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18598323-DS-6 | 29,938,211 | Mr. ___,
You were admitted with worsening right sided chest/abdominal
pain that is due to your underlying cancer. With
recommendations from oncology and palliative care your pain
regimen was adjusted with improvement in your pain control.
Continue to follow up with palliative care outpatient to assist
with further adjustments in your regimen. Continue to follow up
with your oncologist to discuss cancer treatment.
It was a pleasure taking care of you.
-Your ___ team | ___ h/o recurrent metastatic urothelial cancer admitted w/ acute
on chronic right side pain.
1. Acute on chronic pain
-Worsening pain due to progressive disease as per CT imaging.
Appreciate palliative care recommendations. started methadone
(discharge dose 10 mg PO q8h), weaned off fentanyl patch, and
continued PRN PO dilaudid. During admission patient was managed
with PRN IV dilaudid and toradol. Pt did note some fatigue
during day. If this continues/worsens after discharge,
Palliative Care recommended decreasing AM methadone dose 10 to 5
mg and increasing HS dose 10 to 15 mg. Alternatively or
additionally, methylphenidate could be added. Pt was offered
output Palliative care follow-up but he refused. As discussed
with pt's oncologist, cancer pain management will continue to be
coordinated by pt's oncologist. Discharge prescriptions
(including newly-started methadone) were filled at provided to
pt @ bedside by ___ bedside delivery.
2. ___ vs CKD
-Baseline creatinine appears to be around ___ with elevation
to 1.3 on admission now improved to 1.1.
3. Hyperkalemia
-Serum K up to 5.2 on ___, subsequently improved to 4.3-4.7.
EKG w/out changes. Continue to monitor.
4. Metastatic high-grade papillary urothelial transitional cell
carcinoma w/ metastatic pleural effusion
-As per H&P, "reportedly good response to restarting
gemcitabine/cisplatin after he progressed through
pembrolizumab," which was held ___ due to persistent nausea.
Defer further management to oncology. Oncology & palliative
care to address GOC as needed.
CHRONIC MEDICAL PROBLEMS
1. Normocytic anemia of chronic disease: stable, continue to
monitor
2. DVT: continue w/ therapeutic lovenox
Discharge home without services on ___. Case reviewed with
pt's PCP ___, MD prior to discharge.
50 minutes spent on discharge planning (>50% time spent
counseling pt @ bedside and coordinating care). | 74 | 278 |
14723024-DS-13 | 21,118,869 | Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You came to the hospital because you were having stomach pain,
bloody diarrhea, and fevers at home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You had a CT scan that showed inflammation of your colon (the
large bowel).
- You underwent a procedure called a flexible sigmoidoscopy that
also showed inflammation of your colon. Samples were taken of
your colon that were suggestive of a condition called ulcerative
colitis, an autoimmune disease that causes bloody diarrhea and
stomach pain. We also sent out other tests to confirm that the
diarrhea is not due to an infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please begin taking Lialda and prednisone to treat the
ulcerative colitis.
- Please call Dr. ___ in ___ days after discharge at
___ to discuss any changes to your medications. You
also have an appointment scheduled in clinic.
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ with no significant past medical history who
presents with six days of acute inflammatory diarrhea and
abdominal pain with elevated CRP, found to have diffuse colitis
on CT abdomen and flexible sigmoidoscopy, with biopsies
concerning for new-diagnosis ulcerative colitis. Studies for
infectious colitis were negative to-date at the time of
discharge. He was started on Lialda and prednisone and
discharged home with close outpatient GI follow-up. | 194 | 73 |
11759130-DS-13 | 29,847,058 | ******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
********Wound Care********
- Please keep your splint clean and dry until your follow-up
appointment. Any stitches or staples that need to be removed
will be taken out at your 2-week follow up appointment.
******WEIGHT-BEARING*******
Touchdown weight bearing R lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
Take Lovenox for DVT prophylaxis for 2 weeks post-operatively
Physical Therapy:
Touchdown weight bearing, R lower extremity
Treatments Frequency:
None | The patient was admitted to the orthopaedic surgery service on
___ with R ankle fracture. Patient was taken to the
operating room and underwent ORIF R ankle fracture. Patient
tolerated the procedure without difficulty and was transferred
to the PACU, then the floor in stable condition. Please see
operative report for full details.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to TDWB RLE. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to PO Dilaudid
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's HCT was stable throughout the
hospitalization and she did not require any blood
products/transfusions.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #1, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with ___, voiding without assistance,
and pain was well controlled. The incision was clean, dry, and
intact without evidence of erythema or drainage; the extremity
was NVI distally throughout. The patient was given written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will be continued on
chemical DVT prophylaxis for 2 weeks post-operatively. All
questions were answered prior to discharge and the patient
expressed readiness for discharge. | 169 | 308 |
11181460-DS-28 | 23,610,500 | You were admitted from rehab with shortness of breath and
required a breathing tube (intubation) for respiratory failure.
You were admitted to the ICU and were treated for a pneumonia, a
UTI, and COPD flare. You were treated with antibiotics and
steroids and the breathing tube was removed. | ___ year old female with hx of COPD on home O2, remote TB w/
pulmonary fibrosis after treatment, Lupus, multiple myeloma,
dementia, who presents with SOB, wheezing, fever to 101.6;
intubated for respiratory failure and admitted to ICU.
#Hypoxemic respiratory failure
#MRSA PNA with LLL collapse
#acute COPD flare
Differential included COPD exacerbation vs CHF vs PNA in the
setting of already scarred lung tissue. Patient's BNP was
elevated to 1378 (from 230 on ___, and has moderate
cardiomegaly on CT chest. Most recent echo ___: EF 55-60%,
mild to moderate (___) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. Patient did not
have crackles, pedal edema. JVD was difficult to appreciate
given patient's clinical status. Her clinical picture in
addition to hx of T 101.6 in ED, made CHF less likely. COPD or
PNA in the setting LLL atelectasis, are more likely given her
documented wheezing and complaints of wheezing, fever, and
relief with O2. She was started on cefepime ___ but this was
stopped in favor of Zosyn due to bronchoscopy ___ that revealed
collapsed LLL. She was also started on Vancomycin for MRSA
growing in BAL cultures. She was initially intubated on CMV but
this was weaned and she was extubated shortly after bronchoscopy
___. She was weaned down to her home 2L NCl. She was
initially on IV methylprednisolone for COPD exacerbation but
this was changed to 40 po prednisone starting ___. Treated with
an 8 day course of Vanco for MRSA PNA and a slow prednisone
taper by 10mg/week for COPD given severity of symptoms and that
she is on chronic steroids. She needs Bactrim for PCP ppx once
___ stabilizes.
.
#MDR ecoli UTI:
Pt on zosyn. Plan to continue for complicated UTI course, 10
days. Day 1= ___.
# Afib:
Continued warfarin for goal INR ___. Rate controlled with
diltiazem, switched to short-acting formulation for easier
titration. Increased warfarin back to home dose of 4gm.
# Elevated troponin:
EKG without elevated ST segments, inverted T waves. Could be
secondary to Afib in setting of infection and also ___
(decreased troponin clearance) with demand ischemia. Troponin
trended until evidence of downtrending, with 0.08 --> 0.06 on
___.
# ___: Improved. Creatinine 2.7 (baseline 0.8-1). Likely
secondary to prerenal injury in the setting of infection.
Possible SIADH component with elevated urine osm and elevated
urine Na. Cr returned to baseline but then increased on ___.
Vanco level was found to be elevated 37.5 on ___. Vanco dc'd
and level was re-checked on ___, 22.8. Vancomycin course
completed.
# Anemia: Chronic anemia. Baselin Hgb 7.5 - 9. could be
secondary to Myeloma, Lupus, hydroxycloroquine. Stable during
admission.
# SLE: Per OMR, her usual flairs include arthralgias, myalgias.
No lung or kidney involvement. Hydroxychloroquine continued.
She is on prednisone 10mg at baseline.
# Hypothyroidism: Continued home Levothyroxine.
.
#multiple myeloma: weekly dexamethasone which was not given as
she is taking prednisone. Also, her home chemotherapeutic
medication was on hold during admission and restarted on
discharge.
.
#goals of care: would continue goals of care conversations as pt
essentially spends a lot of time at rehab and is also frustrated
of going back and forth between rehab and hospital. | 50 | 550 |
11001090-DS-10 | 21,826,037 | Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ after pasing out. There were no concerning findings on
your labs, EKG or cardiac monitoring. Please be sure to drink
plenty of fluids and avoid further marijuana use. | ___ with no significant past medical history presenting with
syncope s/p polysubstance use.
# SYNCOPE
Ms. ___ presented to ___ after a witnessed syncopal
event outside of a ___ apartment. Per witnesses, she lost
consciousness, stumbled to regain her balance and fell into the
apartment building wall. She may have struck her head on the
side of the building. Her loss of consciousness was associated
with extremity shaking and post-event confusion. In the ED there
was a concern for an alcohol withdrawal seizure however the
patient and her girlfriend denied a significant history of
alcohol abuse. Her history was convincing for neurocardiogenic
syncope, with a prodrome of lightheadedness and palpitations.
She denied preceding nausea or diaphoresis. Triggers for the
event included alcohol, poor PO intake, caffeine and marijuana.
Orthostatics upon admission were normal. Seizure seemed unlikely
given no tonic-clonic activity, tongue biting, bowel or bladder
incontinence, alcohol abuse, or history of seizures. Shaking or
tremors and post-event confusion as reported by the witnesses
may be seen with syncope and alcohol/marijuana use. CT
head/C-spine were negative for acute pathology. Primary cardiac
etiology seems unlikely given history, no murmurs on exam,
normal EKG, no events on >12 hours of telemetry and no family
history of sudden death. Basic infectious work up with UA and
CXR was negative.
# ANION GAP
Patient presented w/ anion gap of 15; does have lactate of 2.6
and potentially has alcoholic ketones. Acetone not detected
however predominant ketone in alcoholic ketoacidosis is B-HB.
Lactate trended and normalized. Gap closed. Electrolytes within
normal limits.
# HEADACHE
Located in region where pt hit her head per witness. No external
signs of trauma and CT head/C-spine negative for acute
pathology.
# H/O OPIOID ABUSE
The patient reported a history of oxycodone abuse s/p detox in
___. She reports being clean since then. Urine and serum
tox only positive for EtOH level of 18.
TRANSITIONAL ISSUES
*******************
None | 45 | 318 |
17341130-DS-7 | 28,017,025 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital because of
shoulder pain and you were found to have an infection of your
shoulder joint. You underwent a procedure to wash this joint out
and were placed on antibiotics to clear the infection ___ the
joint and ___ your blood. You also had a procedure to look at the
valves of your heart and this found no evidence of infection ___
your heart. You also had a urinary tract infection that was also
treated with antibiotics.
Additionally, your kidney function declined while ___ the
hospital. This was thought to be because of dehydration and
because of the antibiotics you were given. You were then
switched to another antibiotic with improvement of your kidney
function. Please avoid taking any over the counter pain
medications (Alleve, Motrin, NSAIDs) as this could worsen your
kidney function. You will need to have your labs drawn ___ the
next ___ days to continue monitoring your kidney function. ___
regards to your sugars, please have them checked first thing ___
the AM, and with all meals. If your sugar is low, please
immediately take crackers/juice and hold your next insulin dose.
Contact your PCP to help with adjusting your insulin regimen
further.
Please follow-up with the appointments listed below and take
your medications as instructed below.
Wishing you the best,
Your ___ team | Impression: Mr. ___ is a ___ man with h/o IDDM, HTN, HLD,
and CKD who presents with septic arthritis, bacteremia, UTI, and
___. | 235 | 24 |
18185045-DS-13 | 28,239,718 | You were admitted because you needed to have a drain placed in
your bile duct as a gallbladder mass is compressing your bile
duct. The interventional radiologists placed a drain to drain
this bile duct. You did not want to stay to be monitored with
the drain being capped so you are being discharged. If you have
ANY fevers, worsening abdominal pain, chills, please uncap the
drain and attach the bag that we have given you. If you have
any questions about the drain you can page the interventional
radiologists by calling the ___ page operator. Interventional
radiology would like to also place a metal stent in the bile
duct so they will call you about this.
You are extremely constipated and you prefer to go home to take
laxatives. I have discharged you with medicines to have a bowel
movement at home.
Unfortunately, the pathology result from your bile duct shows
cancer - adenocarcinoma. I made you an appointment to see Dr
___ oncologist next week. She can talk to you about
your diagnosis, prognosis and treatment options available to
you. I have prescribed dilaudid that you can take for your
abdominal pain. Please ask Dr ___ refills or you can
also speak with Dr ___. | ___ with hx of htn, COPD not on home O2, recently diagnosed
metastatic gallbladder carcinoma diagnosed in the setting of
obstructive jaundice, s/p ERCP ___ with stent placement,
returning at ___ recommendation for urgent intervention, ERCP
versus PTBD placement.
