate this further first by implanting a small recorder to
measure your heart rate over time which was placed while you
were here. | ___ male with a history of liver localized gallbladder ca, IPF
and Afib who was found to have slow afib HR ___ after a syncopal
episode and admitted.
Syncope
- The patient had a sudden drop attack consistent with a cardiac
etiology and was bradycardia on arrival to the ED. Cardiology
was consulted. His home atenolol was stopped and he had episodes
of tachycardia to the 120s so he was started on metoprolol. He
does have a history of atrial fibrillation. He had a implanted
recorder placed which will be monitored by cardiology to
determine if he will need a pacemaker in the future. He will
follow up with cardiology as an outpatient.
Leukocytosis
- He had a leukocytosis present on admission. He did not have
any localizing symptoms and cultures were negative so it was
likely reactive.
Gallbladder cancer
- He will follow up with his oncologist as an outpatient for
scheduled reimaging.
Idiopathic pulmonary fibrosis and Asbestosis
- He will continue his home continuous oxygen. | 91 | 160 |
13696547-DS-20 | 24,825,375 | ___,
You were admitted to the hospital for fever after chemotherapy.
You were found to have some e coli bacteria in your urine, for
which you were treated with antibiotics.
You should discuss your chemo/treatment action plan further with
your oncologist.
It was a pleasure taking care of you!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with recurrent/metastatic
cervical cancer who presented for fever iso active chemotherapy
and radiation. | 49 | 19 |
13814277-DS-2 | 23,883,348 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take enoxaparin (Lovenox) 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- You may bear weight as tolerated with the left leg. Please
adhere to the posterior hip precautions taught to you by the
physical therapist. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left total hip arthroplasty,
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. The patient
was given perioperative antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity with posterior hip precautions, and will be
discharged on enoxaparin for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. | 145 | 243 |
16319376-DS-16 | 26,843,409 | -You were diagnosed with an infection of the blood and urine. A
MID-LINE IV was placed for ongoing IV antibiotics.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ OTHERWISE NOTED; AVOID aspirin or aspirin containing
products and supplements that may have blood-thinning effects
(like Fish Oil, Vitamin E, etc.). This will be noted in your
medication reconciliation.
IF PRESCRIBED (see the MEDICATION RECONCILIATION):
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
For pain control, try TYLENOL (acetaminophen) FIRST, then
ibuprofen, and then take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > 101.5 F, vomiting, syncope (fainting
concerns)call your doctor or go to the nearest emergency room. | This patient was admitted to Dr. ___ service for
fever and syncope following a prostate biopsy. He was started
empirically on vancomycin and ceftriaxone for antibiotic
coverage. He was voiding without difficulty and had a documented
low PVR. Over the course of the next ___ he continued to
develop fevers as high as ___. As such he was switched to IV
zosyn and the infectious disease service was consulted. His
urine and blood cultures ultimately demonstrated multi-drug
resistant E coli. He was switched to meropenem based off the
sensitivities and remained afebrile for >24hrs. A PICC was then
obtained and he was discharged on meropenem monotherapy.
Of note, he was also kept on telemetry during his hospital stay
given his syncope prior to admission in the setting of fevers
and infection. An EKG and cardiac markers were negative and he
experienced no other episodes of syncope or angina. | 325 | 147 |
12847530-DS-4 | 23,238,339 | Dear Mr. ___,
You were admitted to ___ with acute cholecystitis, which is an
infection of your gallbladder. You were started on IV
antibiotics and given IV fluids. You underwent a procedure
called percutaneous cholecystotomy, meaning a drain was placed
in your gallbladder to help drain the bile and clear your
infection. You tolerated this procedure well and your pain
improved. You are able to be discharged safely from the hospital
and should follow up so that your drain can be removed.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Mr. ___ is a ___ year old male with pmh significant for CAD
s/p PCI, HTN, DM2, and COPD that presented to the emergency
department for evaluation of abdominal discomfort, nausea, and
diarrhea. Labs on arrival were notable for a leukocytosis of
15.7 and lactate of 4.9. His imaging showed evidence of
ileocecal inflammation, cholelithiasis and gallbladder wall
thickening, significant pericholecystic edema, and potential
evidence of pneumonia incompletely evaluated on CT scan. Given
his overall picture was consistent with acute cholecystitis, he
was admitted and made NPO. He was started on IVF for
resuscitation, and started on cefepime/flagyl, which was
subsequently switched to ceftriaxone/flagyl. A foley was placed
for UOP monitoring and his lactate was trended and came down to
1.4 over the next few hours. He was hemodynamically stable, with
improvement in abdominal pain and nausea, so was therefore
admitted to the floor.
He was evaluated by ___, and on HD2, underwent percutaneous
cholecystostomy. He tolerated the procedure well and RUQ pain
continued to improve. Diet was advanced as tolerated
post-procedure. He received IV fluids post-procedure which were
stopped once he had adequate PO intake. During this
hospitalization, he ambulated early and frequently, was adherent
with respiratory toilet and incentive spirometry, and actively
participated in the plan of care. He received subcutaneous
heparin and venodyne boots were used during this stay.
At the time of discharge, he was doing well, afebrile,
hemodynamically stable, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. He was
discharged home without services. He received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 299 | 267 |
14120129-DS-15 | 25,812,689 | you were admitted with diabetic ketoacidosis and L ear infection
it is critical to your health to use insulin correctly. your
diabetes is a chronic condition and safe and correct use of
insulin is SO important to keep you healthy
you will need antibiotics for your ear infection
you should have a repeat exam with the ear nose throat
specialist | ___ F with poorly controlled type 1 diabetes with recent
admission to OSH for DKA presenting with left ear pain and
vomiting and found to have evidence of mild DKA.
# Diabetic Ketoacidosis: patient with HCO3 of 13 with anion gap
of 23 on presentation to the ED and 1000 glucose and + ketones
on UA. Blood gas not done. She was started on insulin drip and
had glucose <250 and normal anion gap by the time of arrival to
the MICU. Precipitant is most likely infection, as well as poor
adherence to insulin regimen. Tox screen negative. She was
given glargine 32 Units and the insulin drip was discontinued.
Anion gap remained <12 on serial re-check. She should be
followed closely for glucose control as an outpt. She reported
that she did not have a glucometer at home and was provided one.
Her Hgb A1c was measured to be 14.7%. Her insulin regimen was
adjusted (see discharge medications below). She was also noted
to have a painful ingrown toenail, which was removed by
podiatry. She will follow up with podiatry as an outpt.
# Ear Pain: per ENT evaluation, most likely uncomplicated otitis
externa with preauricular cellulitis, (hard to assess for otitis
media as TM not fully seen), mastoiditis or bony invasion in
area of maxillary sinus. She had L maxillary sinus opacification
that could be mucocele or mycetoma.. Emperic antibiotics will
treat both processes. Patient afebrile without elevated WBC.
She was not compliant with full nasal endoscopy with ent but no
purulence seen in nasal passages. Plan will be to offer her ENT
outpatient f/u She was treated with Ciprodex drops and
amp/sulbactam 3mg IV q6h with plan to transition to PO augmentin
to complete 7d course. She will follow up with ENT for her
otitis externa and for the maxillary sinus finding on CT.
# Depression: patient appeared depressed on admission without
suicidial ideation. She has been engaging in self-neglect with
avoidance of insulin despite knowing diagnosis of DM type 1 and
consequences of poorly managed glucose. She should be considered
for outpt psychiatry and counseling for depression.
# Thrombocytosis: most likely hemoconcentration in setting of
volume depletion | 58 | 369 |
15393180-DS-25 | 27,577,330 | Dear Ms. ___,
You were admitted to the hospital for shortness of breath. You
were treated with medicine to get rid of excess fluid from heart
failure. Please take all your medicines as prescribed and weigh
yourself every morning. Please call your doctor if weight goes
up more than 3 lbs or you continue to have shortness of breath
or chest pain.
It was a pleasure taking care of you, ___ of luck.
Your ___ medical team | Summary
Ms. ___ is a ___ woman with a history of diastolic
heart failure, hypertension, and COPD with recent admission for
NSTEMI found to have newly depressed EF consistent with
Takotusbo's who presents with PND and dyspnea on exertion. She
improved with a dose of IV diuresis and was discharged to rehab.
Acute issues
#Takotusbo cardiomyopathy: On previous admission, she was
diuresed with IV Lasix and her home Lasix was increased to 40 mg
daily. She was started on metoprolol XL and apixiban to prevent
apical thrombus. Weight on discharge was 66.6 kg. Since
discharge, the patient reported multiple episodes of PND,
weakness, and dyspnea on exertion. On this admission, she was
treated with further IV diuresis and started on carvedilol 3.125
mg BID. She appeared euvolemic on discharge with normal
laboratory values and improved symptoms. She will be discharged
on Lasix 40 mg po qd and Carvedilol 3.125 mg BID. She was
evaluated by OT and ___ with plans to go to ___
___ after discharge with close follow up with her PCP and
cardiologist.
Chronic issues
# Apical thrombus prophyllaxis: Continue apixaban 5 mg.
# COPD: Continued home albuterol and montelukast 10mg PO Daily
# Hypertension: Started carvedilol 3.125mg BID as above.
# GERD: Continued home ranitidine 150mg PO BID.
# Allergies: Continued home cetirizine 10mg PO BID. | 75 | 223 |
17669282-DS-14 | 22,255,704 | Surgery/ Procedures:
You had a diagnostic angiogram x2 which were both negative for
aneurysm or vascular abnormality. You may experience some mild
tenderness and bruising at the puncture site (wrist).
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Please do NOT take any blood thinning medication
(Aspirin, 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:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
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 | #SAH
___ presented as a transfer from an OSH ___ with
worst headache of life and SAH. While in the ED, he became more
lethargic so repeat CT was done, which showed increased edema,
increased SAH, and trace IVH. CTA at outside hospital was
negative for vascular abnormality. He was admitted to the Neuro
ICU. Blood pressure was maintained for SBP goal <140. He was
started on Nimodipine 60mg q4h. On ___, he underwent a
diagnostic cerebral angiogram which was negative for aneurysm.
On ___, blood pressure goal was liberalized to <160 and he was
called out to the ___. On ___, the patient was started on
prophylactic SQH. The arterial line was discontinued. TCDs were
ordered for daily. On ___ they were negative for acute
vasospasm. He was called out to the ___ and transferred
overnight on ___ for continued close neurological monitoring.
Patient continued to complain of severe headaches despite PRN
analgesics. Patient was started on a 3day steroid taper on ___
for headache relief. Patient's fluid status was maintained as
euvolemic. TCD on ___ was negative for acute vasospasm. His
7-day course of Keppra completed the evening of ___. On ___, he
remained neurologically intact on examination. He remained in
the ___ for close neurologic monitoring in anticipation for
repeat angiogram the following day. Angiogram was repeated on
___, which was also negative. The patient remained
neurologically stable. The patient and wife were provided
discharge education together on day of discharge and patient was
advised to set up a PCP after discharge. His Nimodipine was
stopped at discharge.
#Headache
The patient endorsed significant headaches throughout his
admission that were not completely resolved with prn APAP and
Oxycodone. He was put on a 3-day Dexamethasone taper, which
improved his headache pain. This taper ended on ___, after which
his headaches became more severe. He was put on another 3-day
Dexamethsone taper starting ___. His APAP was also increased and
made standing. The patients pain was well tolerated on Tylenol
and oxycodone.
#Constipation
Patient on ___ made note that he was feeling very constipated
and had not had a bowel movement since ___. Patient admits to
passing gas, no complaints of abdominal pain and abdomen were
soft/ND. Patient's bowel regimen was increased and he was able
to successfully move his bowels three times per patient report.
He was discharged with education on using over the counter
medications for constipation while on narcotics.
#Disposition
Physical therapy evaluated patient on ___ and recommended home
following ___ more visits. Occupational therapy evaluated
patient on ___ ___nd recommended home following ___ more
visits. On re-evaluation it was recommended the patient
discharge to home with outpatient ___. He was provided with a
prescription for ___ at discharge. | 298 | 451 |
13450481-DS-6 | 24,831,469 | You were transferred from another hospital for further
management of gallstone pancreatitis. For this, you underwent an
ERCP where stones were removed from your bile ducts and a
sphincterotomy (an area of narrowing was opened) was performed.
You were also evaluated by the surgical team who recommended
that your follow up in surgical clinic to discuss having your
gallbladder removed. You declined surgery during admission. Your
abdominal pain resolved and your diet was successfully advanced
without complications.
.
Medication changes:
1.start antibiotics, cipro and flagyl for 5 more days
.
Please take all of your medications as prescribed and follow up
with the appointments below. | Assessment/Plan: ___ is a ___ y.o male with no significant PMH who
was transferred from OSH for gallstone pancreatitis.
.
#gallstone pancreatitis/bile duct
obstruction/transaminitis-Secondary to gallstones as gallstones
were seen on imaging and ERCP. Denied ETOH. Pt presented with
transaminitis and elevated bilirubin suggestive of obstruction.
ERCP performed finding choledocholithiasis. Sphincterotomy was
performed. General surgery was consulted for consideration of
CCY. However, pt stated that he preferred to wait several weeks
before undergoing a surgery. For pancreatitis, pt was treated
with bowel rest, IV fluids and medication for pain and nausea.
Pt also treated with antibiotics for a total of 10 day course.
He was discharged with cipro/flagyl for 5 more days of therapy.
Pt's symptoms gradually improved and his diet was slowly
advanced without complications. LFTs and lipase trended down and
essentially normalized during admission. Pt was advised to avoid
ETOH (which he denies anyway) and follow a low fat diet. Pt will
follow up with PCP and general surgery for ongoing care and to
continue to discuss cholecystectomy. (see below for
appointments)
.
#fever/chills/leukocytosis-likely related to biliary
obstruction/cholangitis and acute pancreatitis. Pt reported
recent mild cough, but CXR was without PNA and pt did not have
any other localizing signs of infection. Pt was given unasyn for
4 days, however UCX (without UTI symptoms) grew 10,000-100,000
ecoli and antibiotics were changed to cipro/flagyl at that time.
Pt will complete 6 days of cipro/flagyl for a total of 10 day
course for cholangitis.
.
#sob-was transient, quickly resolved. Likely in the setting of
aggressive IVF. CXR was negative. EKG showed LBBB (the morning
after SOB had already resolved). 1 set of cardiac enzymes
negative. There were no prior EKG's for comparison and PCP's
office was called several times to ask for fax of prior EKG
unsuccessfully. Would consider further outpt cardiac work up. ___
did not have any chest pain, palpitations or any other cardiac
symptoms.
.
#EKG findings-LBBB-would compare to prior EKG's. Pt had
transient SOB in the setting of IV fluids for pancreatitis.
Please compare prior EKG's and consider further cardiac work up
as needed. Unable to obtain prior EKG's during admission. No
prior on file at ___.
.
#ecoli in the urine- no symptoms of UTI. However, Cipro for
cholangitis will tx for UTI. .
#normocytic anemia-no currently signs of active bleeding.
Unclear baseline. HCT remained between ___ during admission
and was 31.2 on the day of discharge. Stools were ordered for
guaiac. Would strongly consider outpatient colonoscopy and/or
iron studies.
.
DVT PPx: hep SC TID
.
CODE: FULL
. | 100 | 435 |
10120826-DS-8 | 23,274,807 | You were admitted with a cord compression. You elected no
surgery. You had urgent radiation to your spine. You will
continue radiation next week for three sessions (mon, tue, NOT
wed, and then resume ___ for your last session). You also
were started on high dose steroids with dexamethasone. You need
this to help the swelling and your weakness. However it caused
an elevation of your sugars so we cut it down to 4 mg twice a
day (ideally every 12 hours). Please talk to your radiation
oncologist on how to reduce the dose. If it causes you
heartburn, let them know. Please keep an eye on your sugars and
follow the instructions you were given from the ___ diabetes
doctor. | ___ PMH of Metastatic Prostate Cancer (previously
Enzalutamide/Lupron) presented to ED with worsening back pain
and lower extremity weakness, found to have cord compression ___
metastatic disease.
# Back Pain
# Lower Extremity Weakness
# Malignant Cord Compression
Patient p/w back pain and lower extremity weakness, found to
have
metastatic lesion at T6 causing cord compression. He was seen
by neurosurgery and patient elected to forgo surgery. He agreed
to receive palliative XRT. His lower ext weakness improved
significantly nearly immediately and he decided to pursue
hospice.
Hospice screen him and accepted him. On discharge, we were
notified
he actually is not accepted at this time because he wanted to
continue the remaining sessions of XRT next week. They will
admit him to their services after his radiation next ___.
- cont dex 4 mg, tapered down to BID bc of hyperglycemia
- continue fentanyl patch
- ___ was being arranged for him but no agencies were responding
to our CM on this ___ afternoon so in respect for his wishes
to leave the hospital asap and considering his ability to care
for himself and his wife's support, they decided to not wait for
us to arrange ___ at home and went home w/o services.
# Metastatic Prostate Cancer
Pt has progressive disease and was clear at time of discharge
did not want any further chemotherapy. Was seen by SW and pt
decided that he wanted hospice.
# HTN
-Continue metoprolol/losartan
# ID-T2DM
Was seen by ___ for uncontrolled DM while on dex. Pt was
adamant he wanted to leave asap so they helped create a sliding
scale for him.