# Obstructive jaundice: Patient s/p PTBD placement, followed by
ERCP to remove plastic stent in CBD followed by ___ procedure to
internalize biliary drain. Patient did not want to stay for
capping trial so he was discharged with the drain capped and
given a bag to attach to drain should he experience abdominal
pain or fevers. ___ will contact him about procedure to place a
metal drain. Will continue ciprofloxacin for five additional
days.
# Adenocarcinoma: Brushings of bile duct positive for
adenocarcinoma. Findings discussed with patient and his wife.
Discussed with oncology - they advised surgical consultation to
discuss surgical resectability but they were unable to see him
in the hospital.
# Constipation: Pt denies BM x3 weeks. CT abd/pelvis does not
comment on significant fecal loading. He preferred to increase
laxatives at home and did not want to take them in the hospital.
# Anxiety: Per prior notes, during last hospitalization patient
frequently requesting to leave the hospital, stating that he was
"sick and tired" of tests. He did not require treatment from
CIWA protocol. Pt endorses escalation of baseline anxiety in the
setting of recent medical events. He reports taking trazodone
for anxiety as outpatient, has not previously used
benzodiazepines. Patient very upset at delays in care and became
very upset when ___ recommended inpatient stay for capping trial
as he had planned to go home.
# Hyponatremia: Likely related to intravascular volume depletion
in setting of above. Received 1L IVF in ED, resolved.
# Pain control: Continued on dilaudid; pain is from tumor as
well as constipation; after constipation is better treated I
hope that he will use less dilaudid and at that point his
opiates can be converted to long acting agents - will need f/u
for this at his oncology visit.
# Hypothyroidism: Pt previously on levothyroxine, reports that
he no longer takes this medication.
- Check TSH
# COPD: Mild, not on daily inhalers or home O2, without evidence
of acute exacerbation.
# Insomnia: Home regimen was previously ambien 10 mg and
trazodone 100 mg at night to sleep. Has used this regimen for ___
years. Counseled on discharge from recent hospitalization to d/c
ambien given initiation of dilaudid; pt notes significant
difficulty with insomnia since discontinuation of ambien.
Continued on trazodone during hospitalization | 219 | 426 |
18056358-DS-18 | 24,003,655 | Dear ___,
___ were admitted because ___ experienced symptoms of double
vision, slurred speech and falling. We were initially concerned
for a small stroke, which results from lack of blood flow to a
part of your brain. ___ had imaging of your brain and the blood
vessels to your brain, which showed no signs of an acute stroke.
It is difficult to know why ___ experienced these symptoms.
However, we would like to follow ___ more closley for this
reason. As ___ have been doing, we encourage ___ to continue
using your walker. | ___ yo female with hx HTN, falls, CAD, depression, GERD, HLD,
remote hx seizure disorder who p/w with a 2-hour episode of
slurred speech and diplopia with history also concerning for
increased fall frequency. She is currently asymptomatic and her
exam is notable only for asterixis.
Neuro: Patient had NCHCT which found no acute infarct. She was
continued on Aspirin 81mg po daily and home dose of
Atorvastatin. She was also continued on home Carbamazepine for
seizure control and cymbalta for mood. We also checked stroke
risk factors: fasting lipid panel (LDL 77) and HBA1c (5.5).
MRI/MRA done and showed no acute infarct is seen. Mild changes
of small vessel disease.
CV: Patient had normal EKG and Cardiac enzymes were negative. We
allowed her BP to autoregulate with goal SBP <180. We held her
home amlodipine, which was restarted on discharge. She was
continued on Propranolol 20mg po BID.
ENDO: We maintained normoglycemia. She was continued on home
dose of Levothyroxine.
FEN: Patient passed bedside swallow evaluation and was started
on cardiac heart healthy diet.
TOX/METAB: We checked LFTs which were normal. We also checked
urine and serum tox screens which were negative.
ID: UA showed ___ and nitrites and 3 WBCs; started Macrobid BID
x 7 days. Her CXR was normal.
Chronic conditions: Patient is on numerous medications for pain
control secondary to back, hip and knee surgeries. She was
continued on standing oxycodone and prn oxycodone as well as
trazodone at bedtime.
PPX: Patient was started on SQ heparin and pneumoboots for DVT
prophylaxis, which was discontinued on discharge.
Dispo: ___ evaluated and felt safe for discharge home. | 92 | 258 |
14425372-DS-16 | 29,457,122 | CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion, lethargy or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ New onset of the loss of function, or decrease of function
on one whole side of your body.
Please return first thing ___ morning for elective surgery. | Pt was admitted to the Neurosurgery service, floor status. A CT
of the C-spine was ordered for pre-operative planning. A
pre-operative work up was completed and the patient was
scheduled for surgical resection of her cervical lesion. ___nd family requested that the surgery be
postponed, as they were still deciding whether to have the
surgery here vs. back home in ___. On ___ she was
neurologically stable, having weakness in the left tricep &
hamstring ___. We re-discussed the plan with the family and
they decided to discharge to home and come inf or elective
surgery with Dr. ___ on ___. All
questions were answered and patient expressed readiness for
discharge. | 92 | 112 |
10671739-DS-22 | 24,000,515 | WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions | Mrs. ___ was transferred to ___ Emergency Department from
___ ED for TIA. A CT of the head was performed
while she was in the ___ ED, which did not show evidence of an
acute stroke. She was admitted to ___ under the Vascular
Surgery Service on ___ with plans for a carotid
endarterectomy on ___. She was taken to the OR on ___ for a L
CEA, the procedure was uncomplicated, please see the dictated
operative note for details of the procedure.
The patient's pain was well controlled post-operatively and she
remained neurovascularly intact. She developed some bleeding
that required a suture to be placed at bedside on POD 0. She was
observed for signs of continued bleeding, of which there were
none. On POD 2 the patient was sitting in a chair when she
became hypotensive (systolic BP 74), unresponsive with
occasionaly myoclonic jerks. A code stroke was called, she was
started on IVF. Her mental status slowly improved, a CTA of the
head and neck did not show any evidence of an acute intracranial
process and her left carotid artery remained open s/p
endarterectomy. Her mental status returned to baseline withing
___ minutes. She was continued on IVF and remained
normotensive to mildly hypertensive for the duration of her
hospital course. She was evaluated by Physical Therapy and found
to have respiratory and balance deficits. She was recommended
for short term rehab.
On the day of discharge she was ambulatory with assistance,
voiding without difficulty, neurovascularly intact and
tolerating a regular diet. She agreed with the recommendation
for short term rehab and was discharged to an ___ rehab
facility. | 367 | 270 |
13641998-DS-20 | 22,072,995 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for fever and suspicion for a
serious infection. You were diagnosed with a liver abscess which
required drainage and IV antibiotics. You improved with
antibiotics and are safe to go home. While in the hospital you
recieved your regular scheduled dialysis.
Please take your medications as prescribed and follow up with
the appointments listed below.
The interventional radiologist will need to remove your drain on
___ at 3:15PM on your dialysis day.
You cannot eat or drink anything for 6 hours prior to the drain
removal to prevent adverse effects.
The following changes were made to your medications:
STARTED metronidazole
STARTED ceftazidime after dialysis on dialysis days
STARTED Lantus (glargine). You will need to check your blood
sugar every morning before eating. Please write this down and
bring it with you to your doctor's appointment. If you
experience sugars <70 or >400 please call Dr. ___. Your doctor
___ help you to adjust your insulin level.
STOPPED labetalol | ___ with a past medical history of HTN, duodenal tumor ___
Whipple, ESRD on HD p/w fever to 104 and altered MS ___ HD.
# GNR bacteremia: Patient presented febrile and with AMS. The
neurology service was consulted in the ED for a potential
stroke. A CT head was negative for an acute intracranial process
and the patient did not have any focal deficits on complete
neurologic exam. The AMS was felt to be secondary to an acute
infectious process. Blood cultures positive for GNR, Bacteroides
fragilis. CT abd/pelvis demonstrated a cystic liver lesion c/w
an abscess which was drained by interventional radiology. The
patient made a dramatic improvement from her presenting
condition after IV antibiotics (pipercillin/tazobactam) and
drainage. CXR w/o evidence of acute infection. The patient's
mental status returned to baseline. The patient was discharge on
ceftazidime 1g at HD and metronidazole PO x 4 weeks.
# Liver abscess: Predisposing factor includes prior Whipple. No
other localized infections were seen on the abdominal CT scan.
Direct puncture of the abscess was performed using an 8 ___
Bard ___ catheter and 20 cc of purulent fluid was aspirated
on ___. The fluid demonstrated 4+ PMNs and 2+ GNRs. The
patient was given 1 dose of both vancomycin and cefepime in the
emergency department. These antibiotics were discontinued and
the patient changed to pipercillin/tazobactam when ED anaerobic
blood cultures turned positive for GNRs. She was discharged on
ceftazidime 1g at HD and metronidazole PO x 4 weeks. The ___
placed drain will be removed on ___ after a follow up
ultrasound by ___ at ___.
# ESRD on HD: The patient initiated HD within the past year. She
had a left upper extremity placed at ___ in ___. The patient
received dialysis on ___ while hospitalized. She was given a
TID phosphate binder and nephrocaps. All medications were
renally dosed. No gross derangments in electrolytes or volume
status were encountered.
# Anemia: The patient's anemia is not new per her nephrologist
and is most likely due to end stage renal diseease. Her dose of
epo was recently increased. As an outpatient she had several
negative guaiacs. She denies symptoms of GI bleed and her other
cell lines are robust. Her red cells have a borderline high MCV.
Her hematocrit was monitored while she was hospitalized.
# Hypertension: The patient takes lisinopril and labetalol at
home. Her PCP discontinued amlodipine due to soft pressures as
an outpatient. While hospitalized the patient's systolic blood
pressures were 90-130 off all antihypertensives. With resolution
of her acute illness. She was discharged on lisinopril 20mg
daily. Labetalol was discontinued and may be restarted as an
outpatient if necessary.
# Leg Pain: Secondary to spinal stenosis. The patient takes
gabapentin at home. Gabapentin was initially held in the setting
of AMS, but reinitiated when her mental status cleared.
TRANSITIONAL ISSUES
*******************
1. Ceftazidime 1g QHD/metronidazole 500mg TID x 4 weeks (last
doses ___ or as specified by the ___ infectious disease
service
2. Follow up sensitivities of GNRs from abscess aspirate
3. Dialysis ___
4. Liver abscess drain to be pulled on ___ after follow up
ultrasound
5. Qweek safety labs (CBC w/diff, Chem7, LFTs) while on
ceftazidime
6. Several blood cultures pending at discharge
7. Monitor fingersticks as outpatient for titration of insulin | 169 | 538 |
19631540-DS-14 | 28,205,868 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ year old male POD# ___ s/p CABG presented from home with
irregular heart rhythm, RAF by EKG in ED. Had converted to SR
rate 65 by time he arrived on floor. Lopressor was increased and
Pradaxa was started after discussion with Dr. ___. He remained
in sinus rhythm for the remainder of his hospital course and was
discharged home on HD2 with follow up appointments advised. | 108 | 67 |
12934309-DS-3 | 29,037,407 | Mr ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with a rash on your thigh and arm. You
were seen by the infectious disease team who did not think that
this was due to an infection. You were also seen by the
dermatologists who thought this could possibly be a urticarial
reaction (hives) or from other cause. You should take Zyrtec
daily to see if this helps.
You have a number of lab tests pending at the time if
discharge. We will contact you with these results,
We wish you the best
Your ___ Care team | Mr. ___ is a ___ male with recurrent cellulitis who
presented with worsening erythema and edema over the right
forearm and right thigh despite taking doxycycline. | 103 | 26 |
19106799-DS-17 | 21,291,939 | Ms. ___,
It was a pleasure taking care of you here at ___.
******It is very important that you go to ___
tomorrow (___) to have your kidney function checked. We have
discussed this with you before discharge. It is also very
important that you drink water and eat salty foods like
chips******
You were admitted for right-sided abdominal pain, which has
since resolved. We believe it was from the mass in your cecum
(colon), that became infected. You have started a course of
ciprofloxacin and metronidazole antibiotics, which you will
finish on ___.
Your antibiotic regimen for your H. Pylori (stomach) infection
has been changed. You will now be taking Metronidazole (which
also treats your cecal infection), Omeprazole, and
Clarithromycin - all for a total of 14 days (ending ___. You
were found to have change in your kidney function that was from
dehydration. Your kidney function needs to be checked on ___ at ___.
Please follow-up with Dr. ___ surgical treatment of
your colon cancer, and with your medical oncologist regarding
future treatment of your cancers. You also have a second opinion
appointment at ___ Cancer Institute for your colon
cancer.