BILLING: >30 min spent coordinating care for discharge | 121 | 262 |
13974811-DS-25 | 26,161,768 | ___ y/o woman with hx of mild extensive ulcerative colitis (dx
___ with diarrhea, bloody stool, abdominal pain not currently
on treatment who presented with abdominal pain several days of
worsening abdominal pain. Attempts at pain control with SL
hyoscyamine, IV compazine, and a GI cocktail were performed. Her
outpatient GI doctor, ___ was contacted regarding
further initiation of more definitive UC therapy. She was also
found to have pyuria and symptoms that seemed to correlate with
a UTI. She received a dose of ceftriaxone. However, the patient
eloped before further assessment and intervention could be made. | ___ y/o woman with hx of mild extensive ulcerative colitis (dx
___ with diarrhea, bloody stool, abdominal pain not currently
on treatment who presented with abdominal pain several days of
worsening abdominal pain.
# Abdominal pain:
Ms. ___ has been followed closely by GI for her UC. A recent
c-scope on ___ did have evidence of mild colitis and at that
discussion surrouding initation of UC treatment began. Prior to
starting any UC directed medications she presented to the ED
with complaints of severe pain. On arrival she was afebrile and
labs were reassuring that she was not incurring a substantial UC
flare: mild leukocytosis, low CRP, furthermore a CT scan was
without evidence of inflammation. She was seen by GI in the ED
who was concerned for non-IBD mediated pain such as functional
pain/IBS. In discussion with the patient, she was very
persistent in asking for narcotic medications for her pain. It
was discussed at length that narcotics are not a great option
for pain in IBD given their motility effects and recurrence of
pain with cessation along with potential for addiction. We aimed
to address her pain with many different modalities including
anti-spasmodics (dicyclomine or SL hyoscyamine), GI cocktail,
and IV compazine for nausea (was refractory to zofran) with a
plan for initiation of more definitive UC therapy per GI. The
morning following her admission, she was evaluated by the
medical team. She was noted to writhing in bed and would not
permit a physician to examine her. Prior to reviewing the case
with the GI team and formulating a plan, the patient eloped.
After the patient eloped, she was called at her number in ___,
but did not answer. She should follow-up with her GI physician
___ further management of her UC.
# Mild leukocytosis: No other signs of systemic inflammation
were present on exam. The pt had abdominal pain as above and
thought she may have had some recent urinary urgency symptoms.
Pyuria on u/a was concerning for UTI. Urine cultures were added
on and are pending at discharge. She received one dose of
empiric IV ceftriaxone before she eloped.
# Recent strep throat: Diagnosed on ___ with rapid strep test
in clinic. Given empiric ceftriaxone as above, amoxicillin was
initially held. However, given that pt eloped, she already was
being treated with amoxicillin at home and can continue this
regimen.
TRANSITIONAL ISSUES
===================
# Results pending: Urine culture, blood culture
# New/changed medications: None.
# Follow-up: Pt should follow-up with PCP.
# Code: presumed full | 97 | 418 |
18886179-DS-21 | 27,917,463 | Dear ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office with
any questions or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking opioids (e.g. oxycodone,
hydromorphone)
* Take a stool softener such as colace while taking opioids to
prevent constipation.
* Do not combine opioid and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 6
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* Leave the steri-strips in place. They will fall off on their
own. If they have not fallen off by 7 days post-op, you may
remove them.
* If you have staples, they will be removed at your follow-up
visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the gynecology
service after presenting to the ED with abdominal pain and
imaging concerning for intermittent torsion. She was admitted
for pain management, observation, and definitive surgical
management.
On hospital day 2, she remained hemodynamically stable with pain
well controlled with intravenous morphine. On the morning of
___, she underwent operative laparoscopy; right ovarian
cystectomy; bilateral salpingectomies; lysis of adhesions.
Please see the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with intravenous dilauded and
Toradol and she was rapidly transitioned to oral oxycodone,
acetaminophen, and ibuprofen. Shortly following her procedure
her pain was well controlled with oral agents and she was
ambulating and tolerating a regular diet. She voided
spontaneously without difficulty. She was thus discharged home
on post-operative day 0 in stable condition with outpatient
follow-up scheduled. | 328 | 142 |
13012527-DS-9 | 29,825,183 | Dear Ms. ___,
It was an absolute pleasure taking care of your during your
admission to the ___. You were
admitted for dizziness and being very sleepy.
For your dizziness, we treated you with IV fluids and a
medication called Meclizine which prevents dizziness. You had a
CT scan which showed no bleeding in your brain. You also had an
MRI scan which showed
There was no infection in your urine or blood. Your chest xray
showed no pneumonia.
The cause of your dizziness is likely Benign Positional Vertigo-
a condition where a crystal in the ear causes dizziness. The
treatment is ___ at your nearest Physical Therapy
location. Meclizine is a medication that can also help.
For your hypertension, we continued your home medications. We
stopped your HCTZ because you were dehydrated and we were giving
you IV fluids. Please continue to stop this medication until
your primary care doctor tells you that you should resume it.
Make sure to stay hydrated each day.
Medication changes:
STOP: hydrochlorothiazide- a blood pressure medication, this is
no longer necessary, talk to your primary care doctor about when
to resume it
START: Meclizine- this will help your dizziness. Only take it
for the next 3 days.
We encourage you to get outpatient physical therapy to address
your vertigo. Please bring the attached prescription to the
physical therapy. | ___ F w/ hx of aneurysms (subarachnoid hemorrhage and found to
have posterior communicating artery aneursym with CN III lesion,
and 3mm L MCA bifurcation, sp coiling of R ICA aneurysm in ___
who is admitted for vertigo.
Vertigo/Benign Positional Vertigo: Clinically improved during
hospitalization. This is likely secondary to Benign positional
vertigo as she was ___ positive L>R. CT, CTA, MRI head
all negative for acute process, posterior infarct, TIA, or
lacunar infarct. Neurology was consulted and agreed with
diagnosis of BPPV. TSH, glucose, cortisol wnl. Pt was started on
meclizine and told to engage in ___ for BPPV to
teach Epley maneuver.
Hypothemia: Pt had one reading in the ED: rectal temp 94. No
signs of infection, TSH, Cortisol wnl. Pt had no further
episodes and temp remained in the 98 range throughout
hospitalization. Per neurology, this isolated hypothermic
episode might be secondary to her history of subarachnoid
hemorrhage that can irritate the hypothalamus and cause
occasional temperature irregularities in setting of illness.
HTN: Continued home medications but held hydrochlorothiazide
since patient was initialy orthostatic. She was told to continue
to stop this medication outpatient unless her outpatient
providers say otherwise. SBP range in the 100s off the HCTZ.
-metop tartate 100mg BID
-spironolactone 25mg daily
-amlodipine 10mg daily
-lisinopril 40mg daily
HLD: continued pravastatin 40mg
Psych: continued sertraline 125mg daily
___ CVA: Continued home plavix 75 mg tablet PO QD | 218 | 227 |
13981844-DS-23 | 23,428,194 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
Why you were admitted to the hospital:
- You were having cough, shortness of breath, and fatigue
What happened while you were here:
- You were diagnosed with influenza (flu)
- You were treated with Tamiflu for the influenza and
intravenous antibiotics for a possible superimposed pneumonia
(bacterial infection)
- You were given oxygen to help you breath and medications to
help your blood counts
What you should do once you return home:
- Continue taking your medications as prescribed and follow up
with the appointments outlined below
- You can continue taking cough medications until your symptoms
improve
- You can walk-in to the second floor ___ to have your
TLSO brace modified by orthotics; ___ need for an appointment
- Please call our clinic or return to the ED for new fever (temp
>100.4)
We hope you feel better!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ y/o female with a history of multiple
myeloma on Carfilzomib/Revlimid/Dexamethasone who presented with
dyspnea and cough, diagnosed with influenza A.
# Influenza A
# Bacterial pneumonia
The patient presented with cough, shortness of breath, and
fatigue. Initial work up included a CTA that was negative for PE
but showed diffuse bronchial wall thickening, enlarged bilateral
hilar lymph nodes and bibasilar consolidations c/w infection.
Influenza A then returned positive and she was started on
oseltamivir. Given her immunocompromised state and borderline
neutropenia, she was also treated for superimposed CAP + MRSA
coverage with vancomycin, ceftriaxone, & azithromycin. Urine
legionella, sputum culture, and blood cultures were negative.
After ___ days, she developed a new oxygen requirement,
prompting a second CT chest that showed mildly enlarged
bilateral consolidations and peribronchial inflammation
concerning for slightly worsening bronchopneumonia. She was
continue on broad spectrum antibiotics, oseltamivir and given
IVIG 400 mg/kg after her IgG level was found to be 181. She
subsequently improved clinically and was weaned to room air.
Vancomycin was narrowed after a MRSA swab returned negative; she
was ultimately treated with oseltamivir x7 days, azithromycin x
5 days, and CTX x7 days before narrowing to levofloxacin with
plan to complete a 14 day course for complicated pneumonia.
# Multiple Myeloma
# Neutropenia
History of multiple myeloma on carfilizomib, revlimid, and
dexamethasone. ___ treatment was given during this admission in
the setting of her acute illness. She had dropping ANC to 550,
likely treatment related. She was given neupogen x1 on ___ with
improvement in counts. She was also continued on ppx acyclovir
and Bactrim. She will follow up with Dr. ___ further
management.
#Aphthous ulcer
Exam was notable for a 0.5 cm aphthous ulcer near tooth 32. She
was treated symptomatically with topical lidocaine with some
improvement. Her exam remained unchanged throughout the
hospitalization. | 151 | 303 |
18092291-DS-10 | 20,400,787 | Dear Mr. ___,
You were admitted to ___ because you were having shortness of
breath. We found fluid around your heart on an ultrasound of
your heart. The fluid was drained through a procedure called a
pericardiocentesis. It is now safe for you to go home. Please
follow-up with your primary care doctor and ___ cardiologist at
the appointment times listed below. You will need weekly
ultrasounds of your heart for the next month to make sure there
is no reaccumulation of fluid. Your echo appointments have been
scheduled for every ___ at 11 AM (on ___, and
___. You should restart your home medication, Eliquis, on
___.
It was a pleasure caring for you,
Your ___ Team | ___ yo M with history of CAD (s/p prior OM1 and mid-RCA
drug-eluting stents on ___ and A-flutter s/p atrial
ablation (___) and subsequent cardioversion (___), with
subsequent AF with slow RVR (40s) s/p PPM (___) on Eliquis,
presented w/ one week of dyspnea and dizziness, found to have a
pericardial effusion and drop in hemoglobin. He is s/p
pericardiocentesis which drained 1.6L of exudative fluid w/ HCT
of 30.0. He had a drain placed temporarily which was later
removed. A repeat TTE showed mild to moderate sized effusion.
His H/H stabilized and we determined it was safe for discharge
home with plan for close cardiology follow up with weekly echos.
# Pericardial effusion: Diagnosed in ED on bedside echo, 400 cc
volume, likely from recent pacemaker implantation. Now s/p
pericardiocentesis with fluid studies demonstrating likely
exudative effusion and drainage of 1.6 L of dark blood. HCT of
30, LDH 1247. He had a drain placed that was removed later. TTE
showing RV dysfunction ___ unclear etiology. possible lung
disease, hepatopulmonary syndrome vs. portopulmonary
hypertension. He had stable H/Hs following procedure and a
repeat ECHO showing mild to moderate reaccumulation. His pulsus
remained normal throughout. His Eliquis was held until a week
after the placement of the drain (restart ___. He is scheduled
for weekly ECHOs for a the following month. He is to follow-up
with EP outpatient.
# ___: Baseline cr of 0.9-1.0, up to 1.7, likely from
pericardial effusion causing poor forward flow. Improved after
pericardiocentesis and albumin administration.
# Concern for GI bleed: Evaluated by hepatology in ED, they were
concerned for GI bleed given description of "black stool".
However, patient reports that he recently started taking iron
tabs, and this is his usual stool color afterward. Treating
cautiously now. Initially on octreotide, pantoprazole, and
ceftriaxone, which were all later discontinued after
consultation with hepatology. His H/H downtrended likely due to
the hemopericardium.
# CAD s/p DES (OM1, mid-RCA): At home, on lisinopril, aspirin,
simvastatin. Beta-blocker was dc'ed in ___ due to low HRs. We
discharged him on metoprolol XL PO 12.5 mg as he had a pacemaker
inserted.
# HCV Cirrhosis c/b portal gastropathy s/p Harvoni treatment.
Finished treatment, considered curative HCV. Followed by ___
Liver Clinic. Most recent EGD in ___ showed portal hypertensive
gastropathy. No issues with jaundice, ascites, or
encephalopathy. He is scheduled for a RUQ U/S outpatient for
follow-up. | 116 | 397 |
14112540-DS-13 | 26,538,897 | Discharge Instructions
Brain Abscess
Surgery
You underwent stereotactic drainage of a cerebral abscess. A
sample of the brain abscess was sent to the lab for testing and
a bacteria was identified.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
You also went to the operating room to have a tooth pulled,
that may have been related to the cause of your brain infection.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You may take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You have been started on antibiotics for your brain infection.
Please continue IV antibiotics (Metronidazole and Ceftriaxone),
at least until follow-up with the infectious disease physicians.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | Ms. ___ is a ___ woman with HTN, HLD, and DM2
transferred to ___ ___ after a non-contrast head CT showed
hypodensities in the left cerebellum. Patient was admitted to
the Neuro-ICU for further workup and close monitoring.
#Right Cerebellar Lesion
Patient was transferred rom OSH with NCHCT concerning for a
hypodensity in the left cerebellum. Originally concerning for
possible stroke. Stroke neurology consult was placed who
recommended further definition with an MRI/MRA. Patient
underwent an MRI on ___ which revealed a 2.3 x 2.0 x 1.6 cm
centrally cystic rim enhancing mass with surrounding edema
centered in the left pons/middle cerebellar peduncle with
prominently slowed diffusion and surrounding mass effect with
effacement of the fourth ventricle. Differential includes
abscess, particularly given prominent slowed diffusion, or
metastatic disease which appears less likely from the T2 signal
characteristics of the wall of the cavity and intrinsic slow
diffusion. Infectious disease was consulted given concern for
brain abscess. Patient also reported pain in L tooth concerning
for abscess so she was started on empiric Vancomycin and
Meropenem. On ___ patient clinical exam noted to be worse than
the previous day. Repeat stat MRI head revealed stable lesion
consistent with abscess. Given clinical deterioration patient
was transferred to the ICU for closer monitoring. She was given
Dexamethasone IV 10mg x1 and started on 4mg Q6H. She was brought
to the OR on ___ for aspiration of the abscess, it was
definitely determined that it was an abscess. Post operatively
she developed cranial nerve palsy of III, VI and VII. She was
started on Clonidine by the ICU team for erratic respirations on
the ventilator causing Resp alkalosis, which seemed to have a
good effect. Clonidine may be discontinued once she's off all
antibiotics. A couple days after her surgery she was extubated.
On ___, she was transferred out of the ICU, exam much improved
but continued with cranial nerve deficits and copious
secretions. After transfer to the floor, the patient remained
neurologically and hemodynamically stable. Occasionally during
the admission, the patient would complain of strange memories
such as the sudden recollection and obsession with seeing a
hospital staff person steal her credit card information after
surgery (family confirmed with the bank that no unexplained
transactions have been made), or that she'd seen a doctor "doing
yoga" in the corner of her room; at each of these times, the
patient was neurologically stable and no medical interventions
were made. She was redirectable by conversation.
#ID
She continue on vanco and meropenum IV, ID was consulted on and
agreed with antibiotic coverage. They also recommended obtaining
MRSA swabs of the nares and mouth. On ___ the MRSA final
cultures were negative and the Vancomycin was stopped. She was
continued on Meropenum. Per ID they have a high suspicion that
the abscess is related to her tooth and do recommend tooth
extraction as soon as possible. For now Meropenum should cover
tooth abscess. Continue to trend CRPs on ___ it was 6.9 down
from 9. ID recommended dental consult for tooth extraction for
source control. On ___ ID recommended d/c'ing foley for
suspicious UA and last UC which grew yeast. ID did not recommend
treatment. On ___, ID discussed her culture with ___
Pathology, who felt bacteria was consistent with odontogenic
Eikenella. Antibiotic therapy was adjusted to ceftriaxone and
flagyl and she was set up with OPAT for follow-up. She is
asymptomatic and afebrile and will continue to be monitored. Per
ID recommendations, a TTE was ordered to rule out leaflet
vegetation to avoid any possible future complications which
showed no masses or vegetations on the aortic or mitral valve.
The patient was discharged on Ceftriaxone and Flagyl.
#Dental Abscess
Patient reported L tooth pain for 1 month at the site of an old
filling. Concern that this could be source for possible brain
abscess. Dental consult was placed on ___. Dental did a limited
bedside evaluation and did not feel that there was an abscess
present. On ___, the ___/dental service was reconsulted as
anaerobic cultures grew fusobacterium nucleatum and ID was
concerned for potential dental source. Mandibular and Panorex
films showed no definitive abscess but revealed an advanced
cavity at tooth no. 20, which they were amenable to pulling in
case it was the source of infection. The patient was cleared for
the OR by the MERIT team. Patient went to the OR on ___ and
had tooth # 20 extracted. The tooth was sent for culture and
gram stain. Gram stain grew gram negative rods and budding
yeast.
#Diabetes Mellitus with Elevated A1c
Unclear if patient was taking insulin at home for history of DM
type 2. ___ consult was placed for management of blood sugar
while inpatient. A1c came back at 10.5. She was started on SSI
and a fixed dose insulin. Throughout the hospital stay her
insulin was adjusted by the endocrinologist for labile blood
glucose levels.
#Hyponatremia
On ___ it was noted that patient was hyponatremic to 131. She
was started on hypertonic saline. Her sodium levels began to
trend up and the hypertonic saline was weaned off. Her sodium
levels remained within normal limits without supplementation.
#Dysphagia
Speech and swallow followed the patient and performed many
assessments of the patient's ability to swallow. Ultimately, a
videoswallow study was ordered which revealed that she was
aspirating nectar thickened liquids; puree consistency solids
and honey-thickened liquids were recommended. She continued on
tube feeds and was started on calorie counts and strict I&O's to
ensure adequate intake and hydration. She had an NGT tube that
she self d/c'd on ___. Since then she has been taking in POs
and calorie counts are being done. Following her tooth
extraction on ___ she was then placed on calorie counts for
___. Her caloric intake was adequate and she did not
require PEG placement. Speech and swallow evaluated again and
upgraded her to ground diet, she continued to aspirate on nectar
so she continued honey thick liquids.
#Orthostatic Hypotension
Patient had intermittent orthostatic hypotension while working
with ___. Labetalol was decreased from TID to BID.
The patient was discharged to rehab on ___. | 459 | 1,018 |
16982881-DS-16 | 21,504,780 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with an ulcerative colitis
flare. You were treated with steroids and a medication called
remicade, which should be continued as an outpatient. We highly
recommend that you continue receiving remicade with our GI
specialists for now so that your care is not delayed. After
these initial doses, please feel free to establish care with any
GI center you prefer. In regards to your steroids, you will take
40mg daily of prednisone for a total of two weeks. Your last day
of the 40 mg dose will be ___. You will then taper down the dose
by 5mg weekly (35, 30, 25, etc). For example, you will start
taking 35mg on ___.
Please continue taking all medications as detailed in your
discharge paperwork and follow up with all scheduled
appointments. If you develop any of the danger signs listed
below, then please call your doctors ___ to the emergency room
immediately.
We wish you the best.
Sincerely,
Your ___ Team | ___ woman with UC presents with increased stool
frequency progressing to bloody diarrhea with lab findings and
imaging consistent with UC flare.
# Ulcerative Colitis flare:
Presented with increased stool frequency progressing to bloody
diarrhea. CRP was 97 on admission. C.diff and CMV VL negative.
Flex sig showed erythema, friability, granularity and abnormal
vascularity with contact bleeding noted in the rectum to the
distal sigmoid colon, consistent with severe UC flare. She was
treated with IV solumedrol q8h (day 1 = ___. She had continued
bloody diarrhea and was ultimately started on remicade rescue
therapy on ___, and repeat dose given ___, which she tolerated
well. On discharge Ms. ___ was having < 4 non-bloody stools
per day. She was discharged with a slow prednisone taper and f/u
with ___ GI as an outpatient.
# Acute Blood Loss Anemia:
Likely secondary to bloody diarrhea as above. Improved with
treatment of UC flare. No blood products givem.
# Hyponatremia:
Resolved. Likely secondary to hypovolemia in setting of diarrhea
and reduced PO intake. Received multiple liters of IVF with
improvement.
# Depression/anxiety:
-continue home escitalopram
# Acne:
- held home spironolactone in setting of hypovolemia. To be
restarted at discretion of outpatient providers.
TRANSITIONAL ISSUES:
==================
- Outpatient GI f/u with ___ GI. Patient may transition care
to alternative facility after that.
- Pt will need remicade dosing at week 2 and week 6 (week 0 =
___. She will then need maintenance remicade every eight
weeks.
- Prednisone 40 mg PO for 2 weeks (Day 1 = ___
- After 2 weeks prednisone 40 mg, slow taper at -5 mg/week.
- Resume spironolactone as clinically indicated
# Emergency Contact: ___ and ___, ___ ___
(cell) ___. | 175 | 275 |
13989655-DS-17 | 22,608,499 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
- You were very weak and dizzy
- Your blood pressure was very high
WHAT WAS DONE WHILE I WAS HERE?
- Your blood pressure medicines were adjusted
- You Depakote dose was lowered
- You were evaluated by physical therapy
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should keep working with Dr. ___ to adjust your seizure
medications.
- You should work with physical therapy to get stronger
- You should work with Dr. ___ to see a neuro-ophthalmologist
- You should continue to tirate your blood pressure medications
with Dr. ___ your primary care doctor.
We wish you the best!
Your ___ Care Team | ___ PMH cerebral palsy, congenital hydrocephalus s/p VP shunt
with seizure disorder, MPGN with CKD stage III, stable
infrarenal aortic dissection, labile BP with recurrent
admissions for labile BP and hypertensive emergency/urgency who
presented for dizziness/vertigo with labile BP. Likely
multifactorial with component of
Depakote toxicity and persistent postural perceptual dizziness.
#Dizziness/Vertigo:
#Weakness:
#Fatigue
Likely multifactorial with probable depakote toxicity as below,
possible contribution from spironolactone (though less likely),
and persistent postural perceptual dizziness per ___ evaluation.
AED management as below. HTN management as below. ___ left
detailed recommendations regarding PPPD which will be
communicated via page 3. In short, patient would likely benefit
from ___ rehab, neuro-opthalmology referral, and possibly
ENT referral pending her improvement.
#Hypertension:
Has a long-standing history of labile blood pressure. Most
recently was admitted for this in ___. Please see
discharge summary for full details of decision making regarding
anti-hypertensive regimen at that time. Of note, because of her
known infrarenal aortic aneurysm her goal SBP is less than 160.
Some concern for eculizumab contributing to labile HTN.
Spironolactone dose decreased from 25 mg BID to 12.5 mg daily
due to concerns from parents regarding timing of her fatigue
and increase in spironolactone. Given concerns for Depakote
toxicity as below, could be reasonable to uptitrate this
medication as needed for BP control while monitoring for
hyperkalemia if appropriate. Would communicate with Dr. ___
at ___ nephrology or her PCP if making any changes to her
regimen, and he may be able to offer insight into agents that
have been effective/ineffective. | 115 | 269 |
16772263-DS-17 | 29,693,002 | Dear Ms. ___,
Why was I admitted to the hospital?
___ were admitted because ___ were constipated.
What was done for me whiel I was in the hospital?
- ___ had an image of your abdomen which showed lots of stool
- ___ were given medication by mouth and through your rectum in
order to help ___ have a bowel movement.
- Once ___ had a large bowel movement ___ were safe to go home.
- ___ has some blood in your stool which related to your
hemorrhoids.
What should I do when I go home?
- Please drink at least 5 glasses of water daily.
- Continue to take the senna and colace twice daily. ___ can
also take the miralax (polyethylene glycol) if ___ have trouble
having stools for 2 days.
- If ___ notice ___ are having black stools or bloody stools
call your primary care provider.
We wish ___ the best! | PATIENT SUMMARY FOR ADMISSION:
===============================
Mr. ___ is an ___ year old male with a history of SAH in
___, atrial fibrillation, history of a DVT who
presents with constipation with unclear trigger. He received an
extensive bowel regimen and once stool was medically stable for
discharge.
# Constipation: No obstruction on ___ CT AP just large stool
burden present in colon and cecum. Suspect decreased
PO intake triggered current episode. He was disimpacted manually
on ___ and ___. He was treated with senna 17.2mg BID, colace
BID, Miralax 17g BID and daily bisacodyl suppository. Once he
was able to stool he was transitioned on discharge to senna and
colace daily with miralax to be used as needed.
# Bright Red Blood Per Rectum: NOted to have some bright red
component to his stool on ___. His hemoglobin remained stable.
Bleeding was felt to be secondary to hemorrhoids. He did not
require transfusion and continued Apixaban during
hospitalization.
# Atrial Fibrillation: Patient currently well controlled
regarding rates. Continued Apixaban BID.
# Overactive bladder: Hold oxybutynin given anti cholinergic
effect and risk of constipation. Restarted on discharge. | 143 | 180 |
11605368-DS-9 | 23,602,009 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
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 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
WBAT BLE
ROMAT
Treatments Frequency:
DSD as needed for wound drainage
No care otherwise | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right subtrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for surgical fixation right femur,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
Postoperative day 1, patient physical therapy, was subsequently
transfused 500 cc of LR. Evening of postop day 1, patient had
hematocrit of 21.9, was subsequently transfused 2 units packed
red blood cells. The morning of postop day 2, patient's
hematocrit was 26.9. Patient remained hemodynamically stable.
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
weightbearing as tolerated in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 556 | 304 |
18508296-DS-5 | 21,162,605 | Dear Ms. ___,
You were admitted to the hospital for nausea leading to
dehydration. The cause of your symptoms was found to be due to
your gastroparesis that was confirmed with repeat studies. You
improved while you were here with medications and IV fluids.
You were seen by our gastroenterologists here who recommended
that you follow-up with your outpatient gastroenterologist 1
week after leaving the hospital. They will adjust your
medications as needed and may perform additional studies as an
outpatient.
Please continue your medications as previously prescribed
including your insulin regiment by ___. You can take reglan
(metoclopramide) as needed to help with your symptoms but should
be aware of the warnings regarding its potential adverse effects
on movements as discussed with you. Please avoid taking your
motilium at this time since it may interact with reglan. Make
sure to also eat small, low fat, lactose free meals to minimize
your symptoms. Be sure to stay well-hydrated.
Continue to follow-up with your primary care physician and
nephrologist for your other medical problems.
Take care.
- Your ___ Team | ___ y/o F PMH of DM1 complicated by gastroparesis, retinopathy,
and CKD, and anxiety here for complaints of nausea/vomiting that
has been ongoing for the past few months c/w prior
gastroparesis. | 173 | 32 |
18553055-DS-32 | 20,153,689 | Dear Mr. ___,
You were admitted ___.
Why you were admitted to the hospital:
- Your INR level (blood thinning) was too low.
- Your blood electrolytes were abnormal, and you needed
dialysis.
What was done while you were in the hospital:
- You were given another blood thinner (heparin) while you took
warfarin until your INR levels were in the correct range.
- You received dialysis in the hospital to improve your blood
electrolyte levels.
While you were here, your care team discussed with you the
possibility that your fistula might not be working appropriately
(your electrolytes are not clearing as they should with
dialysis). We discussed a procedure to evaluate (and possibly
correct) your fistula while in the hospital. In discussion
regarding the risks and benefits of the procedure, you opted to
leave the hospital. We are helping to arrange ___
appointments for you.
It was a pleasure caring for your!
Your ___ Care Team | ___ y/o M s/p mechanical MVR on warfarin, HTN, HLD, CAD, ischemic
cardiomyopathy presented for subtherapeutic INR. He had not
taken warfarin x2 days due to supratherapeutic INR. Patient
denies CP, SOB, ___ edema concerning for clot formation. He was
started on a heparin bolus, drip. Additionally he was restarted
on his home regimen of warfarin until his INR was therapeutic.
Additionally, patient was found to be uremic, hyperkalemic to
6.0 on admission and was complaining of whole body aches. This
was felt to be due to his uremia. Patient was given
Insulin/dextrose and calcium gluconate as needed for
hyperkalemia. He did not have any EKG changes. Patient was taken
for urgent dialysis overnight on the night of his admission with
improvement in his electrolytes. On hospital day 1, patient was
again taken for dialysis due to continued elevated BUN and
hyperkalemia.
He continued to receive dialysis and heparin bridging to
warfarin on the floor. Due to persistent hyperkalemia despite
appropriate dialysis, Nephrology was concerned that pt's fistula
might be malfunctioning. Fistulagram was arranged with ___, and
serial K monitoring was planned; however, after a long
discussion with Med attending and Nephrology consult, patient
elected to leave the hospital with plan for dialysis on
___ day 1 and ___ clinic on ___ day
2. Primary team also planned to continue heparin bridge until
___ INR was therapeutic (given variability in Coumadin dosing);
however, after counseling about stroke risk, patient still
elected to leave with the plan above.
TRANSITIONAL ISSUES
===================
- HD ___
- AV fistula appointment ___
- PCP appointment
- CAD: patient is only on atorva 10, consider uptitrating
- HFrEF: after his STEMI, patient had EF 25% with apical
akinesis; he needs TTE with Lumison (scheduled for ___. if
persistent low EF, needs optimal med Rx for HFrEF. If persistent
apical akinesis or LV thrombus, needs AC.
- Patient is being discharged with 5 days of oxycodone.
Attending reviewed the PMP, and there was no evidence of opioid
rx misuse | 150 | 327 |
18515014-DS-18 | 25,106,307 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because of difficulty swallowing. You had a barium swallow that
showed esophageal dysmotility without obstruction or stenosis.
You also had esophageal manometry which your outpatient GI
doctor ___ follow to determine further need for botox or other
procedures.
All the best,
Your ___ Team | ___ y/o female with a history of CAD and esophageal dysmotility
who presents per her gastroenterologist, Dr. ___
"another swallow study."
ACTIVE ISSUES
# Esophageal Dysmotility
Patient was referred from ___ by her
gastroenterologist for work-up for her esophageal dysmotility.
She reports difficulty swallowing solid foods as well as a
significant 30 pound weight loss over the last several months.
She had a barium swallow which showed esophageal dysmotility
with premature termination of the primary peristaltic wave and
presence of extensive tertiary contractions without obstruction
or stenosis. She then had an esophageal manometry study and the
final results are pending. She tolerated a pureed diet well and
was discharged in stable condition.
CHRONIC ISSUES
# CAD
Her Plavix and Aspirin were continued.
# HTN
We continued her home anti-hypertensive medications.
# DM
While hospitalized her metformin was held and she was on an
insulin sliding scale. Her blood sugar was well controlled.
# Depression
We continued her home sertraline.
# Atrial fibrillation
Not anticoagulated due to GIB in the seting of coumadin. No
anticoagulation, currently well rate-controlled.
TRANSITIONAL ISSUES
- ___ results of esophageal manometry study. | 66 | 198 |
17049635-DS-12 | 23,483,060 | It was a pleasure looking after you, Mr. ___. As you know,
you were admitted with pneumonia and respiratory failure. You
were intubated (connected to a ventilation machine) and admitted
to the intensive care unit. You were extubated (removal of the
breathing tube) 2 days thereafter.
You were treated with antibiotics with steady improvement.
You had improved oxygenation and by the time of discharge, have
been able to maintain good oxygenation without any oxygen
supplementation. You do, however, have low oxygenation at night
and thus will benefit from supportive oxygenation (2L nasal
cannula) at night.
Please continue with the antibiotics (levofloxacin) for until
___. Also take the atrovent nebulizer treatment regularly for
your COPD (emphysema). Also you were given prednisone
(steroids) slow taper to be slowly weaned off over the next 5
weeks and ipatropium nebulized treatment which can be taken
regularly (instead of albuterol/ventolin) for your emphysema. | ___ with history of multiple myeloma on velcade/cytoxin/decadron
s/p BMT ___ years ago transferred from ___ on
___ with sepsis and hypoxic hypercarbic respiratory
failure/ARDS found to have multi-focal pneumonia and COPD
exacerbation.
FICU STAY: Intubated on ___ for respiratory distress and met
criteria for ARDS, started on ARDSnet protocol and HCAP ABx
coverage. Did require pressors for < 24 hours d/t hypotension.
Was extubated on ___ without complications after passed SBT
trials. Did have profound expiratory wheezing post extubation
that was consistent with COPD exacerbation + component of TBM,
improved with nebs+steroids. Sputum Cx grew H.influenza. Was
delirious for 24 hours post extubation but improved back to
baseline (did receive 1 dose zyprexa) prior to calling patient
out to the medical floor. | 161 | 122 |
17652373-DS-13 | 29,870,320 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
in the hospital because of abdominal pain. We also noted that
you had blood in your urine. We obtained blood tests that look
at your electrolytes, blood cells, liver and pancreas which were
normal. We got a CT scan of you abdomen which did show some
evidance of mild cecal wall. The preliminary read of the MRI of
your pelvis did not show evidance of any abcess or evidance of
acute inflammation, but did show evidence of a possible old
fistula tract (the final read of the MRI is pending). We started
you on antibiotics (ciprofloxacin and metronidazole) for your
perianal disease, which you were prescribed as an outpatient. We
think your symptoms may have been related to a kidney stone, as
you had blood in your urine that cleared up. Your urine cultures
did not grow enough organisms to suggest a urinary tract
infection.
Please follow up with Dr. ___ as below.
The following changes have been made to your medications:
START taking Ciprofloxacin 250mg by mouth twice a day for 3
months or as directed by Dr. ___.
START taking Metronidazole (flagyl) 250mg by mouth twice a day
every day for 3 months or as directed by Dr. ___.