All the best,
Your ___ team | ___ with recently diagnosed triple-negative right invasive
ductal carcinoma s/p partial mastectomy on ___ (awaiting
adjuvant chemotherapy and/or radiation), recently diagnosed low
grade colonic adenocarcinoma on screening colonoscopy (no
intervention performed yet), and H.pylori gastritis
(amoxicillin, lansoprazole, and clarithromycin started on ___
- who presented with RLQ abdominal pain and fevers.
# ___: Discovered ___, FeNa 0.2% indicating prerenal azotemia.
Given bolus of 1L IVF fluids. Unable to draw repeat labs despite
multiple attempts. Patient desired to leave, was making and
passing urine, and looked well, so decision was made to have
labs checked next day as outpatient.
# Abdominal pain/fevers:
Upon admission, the patient presented with RLQ abdominal pain
that radiated to the suprapubic area, and a fever of 100.0F in
the ED (previously 101.8F in an urgent care clinic the night
before). This pain was originally thought by Radiology to
represent infection, or possibly a microperforation. Surgery saw
the patient, and found no obstructive symptoms or evidence of
perforation, and determined there to be no acute surgical
issues. Since admission to the floor, the patient has been
afebrile with a Tmax of 98.9. Ciprofloxacin and Flagyl were
started to treat the suspected colonic infection. The abdominal
pain was adequately controlled on Tylenol, and as of ___, has
completely resolved. The patient will continue
Ciprofloxacin/Flagyl for a total of 14 days (ending on ___
# H.pylori infection:
The infection was discovered during an EGD on ___. The patient
started treatment as an outpatient on Amoxicillin, Lansoprazole,
and Clarithromycin, but only took the meds for one day. Upon
admission (___), the patient was switched to the
Metronidazole-Omeprazole-Clarithromycin regimen (so
metronidazole would cover both H. Pylori and potential infection
of cecal mass). She will continue this regimen for a total of 14
days (ending on ___.
# Urinary incontinence:
The patient has had a history of minor stress
incontinence(occasional spotting with cough), that seemed to
improve with ___ exercises. During this hospitalization, she
has had about one episode of incontinence/night, usually when
waking up and trying to go to the bathroom. Immediately after
feeling the urge to use the restroom and getting up, she felt
urine. U/A cultures negative x 2. MRI of the spine showed no
evidence for cord etiologies for incontinence. This is likely
baseline stress incontinence exacerbated by recent bloating.
# Colon cancer: Requires surgical intervention. CEA of 42 while
inpatient. Will schedule appointment with Dr. ___.
# Constipation:
During this inpatient stay, the patient had trouble having BMs
(likely due to poor PO intake, secondary to abdominal pain).
Docusate was started and helped the patient achieve soft BMs.
# Posterior thoracic epidural collection: Found during MRI T/L
spine to evaluate for cord compression in setting or urinary
incontinence. This was not felt to be consistent with hematoma
or infection by radiology, and may be artifact. No neuro
deficits. Evaluated by neurology who felt there was no cord
compromise. | 195 | 473 |
15319040-DS-17 | 29,963,823 | Dear Ms. ___,
You came to the hospital for fevers and chills and were found to
have a pneumonia. We started treating you with antibiotics
through an IV and you got better. We are giving you antibiotics
that you can take by mouth to finish treating you for your
pneumonia.
You started to have difficulty swallowing. We think this is most
likely from one of your antibiotics (doxycycline). It is
important to take this medication with food and to stay sitting
up for 30 minutes after taking it.
You have an apoointment with an Infectious Disease doctor which
is detailed bellow.
Your medications are detailed in your discharge medication list.
We wish you the best!
Your ___ Care Team | ___ year old female presented to the emergency department for
fevers and chills was found to have a RUL PNA. Due to the
location of PNA, the patient was r/o for TB.
#RUL PNA: RUL consolidation on CXR. Started on CTX and doxy. TB
ruled out by 3 negative acid fast smears, QuantGold
intermediate. PJP stain negative. Transitioned to cefpodoxime
and doxycycline to complete course for CAP. Avoiding quinolones
or macrolides due to presumed ___ or Tb.
-Cont. Doxycycline (last day ___
-Cont. Cefpodoxime (last day ___
#Pill Esophagitis: Dysphagia noted morning of ___ to both
solids and liquids. Does not complain of any burning and
although uncomfortable. No signs of oropharyngeal thrush. The
patient's dysphagia is likely secondary to pill esophagitis from
her doxycycline.
-Pt educated to take doxycycline with food and remain upright
x30mins after taking
#Microcytic Anemia: Hgb 7.4, down from 8 (___). Fe studies
___ Iron, low-normal TIBC with elevated Ferritin and Hapto.
These findings suggest anemia of chronic disease, likely
contributions from iron deficiency as well. Elevated Haptoglobin
r/o'd hemolysis.
-Fe replacement after infxn cleared
#Low White Count: WBC 2.2 ___, was 6.8 ___. ANC 1.69 (1700)
-Continue to monitor | 113 | 186 |
19505750-DS-14 | 26,887,282 | Instructions: Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had been admitted for behaving differently than your usual
self.
====================================
What happened at the hospital?
====================================
-You were found to have a urinary tract infection. With the
treatment, you improved.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Take your medications every day as directed by your doctors
-___ attend all of your doctor appointments, this is
especially important to help with your COPD and making sure your
infection is cleared.
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team | TRANSITIONAL ISSUES:
-Patient will complete a 10 day course of cipro for the UTI,
last day to take is on ___
-Of note she had elevated JVD on exam. It is reasonable to
presume she has CHF, with unknown EF. She appeared comfortable
and stable on a daily exam, and is likely at euvolemia. She had
SOB earlier in her stay resolved with
treatment of COPD, so it was unlikely due to CHF exacerbation.
But, given her COPD history, she may very well have predominant
right
sided heart failure.
This should be followed up as an outpatient. She should have
consideration for outpatient echocardiogram, with low threshold
to initiate diuretic therapy if signs or symptoms of
hypervolemia
occur. She should have daily weights to monitor this as well. If
her weight exceeds 3 pounds from a baseline weight, her PCP
should be notified. | 109 | 134 |
14729536-DS-19 | 28,509,993 | Ms. ___,
It was a pleasure taking care of you. You were admitted for
cellulitis (skin infection). An ultrasound showed no leg clots
and xray of your hip showed no fractures. Your blood did not
grow any bacteria. You were treated first with IV antibiotics,
then switched to oral antibiotics, which you should continue
till ___.
You also continue to have right hip pain and a CT scan was done
which showed inflammation of one of the pelvic joints
(sacroilitis). We treated your pain with oxycodone IV pain
medications. You have an appointment to have a joint injection
for ___.
It was a pleasure to meet you. We wish you all the best.
-Your ___ Team | PRIMARY REASON FOR HOSPITALIZATION:
================================================
___ year old female with PMH of ankylosing spondylitis, psoriasis
and obesity presented with right leg pain. | 115 | 21 |
10062617-DS-4 | 27,056,234 | Mr. ___,
You were hospitalized with complaints of SOB and difficulty
walking. Upon admission, it was thought that you had too much
water in your body, most likely because of your heart failure.
We gave you medications (diuretics) to reduce the amount of
water in your body. This has helped to make it easier to
breathe. We have increased the dose of your diurectic medication
in order to help decrease the amount of fluid build up in your
body. We have also stopped one of your blood pressure
medications as well because your blood pressure was low on
admission. Since stopping this medication your blood pressure
has improved.
The following changes were made to your medications:
STOP: Atenolol
INCREASE: Furosemide to 40mg daily
Please make sure to weigh yourself daily and call your doctor if
you weight increases by more than 3lbs. Also make sure to try
and limit your fluid intake to a maximum or 2L per day. | The patient is a ___ year old male with history of CHF EF45%, AV
insufficiency, and sick sinus syndrome here with SOB, difficulty
ambulating, confusion. | 155 | 25 |
13663782-DS-5 | 21,734,467 | Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your ___ 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.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
***You are being discharged on sodium chloride tablets. You MUST
___ with your PCP closely to have this medication tapered
appropriately. You should see your PCP in two days with
associated serum sodium testing, and your PCP ___ continue to
taper this medication to "off" | Ms. ___ was brought to ___ as a Trauma Alert transfer
after a bicycle accident with heatstroke and LOC. She was
brought to OSH where head CT showed multiple foci of
intracranial hemorrhage. Her mental status declined while in the
trauma bay and she was intubated for airway protection. Repeat
imaging confirmed multiple intracranial hemorrhages - SDH, SAH,
and IPH. She also had facial fractures and a right clavicle
fracture. She was admitted to the ___ under Acute Care/Trauma
Surgery service and started on hypertonic saline per Neurosu.
She was followed with serial CT scans as well as q1h neuro
checks. Repeat scans did show blossoming of a right temporal
contusion and increasing cerebral edema though her neurologic
exam remained intact and stable. She was successfully extubated
on HD2. She was initially lethargic but showed improvement in
her mental status over ensuing days. Hypertonic saline was
adjusted accordingly to a goal Na of 145; salt tabs were started
as well once she tolerated POs.
In regards to her other injuries, her clavicle fracture was
managed non-operatively and a sling provided for comfort. Her
right side facial fractures were also non-operative per Plastic
Surgery. Ophthalmology recommended outpatient follow up.
Tertiary surgery showed no additional injuries.
On HD5, the patient was stable from the trauma standpoint. Her
only active issue was cerebral edema that required hypertonic
saline. She was subsequently transferred to the Neurosurgery
service for the remainder of her care.
On ___ the patient the patient remained neurologically intact,
moving all of her extremities with full strength and alert and
oriented x3. Overnight the patient complained of a severe
headache, and had a stat repeat NCHCT done which demonstrated
1. Decreased mass effect, including significant interval
improvement in diffuse cerebral hemispheric sulcal effacement.
Patent basal cisterns.
2. No appreciable interval change in the appearance of
multifocal,
multi-compartment intracranial hemorrhage, as above. No new
focus of
hemorrhage. 3. Unchanged sphenoid sinus mucosal thickening. The
patient was given dexamethasone, reglan and intravenous fluids
for the pain which provided significant relief from the pain.
The patient continued on a 3% sodium drip and it was decreased
to 30 ml/hr and her serum sodium was stable at 140. The patient
was transferred out of the ICU to the step down unit.
On ___, the patient requested an additional dose of
dexamethasone/reglan for headache. For pain control she was
given reglan with codeine. Her magnesium and potassium levels
were repleated, and her fluid restriction and NS were
discontinued. given normal Na level of 143. The team began
weaning 3% (now at 20cc/hr). The patient was started on a Medrol
dosepak for headaches.
On ___, the patient had an episode of morning epistaxis,
however she reports that this frequent at baseline, and it
resolved spontaneously. Her headache was controlled, however
overall still causes significant pain. Otherwise, she continues
to do well and is looking forward to discharge soon.
On ___, the patient had with one episode of emesis overnight.
In the morning she was complaining of HA, and received her
scheduled codeine. Her fioricet frequency was increased for
improved pain control. Otherwise she has been hemodynamically
and neurologically stable. Her sodium level remained stable at
137, therefore the 3% was discontinued and her central line was
removed. The patient had a repeat sodium in the evening and it
was 136.
On ___, the patient remained hemodynamically and neurologically
stable. Her sodium in the morning was 136. She was deemed stable
and ready for discharge with close ___ for sodium chloride
tapering by her PCP, ___ with Dr. ___,
___ with Plastic surgery. | 454 | 595 |
14976423-DS-18 | 27,560,400 | Dear Mr. ___,
You were admitted to ___ because you were having dizziness.
We think this was likely due to a combination of dehydration and
your blood pressure medication (metoprolol). We gave you IV
fluids and decreased your metoprolol dose and your dizziness
improved.
We made the following changes to your medications:
-DECREASE metoprolol to 12.5 mg by mouth TWICE daily
We made no other changes to your medications while you were in
the hospital. Please continue taking the rest of your
medications as prescribed by your outpatient providers.
Please see below for your currently scheduled clinic
appointments.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery. | ___ M with h/o Ph+ NPM1 neg, FLT3 neg ALL dx ___ recently
hospitalized for C#5 HyperCVAD Part A also with hx of HTN, CAD
s/p stent, presented to clinic with dizziness, mild frontal
headache and orthostasis.
#Dizziness - Pt demonstrated orthostatic hypotension on
admission, thought likely ___ hypovolemia. In addition, his
home metoprolol was held and he remained normotensive, and it
was thought he may require smaller doses of beta blockade in
setting of chemotherapy and weight loss. His orthostatic
hypotension resolved and he was discharged home on decreased
dose of metoprolol tartrate (12.5mg PO BID).
# ALL 9:22: Pt recently completed Hyper CVAD Part A on ___
with IT methotrexate on ___. He was continued on Gleevac and
Neupogen. For ppx he was continued on his home acyclovir and
bactrim.