Please continue taking all of your other medications as you were
before. | #Abdominal Pain and Nausea - The most likely cause of his
symptoms is a passed renal stone vs. gastroenteritis. He
initially presented with symptoms of abdominal pain which later
progressed to nausea and vomiting with a few episodes of
diarrhea. His exam was notable only for LLQ tenderness and a
perianal fistula. It is unlikely that his presentation was a
result of a Crohn's flair given that these were different then
his typical symptoms. Furthermore, his ESR and CRP was not
elevated and he did not have a leukocytosis. CT and MRI of
pelvis did not show evidence of an acute abdominal process of GI
inflammation. On HD2 he felt much better, had minimal pain,
tolerated POs and was without nausea or vomiting. He never
received steroids. He received IV cipro and flagyl for his
perianal disease and initial question of UTI. An MRI was
obtained on HD2 and prelim read did now show signs of abscess or
active Crohns. He was discharged home on oral cipro/flagyl for
his perianal disease with close GI follow-up.
.
#Hematuria: His initial UA in the ED showed large blood, >182
RBCs. neg leuks/nitr, 12WBC. He did have dysuria on the day of
presentation and CT of his abdomen could not exclude early
pyelonephritis however urine culture was negative. GC/Chlam
pending at discharge.
This may have been due to a passed kidney stone which could have
cause his dysuria, abdominal discomfort, hematuria and emesis.
Interstitial nephritis from mesalamine was considered but he has
not had a change in his regimen and he did not have eosinophils
in his urine. Repeat UA was unremarkable. He should have a
follow up outpatient UA to ensure hematuria is resolved.
.
# Crohn's disease: See above. Does not seem to have very active
disease at baseline. Has never needed steroids in the past.
Mesalamine initially held on admission as possible cause
interstitial nephritis but this was restarted at discharge. He
will have close GI follow up.
.
#Hypercholesterolemia: Stable. He was continued on home
simvastatin. | 223 | 331 |
12780990-DS-12 | 25,043,126 | You were hospitalized for dizziness which was due to a condition
called orthostatic hypotension, which means that your blood
pressure drops when you stand up. We gave you IV fluids and
decreased your blood pressure medication and your symptoms
resolved and your blood pressure improved. You should be sure
to drink plenty of fluids to reduce your risk of becoming
dehydrated and having your blood pressure drop.
You were noted to have some blood in your stool in the emergency
department, but you had a normal, non-bloody bowel movement
during your hospitalization. You have mild iron deficiency
anemia, so you can discuss with your PCP whether you should have
a colonoscopy.
It was a pleasure caring for you! We wish you all the best! | ___ year old female with h/o paranoid schizophrenia who presents
with light headedness with standing and falls x 3 days found to
have orthostatic hypotension
# ORTHOSTATIC HYPOTENSION:
Patient was given 2L of IV fluids - her symptoms resolved and
her orthostatic vital signs normalized. She was cleared for
discharge home by physical therapy thereafter. Suspect this is
due to dehydration as patient admits to recent poor PO intake
and occasional nausea/vomiting especially after eating
lactose-containing foods (she is lactose intolerant)
.
# ANEMIA / GUAIAC POSITIVE STOOLS
Mild iron deficiency anemia. Guaiac positive stool in the ED,
but guaiac negative brown stool on the day of discharge.
- Consider outpatient colonoscopy if within goals of care
.
# WEIGHT LOSS:
Pt has lost 60 lbs over ___ and 30 lbs over ___ years. States
she intentionally lost 50 lbs in one year by eating smaller
portions. She denies black stools. Her last colonoscopy was in
___ and was wnl. As above, consider outpatient colonoscopy if
within goals of care
.
# HTN: Decreased home amlodipine from 5mg to 2.5mg given
orthostatic hypotension
.
# HYPERLIPIDEMIA: Continued Atorvastatin 20 mg PO QPM
.
# SCHIZOPHRENIA: Continued home medications:
- Divalproex (EXTended Release) 500 mg PO QHS
- QUEtiapine extended-release 300 mg PO DAILY
- QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia
- Fluphenazine DECANOATE 25 mg IM/SC Q 2 WEEKS
.
# HYPOTHYROIDISM: Euthyroid at present. Continued home
levothyroxine
Discussed with healthcare proxy, son ___
> 30 minutes on discharge activities - counseling of patient and
family | 126 | 254 |
15425514-DS-10 | 23,167,698 | Dear Ms. ___,
You were admitted to ___ due to confusion and abdominal pain.
We gave you lactulose to increase the number of bowel movements
you were having and to help clear your confusion. We also
decreased your pain medications and methadone as we felt these
were also contributing to your confusion. You tolerated this
well. Please continued to take your lactulose and rifaximin
daily. Please also finish your 14 day course of metronidazole
(END ___ to help clear some bacteria in your intestinal
tract.
We wish you all the best.
Sincerely,
Your team at ___ | ___ y/o F with history of ETOH cirrhosis and recent admission for
ETOH hepatitis presents with ___ weeks of worsening
encephalopathy and abdominal pain.
# HEPATIC ENCEPHALOPATHY - Confusion and asterixis support
encephalopathy, especially in context of lactulose. Per her
pharmacy, she had not filled her rifaximin or lactulose since
___. ___ US showed no evidence of portal vein thrombosis. No
ascites appreciable or tappable. No other signs or symptoms of
infection. Symptoms improved with administration of lactulose.
After several days, however, she still appeared slightly
encephalopathic and had slight asterixis with prolonegd hold.
Her gabapentin and methadone were reduced and her lorazepam was
discontinued completely. She tolerated these changes well. She
was then started on metronidazole to complete a 14 day course
for further treatment.
# ABDOMINAL PAIN - Pt has a long history of recurrent migratory
abdominal pain of unknown etiology. She does, however, have a
history of choledocholithiasis managed symptomatically and
remote SBO. KUB demonstrated no evidence of obstruction or
ileus. Given her constipation on admission, her abdominal pain
was presumed to be related to constipation and she was treated
with lactulose as described above. She then developed crampy
abdominal pain, likely due to the lactulose. As she cleared her
bowels and her lactulose dose was reduced, her pain improved.
She was discharged home on a lower dose of methadone.
# ALCOHOLIC CIRRHOSIS - Pt. with decompensated cirrhosis given
hepatic encephalopathy and history of ascites. No history of
varices on last EGD in ___. No ascites during this admission.
Pt. is not on transplant list given active alcohol use. She was
continued on spironolactone.
# ALCOHOLISM - Pt. struggles with continued alcohol use, though
she is working on abstinence. Pt. was initially on CIWA, but had
no evidence of withdrawal. She was maintained on thiamine and
folic acid.
# ASTHMA - Pt. maintained on home advair and albuterol as
needed.
# DEPRESSION AND ANXIETY - Pt. was continued on home citalopram.
Her ativan was discontinued and the pt. tolerated this well with
no increase in abxiety. | 96 | 354 |
19693808-DS-20 | 25,155,594 | Dear Mr. ___,
It was a pleasure to care for you at ___. You were admitted
for a prolonged loss of consciousness and fall that required
intubation with mechanical breathing and monitoring in the
intensive care unit. As your mental status recovered, the tube
was removed and you were stable enough to move to the general
medicine floors. Testing for seizure and stroke were
abbreviated, however, the EEG study showed evidence of possible
seizure activity. We started you on medications to prevent
future seizures and recommend that you follow up with your
neurologist.
It is very important to take all of your medications medications
as prescribed, especially your blood pressure medications:
Metoprolol XL and Isosorbide Mononitrate. It is very important
to take your ___ medication, called levetiracetam.
Please also follow up with your primary care provider ___ 2
weeks. If you experience any weakness, slurred speech,
disorientation, or lightheadness, please seek medical attention.
Wishing you the best of health moving forward,
Your ___ team | Mr. ___ is an ___ gentleman with HTN, HLD, remote
h/o prostate cancer and s/p AVR for stenosis who presented to
OSH w/ acute change in MS ___ 5), was intubated and transferred
to ___ MICU for mechanical ventilation. Per wife, ___
looked disoriented at home with left gaze deviation, repetitive
mouth movements but ___ and ___. She sat
him down in chair after which ___ fell and hit his head. Per EMS
report, initial SBPs were in the 240s and was taken to
___. At OSH, ___ remained encephalopathic and was
intubated for protection of his airway, followed by transfer to
___. As ___ regained consciousness, ___ was extubated with
recovery back to his baseline mental status. ___ had EEG
significant for slowing on the left, for which ___ was loaded and
maintained on Keppra. CTA with atherosclerotic disease without
stenosis of the ICAs and notable for 4 mm aneurysm involving the
anterior communicating artery. MRI only partially completed due
to claustrophobia but without acute abonormality. TTE
unremarkable, with EF > 55%.
ACTIVE ISSUES:
#Seizure with ___ state w/ head strike: Initially
presented with AMS, GCS 5 requiring intubation. EMS reports
systolics in the field to the 240s. Rapid resolution of
condition and was extubated less than 24 hours later. CTA not
indicative of stroke. No pathology from head trauma. No
significant metabolic abnormalities. Toxicology screen
unremarkable. AMS began resolving quickly after extubation, per
___ family, to baseline. Did receive Haldol x3 after ___
was extubated for agitation. EEG findings were consistent with
focal subcortical
dysfunction over the left hemisphere consistent with story of
staring episode and seizure episode at ___ was
loaded with Keppra dose and maintained on 500mg bid. Pt was seen
by neurology here throughout the hospitalization, and per their
recommendations, ___ to follow up with PCP and neurology in
setting of new seizure disorder. ___ was also counseled on
importance of continuing his hypertensive medications.
# Pulmonary edema vs Aspiration pneumonitis vs CAP: Initial CXR
significant for bilateral perihilar and basilar opacities may be
due to pulmonary edema vs pneumonia. ___ did not have a fever or
leukocytosis of pneumonia, however, given initial need for
intubation, ___ was covered empirically for community acquired
PNA with CTX and azithromycin. Antibiotics were discontinued
___ lungs sounds ___. Given
hypertensive emergency, likely flash pulmonary edema.
Respiratory status stabilized with unremarkable exam, saturating
well on RA by discharge.
# Anemia: Admission hemoglobin 9.3 which remained stable. MCV
93.
# Hyperkalemia: Resolved. Admission K of 5.5, without peaked T
waves. Potassium values normalized on subsequent labs without
intervention. | 161 | 430 |
19731864-DS-20 | 26,717,645 | You were admitted to the hospital for nausea/vomiting, blood in
the vomit and found to have elevated INR, which is a marker of
your Coumadin level. CT of your abdomen showed some evidence of
inflammation in your small bowel. The exact cause of this
finding is unclear at this time and can be related to viral
process as known as viral gastroenteritis. During your
hospitalization, you complained of left-sided facial pain,
postnasal drainage, and headache. Given your recent dental
procedure, you underwent CT scan of face/sinuses, which showed
some complications of your recent transfer procedure. We
discussed your case with our oral surgeons who recommended that
you start on antibiotics and follow-up with your outpatient oral
surgeon.
You had an endoscopy given your bleeding but we did not any
ongoing blood loss. Your INR was above 7 when you came in so we
think that you bled due to your blood being too thin. Please
continue to take the medication omeprazole 40 mg (sent to your
pharmacy) until you follow up with GI.
Your augmentin may increase your levels of Coumadin so we
recommend that you take Coumadin five milligrams daily for now.
Please go to the lab on ___ to get your level rechecked.
You and your daughter are concerned about your intermittent
diarrhea and weight loss. We are working on a GI appointment.
You had some low grade temperatures the day prior to discharge,
and these may have been from your sinusitis and UTI. The
antibiotic augmentin will cover both infections. | Ms. ___ is a ___ female with history of AF on
Coumadin, hypothyroidism, HTN, recent dental procedure who p/w
hematemesis in the setting of supratherapeutic INR and acute
onset N/V.
#Hematemesis in setting of
#Supratherapeutic INR
GI team consulted who recommended close CBC and hemodynamic
monitoring with plan for EGD on a nonemergent basis. The
patient's hematemesis and self resolved on holding coumadin.
EGD was performed and
did not reveal a source of bleeding. GI recommended PPI,
which was started (omeprazole 40 mg daily) We resumed
anticoagulation with coumadin and advised patient to avoid supra
therapeutic INR and to consider treatment with DOAC. She is
not interested in DOAC, stating she has seen the ads about the
side effects and has her doubts. She states that her INR is
typically within the proper range - ___, and that she will have
it checked through PCP ___. Given that she was started on
augmentin for sinusitis, pharmacy advised her to continue on
coumadin 5 mg of snow.
#Enteritis
Likely viral process. Low suspicion for bacterial infection.
Nausea and vomiting resolved with as needed antiemetics.
#OroAntral communication resulting in maxillary sinusitis
following recent dental procedure
___ recommended 2-week course of Augmentin with close
outpatient oral surgeon follow-up. Daughter will arrange for
outpatient f/u. She will finish a two week course of this
#UTI - seen on Ucx, but may represent asymptomatic bacteriuria.
Will also be covered by augmentin
#Incidental renal mass - discussed with urology who feel that it
is likely an angiomyolipoma that was seen in prior scans. They
have left a note in OMR. I have asked on radiologists to
comment on this as well.
# Intermittent diarrhea, unintentional weight loss: Daughter is
concerned about patient's ongoing intermittent diarrhea and ?
contribution to unintentional weight loss. Patient did not have
any diarrhea while in the hospital so w/u could not be
initiated. Our schedulers are working on obtaining outpatient
GI f/u.
Seen by ___ who advised home ___. Ordered.
Discharge plan discussed extensively with patient and daughter.
Greater than ___ hour spent on care on day of discharge | 262 | 368 |
12631532-DS-5 | 20,256,809 | Dear Ms. ___,
You were admitted to the hospital because you had anemia in the
setting of bleeding from your stomach and required blood
transfusions.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You received 2 units of red blood cells and your blood counts
improved (hemoglobin 5.7 -> 7.9) and remained stable.
- You underwent an EGD to evaluate your esophagus and stomach
for any signs of bleeding.
- 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
- Seek medical attention if you have new or concerning symptoms
or you develop increased black or bloody stools with
accompanying lightheadedness or weakness, or if you begin
coughing up blood.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY STATEMENT:
==================
___ with history of primary biliary cirrhosis c/b portal
hypertension (esophageal varices s/p banding, GAVE), iron
deficiency anemia, s/p EGD ___ with grade I varices and GAVE,
who presents from clinic with anemia Hgb 5.7 and recurrent
melena.
ACTIVE ISSUES:
==============
# UGIB
# Acute on chronic blood loss anemia
Patient with Hgb 5.7 on admission in setting of recurrent
melena, with known GAVE s/p multiple APC treatments as well as
ligation banding, and esophageal varices s/p banding, overall
concerning for recurrent UGIB from known GAVE vs from
post-banding ulceration. Hgb improved s/p 2u pRBC to 7.5 and
remained stable throughout admission. She was treated with IV
pantoprazole 40mg BID, sucralfate 1g QID, CTX 1g daily, and
maintained on an octreotide drip until discharge. She remained
hemodynamically stable and underwent an EGD on ___ which showed
grade I varices in distal esophagus with no signs of bleeding
and GAVE with nodularity; she was treated with APC for planned
repeat EGD in 1 month for additional APC. She received an
additional 1u pRBC after her EGD with APC and her Hgb on
discharge was 8.8. She received IV ferric gluconate 125g on day
of discharge and will continue scheduled outpatient iron
transfusions.
# Primary Biliary Cirrhosis (Child A/6, MELD 6)
Past history of decompensation by HE, esophageal varices and
GAVE, as well as ascites. No known history of SBP. Note that
although liver transplant candidacy usually discussed after MELD
>= 15, patient was interested in learning more about potential
transplant. Given age and frailty, patient may not be
appropriate transplant candidate at this time but will continue
this discussion with her outpatient hepatologist. Her home
lactulose and diuretics were held in setting of active upper GI
bleed on admission. Her home ursodiol and rifaximin were
continued throughout admission. She did not have any signs of
hepatic encephalopathy throughout her admission. Her MELD on
discharge was 8.
CHRONIC/STABLE ISSUES:
======================
# Hashimoto thyroiditis: Continued on home levothyroxine 125 mcg
TRANSITIONAL ISSUES:
====================
[] Should have EGD in 1 month for repeat APC
[] Continue outpatient iron transfusions for chronic blood loss
anemia. Hgb on discharge 8.8 with IV ferric gluconate 125g
infusion prior to discharge.
[] MELD on discharge 8
[] HCC: No concerning lesions on admission US. Will need
outpatient screening q6 mo with RUQUS or other appropriate
imaging
[] Check HAV serology. Consider vaccination if not immune.
#CODE: FULL
#CONTACT: Health care proxy chosen: No
Info. offered to patient?: Yes
Offered on date: ___
Comments: Pt wants her husband ___ ___
daughter to be her HCP. Pt advised to file HCP form with family.
Verified on date: ___ | 187 | 429 |
14471973-DS-12 | 20,988,100 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for nausea and vomiting.
What was done for me while I was in the hospital?
- You were found to have an infection of your kidney and in your
blood.
- You were treated with antibiotics which you will need to take
until ___.
- You were found to have fluid around your lungs. You had a
procedure (thoracentesis) to remove this fluid.
What should I do when I leave the hospital?
- Continue taking your medications as prescribed.
- Keep all of your follow-up appointments.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old female with recently diagnosed colon
cancer who presented with nausea, vomiting, and fever due to
pyelonephritis and found to be bacteremic with proteus. She was
treated with antibiotics narrowed to ciprofloxacin for a ___nding ___. She was also noted to have a
transudative pleural effusion s/p thoracentesis, cytology
without malignant cells. | 122 | 58 |
14749274-DS-16 | 29,133,234 | You were transferred to ___ from ___ after a fall down
stairs and suffered an injury to your spleen and your kidney.
You were monitored closely for any ongoing bleeding, as imaging
revealed some blood in your abdomen. Your lab work and vital
signs have been stable. You are medically clear to be discharged
home to continue your recovery. Please note the following
discharge instructions:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA. | ICU course:
___ Mr. ___ was admitted to the trauma surgical ICU
after a fall down stairs while intoxicated with splenic
laceration and renal cortex contusion. A foley catheter was
placed for urine output monitoring. He received as needed
Tylenol and dilaudid for pain control. He received 2U PRBCs at
OSH, but did not require any blood products or pressors at
___. Interventional radiology was made aware of his injury
and status and they were available in case he became unstable.
He was observed overnight in the ICU and his hct was checked
every ___. His hct and HD status remained stable and he was
therefore transferred to the floor and his diet was advanced on
HD2. His foley catheter was discontinued.
The patient remained hemodynamically stable on the floor.
Hematocrit was trended and remained stable without any drop.
Diet was advanced to regular with good tolerability. The patient
was seen by Occupational Therapy for a cognitive evaluation. He
was showing signs of post-concussive syndrome and was referred
to follow-up in the Cognitive Neurology clinic.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 146 | 235 |
11502574-DS-4 | 21,028,357 | Dear ___,
You were admitted to the ___ due to fever, abdominal pain, and
cough. We performed an infectious workup for your condition and
imaged your abdomen and lungs. You were found to have a segment
of your bowel that was temporarily overlapped with another
segment of your bowel. However, this resolved spontaneously
without any problems. This may have caused your constipation. We
monitored your blood oxygenation and respiratory status
throughout your stay. The most likely cause of your symptoms is
a viral infection that caused your cough and fever. The pain in
your abdomen and sides is a side effect of your constant cough.
Your sodium level and your chest x-ray may point toward some
issues your doctor can look at with you once you leave the
hospital. They do not require continued hospitalization, but
should be checked soon (especially in the setting of your
steroid use).
Sincerely,
Your ___ medicine team. | ASSESSMENT & PLAN: ___ year old male with HIV on HAART (good
control, CD4 ~800), chronic HBV infection, and depression
presenting for 2 days of abdominal/flank pain, fevers/chills,
and cough. Multiple imaging including CXR, KUB, and CT scans
were done to find sources of his symptoms. Only significant
finding was an intussuption that spontaneously resolved.
# Fever: Patient presenting with symptoms of fever, chills,
abdominal/flank pain and cough with CT abdomen showing transient
small bowel intussusception, CXR showing bilateral lower lobe
atelectasis and enlarged cardiac silhouette but no PNA. In the
setting of intussusception, fever potentially associated with
infection, ischemia, and necrosis. However, per surgery, the
patient's pain does not correlate with location of pain. Other
infectious work-up currently negative (UA neg, flu negative, CXR
negative though it is also possible he has a viral illness with
exposure to sick contact in ___. Although the patient has
HIV, his last CD4 count in the 800s does not make him
immunocompromised. Conservatively, will cover with Cipro/Flagyl
for potential intraabdominal source from bacterial transloaction
in the setting of intussusception pending further infectious
work-up.
# Dyspnea: Upon arrival to floor, patient was noted to have RR
to 33. Per patient, his breathing does not bother him and does
not feel short of breath. He did have a 14 hour flight from
___ 3 days ago but he is satting at 95%, making PE less
likely. ___ be due to pain and anxiety. ABG was obtained and
repeat CXR was sent. ABG came back normal. He was put on tele to
monitor his O2 status throughout his stay. CXR showed increased
vascular congestion. A BNP sent after discharge was elevated at
274. Although these findings are subacute and dyspnea resolved,
the team feels he should have out-patient cardiac echo and
follow up of electrolytes. His use of anabolic steroids puts him
at increased cardiac risk.
# Hyponatremia: Likely hypovolemic in the setting of
intussuseption, which generally occurs with dehydartion. Now s/p
3L IVF in ED, so will recheck Na this AM. If not improved, will
check urine lytes/Osm and serum Osm to for further work-up.
- Repeat Na this AM
- Urine lytes/Osm and SOsm if no improvement.
- ___ be related to cardiomyopathy - check out-patient cardiac
echo as above.
# HIV: Well-controlled on HAART with most recent ___ CD4
count/% in our system 680/38%, per patient ___ CD4 ~800. As
such, would not consider the patient particularly
immunocompromised, though well-controlled HIV patients can be a
higher risk of community-acquired infection due to residual
T-cell dysfunction. Continued home complera
# Depression: Stable. Continued home buproprium and escitalopram | 151 | 441 |
11021643-DS-52 | 21,279,207 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had increased shortness of breath, chest
pain/pressure, and leg swelling for two days. We gave you IV
medications to get rid of the excess fluid. We will discharge
you on torsemide 80mg once a day.
Your blood pressure was elevated on admission, so we increased
your lisinopril. We continued your other medications for high
blood pressure.
Because of your chest pain, you underwent a pharmacologic stress
test, which did not show any signs of damage to your heart.
Your weight on discharge is 141.9 lbs. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs. You will
need to have your labs drawn on ___.
We are glad you are feeling better and we wish you the best.
Your ___ team | ___ with a history of diastolic CHF, HTN, IDDM, CKD(baseline Cr
1.8-2.0), HLD, CAD s/p CABG presented with a two-day history of
dyspnea, chest pressure/pain on exertion, and increased edema. | 143 | 30 |
14267880-DS-22 | 24,506,871 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___. As you know, you were admitted with low blood
pressures with positioning (called orthostatic hypotension). We
started a medication called Midodrine which improved your blood
pressures and symptoms. We also recommended compression
stockings. During this hospitalization, you had fast heart
rates. We reviewed your EKG which revealed a rhythm called
atrial flutter/atrial tachycardia. Your abnormal heart rhythm
improved without intervention. Electrophysiology was consulted
who recommended follow up in clinic. Please take your
medications as instructed. Please follow up with your primary
care doctor and cardiologist.
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ year old man with a history of severe
AS s/p AVR, severe HFrEF, CAD s/p CABG and multiple (15+)
stents, IDDM, who is admitted for dizziness and orthostatic
hypotension with course complicated by tachyarrhythmia.
ACUTE ISSUES
# Dizziness/lightheadedness
# Orthostatic Hypotension
Positive orthostatics by SBP and symptoms. No heart rate
elevation to accompany orthostatic hypotension suggesting
central etiology of orthostasis (i.e. autonomic orthostatic
hypotension). However, lack of heart rate elevation could also
be in setting of beta blocker, but persists in setting of
holding carvedilol. Less likely, but could also be secondary to
medication effects: carvedilol increased 3 weeks prior to
admission and increased Lasix dosing as outpatient. Appears
euvolemic-to-dry on exam. Has reported palpitations in past, but
no rhythm abnormalities on EKG. Neurology was consulted and felt
that it was most likely autonomic dysfunction ___ uncontrolled
diabetes. Hydralazine, Lasix, carvedilol and tamsulosin were
held. He was started on midodrine 2.5mg TID, encouraged PO fluid
intake, and given thigh high compression stockings. Pt will
follow up with Dr. ___ ___ ___ after discharge.
# Tachycardia
On ___ and ___, new tachycardia on telemetry, with strip
concerning for atrial flutter with 2:1 conduction vs. A-tach vs.
A-fib vs. sinus tach with prolonged PR interval. This was
accompanied with diaphoresis, hypotension, and worsened
orthostatic hypotension with tachycardia. EKG showed no new
ischemic changes and troponins were flat throughout admission.
EP was consulted and recommended, but this was held in favor of
observation. Telemetry revealed no further episodes in the 24
hours prior to discharge. He was continued on apixaban. He will
follow up with Dr. ___ Dr. ___ discharge.
# Fall
On AC. NCHCT normal. Neuro exam normal. Possibly ___
orthostasis, discussed above (occurred when standing and
turning).
CHRONIC ISSUES
# CKD: Though creatinine 1.2-1.3 in ___, review of prior
records suggests baseline 1.5-1.7. Most recently 1.5, suggests
patient at baseline.
# HFrEF: Last EF ___ with 1+MR. ___ BB, ACE, Lasix. Carvedilol
recently uptitrated as above. Held hydralazine, Lasix, and
carvedilol as above.
# CAD/CABG: No chest pain or angina equivalent. Continued
aspirin, atorvastatin
# sAS s/p AVR: History of very severe AS pV > 5.0m/s. Caution
with BP, volume status.
# IDDM c/b neuropathy: c/b neuropathy, retinopathy. Held home
oral antiglycemics. Continued lantus 16U QHS along with sliding
scale. Continued gabapentin for neuropathy.
# Additional Chronic Medical Issues
- HLD: Continued atorvastatin
- HTN: Cardiac meds as above.
- Overactive Bladder: Held tamsulosinas above
- Cataracts/Glaucoma: Continued brimonidine, timolol drops.
- Psych: Continued venlafaxine, donepezil
- GERD: Continued esomeprazole, ranitidine, sucralafate
=================================
TRANSITIONAL ISSUES
=================================
[ ]Patient's home Carvedilol, Furosemide, Hydralazine,
Tamsulosin held at discharge
[ ]Patient discharged on Midodrine 2.5 mg PO TID (Doses ___ be
given in approximately 3- to 4-hour intervals (eg, shortly
before or upon rising in the morning, at midday, in the late
afternoon not later than 6 ___. Avoid dosing after the evening
meal or within 4 hours of bedtime)
[ ]Recommend compression stockings at home
[ ]Patient will follow up with Electrophysiology (EP) as
outpatient
# CODE: Full, confirmed
# CONTACT: ___ (wife) ___ | 101 | 489 |
13398771-DS-13 | 26,468,262 | You were admitted to ___ with abdominal pain and found on CT
scan to have a small bowel obstruction. You were taken to the
operating room and underwent an exploratory laparotomy with a
small bowel resection. You tolerated this well. You are now
tolerating a regular diet and having bowel movements. You are
medically clear for discharge home to continue your recovery.
Please note the following:
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.
-Your Coumadin has been restarted. Please follow-up in the
___ clinic as usual to monitor your INR.
-Incidental findings found on CT scan, noted below. | ___ history of Laparoscopic cholecystectomy ___ at ___
presents with recurrent abdominal pain, nausea and vomiting. CT
scan consistent with small bowel obstruction with transition
point below the umbilicus. The patient was made NPO with IV
fluids and nasogastric tube decompression. Due to her recurrent
presentations it was felt that diagnostic laparoscopy was
indicated to evaluate for obstruction. The patient underwent
diagnostic laparoscopy converted to Exploratory laparotomy,
jejunal resection with primary anastomosis which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the NPO with NGT, on IV fluids, and IV
analgesia for pain control. The patient was hemodynamically
stable. A heparin drip was started to bridge the patient to
warfarin.
.
Pain was well controlled. Once having bowel function, diet was
progressively advanced as tolerated to a regular diet with good
tolerability. Warfarin was restarted. The patient voided without
problem. During this hospitalization, the patient ambulated
early and frequently, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. Her INR was therapeutic. The patient was discharged
home without services. The patient and her family received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 363 | 255 |
18607258-DS-10 | 22,681,012 | Dear ___ were admitted to ___ for episodes concerning for seizures.
___ underwent cvEEG which did not show any seizure activity. ___
also underwent MRI of your brain which was normal. In addition,
___ underwent a lumbar puncture which was also normal. The
etiology of your symptoms is thought to be psychogenic in
nature. Psychiatry was consulted and recommended mindfulness
based type of program on an outpatient basis to help with your
symptoms. No changes was made to your medications. Please take
your medications as instructed. ___ have follow up appointments
scheduled as below. | Ms. ___ is a ___ old woman with a past medical history
of
concussion with multiple residual neurologic complaints, recent
second head strike who presented with multiple seizure-like
episodes most consistent with psychogenic nonepileptic seizures.
Her exam is non-focal aside from lack of speech production which
was initially intermittent but has since been constant. She was
evaluated by speech and her oral mechanism exam appeared normal.
There was no neurological or mechanical cause for her lack of
speech and it was deemed most likely functional. She also
complained of difficulty swallowing and underwent a swallow
evaluation which did not show any abnormality. She underwent
cvEEG which did not show any seizure activity and strongly
suggested PNES. To ensure that she does not have underlying
encephalitis causing her symptoms she underwent MRI brain which
was normal and lumbar puncture which was bland. She developed a
post LP headache for which anesthesia pain service was
consulted. Anesthesia did not feel the need for a blood patch.
Her ibuprofen and Tylenol were increased with improvement of
headache. Psychiatry was consulted and recommended mindfulness
based type of program on an outpatient basis to help with her
symptoms. Physical therapy saw her and recommended rehab.
Of note she was noted to have asymptomatic intermittent
bradycardia during sleep down to HR of 40's. EKG was obtained
during one of these episodes and showed sinus bradycardia.
She was discharged in stable condition to ___
Facility. | 94 | 238 |
13193330-DS-14 | 25,709,609 | Dear Ms. ___,
You were admitted to the hospital with shortness of breath. This
was attributed to a few different factors. First, you have
atrial fibrillation ("afib"), which is an abnormal heart rhythm.
When you were in afib, you felt short of breath. We gave you a
medicine called sotalol, which returned your heart rhythm to
normal (so called "sinus rhythm"). In addition to this, you were
found to have fluid in your lungs. We drained almost a liter
from your right lung. This fluid showed inflammation, which may
be due to a virus. When you were discharged, it sounded like you
still have fluid on your lungs. We can repeat this drainage
again if you become more short of breath. However, we did not
drain the fluid at this time because you did not need oxygen,
and you were comfortable without shortness of breath.
Finally, you were also short of breath due to fluid around your
heart and inflammation of the sac surrounding your heart. The
fluid around your heart decreased during your hospital course.
However, we saw that there is inflammation of the sac that
surrounds your heart. This is called "pericarditis." This fluid
does appear to be constricting your heart muscle. The cause of
this pericarditis is unclear. It may be due to a virus. There is
a concern, however, that it could be related to your thymoma.
You may benefit from surgery to relieve the constriction and/or
to take a biopsy of the sac around your heart. A biopsy would
rule out thymoma causing this problem. Because you were doing
well, we are not going to do surgery at this time, but your
outpatient doctors ___ and cardiology) may
consider this in the future.
During this admission, you were started on some medications,
including sotalol as mentioned above and Lasix. Please take all
medications as prescribed and please follow up with the
appointments we have arranged.
This pericarditis is an inflammation of the sac around the
heart; it may be caused by your thymoma or potentially another
inflammatory condition.
You were treated with medicines to remove extra fluid and also
anti-inflammatory medicines. You should continue to take these
medications and follow up with the cardiologists and your
oncologist.
Please seek medical attention if you develop fevers, chills,
shortness of breath, worsening chest pain, weight loss, or any
other symptom that concerns you.
Please weigh yourself daily and call your doctor if your weight
goes up by more than 3 lbs.
Thank you for letting us participate in your care,
Your ___ team | ___ yo female with a history of afib on Coumadin, myasthenia
___ with thymoma s/p surgical resection and current radiation
therapy), and atrial fibrillation who presented dyspnea and
fatigue.
#Dyspnea on exertion: EKG showed Afib, CXR showed pulmonary
edema and pleural effusion, and BNP elevated at 574. She
initially required ICU course for BiPAP and IV diuresis for
volume overload. Ultimately, her DOE and SOB was felt to be
multifactorial, namely due to constrictive pericarditis vs afib
vs pleural effusion, which are described in detail below.
#Pericardial effusion and likely constrictive pericarditis: TTE
showed pericardial effusion without evidence of tamponade but
with MV inflow variation. Given concern for constrictive
pericarditis, she was initiated on colchicine and indomethacin.
She had a cardiac MRI that did show evidence of pericarditis
with the suggestion of constrictive pericarditis. Patient was
recommended for right and left heart catheterization to
demonstrate equalization of pressures and confirm constriction;
however, patient was not amenable to procedure. The etiology of
her pericarditis and pericardial effusion was unclear. She had
negative rheumatologic work up, including negative ___,
Rheumatoid factor, and anti-CCP. CRP was elevated at 60.6, and
ESR was elevated at 34. Pericarditis and pericardial effusion
was suspected to be post-viral in origin; however, the
possibility of malignancy could not be ruled out. An extensive
discussion was had with consulting and specialty providers
including oncology, cardiology, rad/onc, cardiac surgery, and
thoracic surgery. She may ultimately benefit from pericardial
biopsy to rule out malignancy, pericardial stripping to
ameliorate constrictive pericarditis, and pericardial window
given her pericardial effusion. However, these procedure(s) were
not pursued while inpatient given that patient declined
procedures and given that she improved subjectively. She was
also on RA and satting well. Pericardial biopsy, window, and
stripping may all be considered in the outpatient setting or on
future admissions should she become symptomatic. Of note,
pericardial effusion was resolving on repeat TTE this admission.