# Indirect hyperbilirubinemia - Unclear etiology. Liver/GB US
was unremarkable and hemolysis labs (including Direct Coombs)
were negative, although he has history of demonstrating
increased bilirubin after blood transfusions. His bilirubin
downtrended and was normal on discharge.
# T2DM: His home glyburide was held while inpatient and his
blood sugars were controlled on ISS. His home glyburide was
restarted after discharge.
# Psoriasis: Pt was evaluated by dermatology service during most
recent hospitalization and his lesions were felt to be improving
on his current regimen. He was continued on his home topical
medications.
# H/o C Diff: He was continued on suppressive PO vancomycin
125mg Q12H.
# HTN: Pt's home metoprolol tartrate was decreased due to
orthostatic hypotension, as above.
# CAD: Aspirin and statin currently on hold due to potential
interactions with chemotherapy.
# Hypothyroidism: He was continued on his home synthroid. | 115 | 288 |
12232409-DS-6 | 28,176,532 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY YOU WERE ADMITTED:
-We were concerned your chest pain was related to your heart, as
your ECG (heart tracing) and labs were abnormal
WHAT HAPPENED IN THE HOSPITAL:
-You underwent a heart catheterization to look at the arteries
on your heart and take tissue samples
-You also had an MRI of your heart
-The preliminary results of your biopsy are consistent with
cardiac amyloidosis but confirmatory tests are pending
WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:
-New Medications:
-Aspirin 81mg daily
-Atorvastatin 80mg daily
-Furosemide 10mg daily
-Methylprednisolone 48mg daily
-Please follow-up with cardiology, they will contact you with an
appointment
-You will also need to see a hematologist, the scheduling
information is below
-Please follow-up with your regular doctors as ___
Thank you for allowing us to be part of your care, we wish you
all the best!
Your ___ Team | ___ with h/o dermatomyostitis w/ scleroderma features c/b ILD,
MVP, MGUS, p/w CP and DOE with likely myocarditis of unclear
etiology.
#CARDIAC AMYLOIDOSIS: Admitted with chest pain, abnormal ECG,
and elevated troponins which peaked at 0.28 with CP/DOE
symptoms. TTE showed thicker walls than prior and mitral valve
deceleration time concerning for restrictive cardiomyopathy. No
culprit coronary lesion on LHC. Etiology possible
dermatomyositis vs amyloid vs more common causes. Preliminary
biopsy results consistent with cardiac amyloid, confirmatory
stains pending. Cardiac MRI read pending. Started on ASA 81mg
daily, methylprednisolone 48mg daily. Free kappa chains 52.9,
free lambda light chains 277, provided information to schedule
hematology follow-up.
# Dermatomyositis with scleroderma features: ___ weakness
progressing in past weeks. Rheumatology following. Recommended
steroids as above and cardiac work-up as above. Will follow-up
with Dr. ___ further management and titration of steroids.
# SOB: Hx ILD. CXR w/o significant pulmonary edema. PCWP
elevated. ___ as below, but unlikely with active disease.
LENIS negative.
- Diuresis with 10mg PO Lasix daily, given initiation of high
dose steroids.
CHRONIC ISSUES:
# Hx ___: Has been off meds for this recently. Saw Dr ___
___ ID specialist) re the ___ on the forearm this week and
she is planning on restarting the combination therapy for the
___ in the next couple weeks--one of the medications needs to be
obtained from the ___ govt however and will not arrive for 2
weeks. Per Dr ___, pt is ok to start back on
immunosuppressive therapy now for her muscle disease. | 147 | 254 |
13595479-DS-7 | 25,535,925 | Dear Dr. ___,
___ was a pleasure caring for you at ___
___. You were admitted for work-up of syncope and
unresponsiveness, which we thought may have been caused by a
ventricular arrhythmia. You underwent an echocardiogram, which
showed a low normal ejection fraction of 50% and focal wall
motion abnormality. We did not detect any arrhythmias on our
monitoring. On telemetry, you had atrial fibrillation ranging in
___, with tachycardia to 100s-110s with exertion. Because
you had no evidence of acute infarction, we recommended that you
return to ___ to see your cardiologist as soon as possible
for rhythm monitoring. We discussed starting a beta blocker, but
felt it was reasonable to hold on until you see your cardiology.
Please continue to hold your chlorthalidone.
Please continue to take all medications as prescribed.
We wish you the very best!
Warmly,
Your ___ Team | Dr. ___ is an ___ y/o man w/ a PMH of atrial
fibrillation on Coumadin, transient global amnesia, and
hypertension, who presented with syncope.
# Syncope. Per his family, he was unresponsive for approximately
5 minutes, with a thready pulse, at which time compressions were
started, and he regained consciousness. EKG demonstrated atrial
fibrillation with no ischemic changes. Seizure was thought to be
unlikely as there were no convulsions, although patient had
urinary incontinence. He was found to be mildly orthostatic, for
which he was given 500 cc fluid bolus. Home chlorthalidone was
held. TTE was performed, which showed low normal left
ventricular systolic function (LVEF = 50%) secondary to
hypokinesis of the inferior septum, inferior free wall, and
posterior wall, with focal inferobasal akinesis. We discussed
initiation of beta-blocker to reduce risk of sudden cardiac
death in setting of recent history and TTE showing coronary
distribution of hypokinesis. Because he has had heart rates in
the ___, and 2s pause on telemetry, the patient declined
beta blockade until discussing with his outpatient Cardiologist.
He had no evidence of heart failure on examination. Because
there were no signs of acute infarction, he was discharged home
with plan for immediate cardiology follow-up for rhythm
monitoring.
# Hypertension. Recently started on chlorthalidone for new
hypertension diagnosis. Had been on this medication for two
weeks without prior symptoms of orthostasis. Held give in mild
orthostasis. Given orthostatsis, chlorthalidone held at time of
discharge.
# Atrial fibrillation. CHA2DS2-Vasc score of 3 for age and
hypertension. He was continued on his home warfarin dosing of 5
mg q.o.d. and 6 mg q.o.d. INR remained in the therapeutic range
(___).
====================
TRANSIITIONAL ISSUES
====================
# Syncope. As above, this was felt most likely to be cardiogenic
in origin, and he underwent TTE, which demonstrated low-normal
LV systolic function (LVEF = 50%), with focal inferobasal
akinesis. As above, initiation of beta blockade was deferred. He
was discharged with plan for immediate outpatient cardiology
follow-up in ___ to arrange for rhythm monitoring.
# Medication changes. Chlorthalidone was held in the setting of
mild orthostasis. Please consider restarting at your discretion.
# Anticoagulation. Was continued on his home warfarin dosing of
5 mg q.o.d. and 6 mg q.o.d.
# Code status: FULL
# Contact: ___ (wife) ___ | 142 | 377 |
12015517-DS-2 | 25,994,239 | Dear ___ was a pleasure caring for you during your hospitalization at
___. You were admitted for abdominal pain and found to have a
UTI. A CT scan of your abdomen showed a possible abscess from
diverticulitis or potentially a mass concerning for cancer, so
an MRI was obtained which was also inconclusive, but seems
consistent with diverticulitis. You will need a colonoscopy
after you complete your antibiotic course to better characterize
what was seen on your CT and MRI.
You should complete a 10 day course of ciprofloxacin and
metronidazole for your diverticulitis and urinary tract
infection. It is important that you do not consume any alcohol
while taking metronidazole (AKA Flagyl) and for the next 2 days
following completion of metronidazole as it can cause flushing,
abdominal cramping, diarrhea, and itching.
We have scheduled you for a colonoscopy in about 2 weeks. You
should be receiving materials in the mail about how to prepare
for this study. Please call your PCP for follow up to make an
appointment within ___ weeks of discharge. | ___ woman with history of CAD and diabetes, diverticulosis and
sigmoid adenomatous polyp on ___ colonoscopy presenting with
abdominal pain for one week and CT scan concerning for
diverticulitis vs malignancy, found to have UTI on admission.
# Abdominal pain: Patient presented with lower abdominal
discomfort and suprapubic pressure for one week, worse in the 2
days prior to admission and worse after eating. CT
abdomen/pelvis was concerning for diverticulitus vs malignancy
as described in "results" section. Patient without fevers,
leukocytosis or malaise that would point toward florid
infectious process. She did have mild anemia and thin caliber
stools, with a history of colonoscopy in ___ with sigmoid
adenomatous polyp raising concern for colorectal cancer.
However, stool guaiac was negative in ED and no recent weight
loss reported by patient to raise red flag, but this does not
rule out malignancy. After discussing management options with
patient, proceeded with MRI for better characterization of
findings, which was also inconclusive. Patient was noted to be
appropriately anxious and tearful about this imaging findings.
She was offered pastoral support and social work consult, but
declined. Patient felt she had adequate social support at this
time. Symptoms began to improve prior to discharge while on
ciprofloxacin and metronidazole.
- Continue Ciprofloxacin 500 mg PO Q12H and MetRONIDAZOLE
(FLagyl) 500 mg PO Q8H 10 day course ___ to ___.
Counseled patient on avoiding alcohol while taking
metronidazole.
- Follow up colonoscopy ___ scheduled. Patient and her
husband are concerned about time of day and operator of study,
they were reassured that they can call to reschedule as needed.
# UTI: Most likely E. Coli but urine cultures suggestive of
contamination. Patient presented with significant suprapubic
discomfort and tenderness, but without dysuria, fever, or
leukocytosis. However, UA was suggestive of infection and
patient had one dose of ceftriaxone in the ED before being
continued on ciprofloxacin and metronidazole for suspected
diverticulitis to complete a ___HRONIC ISSUES:
# Hypothyroidism: Continued levothyroxine
# Hyperlipidemia: Continued atorvastatin
# Diabetes melitus: Held glipizide while admitted. Used QID
finger sticks and insulin sliding scale but patient required
minimal insulin as had very poor appetite due to emotional
distress while waiting for MRI results.
- Patient reports that she takes GlipiZIDE XL 5 mg PO BID and
states she is sure it is the XL form despite being twice daily
dosing
# Hypertension: Continued spironolactone, valsartan, metoprolol
# Coronary artery disease: Continued aspirin, antihypertensives
as above
# Nutrition: Continued vitamin B12, vitamin E, Multivitamin,
calcium, vitamin D | 176 | 407 |
17745031-DS-14 | 22,064,479 | Dear Mr. ___,
You were admitted to the ___
because you were having light-headedness, palpitations, tremor,
and instability while walking that caused you to fall down. A
full work-up was done to evaluate your symptoms. Your
examination did not show any neurological problems. You lab
work-up was completely normal, and the scan of your head did not
show any sign of injury. You improved significantly while in the
hospital.
You should follow-up with your primary care physician, ___.
___ (___) after your discharge.
We wish you a speedy recovery,
Your ___ Care Team | Mr. ___ is a ___ yo man with history of anxiety presenting
with light headedness, presyncope, and unsteadiness on
ambulation.
# Dizziness: Patient reports sweating, blurred near vision,
tachycardia, SOB, fluttering under his arm and poking sensation
in his back the morning of ___. He also reports dizziness and a
near syncopal event. He took an Ativan as some of the symptoms
felt similar to prior panic attacks, but his unsteadiness did
not improve. He presented to ___, walking out of the parking,
felt lightheaded in the stairwell and tripped, landing and
hitting his head. Patient had no LOC. In the ED, the patient was
hemodynamically stable. He was evaluated by neurology with a
non-focal exam. Labs were unremarkable including CBC,
chemistries, trop x2, LFTs, TSH, and tox screen. Head CT and CXR
were negative. Patient was admitted for monitoring overnight and
improved significantly. He remained neurologically intact. He
was seen by physical therapy who thought he was able to ambulate
independently and is a low fall risk based on their assessments.
Given his fall, they felt the patient would benefit from
out-patient physical therapy. | 89 | 185 |
10679464-DS-10 | 28,441,548 | Dear Mr. ___,
You were admitted to ___
because you were experiencing severe pain, along with multiple
other symptoms. While you were here, we performed multiple
imaging studies to help evaluate what the source of your pain
was. Based on these studies, we found that there was some bony
loss of the bones in your spine, which may be contributing to
your pain. You were feeling much better by the time you were
discharged.
We also treated you with antibiotics for a skin infection on
your arm, which was improving during your hospitalization.
It is important that you continue taking your medications as
prescribed.
It was a pleasure caring for you!
Your ___ Care Team | ___ with PMH of bifasicular block, copd, new diagnosis of small
cell lung CA on ___ (___) who presents
reporting ongoing pleuritic chest pain and new right hand
swelling along with leukocytosis, concerning for cellulitis.