Patient was continued on colchicine at discharge and was
initiated on low dose diuretics with Lasix 10 mg daily as
medical management. Of note, radiation therapy was felt to be
highly unlikely the cause of her pericardial effusion given
a)small radiation window used to treat her thymoma and b) time
course (effusion from XRT typically occurs some time after
completion of XRT rather than during ongoing XRT as in this
case).
#Pleural effusion: In addition, patient was noted to have
pleural effusions bilaterally on CXR and CT chest which likely
contributed to her SOB. She underwent R thoracentesis during
hospital course with 800 ccs grossly bloody pleural fluid
drained. This was exudative but negative for malignancy,
negative in culture/gram stain. Pleural fluid was therefore also
suspected to be post-viral in origin as with pericardial
effusion/pericarditis above. Patient was offered repeat
thoracentesis given inability to lie <30 degrees with decreased
breath sounds in bases; however, she declined thoracentesis
given that she felt well and was not SOB with exertion or at
rest. Repeat thoracentesis should be considered if patient
becomes symptomatic or hypoxic.
#Atrial fibrillation: Finally, patient's DOE was felt to be due
to her afib as well. She was noted to have frequent episodes of
afib with RVR, for which she was symptomatic with SOB and for
which she had frequent triggers during initial hospital course.
In the outpatient setting, she had been considered for
propafenone but had not initiated due to insurance reasons.
During this admission, she was started on sotalol and converted
to NSR. She remained essentially asymptomatic after converting.
Her home Coumadin was held during her hospital course due to
anticipation of procedures but restarted at the time of
discharge.
#Community Acquired Pneumonia: Of note, patient was treated with
an empiric 7 day course of levofloxacin due to SOB and RLL
infiltrate noted on CT chest concerning for CAP. She denied
cough and remained afebrile without leukocytosis during hospital
course.
#Myasthenia ___: Patient was seen by neurology, who felt that
her SOB was not secondary to myasthenia. Her NIFs and VC were
monitored initially, with NIF generally -20 to -30.
#Thymoma: s/p thymomectomy and ongoing radiation. Patient did
not receive radiation during hospital course given inability to
lay flat throughout much of hospital course. There was a concern
for possible involvement of thymoma into the pericardium causing
this presentation of DOE. Please see above for details. | 419 | 709 |
16130527-DS-30 | 21,738,352 | It was a pleaseure caring for you during your hospitalization at
___.
You were admitted to the hospital with a very low heart rate and
low blood pressure.
You had a permanent pacemaker implanted on ___. You can remove
the original dressing and shower on ___. You have
steristrips under the dressing, do not remove these, they will
fall off on their own.
You are restricted from lifting your left arm above your
shoulder for 6 weeks. No lifting, pushing, pulling or extending
your left arm for 6 weeks.
For your heart failure diagnosis: Weigh yourself every morning,
call MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days, follow a low salt diet and restrict your fluid intake to
1500ml/ day.
Medication changes:
-stop your metolazone twice weekly. weigh yourself daily, if the
weight is up call dr. ___ may ask you to take a dose
of metolazone
-switch your metoprolol to Toprol 12.5mg daily (loger acting
form of the same medication, lower dose) | Primary Reason for Hospitalization: Mr. ___ is a ___ with
PMH of dCHF secondary to senile amyloid, hypertension, afib and
CKD who presents with bradycardia and hypotension, from which he
is relatively asymptomatic. | 167 | 34 |
15526108-DS-8 | 21,989,028 | You had an open reduction-internal fixation of a left distal
radius fracture.
.
Personal Care:
1. Keep injured extremity elevated (above the level of your
heart) as much as possible.
2. Keep splint dry and in place.
3. Notify provider (contact ___ and ask for Plastic Surgery
resident on call) if you experience sudden onset of numbness,
tingling, or paralysis of affected hand.
.
Activity:
1. You may resume your regular diet.
2. Avoid heavy lifting with affected extremity
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength
Tylenol for mild pain as directed on the packaging. Please note
that Percocet and Vicodin have Tylenol as an active ingredient
so do not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. 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.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* 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, increased redness,swelling or
discharge from incision, 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. | The patient presented to the ___ ED on the evening of ___,
as per the HPI. He was admitted by the Plastic Surgery service
following reduction and splinting in the ED, and subsequently
was taken to the operating room early in the morning on ___. He
received Ancef x1 preoperatively. He underwent ORIF of left
radius fracture, which he tolerated well. Postoperatively, he
received IV dilaudid for pain control, to good effect. On the
morning of POD1, he was ambulating and voiding with good pain
control, and therefore discharged to home. He will follow-up in
Hand Clinic in 1.5-2 weeks. | 343 | 102 |
13470788-DS-42 | 24,311,806 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for abdominal pain. You were
treated with bowel rest and pain medication and your pain
improved. At discharge, you were tolerating a regular diet.
We want to reassure you that everything is appearing well.
Please continue to advance your diet as tolerated at home and
use the morphine as necessary for pain.
Please STOP taking your diuretics for now. Please do not
re-start them until directed by your doctor.
Thank you for allowing us to participate in your care. | Impression: Ms. ___ is a ___ with PMH significant for
significant for chronic HCV infection with cirrhosis (with
decompensation complicated by esophageal varices and history of
SBP on fluoroquinolone prophylaxis), known HCC (s/p RFA in
___ who presented with worsening abdominal pain concerning
for chronic pancreatitis in the setting of prior HCV treatment.
**ACUTE ISSUES**
# Abdominal pain: Ddx included chronic pancreatitis, PUD,
gastritis, and nonulcerative dyspepsia. Lipase wnl but may be
c/w chronic inflammatory burnout. ___ managed conservatively
with bowel rest and IV pain management. Dr. ___ the
pancreatic team evaluated ___ and per their recommendations,
there did not appear to be any objective evidence of ongoing
pancreatic inflammation. Thus, an EGD was performed on ___ to
r/o evaluate other potential causes. A small polyp was biopsied
and mild gastritis noted in antrum. PPI was continued and
pathology showed hyperplastic polyp. ___ diet was advanced
and at discharge, she tolerated a regular diet and PO pain
medication. Per Dr. ___, she will
transition to viokase from creon and will likely need MRCP with
secretin as outpatient.
# Hyponatremia: Sodium noted to be 126 on ___ after initiation
of 20mg furosemide and 25mg spironolactone. They were thus held
again and hyponatremia improved. ___ maintained on
low-sodium diet and 1.2L fluid restriction. Please evaluate need
for diuretics as outpatient.
**CHRONIC ISSUES**
# HCV Cirrhosis c/b c/b ascites, prior SBP, grade 1 varices (EGD
___, and h/o HCC with RFA in ___. ___ previously
treated for HCV and failed therapy. Diuretics were held as noted
above. Ciprofloxacin for SBP prophylaxis was continued.
# GERD: ___ maintained on omeprazole while hospitalized and
continued on home PPI at discharge.
# Depression/Anxiety - Home citalopram continued.
**TRANSITIONAL ISSUES**
- Please evaluate need for diuretics as outpatient. ___ did
not tolerate low doses due to hyponatremia.
- MRCP with secretin recommended as outpatient per Dr. ___
- ___ transitioned from Creon to Viokase at discharge. | 92 | 314 |
15727523-DS-12 | 20,691,238 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were here
because you had low pressure and fainted. While you were in the
hospital, we monitored your heart. We did not see any problems
with the electrical system of the heart. We also lowered your
heart failure medicines. We did an ultrasound of your heart that
showed that your heart failure was stable.
What should I do when I get home?
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
DO NOT TAKE YOUR METOPROLOL AND SPIROLACTONE ON DIALYSIS DAYS | Ms. ___ is a ___ yo woman ___ lupus nephritis c/b ESRD s/p
LRRT now with failed graft on HD, CAD s/p NSTEMI in ___, and
chronic systolic CHF with one month of hypotension presenting
with hypotension and syncope from dialysis. Echocardiogram was
stable as compared to ___ (EF 40%). Metoprolol and
spironolactone were held on HD1 and then restarted on HD2. Of
note metoprolol tartate dose was decreased from 100 mg to 50 mg.
Spironolactone dose was continued at 12.5 mg. After discussion
with her oupt cardiologist, decision made to hold these
medications on dialysis days. She had dialysis on ___.
# Syncope: Differential initially included arrythmia, valvular
disease, worsening HF, medication effect leading to orthostasis.
EKG was at baseline, tropoin stable. She had positive
orthostatics on admission. She was placed on telemetry x 24
hours without any events making arrythmia less likely. A repeat
echocardiogram was performed, which was stable from ___ echo
(EF 40%). In discussion with her outpatient cardiologist,
metoprolol was decreased to 50 mg and held on dialysis days.
She will also hold spironolactone on dialysis days.
Chronic Issues:
# ESRD on HD: S/p failure transplat. Dialysis ___. Received
dialysis on ___ during hospital stay.
- continued tacrolimus
# systolic HF: EF 40%.
- metoprolol and spironolactone as above
# Lupus: Continued home prednisone.
# CAD: History of bare metal stent.
- continued aspirin
# HLD: continued statin
=
=
=
=
=
================================================================ | 100 | 241 |
11381628-DS-10 | 23,429,901 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated (Right Leg), may use crutches for
support. Range of motion as tolerated. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a Right transverse tibial fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for Operative fixation of a Right
Transverse Tibial 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 and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is Weight Bearing as Tolerated in the
Right lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 134 | 245 |
13144467-DS-6 | 21,940,800 | Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization for pericarditis. We restarted indomethacin and
your pain improved. Your heart seems to be working well and you
can be safely treated as an outpatient. Recurrences of
pericarditis are common, and usually occur at variable intervals
for up to several years. Over time, recurrences are typically
less severe and less frequent. Long-term or serious
complications are exquisitely rare.
Please follow-up with your primary care physician and
cardiologist as listed below
TRANSITIONAL ISSUES
- Educated patient regarding natural course of pericarditis,
with recurrences being common and complications being rare.
Typically pericarditis can be managed as an outpatient.
- Please see discharge summary for recommended medical
management of
pericarditis.
- Incidentally found 4-mm perifissural left upper lobe nodule.
If this patient is considered low risk for malignancy, no
additional followup is required. Otherwise, recommend followup
chest CT in 12 months. | ___ with history of acute pericarditis (s/p treatment with
colchicine, indomethacin, ibuprofen), most recently hospitalized
for dyspnea & edema (started on lasix) who presents with fevers
and chest/back pain, c/w recurrent pericarditis without evidence
of pericardial tamponade.
#Pericarditis, recurrent - Etiology is idiopathic vs viral.
Patient admitted for recurrent pericarditis, known pericardial
effusions since ___ completed 2 weeks of indocin on ___, and
had been on colchicine, ibuprofen, lasix. No evidence of
tamponade physiology on exam or EKG, with normal pulsus ___.
Though she experienced subjective dyspnea (likely secondary to
pain), she did not have any evidence of heart failure, was
euvolemic on exam, and recent echocardiogram ___ showed
preserved systolic function. She had good oxygen saturation.
CRP elevated at 236.8, consistent with pericarditis.
- Continue colchicine 0.6mg twice daily for 6 months
- Continue Indocin 50mg three times daily for ___ weeks and
taper as below:
--> CRP should be checked weekly 236.8 on discharge.
--> Indomethacin can be decreased by 25mg every ___ weeks once
the CRP has normalized (i.e. 50+25+50 daily for ___ weeks, then
50+25+25 for ___ weeks, etc)
- Continue omemprazole 20mg daily while on indomethacin.
- Cont home furosemide on an as needed basis
- Workup for causes of pericarditis negative to date: HIV
negative, ___ negative, TSH wnl. No arthralgias but we checked
lyme serologies, which are pending at time of discharge. ___
consider TB testing as outpatient. | 153 | 236 |
15621011-DS-18 | 29,048,248 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted to our hospital after developing shortness of breath
and leg swelling. These symptoms were caused by a buildup of
fluid in your legs and lungs, making it harder to breath. It was
also found that your kidney function has gradually gotten worse,
and because of this you were started on dialysis to remove
fluid. You will continue dialysis on ___ as an
outpatient. You will take 160mg of Lasix on non-dialysis days.
It will be very important to continue to take your lasix on
non-dialysis days, and to attend all your dialysis sessions.
Otherwise, there is a risk of fluid building back up and causing
trouble breathing again.
We recommend that you take 160mg of PO Lasix all at once on
non-dialysis days, rather than 80mg twice daily. This will help
the Lasix work better at removing fluid.
Once again, it was a pleasure participating in your care. We
wish you nothing but the best.
___ Medicine Team | ___ y/o M w/ a history of CKD (baseline Cr ___ PCKD s/p
transplant c/b chronic allograft nephropathy, obstructive sleep
apnea, HTN, and pulmonary hypertension who presented with acute
on chronic dyspnea. Dyspnea was felt to be likely due to fluid
overload secondary to HFpEF and worsening renal function,
exacerbated by medication noncompliance (not taking all
diuretics as prescribed due to fear of becoming "too dry"), and
higher salt diet. He was initially treated with IV Lasix and
BiPAP in the MICU, then was transferred to the floor once he was
able to transition to nasal cannula oxygen. Per discussion with
his outpatient nephrologist, he was initiated on hemodialysis
___, and dialyzed again ___ and ___. He will continue on HD as
an outpatient with a TuThSat schedule, and will follow with his
outpatient nephrologist Dr. ___.
ACTIVE PROBLEMS
# CKD secondary to PKD, s/p transplant ___, complicated by
graft failure: Allograft has been failing, with uptrending
Creatinine prior to admission per chart review. Transplant
ultrasound showing mildly elevated resistive indices. Has
working AV fistula on left arm. Per discussion with outpatient
nephrologist, HD was initiated this admission, with first day
___. Cyclosporine level slightly high at 178 on ___, so dosage
decreased from 150mg BID to ___ BID. He was dialyzed again on
___ and ___. He will do a TuThSat HD schedule as outpatient. PPD
was placed and documented as negative. He remained on
mycophenolate 500mg BID, and cyclosporine was decreased to 100mg
BID. He continued on Sevalemer 800mg daily. As an outpatient
there will be a continued discussion and workup for the
possibility of a second transplant.
# Acute exacerbation of HFpEF: Presented with dyspnea on
exertion, orthopnea, PND, edema in the setting of dietary and
medication noncompliance. Fluid retention complicated by
recently worsening renal transplant function. Given Lasix 80mg
IV x3, then 100mg IV x1, but continued to be volume overloaded
and urine output was not robust enough with diuretics alone. HD
was initiated per above for the primary mechanism of fluid
removal. As an outpatient he will do Lasix 160mg PO on non-HD
days. He will continue metoprolol succinate 200mg daily, and
nifedipine 120mg daily.
# HTN: Had episode of SBP >170 soon after admission, responded
to IV labetalol x2. SBP's remained elevated overnight prior to
HD, as high as 180's systolic and >100 diastolic. BP's improved
after dialysis and receiving his anti-hypertensive medications.
He will continue on nifedipine 120mg daily, metop succinate
200mg daily, and Lasix 160mg on non-HD days as outpatient.
# Opacity noted on past chest imaging: Chest imaging was
repeated as part of pre-transplant evaluation once his pulmonary
edema had resolved. CXR was done ___, showing likely residual
atelectasis. Non-con CT chest was done ___, showing no worrisome
lung nodules or pneumonic consolidations.
CHRONIC PROBLEMS
# OSA: With CPAP noncompliance at home. Was on supplemental
oxygen due to pulm edema during much of this hospital stay, but
back to RA by discharge. CPAP was offered in house, but pt
refused. We recommend he strongly consider using it as an
outpatient.
# Macrocytic anemia: Hgb 9.9 on admission, as low as 8.7, and
9.1 on day of discharge. MCV elevated at 99. LDH, Bilirubin,
Haptoglobin normal. Likely in part due to renal dysfunction, low
epo, and chronic disease.
# HLD: continue Atorvastatin 20mg nightly and Fenofibrate.
# Incisional hernia with bowel obstruction, repaired ___:
Healing well. Staples were removed by surgery team on ___.
TRANSITIONAL ISSUES
- Will do HD on TuThSat
- Will take Lasix 160mg PO on non-HD days
- Cyclosporine dosing was decreased due to elevated level in the
hospital
- CXR and CT chest were done to better define a lung opacity
noted on previous imaging. Ground-glass opacities and mosaic
pattern throughout the lungs were found, but there was no
worrisome nodule or consolidation on CT scan.
- Patient also had issues with hypertensive urgency with SBP as
high as 192 which improved with dialysis. This was thought to be
secondary to holding of antihypertensives prior to dialysis and
volume overload. He was advised to take higher dose of lasix
160mg daily for improved management of volume status and blood
pressures. Please follow blood pressures closely in the
outpatient setting.
- PPD negative
- Full code | 169 | 690 |
13774759-DS-11 | 27,648,828 | Discharge Instructions:
Personal Care:
1. Your chest dressings should be changed once to twice a day.
Once will be by the visiting nurse, and if possible a second
should be by family member. ___ to dry kerlex should be packed
in the wound at least until your follow-up appointment ___.
The size of the wound should naturally decrease in size with
time and continued wet to dry dressings.
2. Clean around the wound with soap and water.
3. You may shower daily. No baths until instructed to do so by
Dr. ___.
4. Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications and take any new meds as
ordered.
2. Take Tylenol or Extra Strength Tylenol for mild pain as
directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. 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.
6. You are going home with a ___ line. This line should be
flushed daily by the visiting nurse. You should receive
antibiotics twice daily through the ___ line.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the wound.
2. A large amount of bleeding from the wound.
3. Fever greater than 101.5F
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* 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, increased redness, swelling
or discharge from incision, 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. | # Sternal incision dehiscence
The patient was admitted to the plastic surgery service on
___ and had a sternal washout, removal of sternal hardware
and removal ___ cardiac device. The patient tolerated the
procedure well. Post-operatively, she was packed with normal
saline wet to dry twice/day to sternal wound.
.
Neuro: Post-operatively, the patient received IV pain
medication 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: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. She was also started on a bowel
regimen to encourage bowel movement. Intake and output were
closely monitored.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
# MRSA infection sternum
Cultures were sent of sternal fluid and grew MRSA. Infectious
Disease was consulted and patient was started on vancomycin IV.
She will have 6 weeks of vanco in total. A PICC line was placed
for this purpose.
.
# poor blood sugar control
Patient known to have poor blood sugar control at home (mainly
non compliance). Admission fingerstick blood sugars: ___:
223, 247, 325, 287. ___ Diabetes was consulted for
assistance with better blood sugar control while inpatient.
___ saw patient daily and reviewed blood sugar data, making
long acting and short acting insulin adjustments. Patient with
improved blood sugars and compliance while inpatient with
discharge blood sugars as noted: ___: 187, 140, 234, 195.
___: 199, 145. She will discharged home on same regimen and
with blood sugar checks by visiting nurse.
.
At the time of discharge on POD#6, the patient was doing well,
afebrile with stable vital signs, tolerating a diabetic diet,
ambulating, voiding without assistance, and pain was well
controlled. inferior sternal wound clean with wet to dry
dressing in place. PICC in place for 6 weeks of IV vancomycin
treatment. | 429 | 369 |
19247265-DS-11 | 23,280,333 | Mr. ___,
You were transferred from an outside hospital on ___ for
Left third toe gangrene. You underwent a diagnostic left
angiography on ___ which revealed a left popliteal
occlusion. You recovered well from surgery and are now ready
for discharge. Please follow these instructions:
Please follow up with Dr. ___ on ___. An appointment
has already been for you.
Wound care instructions for your left foot and right BKA stump
have been provided. Please keep your left foot clean and dry.
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
You have been placed on an antibiotic, Augmentin for 10 days.
Please finish the entire course of this medication.
You were started on amlodipine, a new medication for your
blood pressure. Please follow up with your primary care
physician ___ 7 days of discharge for appropriate blood
pressure management.
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Mr. ___ is a ___ w/ PVD s/p R BKA ___ who
presented on ___ w/ L ___ toe dry gangrene and heel ulcer.
Following his BKA in ___, the pt has undergone serial
evaluations for local wound care of RLE BKA stump as well as
chronic dry-gangrene of his L third toe and ulcerated L great
toe. On ___, Mr. ___ presented to Dr. ___,
where he was noted to have wet gangrene L third toe. He was
subsequently referred to the ED for admission to the vascular
surgery service.
In the ED, the pt complained of severe phatom pains at the R BKA
site, w/o any identifiable precipitating factor. He also
complained of intermittent L heel pain and "stiff toes." An
X-ray of pt's left foot performed in the ED revealed a
radiopaque foreign body. Due to his calcaneal ulcer, first, and
third toe gangrene, the pt was started on IV Vanc/Zosyn and
admitted to the Vascular Surgery service.
On ___, the pt underwent a diagnostic angiogram, to
determine potential for revascularization (last angio on
___. The angiogram revealed occlusion of the left
popliteal, TP trunk, ___, and peroneal arteries. The patient
tolerated the procedure. In the PACU, he did require a dose of
hydrazine for hypertension and was started on amlodipine
thereafter.
On ___, given the angiogram findings, the pt underwent vein
mapping of both upper and lower extremities to determine if he
had suitable conduit to be used for a fem-AT bypass. He was
found to have a patent left saphenous vein but it was small in
caliber. In the upper extremity, he had patent bilateral
cephalic and basilica veins and radial arteries bilaterally were
densely calcified.
The patient was discharged on ___. Throughout his hospital
course, he remained afebrile with stable vital signs and no
leukocytosis. Urine cultures grew Enterococcus. His distal
extremity wounds were tended to with daily dressing changes and
Aquacel treatment at the right BKA stump. Prior to discharge, IV
antibiotics were stopped, and the pt was transitioned to oral
antibiotics (Augmentin) to be taken for a total 10-day course at
home. He was also discharged with amlodipine for added BP
control. Follow up with Dr. ___ was arranged in Vascular
Surgery Clinic. The patient was also instructed to follow up
with his PCP. | 467 | 392 |
16022440-DS-13 | 24,761,817 | You were admitted to ___ on
___ with complaints increasing fatigue, vomiting, and
maroon/black-colored stools. On further evaluation, you were
found to have a low hematocrit, which required you to receive 3
blood transfusions. Because you were thought to have bleeding
from your bowels, so you underwent a capsule study. Results
showed that cysts in your small bowel that required you to have
that portion of your intestine removed (approximately 30cm).
After surgery, you were kept NPO (nothing to eat) and given IV
fluids. As your bowel function returned, your diet was
advanced. You had periods of nausea and vomiting which required
that a ___ tube be inserted for stomach decompression.
Imaging showed that you had a post-operative ileus, which
sometimes occurs right after surgery. Again, your were given
bowel rest (nothing to eat) until your bowels began to work
again.
You are now tolerating a regular diet and are ready for
discharge with the following instructions:
PACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing 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.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | ___ w/ PMH sig for severe iron deficiency anemia p/w 4 day h/o
generalized weakness, fatigue, body aches and malaise, initially
admitted to the medical service and found to have severe anemia
and a history of a cystic lymphatic malformation in ileocecal
region.
On admisison, the patient was resuscitated with 3 units PRBCs
with Hct increase to 24 from 14. Capsule study performed
showing distinct site of bleeding in distal small intestine. The
patient reported a history of a multiloculated mesenteric cystic
formation in distal small bowel near ileocecal junction, thought
possibly to be a mesenteric lymphangioma. She was evaluated by
surgery and GI and planned for resection. She was taken to the
operating room and underwent laparoscopic assisted push
endoscopy, exploratory laparotomy and small bowel resection
measuring approximately 30cm. Please see operative report for
details of this procedure. She tolerated the procedure well and
was extubated upon completion. He was subsequently taken to the
PACU for recovery.
She was transferred to the surgical service post-operatively and
brought to the surgical floor hemodynamically stable. Her vital
signs were routinely monitored and he remained afebrile and
hemodynamically stable. He was initially given IV fluids
postoperatively, which were discontinued when he was tolerating
PO's. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
Her pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed. Her NGT was
discontinued on ___ and to ___ the patient was doing
well from a dietary standpoint, and had been advanced from sips
to clears. However, she again began developing nausea at this
time, and she was made NPO and her NGT replaced. Again she began
to feel improved, was passing flatus and bowel movements, so her
diet was resumed on ___ and advanced to clears. She again
began to develop nausea and vomiting on ___ and her diet was
made NPO, although she did not require NGT at that time. Due to
failure to progress, a CT abdomen/pelvis was obtained which
demonstrated no signs of bowel obstruction, and expected
post-operative changes. It was theorized that her intermittent
nausea and vomiting was due to her having food brought to her by
friends while on NPO/sips diet, as half-eaten solid food was
often found in the patient's room. Final pathology results of
her resected segment of small bowel resulted on ___, showing
benign vascular malformation, 8 cm, transmurally involving small
intestine and present at radial margin. She was advanced to a
regular diet finally on ___ which she tolerated without
incidence of nausea, vomiting, diarrhea or abdominal pain. It
was our recommendation that Ms. ___ stay another day to
further ensure that she was tolerating adequate oral intake,
however, she expressed wishes to be discharged on ___. It
was discussed at length with Ms. ___ that risks of leaving
early included, but were not necessarily limited to, recurrence
of nausea, vomiting, and abdominal pain which could necessitate
return to the emergency department and re-admission. She
verbalized understanding of these risks and accepted them.
Ms. ___ was discharged on ___ in good condition,
tolerating oral intake, afberile with stable vital signs. She
was arranged outpatient follow up with both ___ and ___ clinics.
It was discussed at length the warning signs with which she
should return to the emergency department and she understands
them. | 718 | 569 |
10280054-DS-10 | 20,177,063 | You were admitted to the hospital after you were involved ___ a
motor vehicle accident. You sustained injuries to your head,
face, back, and abdomen. You were monitored ___ the intensive
care unit until your stable and then transported to the surgical
floor. You have slowly improved from your injuries but will need
a ___ facility to assisst you. Your vital signs
have been stable and your neurological status is improving. You
are now preparing for discharge to a ___ facility. | The patient was an unrestrained driver who hit a tree. The
patient was intubated at the scene and transported to the ___
___ for further management. Upon
admission, the patient was given intravenous fluids and
underwent imaging of his head, neck, chest, and abdomen. He was
transported to the intensive care unit for monitoring. After
review of the imaging. the patient was reported to have
sustained a right 5th rib fracture, bilateral pulmonary
contusions, grade 1 liver laceration, S1-2 fracture, L5
transverse process fracture, right mastoid/sphenoid fracgture,
diffuse intraparenchymal hemorrhage, and right carotid
dissection. Because of the extent of his injuries, the patient
was evaluated by neurosurgery, ortho-spine, and neurology.
The patient was found on head cat scan to have multiple punctate
hemorrhages ___ the left frontal, left cerebellar and left and
right temporal lobes. On CTA, he was noted to have a possible
dissection of the right internal carotid artery Neurosurgery was
consulted and gave recommendations including initiating Mannitol
but no surgical intervention was needed. Daily doses of aspirin
were ordered for management of his right carotid dissection.
Because of his head injury the patient had bouts of agitation
controlled with Ativan. There was concern for alcohol
withdrawal and and the psychiatric service was consulted. The
patient was started on clonidine, methadone, Ativan and Haldol.
The patient self-extubated on HD #3 and required re-intubation
within 24 hours for respiratory failure. After aggressive
pulmonary toilet, the patient was extubated on HD #6. The
patient was bronched and was reported to be growing staph aureus
coag. + was started on a 7 day course of naficillin. ___ order to
provide nutrition to the patient, a Dobhoff feeding tube was
placed and later changed to a PEG for long term nutritional
support. Tube feedings were initiated. The patient continued to
experience bouts of agitations and the Psychiatry service was
again consulted. After evaluating the patient, they recommended
a weaning regimen for the Ativan, Haldol, and methadone.
Monitoring of the QTC interval was ordered and measured prior to
dosing of medications. After completing his 7 day course of
nafcillin, the patient completed a 5 day course of levaquin for
persistent pneumonia. Psychiatry reevaluated the patient and
switched his medication regiemen to Ativan, Seroquel, and a
standing dose of methadone.
During his hospital course, the patient was seen by the Spine
service because of his transverse process and sacral fracture.
No surgical intervention was indicated and no weight bearing
restrictions were implemented. He was reevaluated by the Ortho
Trauma service and they recommended 50% weight bearing on the
left side and WBAT on the right however they commented it is
unlikley he would be able to comply. The patient was evaluated
by physical therapy and a plan for discharge was developed. A
mild increase ___ his white blood cell count was noted on HD #10
and the patient's foley catheter and central venous line were
removed and sent for culture. No The patient underwent a chest
x-ray which showed a right lung opacity and the patient was
started on a week course of levofloxacin. He remained afebrile
and his white blood cell count gradually normalized. The patient
also had his feeding tube pulled before discharge as he was
taking adequate food and nutrition.
The patient's mental status has been variable with periods of
confusion and lucidity. The psychiatric service has been
evaluating him and adjusting his anti-psychotic medications.
Over the last few days, he has become oriented to time, person,
and place and has been cooperative with activities. He still
requires assistance with toileting and reminders of daily
activity. Over the last 24 hours he was noted to have a rash on
his lower back. He also reported intense muscle spasms ___ lower
extremities which were relieved with ambulation. His
electrolytes were monitored and within normal limits. The
patient's vital signs have been stable and he has been afebrile.
He has been tolerating a regular diet with 1:1 superivsion and
voiding without difficulty. He has been maintained ___ a Veille
bed because of his episodes of compulsiveness and to reduce the
risk of falls. On HD #26, he was discharged ___ stable condition
to the ___ facility. Follow-up appointments were
scheduled for him, including 2 ENT appointments with
Ortho-spine, Neurosurgery, and the acute care service. | 85 | 753 |
19209226-DS-20 | 26,509,964 | Mr. ___,
You were admitted due to influenza viral infection, this
improved with antiviral medication and supportive treatments. We
also started you on a bacterial antibiotic to treat a secondary
bacterial infection. Your symptoms improved and you will be
discharged home. You will follow up as stated below. Please do
not hesitate to call in the meantime with any questions or
concerns. | ASSESSMENT AND PLAN: ___ yo man with hx of CLL s/p alloSCT in
___ who is admitted with fevers and cough.
#Neutrapenia: Evidence of neutropenia on CBC ___ (___ 490/WBC
1.6). Repeat WBC 1.9 with ANC 820. Etiology Likely as a result
of viral infectious process as below. Received x 1 dose of
neupogen prior to discharge and will follow up outpatient.
#Influenza: Has influenza A swab positive, his symptoms have
been present for > 48 hours. Given his of SCT, we will treat
with 7 day course of Tamiflu. Will also cover for super imposed
CAP given his persistent symptoms and mucous production. Does
not
have history of immunoglobulin deficiency since transplant and
is
not toxic appearing so will not give IVIG at this time.
-Levaquin renally dosed for now for 5 days [___]
-Tamiflu for 7 days [___]
-___ and ___ prn for cough
-monitoring fever curve closely
___: Creatinine elevated to 1.6 from 1.1 previously, likely
secondary to acute illness and poor PO intake. Stable on ___ at
1.1. UA with 4 urine casts/trace hem but otherwise negative.
Urine culture pending at discharge. S/p 1L NS ___, will continue
to monitor I/O and trend lytes closely
#CLL s/p Allo: His last marrow from ___ was suggestive
of very minimal residual disease, still had evidence of deletion
of chromosome 11 long arm, however he was 95% donor. Chimerism
studies from ___ show 100% donor.
-Diagnosed with CLL in ___
-Initiated treatment on ___ with FCR x4 cycles
-Multiple other chemotherapy regimens
-Most recently s/p 5 Cycles or R-CHOP
-XRT to decrease bulky disease prior to transplant (completed
___ MUD Allo SCT. Reduced intensity: Flu/Bu/ATG
-continues on acyclovir PPX
-Off all immunosuppression
#Diarrhea: New episode ___ but none overnight, will send C-diff
if occurs again, could be in setting of viral etiology with
influenza as above, ? levaquin vs Tamiflu effect? No
reoccurrence of diarrhea at discharge
CODE: Full
COMMUNICATION: Patient
EMERGENCY CONTACT HCP:
DISPO: Discharged ___, follow up appointment arranged | 61 | 321 |
16787711-DS-9 | 28,651,222 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint should be worn for comfort measures on right wrist
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
Physical Therapy:
Weight bearing as tolerated left lower extremity
Treatments Frequency:
Staples will be removed at follow up appointment. Dressings not
needed if wound continues to be non draining, may be used for
comfort. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left mid shaft femur fracture and was admitted to the
orthopedic surgery service. The patient was also found to have a
triquetral avulsion fracture in his right wrist and was given an
adjustable splint for comfort measures. The patient was taken to
the operating room on ___ for left hit piriformis nail, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, weight bearing as tolerated in the right
upper extremity with splint for comfort and will be discharged
on lovenox for DVT prophylaxis. The patient will follow up in
two weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge. | 165 | 277 |
19876293-DS-15 | 27,053,236 | Dear Ms. ___,
You were hospitalized after you accident for management of the
following injuries: bilateral sub-arachnoid hemorrhages, L ___
rib fxs with small hemopneumothorax, L scapula fx, L clavicle
fx, L distal radius, ulna and ___ metacarpal fxs. Your left
arm fractures were management nonoperatively with a cast and
support with a sling. You have scheduled follow-up appointments
with the appropriate surgical services.
Please hold your coumadin for 1 month until follow-up with
neurosurgery. You may restart your aspirin on ___. Continue
Keppra until you follow-up with neurosurgery
Further information regarding your rib fractures:
* Your injury caused ___ 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).
Sincerely,
___ Acute Care Surgery | Ms. ___ was admitted to the trauma ICU for close
observation of of her injuries. In total, she suffered from the
following injuries: b/l SAH, L ___ rib fxs with small
hemopneumothorax, L scapula fx, L clavicle fx, L distal radius,
ulna and ___ metacarpal fxs. Her INR was 2.2 on admission
and her warfarin was held. She was transferred out of the ICU to
the floor after confirmation of hemodynamic stability. Her pain
was well controlled and her oxygen status was improving.