# Diffuse shooting pains
# Bilateral neck pain
# History of right mandibular infections
Difficult constellation of symptoms to integrate. Recent PET
without evidence of FDG avid lesions in spine, though
degenerative changes noted, and nerve compression is a possible
etiology of pain. It was thought possible that hematogenous
spread of infection related to incompletely treated jaw
infection (cellulitis, epidural abscesses) could explain
patient's symptoms. In order to further evaluate these possible
etiologies, the patient underwent a noncontrast max/facial CT
and noncontrast CT of soft tissues of neck, which did not have
any evidence of infection. Patient also underwent a MRI of C/T/L
spine to assess for metastatic disease, nerve impingement,
epidural abscess, or other etiology of patient's diffuse pains.
MRI revealed multilevel degenerative changes in the cervical
spine, most severe at C4-C5, resulting in moderate narrowing of
the spinal canal and remodeling of the spinal cord. This may
account for some of patient's presenting symptoms. Other
degenerative changes were noted in the lumbar spine. No
metastatic disease or evidence of infection. Patient's pain was
significantly improved with cyclobenzaprine, oxycodone, and
toradol for breakthrough pain.
# Leukocytosis
# cellulitis of the hand
# R hand swelling
Lactate reassuring at 1.5. Neurologic and sensory function of
hand intact. Pt reports cut on the hand likely portal of entry
for infection. While some component of his leukocytosis may be
sequela of neulasta, this elevation seems a bit protracted for
an injection last given on ___. From photos from ED, hand/arm is
swollen, but no significant erythema. Per hand surgery, doubt
septic joint given no focal tenderness of one joint but rather
diffuse swelling of the hand - though exam not that impressive,
given chemo, the abrasion, swelling, immunocompromise - per hand
team reasonable to treat as cellulitis. Patient was started on
vanc/ceftriaxone on ___, and was transitioned to PO
Bactrim/Keflex on ___ with plan for 7 day course. Hand surgery
continued to follow, and noted CT of hand demonstrates no fluid
collection or fracture/foreign body. Patient remained
neurovascularly intact and has near full ROM (limited by pain).
Patient was maintained in a splint with hand elevated.
# Pleuritic chest pain
___ has been reporting this pleuritic chest pain for months; in
fact it is what prompted his chest imaging which resulted in his
new diagnosis of malignancy. Suspect related to his lung cancer.
Prior cardiac workup was reassuring, and EKG stable compared to
prior with normal troponin and CTA without e/o PE.
# Hyponatremia - Ulytes with Na 39 c/w SIADH, may be in setting
of pain and/or malignancy. Improved during admission with better
pain control.
# Diabetes - held home metformin during hospitalization.
# COPD - stable on home ___ O2.
# Anxiety - cont prn Xanax home med | 113 | 485 |
17740852-DS-24 | 20,728,280 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic injury. This was
non-surgical It is normal to feel tired or "washed out" after
these injuries, 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 with home cane/walker
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks or until mobility
improved to help prevent blood clots
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Weight bearing as tolerated right lower extremity with aid of
cane/walker
Treatments Frequency:
WOUND CARE:
- You may shower
- Splint must be left on until follow up appointment unless
otherwise instructed (except during supervised shower)
- Do NOT get splint wet | ___ yo M PMH L knee TKR ___ ___ after
mechanical fall onto L knee. The patient presented to the
emergency department and was evaluated by the orthopedic surgery
team. The patient was found to have L periprosthetic distal
femur fracture and was admitted to the orthopedic surgery
service. The injury was deemed non-operative. 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, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated with
cane/walker in the left lower extremity, and will be discharged
on lovenox for DVT prophylaxis until improved mobilization. The
patient will follow up with Dr. ___ NP
per routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 262 | 192 |
19593675-DS-15 | 29,853,928 | Dear Mr. ___,
You were admitted to the hospital with an infection of your
right ___. This infection was treated with IV antibiotics
(first vancomycin, then nafcillin). You were seen by podiatry,
who did several I&D procedures (incision and drainage). They
also closed the wound on ___. You had a PICC line placed
for administration of IV antibiotics. You should continue
taking the antibiotic until you are seen by your podiatrist Dr.
___ on ___. He will determine whether the antibiotics can
be stopped.
While you were here, you also had heart failure,
gastrointestinal bleed, hypertension (high blood pressure), and
low potassium level. The heart failure was treated with IV
diuretics and then by increasing your oral diuretic pill
furosemide (Lasix). For the gastrointestinatl bleed, you
required a blood transfusion with 2 units of red blood cells.
You had an upper endoscopy (EGD), which showed inflammation and
erosion or your stomach. We started you on a medication called
pantoprazole to protect your stomach from further bleeding. You
will need to get a colonoscopy in the future, which your PCP can
help you set up. The high blood pressure was treated by
increasing the dose of your labetolol. You were given
potassium, and the medication Kayexalate was stopped.
Your diabetes was not ___, and we suggest you go to
an endocrinologist (diabetes specialist) after you leave rehab
for further management of your diabetes.
Please make sure to avoid putting weight on your right ___
until at least until you are seen by the podiatrist. Partial
weight on the heal while wearing a surgical boot is okay. You
will work with physical therapy at rehab on improving your
strength and mobility.
You should adhere to a ___ diet,
___ diet and weigh yourself every morning.
If your weight changes by more than 3 lbs, call your doctor
immediately. You current weight is 169 lbs.
It was a pleasure caring for you here at ___. | Mr. ___ is a ___ with h/o poorly controlled IDDM2, HTN,
sCHF presenting with R ___ infection.
# Cellulitis/Abscess: Expanding cellulitis after failing oral
keflex. This was likely exacerbated by diabetic nephropathy and
peripheral vascular disease. Staph was thought to be most likely
given ___ abscess. Given the extent of disease and
elevated ESR and CRP, osteo was considered as well. Podiatry
was consulted and did I&D w/ daily debridement for several days.
It did not probe to bone. ___ was negative for osteo, but is
only about 50% sensitive. MRI also without evidence of osteo.
Micro swab cultures showed MSSA and enterococcus sensitive to
penicillins. Patient was initially on vancomycin, but when Cx
sensitivity returned, he was transitioned to nafcillin. Though
enterococcus is generally not covered by nafcillin, patient
improved clinically on nafcillin, and staph was thought to be
main pathogen responsible for purulent abscess and cellulitis.
Therefore, pt will be continued on a >2 week course of
antibiotics with nafcillin. Podiatry did definitive closure of
the ___ wound on ___ at the bedside. Patient will follow
up with podiatry on ___, and it can be decided at that time if
any further antibiotics are necessary. PICC was placed in
dominant (left) arm, as ___ arm needs to be spared for
possible HD access in the future. Blood cultures are negative.
Daily dressing changes: NS wash, betadyne, pat dry, apply 4x4s,
wrap in curlex.
# GI Bleed: Upper GI bleed with melena, rising BUN, dropping HCT
on ___. GI was consulted. Patient remained hemodynamically
stable. Patient received 2u pRBCs on ___ and HCT appropriately
increased from 18 to 25. HCT has remained stable at 25 since.
EGD showed gastritis and duodenitis with erosions, but without
active bleed. Patient was initally started on IV pantoprazole
BID. He was transitioned to PO pantoprazole BID. Colonoscopy
was recommended by GI, but patient refused. He agreed to follow
up with PCP for outpatient colonoscopy.
# HTN: Pt with poorly controlled HTN. Labetolol was uptitrated
for better control. Increased eventually to 800mg TID from
200mg BID. He continued to have hypertension up to 170s, but
was always asymptomatic. He is on max doses of labetolol,
amlodipine, and losartan. U/S doppler showed no renal artery
stenosis. Etiology is likely his CKD. An additional agent may
need to be initiated in the future. Patient is obejctively
orthostatic, but has no symptoms of orthostasis (likely from
autonomic dysfunction and antihypertensives). Blood pressure
and signs/sxs of orthostasis should be monitored closely at
rehab and upon discharge from rehab.
# Acute on Chronic Systolic CHF: Pt has known history of
systolic CHF likely secondary ischemic cardiomyopathy, last
documented EF in ___ was 40%. Upon admission, he presented with
new hypoxia and O2 requirement. Initial exam was consistent with
volume overload. CXR with some interstitial edema. Exam and sxs
and O2 requirement improved with IV Lasix. His home Lasix was
increased to 60mg from 40mg. Carvedilol or metoprolol could be
considered in future given benefits in patients with heart
failure. Losartan was continued. Patient was placed on a salt
restricted, 1.5L fluid restricted diet. Adherence to dietary
recommendations was an issue during hospitalizatin (family
brought in fast food for pt) and may be an issue in outpt
setting as well. Discharge weight was 76.8 kg, and pt appeared
euvolemix.
# IDDM2: poorly controlled IDDM2, recent A1c 8.5. Worsening
hyperglycemia in the setting of acute infection. Glargine and
insulin sliding scale were uptitrated for better control.
# Hypokalemia: Patient came in with a K+ of 2.8. This was
likely in the setting of diuretics and kayexalate use. EKG
showed no U wave. He was repleted, and Kayexalate was stopped.
# Anemia: In addition to acute bleed, he most likely has chronic
anemia secondary to to CKD and iron deficiency with low iron
level and iron saturation of 6%. No evidence of hemolysis. TSH
and B12 NML. PO iron supplement, but will need IV iron and EPO
as outpt.
# CKD: Current Cr at recent baseline, which makes him stage ___
CKD. Pt had worsening GFR likely secondary to diabetic
nephropathy. He has been followed by Dr. ___. No blood
draws or IVs in ___ (right) arm. We attempted to get
midline instead of PICC, but nafcillin is not compatible with
midline, so PICC was put in.
# CAD: Pt not on statin due to hx of rhabdo. We continued
aspirin 325 mg.
# Depression: Continued citalopram. | 334 | 784 |
10625726-DS-20 | 21,961,352 | Dear Ms. ___,
You were admitted to ___ for abdominal pain. Imaging of your
surgical region was normal. We are discharging you with
follow-up in our clinic to assess the severity/change in your
pain. You will also follow-up with GI/ERCP for removal of your
stent.
Please resume your regular home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
If you are prescribed analgesic medications, you should take
them if needed. You may not drive or heavy machinery while
taking narcotic analgesic medications. You may also take
acetaminophen (Tylenol), but do not exceed 4000 mg in one day.
For any pills, we recommend crushing and taking with apple
sauce, pudding, or juice.
Please get plenty of rest, but also be sure to to walk several
times per day. Avoid strenuous physical activity until you
follow-up with your surgeon, who will instruct you further
regarding activity restrictions. Please also follow-up with your
primary care physician in addition to your surgical follow-up.
Please call the clinic or come to the Emergency Department:
*If you have increasing abdominal pain
*Fevers or drainage from your incision site
Thank you for allowing us to take part in your care. We look
forward to seeing you at your follow-up appointment in clinic.
Please do not hesitate to call us with any questions or
concerns.
Sincerely,
Your ___ Surgery team | On ___ Ms. ___ presented to the hospital due to burning
right upper quadrant pain and she was admitted to the inpatient
Surgery service for further workup and care. Please refer to
the HPI for additional details regarding her initial
presentation to the hospital. A right upper quadrant ultrasound
was performed, which yielded the following findings: Common bile
duct stent in place with pneumobilia reflecting stent patency.
Mild amount of free air seen in the gallbladder fossa may be
secondary to the patient's postoperative state. No fluid
collections. 3.1 cm right lower lobe hepatic hemangioma. Ms.
___ labs on admission were unremarkable (WBC and LFTs
within normal limits) and are reflected in the pertinent results
section of this report.
She was kept NPO and GI was consulted for possible stent
removal. The GI team reviewed the findings on her ultrasound,
and said that the stent appeared functional and in proper
position, and in the setting of her abdominal pain, they
recommended deferring stent removal until a later date.
On ___ Ms. ___ underwent an ___ to elucidate the
etiology of her abdominal pain. The ___ showed no evidence of
extravasated biliary contrast agent, i.e., no leak. There was
no intrahepatic or extrahepatic biliary ductal dilatation. It
also showed an unchanged right hepatic lobe hemangioma, as
previously noted on ultrasound.
The following day Ms. ___ opted for a regular diet (contrary
to the recommendation to remain NPO should she require any
additional procedures for workup of her abdominal discomfort).
She tolerated the diet without any issues, but continued to
experience the same burning right upper quadrant pain she
presented with.
On ___ Ms. ___ was discharged home. She had no
pertinent imaging or laboratory abnormalities, her physical exam
was benign, and she was tolerating a regular diet. She will
follow-up with Dr. ___ on ___ at 9:00am for stent
removal. | 224 | 318 |
10791653-DS-15 | 20,702,017 | Dear Ms. ___,
It was a pleasure taking care of you during this admission. You
were admitted for dehydration, low sodium and high blood sugars.
You were given fluids and improved. Your CT scan showed no
pancreatic mass. However, it did show some pulmonary nodules,
which could suggest infection. Given your recent travel to
___, we were concerned about a specific type of fungal
infection and sent tests for this.