However, she continued to have poor techique with incentive
spirometry despite multiple instruction. It was thereby
difficult to fully evaluate her abily to determine her
inspiratory capacity.
Neurosurgery was consulted regarding her b/l SAH and recommended
Keppra and holding coumadin until patient is seen in outpatient
follow-up. Aspirin is to be restarted on ___. She will be seen
in ___ clinic in 1 month with a noncontrast head CT and
the decision will be made whether or not to restart
anticoagulation. Orthopedics recommended nonoperative management
of left upper extremity injury. A cast was placed on her left
extremity and her left arm was placed in a sling. She has
follow-up in ___ clinic in 2 weeks for outpatient management
and monitoring of her left arm fractures. At time of discharge,
she was resting comfortably and tolerating a regular diet. ___
evaluated patient and ___ rehab. She was discharged to
rehab with agreement with the treatment plans. | 339 | 239 |
19989126-DS-15 | 22,853,928 | Ms. ___,
It was a pleasure participating ___ your care at ___
___. You were admitted to the hospital with
headache, nausea and vomiting. You were found to have
intraventricular hemorrhage (bleeding into the ventricles of
your brain), caused by your ___ disease. Extraventricular
drains (EVDs) were placed for monitoring and drainage, and you
were admitted to the ICU. ___ the ICU you developed meningitis -
infection of the fluid surrounding the brain. You were treated
with antibiotics and your meningitis resolved. Your EVDs were
then removed and you were transferred to the medical floor where
your symptoms continued improving. Because you are still too
weak to go home alone, you are being discharged to rehab.
We made the following changes to your medications:
1. STARTED Linezolid ___ by mouth every 12 hours for your
meningitis. (Last ___ = ___
2. STARTED Fioricet (acetaminophen-caffeine-butalbital) ___ tabs
every 4 hours as needed for headache
3. STARTED Topomax (topiramate) 25mg by mouth twice daily for
headache
4. STARTED Benadryl 25mg by mouth every 6 hours as needed for
itching
5. STARTED Heparin subcutaneous 2500mg twice daily to prevent
blood clots ___ the legs until you are able to walk independently
6. STARTED Colace (docusate) and Senna for constipation
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change ___ mental status.
Any numbness, tingling, weakness ___ your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | On ___, Ms. ___ required urgent placement of bilateral
EVDs for obstructive hydrocephalus ___ the setting of bilateral
intraventricular hemorrhage. The EVDS were placed emergently ___
the ED and she was subsequently transferred to the Neuro-ICU
intubated.
The patient was extubated on ___, HD #2, without event. Her
total drain output was maintained at > 20 mL/hr. On ___, it
was noted that right EVD drained well with left EVD having
minimal output. Protocol drain trouble shooting efforts,
improved the left EVD output.
On HD #4, ___, bleeding from EVD site was observed on rounds.
PTT was elevated at 64.8. Patient's subcutaneous heparin was
temporarility discontinued. The head CT remained stable.
On HD #5, ___, patient's subcutaneous heparin was
re-initiated with a bid dosing schedule rather than tid. On
examination, patiet appeared delerious, which was attributed to
sleep deprivation.
On HD #6, ___, patient remained agiated on examination. We
continued to monitor her closely ___ the neuro-ICU.
On ___, PTT was elevated to 57.1, SQH was decreased to 2500
units. She was febrile to 101.1 overnight, urine culture was
sent. Patient reported significant headache and toradol was
added. Her L EVD was clamped ___ attempt to remove and R drain
remained open.
On ___, there were no issues with elevated ICPs while L EVD
clamped. A head CT was done which showed stable ventricle size
and L EVD was removed. R EVD was clamped ___ attempt to removed
as well. She was afebrile overnight. Patient reported pain and
aggitation, she was placed on standing toradol and prednisone.
On ___ patient was found to have an enterococcus UTI and was
started Vancomycin. The patients Intercranial pressures were
___ and the EVD was opened.
On ___, The External Ventricular Drain was open and the ICP was
10. The patient had complaints of severe headache and a Head Ct
was performed which was consistent with interval removal of a
left frontal approach EVD with post-procedural small
amount of air ___ the right frontal horn and moderate amount of
air ___ the
right temporal horn. Allowing for the new air ___ the ventricular
system, the right lateral ventricle is unchanged and there is no
evidence of hydrocephalus or new mass
effect. Right frontoparietal subarachnoid hemorrhage is stable.
Ampicillin was added by ICU for the UTI. On exam, the patient
opened eyes to command, exhibited signs of photophobia. The
patient was not answering questions secondary to pain, but did
follow commands ___ all 4 extremities.
On ___, The patient had a temperature of 101 overnight and
urine/blood/Cerebral SpinalFluid cultures were sent. The CSF
culture prelim findings were consistent with +3Gram Postive
Cocci and 2+Gram Negative Rods. There was a question that this
may have been a contaminant and a second CSF culture was sent.
The patient was more lethargic ___ am and this was thought to be
due to fever and lack of sleep. The neurological assessment was
changed to every four hours to allow for sleep. The patient
became more alert as the ___ progresses and followed command
more readily. The serum sodium was 129. Urine lytes were send
dueto urine output of 200cc /hr for repeated hours and were
consistent with Creatinine of 15, serum sodium 10, potassium 9,
chloride of 16, and Osmolality of 92. Due to poor nutritional
intake the patient was initiated on IVF at 75cc/hr. The
External ventricular drain was open and draining well. The EVD
was level at 10 above the tragus. A Infectious Disease consult
was called to recommend planning for laproscopic Ventricular
Peritoneal shunt and steroid therapy for headache given fevers
101-103 and infection. The White Blood Count was slightly
elevated at 11.1. The patient continued to complain of servere
headache and neck pain. Topiramate (Topamax) 25 mg PO/NG BID for
headache was initiated perthe ICU team. A KUB was performed
given temperature of 103 for abdominal tenderness. On exam, the
patient opened eyes to voice and followed intermitent commands.
The pupils were equal reactive. The patient briskly localized.
The patient moved the bilateral lower extremities to command
intermitently.
On ___, pt continued spiking fevers (Tmax 102.8). Her
antibiotics were switched to Vanc/Meropenam per ID recs for
empiric treatment of meningitis (Vanc also covering her
pan-sensitive UTI). Her EVD was replaced ___ the OR out of
concern that EVD contamination had caused the meningitis.
On ___, pt remained confused with persistent photophobia and
meningismus. Head CT assessing EVD position showed Status post
revision of EVD. Increased air ___ frontal horn of the lateral
ventricle. Decreased air ___ the temporal horn of the right
lateral ventricle. Small amount of blood seen ___ the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage. The
Cerebral Spinal Fluid preliminary culture grew gram negative
staph, cornyebacterium (diptheroids), enterococcus (rare
growth). Per infectious disease recommendations antibiotics were
narrowed to Vancomycin 1g every 8 hrs for External Ventricular
Drain-associated meningitis. Severe headaches persist and
patient pain managed with fioricet/dilaudid/topomax.
On ___, The patient exam was slightly improved exam improved
and the patient was noted to have multiple loose stools. A urine
culture was sent which was negative.
On ___, The patient experienced fever to 101.8 overnight, The
external ventricular drain was clamped as a trial to see if the
patient would tolerate it. The Intercranial Pressures were low
___ ___ the morning. Intercranial pressures rose, prompting the
right EVD to be re-opened wtih 5 mL of drainage. Pysical
Therapy and Occupational Therapy orders were placed. The foley
catheter was discontinue. The patient has had poor po intake due
to pain and delerium and was initiated on intravenous fluid at a
rate of 75cc/hr.
On ___, the patient remained agitated during examination. As
her ICPs were ___, her EVD was reclamped. ICPs remained near 3.
Ms. ___ Foley was replaced per nursing request to optimize
care.
On ___, patient's examination was dramatically improved.
Agitation was substantially decreased and patient was able to
move all four extremities to command. The EVD remained clamped
with tolerable ICP. Repeat head CT revealed decrease ___ right
lateral ventricular air and decreased intraventricular blood.
___ the afternoon, the patient was febrile to 100.3, a fever
workup was institued and CSF cultures were obtained.
___, patient spiked to Tm 102.8. As per ID's recommendations we
change her antibiotics from Vancomycin to Linezolid to rule out
Vancomycin as the source of her fevers. Her EVD was removed and
a CSF sample was sent again. Patient no longer requires ICU
level care and is ready for transfer to a SD unit.
On ___, patient remained afebrile on the floor; photophobia
mildly improved but still confused and oriented only to self.
Her right EVD staples were removed. CSF cultures have shown no
growth to date since the positive cultures on ___.
On ___, Patient self-DC'd her PICC twice, so her Linezolid was
switched to PO (confirmed OK with ID).
On ___, patient spiked fever to 102.3. Blood cultures were sent
(no growth to date). Chest x-ray showed no infiltrate. Unable to
obtain urine culture as patient incontinent and refusing
straight cath.
On ___, patient was discharged to rehab.
===================================== | 327 | 1,228 |
11867658-DS-5 | 24,418,227 | You were admitted after a fall.
Unfortunately, you sustained pelvic and sacral fractures.
Orthopedic surgery did not believe your injuries required
surgery. You will continue to recover though physical therapy.
We also noted that you were feeling weak and you were given a
blood transfusion for low blood counts.
A repeat head CT on the day of discharge for evaluation of
headache showed 2 lesions which have mildly increased but in
discussion with your radiation oncologist and the
neuro-oncologist they did not feel that steroids (ie
dexamethasone) would clearly provide benefit.
Please follow up with your doctors ___ 1 week as already
scheduled to repeat your labs and for further monitoring.
Please take your oxycodone only as needed as this can cause
drowsiness and increase your risk of falls. You can take miralax
as needed for constipation to ensure once daily bowel movements.
Likewise please continue to work with your primary care doctor
to consider stopping ___ at night and consider alternatives
as this can also increase your risk of falls.
If you develop nausea, vomiting, fevers, chills, chest pain,
shortness of breath, lightheadedness/dizziness, worsening
instability or falls or any other symptoms that concern you,
please call your doctor or return to the emergency department.
It was a pleasure taking care of you! | ___ years-old female with chronic left foot droop and breast and
lung cancer with known brain metastasis presents after a
presumed mechanical fall with pelvic and sacral fractures.
Orthopedic surgery evaluated the patient and recommend ___
surgery. Physical therapy recommend rehabilitation facility
placement for adequate improvement in functional status.
Additional details by problem listed below.
#SACRAL FRACTURE. PELVIC FRACTURE DUE TO MECHANICAL FALL.
CT pelvis with nondisplaced pelvic and sacral fractures. Initial
XR was without evidence for acute fracture or malalignment of
prosthesis. Orthopedic surgery recommend weightbearing as
tolerated and ___ consulted for evaluation and treatment. ___
recommend SNF placement. Patient monitored on fall precautions
and given Oxycodone ___ PO ___ mg Q4H PRN and Lidocaine patch
PRN for pain.
Ultimately pt was cleared for home by ___ following multiple
inpatient ___ sessions.
#SECONDARY MALIGNANCY OF BRAIN
#HEADACHE
NCHCT without clear new pathology, though better characterized
on recent MR. ___ focal neurological deficits to suggest an acute
intra-cranial pathology to explain the fall. Patient's
lightheadedness on the day of the fall is suspected to be a
result of Ativan that she took that morning. ___ history to
suggest seizure. Neuro-oncology evaluated the patient without
formal recommendations, but plan outpatient visits and treatment
as scheduled. Patient is continued on home Keppra.
Notably patient sustained a ?new headache on the morning of the
discharge and a brief episode of likely delirium the night
preceding; though her neuro exam was reassuring she underwent a
repeat NCHCT with perhaps slight worsening of her metastatic
brain disease but in discussion with rad-onc and neuro-onc,
unlikely to account for her symptoms. She was given a 1x dose of
dexamethasone with resultant emesis and in further discussion
with rad-onc and neuro-onc it was felt the benefits of ongoing
therapy were outweighed by risks/AEs and it was decided to not
d/c the pt on further outpatient therapy.
#LEUKOCYTOSIS: Likely reactive to physiologic stress without
other signs/symptoms of infection such as fevers. Could be
related to atelectasis/LLL collapse. We encouraged incentive
spirometry. Patient is status post recent treatment of
pseudomonas pneumonia x7 days. ___ hypoxia to suggest acute or
recurrent pneumonia. Initial CXR unchanged from prior. Blood
culture without growth. Patient not given antibiotics. Nearly
normalized to 10.1 on the day of discharge.
#BREAST CANCER AND LUNG CANCER: Patient is treated by Dr. ___ at
___ with Adriamycin/Cytoxan. Initially next tx was due
on ___ with ultimate course to be dictated by outpatient
provider; this was rescheduled to ___ with med-onc with rad-onc
scheduled the day prior (___).
#HYPONATREMIA. Likely hypovolemic hyponatremia. Possible SIADH.
Monitored during the hospitalization and patient encouraged to
maintain adequate oral intake. Resolved on the day of discharge
following a transfusion.
#HYPOTHYROIDISM: Continued on home levothyroxine
#INSOMNIA: Continue home Ativan, but would plan transition to
another sleep aid when possible given falls. I counseled the pt
on risks on the day of discharge and she agreed to hold on
continued therapy and discuss alternatives with her outside
providers (pt declined Trazadone)
#ENCOUNTER FOR PALLIATIVE CARE: Goals of care were discussed on
admission. Ongoing education about the severity of patient's
disease being pursued with both patient and daughter (health
care proxy).
>30 minutes were spent in discharge planning and coordination of
care on the day of discharge. | 209 | 534 |
19624478-DS-24 | 29,555,124 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non weight bearing right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- 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. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
- non weight bearing right lower extremity
Treatments Frequency:
- short leg splint to stay on until follow up | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF R ankle fx, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the right lower extremity, and will be
discharged on aspirin 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. | 356 | 254 |
12216053-DS-20 | 29,514,291 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for replacement of your
nephrostomy tubes after one was dislodged and blood was found in
the other. You also had a urinary tract infection. Your tubes
were successfully replaced. The right tube became dislodged
during admission and was replaced again. You were also treated
with antibiotics. During your admission you noticed some blood
in some of your stools. Your blood counts remained stable and
this resolved.
You were started on baby aspirin for your history of coronary
artery disease. You should continue to take this every day.
You also had a small flare of the gout in your toe. You were
given a medication called colchicine, which helped it resolve.
You were seen by physical therapy, who felt you were not moving
well enough on your own to go home safely. Because of this, you
were sent to a rehabilitation facility to help get your strength
back.
Please be sure to attend all follow-up appointments below.
Thank you for allowing us to be part of your care. | ___ woman with complex medical history notable for advanced
bladder cancer s/p partial resection, c/b obstructive
nephropathy requiring bilateral nephrostomy, s/p L nephrostomy
replacement and R nephrostomy re-sizing, course complicated by
UTI , constipation with isolated trace BRBPR and gout attack, as
well as migration of right nephrostomy tube requiring a second
replacement.
Acute Issues
============
#NEPHROSTOMY TUBE CLOG/MIGRATION: Cause of initial
clog/migration and repeated right tube migration not clear.
Patient underwent uncomplicated L nephrostomy replacement, right
nephrostomy upsizing, and later right nephrostomy replacement.
Both tubes were draining well and securely on place on
discharge.
#BLOOD PER RECTUM: Patient had light-colored bowel movement with
blood-tinged toilet water on HD2. Soon thereafter she had a
loose light stool and noted small blood on the toilet paper.
This was presumed to be due to hemorrhoids as she had been
constipated for multiple days and straining to have a bowel
movement. She was started on stool softeners with relief of her
constipation. She had isolated episodes of blood on the toilet
paper throughout her admission but stools remained light in
color and she remained hemodynamically stable with baseline
hematocrit.
#HEMATURIA: Patient had one episode of blood-tinged urine during
admission. Per discussion with our Urology colleagues, this was
accepted as normal in a patient with avanced bladder cancer. As
above, she remained hemodynamically stable with baseline
hematocrit. Urine draining into nephrostomy bags was light
yellow without gross blood.
#UTI: Patient received a short course of bactrim. She remained
symptomatic throughout admission.
#L GREAT TOE GOUT: Mild gout attack presented on HD3 in L great
toe. Patient received two doses of colchicine with good effect.
Her symptoms were fully resolved on discharge.
#ACUTE ON CHRONIC RENAL FAILURE: Patient's creatinine gradually
trended downward after nephrostomy tube replacement. It
remained stable at her baseline through the remainder of
admission.
Chronic Issues
==============
#HTN: Patient was continued on her pre-admission metoprolol XL
and furosemide.
#HL: Patient was continued on her pre-admission simvastatin.
#CAD: Patient was started on daily aspirin 81mg prior to
discharge with instructions to continue indefinitely.
#ASTHMA: Patient was continued on her pre-admission advair.
#IDDM: Patient was managed on an insulin sliding scale with
adequate glucose control.
#BLADDER CANCER: No further intervention.
Transitional Issues
===================
- Patient should be continued on daily aspirin 81mg
indefinitely. | 189 | 377 |
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