We restarted the prednisone to complete the three week course
that your doctors had ___. You were started on insulin to
prevent high blood sugars while you are on the steroids. Please
discuss the need for continued prednisone when you see Dr.
___.
Your prednisone will finish on ___ (20 mg daily until ___,
then 10 mg daily until ___. While you are taking the
steroids, please stop taking metformin and check your blood
sugar four times a day: before breakfast, before lunch, before
dinner, and before bedtime. You should use the sliding scale
(see printout) to determine how much humalog insulin
(___) you will need to ___ each time you
check your blood sugar. In addition, you will take 5 units of
glargine insulin (___) before bed each night. On
___, you can stop taking insulin and begin taking metformin
again.
You should monitor how you are feeling for side effects while
using insulin. Very high or very low blood sugars can both cause
you to feel poorly. If you feel shaky, sweaty, nauseous, or
lightheaded please check your blood sugar to be sure that it is
not too high or too low. If your blood sugar is less than 70,
you should take dextrose tablets as directed to raise it and
___ your blood sugar after ___ minutes to make sure it
has improved. If you find that your blood sugar is routinely
(e.g. more than once a day) too low (< 70) or too high (> 350),
please call your PCP ___ office to discuss
adjustments to your regimen.
Please see the attached medication list. | Brief Course:
Ms. ___ is a ___ F pt with PMH of chronic pancreatitis who
presents with poor intake and dry mouth, found to have
hyperglycemia and dehydration, likely secondary to recent
corticosteroid use.
#. Hyperglycemia: Pt with DM type 2, poorly controlled currently
likely due to recent prednisone use, most recent A1c 7.0. At
home, pt is only on Metformin BID. Pt has UA with 1000 glucose
but no ketones, pH from VBG is 7.31, and no AG acidosis. Pt was
hydrated and given insulin in house and her glucose control. She
was restarted on the corticosteroids per GI recs, and was
discharge on Lantus insulin with a sliding scale while on
prednisone. She was given instructions to call if BG
persistently high.
#. Leukocytosis: Most likely ___ recent steroids vs. infection.
Pt with ___ cough, nd pulmonary nodules seen on CT
(see below), though CXR clear. No other localizing symptoms.
Blood cultures were sent and pending on discharge. Her WBC was
trended and decreased but remained elevated likely secondary to
corticosteroids. See below re: ground glass nodules.
#. Ground glass nodules in lungs: Seen in lung views of CTAP.
New since ___, as above, thought most likely infectious in
etiology. CXR was clear. Recent travel to ___ and could
considered coccidomycosis; less likely given region are other
fungal etiologies such as histoplasmosis and blastomycosis.
Other ddx includes bacterial infection, though syx not
consistent with PNA given ___ cough and afebrile.
Other etiologies considered include pneumoconioses or
malignancy. Sent coccidioides serology, which was pending on
discharge. Given afebrile and pt feeling well, pt was not
started on empiric treatment.
# Chronic autoimmune pancreatitis: Pt sees Dr. ___, Dr.
___ Dr. ___ her chronic diarrhea and autoimmune
pancreatitis. ESR done grossly elevated in ___. Pt has been
on prednisone for 2.5 weeks for planned 3 week course then taper
prior to admission. However, she had ___ 1 day
prior for hyperglycemia as above. Contacted her outpatient
providers via email on patient's admission. Her prednisone was
continued with treatment for hyperglycemia as above. She was
seen briefly by GI who recommended start to taper steroids and
for her to ___ with Dr. ___ as previously scheduled
for EUS on ___.
# Weight loss: possibly ___ poor po intake from infection as
discussed above vs. malignancy vs. chronic pancreatitis. CTAP
ordered by Dr. ___ during this admission showing no
mass, though continued pancreatic duct abnormality. Nutrition
saw her and she recommended supplementation in house. She will
required close ___ with her outpatient providers.
#. Hyponatremia: Likely pseudohyponatremia ___ hyperglycemia and
hypovolemia. She corrected with IVF's and treatment of
hyperglycemia.
#. Hypothyroidism: Continued Levothyroxine 112mcg daily | 337 | 453 |
12502220-DS-6 | 21,737,102 | Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted because you had an infection in your blood and
urine that made your blood pressure drop significantly. You were
initially brought to the ICU for treatment and then transferred
to the medical floor for further care. We asked our infectious
disease doctors to ___ and they recommended an antibiotic,
ceftriaxone, to treat your infections. You will need a daily
infusion of this antibiotic for a total of 3 weeks, THROUGH
___.
Please take care,
Your ___ Team | ___ with history of HFpEF, HTN, CAD s/p pacemaker/AICD, and
thoracic AA who initiated presented from OSH with septic shock,
found to have group G strep bacteremia, likely from foot ulcer
and recent debridement.
# Septic shock ___ Group G Strep Bacteremia: Initially admitted
to the ICU with pressor-dependent septic shock with unclear
etiology for which he was treated with IVF resuscitation,
empiric IV vancomycin, zosyn, as well as empiric c.diff coverage
given recent diarrhea with PO vancomycin and IV flagyl. Blood
cultures taken from a clinic visit on day of admission returned
positive for group G strep. A recent foot ulcer culture from
another instution was also positive for this same organism.
Podiatry was consulted and did not believe his foot ulcer
required any current interventions. Urine cultures sent to a
third instition grew klebsiella, which was thought to be
incidental and likely not a large contributor to initial
picture. TTE and subsequent TEE were negative for endocarditis.
Home carvedilol and diuretics were held. ID was consulted and
recommended a 4 week course of 2g ceftriaxone Q24h ___ -
___.
# ___: Elevated BUN and Cr likely in the setting of hypotension.
Baseline Cr 0.9-1.0. He was given fluid resuscitation with
appropriate downward trend in creatinine.
# LLE inflammation: Initially thought to be cellulitic but
collateral information from son reports that his LLE is actually
much improved compared to prior erythema and edema. Has
previously been hospitalized for lower extremity cellulitis, and
edema and redness are chronic issues. He has a remote history of
DVT, and although anticoagulated with clopidogrel, he had
subtherapeutic INR. We treated with vancomycin and performed
left-sided ___ which was negative for DVT.
# Troponinemia: likely demand ischemia given pressor
requirement, no chest pain or trouble breathing, elevated
troponin more likely in setting of ___. His troponin peaked and
trended down. TTE did not show any vegetations and not
significantly changes from prior.
# Ventricular tachycardia: Patient noted to have tachycardia to
120s in the ED that appeared to be ventricular tachycardia. His
pace-maker was evaluated by EP and was found to be functioning
normally and could not rule out slow VT. His tachycardia
improved with IVF hydration and he did not have any further
episodes of VT.
# Blurred vision: patient reports new blurry vision over past
___ days, worse in right eye. No new visual field deficits per
ophthalmology exam. Recommended lubricating drops for dry eyes
and could follow-up with Dr. ___ as outpatient.
# acute gout: Patient complained of worsening left toe and ankle
pain, which is similar in location to his prior gout flares. He
was treated with colchicine. Please continue until resolution of
flare. Could restart allopurinol as outpatient.
CHRONIC ISSUES
# HFpEF: No respiratory distress. Carvedilol held in setting of
sepsis.
# HTN: anti-hypertensive medications were held in the setting of
hypotension. Torsemide restarted as above
# Hypothyroidism: continue synthroid
# BPH: Foley was placed initially for UOP monitoring and then
discontinued. Home mirabegron and tamsulosin were held during
hypotension. Tamsulosin was restarted.
# Hyperlipidemia: continued home statin
# GERD: continued home PPI | 93 | 504 |
16179898-DS-18 | 27,353,075 | Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with gastrointestinal bleeding. You
were seen by gastroenterology and had an endoscopy which showed
inflammation in your esophagus and stomach. This is most likely
from drinking alcohol. You also had biopsies taken to evaluate
for H. Pylori infection. You will be discharged on a medication
to reduce acid which you should take for 4 weeks.
You were also treated for alcohol withdrawal while in the
hospital. It is important for your health that you stop drinking
alcohol. You were seen by social work and have resources to
support your recovery.
It is also important that you see your primary care doctor. If
you would like to set up an appointment with Dr. ___
please send her a message through the ___ patient portal to
set up an appointment.
We wish you the best,
Your ___ Care team | ___ h/o Etoh abuse admitted with coffee ground emesis, melena.
#Gastritis/Esophagitis:
Presented with coffee-ground emesis, melena without evidence of
active bleeding. H/H stable. The patient was seen by GI and had
an EGD which showed esophagitis and gastritis. GI recommended
complete alcohol abstinence, and PO PPI BID x4 weeks. Biopsies
were taken for H. pylori which are pending on discharge.
Recommend treatment if positive.
# Alcohol abuse with withdrawal.
# Mild tranaminitis:
The patient was noted to have mildly elevated LFTs most
consistent with alcohol use. He was monitored on CIWA and
required few doses of diazepam. He was seen by ___ who provided
resources for alcohol relapse prevention. He is interested in
attending an IOP at ___.
# Depression/anxiety:
Continued Lexapro, gabapentin PRN | 150 | 120 |
11864776-DS-19 | 26,893,156 | You were admitted with an acute ischemic stroke and received
partial re-establishment of blood flow by an intra-arterial
procedure. However, given the large size of the stroke and
discussions with family, it was decided to focus on comfort
care. We placed you on medications to help with pain and
shortness of breath. At this time you are being discharged to a
___ facility for further care. | ___ is an ___ RH M with a h/o Afib, HTN, HLD, CAD s/p
CABG, prior left parietal infarct in ___ and recent scattered
left MCA embolic infarcts in late ___ with residual aphasia
who is transferred from ___ after the acute onset of severe left
MCA syndrome at 12pm the day of admission. The patient had been
discharged to home after his recent stroke after being
transitioned from coumadin to rivaroxaban. He unfortunately was
readmitted to the ICU at ___ on ___ with a GI bleed. For this
reason his anticoagulation was stopped. He was doing well and
transferred from the ICU to the floor shortly before the onset
of his new stroke symptoms at noon. CTA demonstrated attenuated
flow through the left ICA and evidence of clot at the M1/A1
bifurcation with severe limitation of flow in the distal vessels
of the MCA territory. He was not a IV tPA candidate due to his
GI bleed and recent stroke. He was therefore transferred to
___ for endovascular treatment.
The patient was taken directly to the ___ suite following
arrival. Cerebral angiogram showed sluggish flow through the
left ICA with a clot at the M1/A1 bifurcation. Unfortunately
only partial recanalization could be achieved. Possible
etiologies include cardioembolic related to Afib or artery to
artery embolism given repeated involvement of the left MCA
territory. He was admitted to the ICU for close monitoring. His
blood pressures stayed within goal (SBP 140-180) without
pressors. He was initially transferred to the floor but
developed bright red blood from his mouth, with desat to 85%,
and was transferred back to the ICU and intubated. The source of
the bleeding is thought due to NG tube trauma to the pharynx.
Based on family discussion on ___, the patient was made DNR/I
and CMO. Palliative care was consulted, and recommended morphine
boluses prn for patient comfort. Patient was subsequently
transferred to the neurology ward and remained stable. Patient
was kept comfortable with sublingual morphine prn and
scopolamine patch with atropine drops for management of
respiratory secretions. Patient was screened for an ___
___ facility.
Pt passed away over the course of the night/early morning on
___. Presumed cause of death was hypoxic respiratory
arrest due to aspiration. | 66 | 370 |
18644449-DS-20 | 20,563,026 | you were hospitalized with ascites related to liver disease
causing swelling in your belly.
this was drained with a needle procedure to drain off the fluid | ___ with HTN, DM2, w cholangiocarcinoma hospitalized with
symptomatic increasing ascites despite outpatient diuretic
regimen.
___ guided paracentesis today peformed w removal of 5.1 liters.
Since there is no clinical suspicion for SBP at this time given
lack of fevers, will NOT send fluid count and culture as she may
have elevated cell count due to malignant ascites.
Reversed coagulopathy 2.4 INR with 1 unit FFP before
paracentesis.
Hypervolemia hyponatremia: fluid restriction and continue
diuretics Lasix and spironolactone as outpatient. Na 129 on
discharge.
I reviewed home med list and discharge plans with family and her
hospice RN.
Advised that it may be worth seeing PCP to further increase
diuretic dose if BP tolerates to treat recurrent edema and
ascites.
I saw patient with her Oncologist on ___ who stopped by for
social visit.
Rising Bili noted, no previous labs checked since ___. | 25 | 142 |
11934478-DS-4 | 26,526,430 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with abdominal pain and
found to have a blockage in your bile ducts. You had a procedure
called an ERCP to remove gallstones from your bile ducts. You
were treated with antibiotics and will continue antibiotics for
an additional 4 days.
You should hold your captopril and furosemide until you follow
up with your PCP.
We wish you the best,
Your ___ care team | ___ hx cholangiocarcinoma (managed with surveillance only and
recent referral made to hospice), DM c/b neuropathy, HTN,
colitis presents with abdominal pain and chills concerning for
cholangitis.
# Choledocolithasis
# Cholangitis
#Cholangiocarcinoma
The patient presented with RUQ abdominal pain and elevated LFTs
concerning for biliary obstruction. She underwent ERCP with
removal of stones and sphincterotomy. There was no involvement
by cholangiocarcinoma on ERCP. Her abdominal pain resolved, and
she was tolerating a regular diet without pain prior to
discharge. The patient was treated with IV ceftazime while
hospitalized and transitioned to oral cefpodoxime (given her
drug allergies) to complete a 7 day course. The patients family
has arranged hospice intake appointment this week.
# Acute on chronic ___ likely pre-renal from poor PO, returned to baseline prior to
discharge.
# Anemia:
HCT lower than baseline values, likely progressive iron
deficiency anemia from malignancy and ___. The patient's H/H
was stable throughout her hospitalization.
# Hypertension
#Congestive heart failure
The patient was initially hypotensive when admitted. Her
Labetolol was resumed in the hospital with good blood
pressure/heart rate control. She was advised to hold her
captopril and furosemide until follow up with her primary care
physician. Her aspirin was continued.
# GERD:
Continued PPi on discharge
# DM w/Neuropathy:
The patient's blood sugars were labile while hospitalized, but
improved throughout the hospitalization. She will resume her
sulfonurea on discharge. | 80 | 222 |
18848162-DS-20 | 23,265,426 | Dear Ms. ___,
You were admitted to the acute Care surgery service with an
infection in your pelvis. You underwent ___ drainage and were
given antibiotics. You also developed a fistula at your midline
incision and so the skin was opened and a vac dressing was
placed to help the skin heal again. The wound/ostomy nurses
continued to try to find an appliance for your ileostomy to
prevent skin break down. You are doing better, tolerating a
regular diet, and pain is better controlled. You are now ready
to be discharge to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Patient is a ___ year old Female s/p TAH/BSO c/b SBO s/p
ex-lap/SBR x2, with enterovesicular fistula, s/p fistula
takedown, complicated by leak status post ileo-right colectomy
with end ileostomy w/ resiting ___, here with leaking ostomy
and nausea/vomitting. Patient was evaluated by acute care
surgery and then admitted to inpatient for further evaluation
and management.
Urology was consulted for concern of Right hydronephrosis and
recommended placement of foley catheter x 1 week, otherwise no
intervention for right hydronephrosis given the patient has no
symptoms and creatinine is at baseline. Urology also requested
to obtain a urinalysis and urine culture and CT cystogram if
fistulogram is inconclusive. She was made NPO and given IV
fluids and was then taken to ___ where she underwent successful
CT-guided placement of an ___ pigtail catheter into the
anterior pelvic collection. Urinalysis was then positive,
demonstrating Urinary Tract Infection and she was started on
course of macrodantin per infectious disease. A cystogram was
done that did not demonstrate a leak from bladder to abcess
cavity. Foley catheter was eventually removed on
On ___, the patient was complaining of increased pain and there
appeared to be drainage coming from her midline incision. This
was explored and the midline was opened and determined that the
patient had developed a fistula. The ___ drain was removed at
this time. Ostomy appliance attempted to be fitted to quantify
fistula output, however, difficult placement given proximity to
ileostomy. Suction via malecot was attempted without success as
was suction via gravity. Decision was then made that fistula
seemed to be low output, so wet to dry dressing was applied and
then transitioned to vac placement. The wound continued to heal
progressively and the vac was removed on ___ and transitioned
to wet to dry dressing changes. Multiple studies including
fistulagram with oral contrast, contrast via presumed fistula
tract, and via ostomy. Contrast was seen migrating from this
open wound directly into the adjacent small-bowel loops,
compatible with an enterocutaneous fistula.
During this time it was also decided that due to poor po intake,
the patient would benefit from supplemental nutrition via TPN.
Nutrition was in agreement and TPN therapy was resumed and she
tolerated it well.
The patient was seen and evaluated by geriatric medicine and
psychiatry to support her mood and coping with prolonged
hospitalization. It was recommended to start sertraline and
Ritalin.
On ___, a family meeting was held to determine her goals of
care as well as facilitate discharge planning. It was determined
she would benefit most from a short term rehab stay and family
was in agreement. Case management then began to screen the
patient for discharge to acute rehab. The patient and family
were actively involved in the plan of care.
At the time of discharge, the patient was doing well. She was
afebrile and her vital signs were stable. The patient was
tolerating a regular diet for comfort with TPN for
supplementation for malnutrition, ambulating, voiding without
assistance, and her pain was well controlled. The patient was
discharged to rehab and discharge teaching was completed.
Follow-up instructions were reviewed with reported understanding
and agreement. | 504 | 520 |
11545281-DS-16 | 24,412,874 | Ms. ___,
You were brought to the hospital by your family members because
you seemed weaker and more fatigued than normal. You were found
to have a very slow bleed in your gastrointestinal tract, most
likely from your colon. After discussions with Dr. ___
family members have decided that it would be best to be
conservative for now and not pursue aggressive workup with
colonoscopies. You received blood transfusions, and Dr. ___
will continue to check your blood. We made sure there was no
infection in your stool.
We made the following changes to your medications:
- Please STOP taking furosemide (Lasix) for now. Dr. ___
re-start this medicine when you see her.
- You may take Lomotil as needed for loose stools. | ___ yo F with h/o HTN, anemia, osteoporosis s/p hip fracture,
squamous cell and basal cell carcinoma of left arm s/p multiple
excisions, and severe pHTN p/w lightheadedness after a bowel
movement, found to have acute kidney injury and anemia more
profound than her baseline.
.
#. Normocytic anemia, guaiac positive stool, Salmonella Colitis
Pt was guaiac negative on exam in ED, but was noted to then have
guaiac positive yellow brown loose stool during her hospital
course. She had a colonoscopy in ___ which showed grade 1
medium sized nonbleeding internal hemorrhoids, diverticulosis of
sigmoid and ascending colon, and angioectasias in the cecum
(also seen in ___, which were cauterized. Given these
findings, three was a suspicion that the patient may have
subacute blood loss from these previously seen/recurrent
lesions. The team and her family had multiple discussions
regarding their desires and goals for this hospitalization. The
decision was made to treat her presumed GI blood loss
conservatively. She received 2 units of PRBCs and did not
undergo a colonoscopy. Her hematocrit increased appropriately.
The patient was found to be Cdiff negative and was treated with
lomotil for her persistent loose stools. However, after
discharge her stool studies were positive for salmonella which
was communicated to the PCP for further followup.
#. Acute Renal Failure
The patient's admission creatinine was 1.6, up from a baseline
of 0.6 in ___. She reported eating less over the 3 days PTA
given her upset stomach and had dry mucous membranes on
admission exam. It was felt that her creatinine rise was
secondary to a prerenal etiology and it improved with fluids.
Her home blood pressure medications (losartan and furosemide)
were initially held. She was restarted on losartan but not
furosemide.
# Irregular heart rhythm:
The patient was noted to have an irregular heart rhythm with P
waves evident. Her ECG in the ED appeared more regular.
Appears most c/w a sinus arrhythmia vs ectopic atrial pacemaker.
No intervention on this admission.
#. Benign Hypertension
The patient was continued on her home medications, although her
losartan and furosemide were held given ___. She remained
normotensive. Her losartan was restarted prior to discharge,
but she was not discharged on furosemide
================================ | 121 | 380 |
16287626-DS-17 | 22,667,358 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | He underwent routine preoperative testing and evaluation.
Overnight he developed worsening chest pain. Nitroglycerin drip
was titrated to 4mcg/kg/min, repeat doses of 2mg morphine (x4)
were given, EKG demonstrated mild T wave flattening and 1mm ST
depression in V3 and V4, troponin and MB were negative. His pain
improved without additional doses of morphine and in discussion
with the attending decision was made to hold interventions until
surgery in the morning. He was taken to the operating room the
following morning and underwent coronary artery bypass grafting
x 2. Please see operative note for full details. He tolerated
the procedure well and was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from inotropic and vasopressor
support. Beta blocker was initiated and he was diuresed toward
his preoperative weight. He developed postoperative atrial
fibrillation and ultimately converted to normal sinus rhythm. He
had no further episodes of atrial fibrillation and was not
discharged on Coumadin. He remained hemodynamically stable and
was transferred to the telemetry floor for further recovery. He
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD 5 he
was ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. He was discharged to home on
___ in good condition with appropriate follow up
instructions. | 108 | 243 |
19530049-DS-19 | 29,276,295 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of worsening
shortness of breath and leg swelling
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given medications to help make you urinate more to
pull the fluid off of your lungs
- Your thyroid function tests were found to be abnormal, so you
were evaluated by the endocrinology specialists. We got an
ultrasound of your thyroid which showed some benign looking
cysts. You were started on a medication to help normalize your
thyroid function
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor at ___
if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 138 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES:
[] TFTs pending on discharge (___), please follow-up as an
outpatient
[] Follow at ___ endocrine and cardiology
[] Patient and daughter should be counseled about the side
effects
of MMI once we start her on it (If she develops fever, sore
throat, rash, jaundice, RUQ pain then she should stop the
medication and go to a lab to get her bloodwork done)
==========================================
___ year old female with PMHx of HFpEF, paroxysmal atrial
fibrillation, breast cancer on anastrazole, prior hypothyroidism
now hyperthyroidism, who presents with DOE and increased leg
swelling.
# Acute on chronic heart failure with preserved ejection
fraction:
Per review of outpatient notes in At___ and patient history,
appears that the patient was slowly accumulating fluid for the
past month despite increasing diuretic doses as an outpatient.
On admission, was noted to have a proBNP of 15,000. Weight on
admission significantly elevated from dry weight at 154 lbs. She
was initially diuresed with IV Lasix boluses, but response to
doses as high as 120mg BID with metolazone were less than ideal,
so she was eventually transitioned to torse___. She had a large
amount of urine output to 100mg PO torsemide and was eventually
downtitrated 10mg PO torsemide as a home dose. Weight at
discharge was 138 lbs. TTE performed this hospitalization
demonstrates low-normal EF at 56%.
# Atrial fibrillation:
The patient has a known history of atrial fibrillation, but it
appears to have been paroxysmal until about 2 months ago, when
it appears to have transitioned to persistent A fib. While
hospitalized, she remained in A fib with adequate rate control
the entire time. She was continued on her previous home
medications for rate control, but her Toprol was decreased from
200mg daily to 100mg daily. Rates remained well controlled at
the lower dose.
# Hyperthyroidism:
The patient previously carried a diagnosis of hypothyroidism and
was on levothyroxine, but this was stopped in ___.
Despite being off thyroid supplementation for 4 months, she was
noted to have low TSH on admission. Endocrinology was consulted
and assisted with management. The patient was eventually found
to have anti-TSH receptor antibodies and thyroid stimulating
immunoglobulin, consistent with a diagnosis of Graves disease.
She was started on methimazole 2.5mg daily. TFTs are pending at
the time of discharge. She should continue to follow with Atrius
endocrinology for further management of her hyperthyroidism. | 215 | 385 |
19930170-DS-12 | 28,627,767 | You were admitted to the hospital with cholecystitis. You were
taken to the operating room and had your gallbladder removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | 1) RUQ abd pain, abnormal transaminases and dilated CBD
Make pt NPO for now and place on maintenance IVF's. Consult
GI/ERCP team in am. Given the fact that the pt did not come with
discs with imaging studies, will repeat RUQ u/s to eval CBD.
Continue to monitor pt's sxs and abd exam.
2) Chronic methadone use
___ is currently closed. Will need to call in am to
confirm that she receives daily methadone. ___ records from ___
says she was recieving 90mg methadone daily then. Pt currently
without any withdrawal sxs despite not receiving any methadone
since sat - suspect likely due to long halflife of methadone.
Will treat with prn morphine overnight for now. Discussed plan
with pt who was agreeable.
3) Low grade fever of ___ on admission
- will continue to monitor pt's temp and sxs. Will plan on blood
and urine cultures if Temp 100 or higher. For now, no need for
empiric abx as pt looks well.
4) Anxiety disorder/PTSD/depression - continue home dose of
xanax
5) Pt reports being raped by multiple men in ___. I
asked if she felt safe currently and wanted to speak with anyone
now - she said no. Will ask social work to see her in am.
6) Hx of prior alcohol abuse
Pt did not reveal this to me but was seen on ___ records.
Will also provide MVI, thiamine and folate for time being.
Assess for any withdrawal sxs.
7) Prophlaxis
pt is ambulatory so no current need for pharmacologic
prophylaxis. Will check urine preg test. Pt states she is not
sexually active. Plan discussed with nurse ___.
Acute Care Surgery was consulted on ___ for further
evaluation and treatment. Patient had already undergone liver
ultrasound and MRCP on ___ with the following findings | 760 | 295 |
15049816-DS-20 | 24,690,376 | Ms. ___,
You were admitted to the hospital because you fainted. We did
an evaluation and found that your heart occasionally has an
abnormality called atrial fibrillation. We gave you a new
medication to control this. We don't think this is why you
fainted, and we feel that the fainting was probably from a
"vasovagal" reaction which occured after you vomited. We also
gave you an antibiotic for a probable urinary tract infection.
You finished a course of this in the hospital. We have also
prescribed you an antibiotic eye drop for conjunctivitis. You
should use these four times daily through ___ and then you
should stop them. We have also decreased the dose of your
allopurinol to 150 mg once daily, because of your renal
function. PLEASE HOLD YOUR CHEMOTHERAPY, YOUR DEXAMETHASONE, AND
YOUR STUDY DRUG until you see you oncologist, Dr. ___, on
___ or ___ of next week.
It was a pleasure taking care of you. | Ms ___ is an ___ yo F with MM on Velcade and Dexamethasone +
study drug (protease inhibitor vs placebo) who presented with
emesis and syncope. Most likely etiology was felt to be
vasovagal, but she was found to have an episode of Afib on tele
and she was also treated for a UTI.
#Syncope: NCHCT negative at OSH. CT C-spine negative for
injuries at our hospital. No evidence of sinusitis or
mastoiditis. Was not dizzy or orthostatic in hospital and had no
new neurological deficits. Had a slight ___ on CKD on
admission, so she may have been dry and orthostatic prior to
coming to the hospital. This improved with fluids. Most
parsimonious explanation for her chemo is an orthostatic
reaction in the setting of dehydration or a vasovagal reaction.
We are holding her lenalidomide and study drug for now and she
will see her oncologist next ___ to decide about restarting.
#Afib: One episode of asymptomatic rapid Afib. Pressures stable.
Resolved with PO metoprolol tartrate 25 mg. She was transitioned
to PO metop succinate 50 mg qAM and had no further atrial
fibrillation during her stay. Since she was asymptomatic, this
was felt to not likely be the etiology of her syncope. We made
the decision not to anticoagulate her given the isolated episode
and her recent fall. She was instructed to set up an appointment
with her PCP next week for followup.
#conjunctivitis: Presented with erythematous conjunctiva and
what appeared to be purulent discharge from the L eye. We
started her on cipro eye drops and instructed her to complete a
7 day course. She will follow up with her pcp regarding this as
well.
#UTI: She had >50 WBC in her urine on admission. UCx was
contaminated. After antibiotics, UCx was sterile. She had no
dysuria. She received a 3 day course of IV ceftriaxone. (got one
dose of ciprofloxacin instead of ceftriaxone).
#MM: Her chemotherapy and steroids were given on her first
hospital day, and then subsequently held. She will followup with
Dr. ___ in clinic.
#transaminits: LFTs were normal on ___. In the ___ on ___ and
then ___ on ___, with AlkP at 130. TBili was normal. We feel
this was a drug effect (antibiotics vs study drug). Other
etiologies of hepatitis are less likely, but a hepatitis
serology panel was sent. This is pending at the time of
discharge and will be followed up during her ___ clinic
appointment. She should have LFTs repeated at this time as well.
#HTN: Her lisinopril and HCTZ were held during her hospital stay
due to her potential dehydration. Her BPs were stable. These
medications were restarted at discharge.
#Transitional issues:
-Needs LFTs rechecked on ___ and needs her hepatitis
panel followed up
-Needs chemotherapy restarted next ___.
-Needs follow up with her PCP regarding her new Afib and
conjunctivitis. | 160 | 465 |
12794612-DS-6 | 26,562,961 | Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted with high fevers and were found to have a pneumonia.
We hope you continue to feel well.
Please be sure to attend the follow up appointments list below
and to review the attached medication list. | ___ with h/o mild cognitive impairment, HLD, and an episode of
urosepsis last year presented with fever, shaking chills and
hypotension.
# Septic shock secondary to PNA
Pt febrile and tachycardic on admission. CXR showed opacity in
the left lung base concerning for pneumonia, which was most
likely source of his sepsis. Patient received 5L of IVF on
medicine floor and remained hypotensive (SBPs in the ___,
lactate was 3.8). He was transferred to ___ overnight for
further management, no pressors were required and his BP
stablized. He remained HD stable for the rest of his hospital
course. He is to complete a 7 day course of antibiotics for
communicty acquired PNA. He intially required oxygen
supplementation but was able to easily ambulate on RA prior to
discharge.
#. Mild cognitive impairment
Pt with a difficulties with word findings. Reported at baseline
on admission per wife and PCP. No intervention.
#. Chronic kidney disease
Cr at baseline (1.4). No intervention.
#. Vit D deficiency
Last level was 25 in ___. His home supplementation was
continued.
#. Vertigo
No current complaints. No intervention. | 52 | 195 |
19276587-DS-20 | 26,950,704 | Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital because your
blood count had dropped slightly. Your blood counts were stable
during your stay here. We performed a CT scan of your abdomen
to look for bleeding and did not find any. We also checked your
stool for blood, and there was none. In addition, you developed
low blood calcium during your hospital stay, which improved over
your course. You were clinically stable and were discharged
back to your rehab facility.
Ultimately, we do not know what caused your blood count to drop
slightly. This may represent worsening of your chronic anemia.
You should continue receiving your weekly Epogen injections. In
addition, you will need to take Calcitriol daily and Calcium
Carbonate supplements four times a day for your hypocalcemia.
Finally, you were treated with steroids for possible temporal
arteritis. You will need to continue this until your follow up
with rheumatology.
Thank you for allowing us to participate in your care. | ___ w/ hx of ESRD on PD, DM, HTN presents with anemia and
falling Hct, found to have no bleeding source in the hospital
with stable hct. Course complicated by hypocalcemia. | 179 | 31 |
14729536-DS-24 | 21,916,782 | You were admitted to the hospital for leg pain and shortness of
breath. Your leg pain was thought to be due to skin changes due
to chronic leg swelling with a healing blister on the left leg.
You had an echocardiogram which did not show any evidence of
heart failure. It was difficult on the echocardiogram to assess
for pulmonary hypertension. If your symptoms continue your PCP
may consider further evaluation for pulmonary hypertension.
Please continue to take your medications as prescribed and
follow up with your primary care provider as an outpatient.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | Ms. ___ is a ___ year old female with history of morbid
obesity, history of DVT, psoriasis, ankylosing spondylitis, and
OSA who presented with dyspnea and acute on chronic lower
extremity pain.
# DYSPNEA: Patient described feeling of air hunger which was
intermittent and improved during her admission. Her workup was
unrevealing with admit EKG without ST changes, troponin negative
x 2, and CXR without evidence of pneumonia or volume overload or
CHF. PE was not thought to be likely in setting of her
maintaining her O2 sats, and not being tachycardic (although on
beta blocker). Differential diagnosis also included poor
respiratory mechanics secondary to her morbid obesity, or
worsening pulmonary hypertension which had previously been noted
as moderate on prior TTE. A TTE performed was unable to
evaluate for pulmonary hypertension, but noted dilated RV. She
was continued on her home CPAP and albuterol nebs prn. If her
symptoms recur, outpatient evaluation for pulmonary hypertension
should be considered.
# LOWER EXTREMITY PAIN: Patient had burning and searing pain in
left lower extremity with chronic venous stasis changes.
Bilateral LENIs were negative for DVT and there was low concern
for cellulitis as she was afebrile, without leukocytosis and she
had bilateral erythema in a distribution and appearance
consistent with lipodermatosclerosis. TSH was in normal range
and labs demonstrated no B12 deficiency. She was noted to have
few blisters on LLE but not in a dermatomal pattern so it was
not felt to be zoster. As her blister healed, her pain
improved. She was advised to use clobetasol as previously
prescribed when blister was healed, and to continue gabapentin
1200 mg TID.
# L knee OA: Patient reported waking up with L knee pain on
hospital day 2, without synovitis and on XR demonstrated
degenerative changes. Pain improved with pain medications.
# Morbid obesity: It was felt that patient's morbid obesity was
causing or contributing to her multiple medical problems.
Patient reported that although she had discussed bariatric
surgery with her PCP, she was afraid of undergoing surgery. She
was encouraged to discuss further with her PCP, and to consider
going to bariatric surgery consultation visit.
# CHEST PAIN: Patient had tenderness to palpation of chest wall
that was thought to be musculoskeletal ___ to morbid obesity.
EKG and troponins negative for ischemia and symptoms
self-resolved.
CHRONIC ISSUES:
# ANKYLOSING SPONDYLITIS: Continued on home prednisone 10mg,
gabapentin, ibuprofen, and oxycodone.
# HTN: Continued on home metoprolol and nicardipine.
# OSA: Patient was continued on home CPAP.
TRANSITIONAL ISSUES:
-Patient will call outpatient providers for ___ with PCP ___.
___ Dr. ___ not yet been scheduled
at discharge).
-If continued SOB, consider outpatient evaluation for pulmonary
hypertension. | 107 | 463 |
13162835-DS-7 | 27,306,083 | Dear Ms ___,
You presented to the hospital with an episode concerning for a
seizure, and you were found to have diffuse edema with a small
amount of blood on an MRI consistent with Posterior Reversible
Encephalopathy Syndrome (PRES). We performed an EEG that did not
demonstrate ongoing seizures. The Rheumatology team was
consulted, and they felt that you did not have symptoms of
lupus. Therefore, we felt that the cause of your seizure was
PRES, which was caused by hypertension caused by a combination
of baseline high blood pressure and medications. | Ms ___ presented with an episode concerning for a seizure
with initial right arm movements. She was loaded with
Levetiracetam, and she had no further episodes concerning for
seizure. She had an EEG that demonstrated some slowing
consistent with a recent seizure but no epileptiform activity.
She had an MRI that demonstrated posterior edema and a small
amount of hemorrhage, which was felt to be consistent with PRES.
Rheumatology was consulted, and they felt that she did not have
SLE given that she did not have any clinical symptoms of Lupus.
However, they recommended several laboratory studies that were
pending at the time of discharge. Therefore, we felt that the
most likely etiology of her PRES was a combination of baseline
hypertension, steroid use, and Adderall. The pain team was also
consulted, and they recommended continuing to wean the opiates
as planned with her PCP because they felt like she was unlikely
to benefit from long term opiate therapy. They also recommended
outpatient psychiatry for coping with her pain and medication
management. | 91 | 172 |
19890770-DS-9 | 27,645,357 | You were admitted to the hospital after you were involved in a
motor vehicle accident. You received rib, facial, and a scapula
fracture. You had a laceration to your right eyelid and
required suturing by the Plastic service. Your pain medicine
was converted to an oral agent. You are now preparing for
discharge home with the following instructions:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
You also sustained a right orbital wall fracture, please follow
these instructions:
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. | ___ year old female admitted to the acute care service afer being
involved in a MVC. Med-flighted in from scene. Upon admission,
she was made NPO, given intravenous fluids, and underwent
radiographic imaging. She was found to have fractures of the
lateral aspects of the right ___, and 6th ribs. She was
also reported to have a right scapular fracture with mild
distraction near the base of the coracoid. She also sustained
right medial/lat/inferior orbital fracture. Because of her
injuries, she was seen by Orthopedics for the right coracoid
fracture. This was determined to be non-operative and a sling
was recommended for comfort. Plastics was consulted to provide
input into the management of her rigth orbital fracture. She was
reported to have a non-displaced orbital fracture which was
non-operative and sinus precautions were recommended. She did
require suturing of a laceration above her right brow.
Her rib pain was controlled with intravenous analgesia and on HD
#2 converted to oral agents. She has maintained on room air with
an oxygen saturation of 96% on room air and has been encouraged
to use the incentive spirometer. She was introduced to clear
liquids with progression to a regular diet. Her foley catheter
was discontinued on HD #2 and she voided without difficulty.
Her vital signs are stable and she is afebrile. Because of her
questionable loss of consciousness, she was evaluated by
occupational therapy to determine the need for outpatient
cognitive evaluation. Physical therapy was consulted to
instruct patient in the ongoing management of the right scapula
fracture and provided instruction in ROM exercises.
She is preparing for discharge home and has been instructed to
follow-up with Orthopedics, Plastics, and the Acute Care
Service. She will need to have her staples removed by the Acute
Care Service and her sutures removed by the plastic surgery
service in outpatient follow up. She should also work with
outpatient ___ to restore full range of motion in her
shoulder. | 452 | 337 |
11041589-DS-17 | 23,050,093 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Aspirin 325 twice daily
with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue Pantoprazole daily while on
Aspirin to prevent GI upset (x 4 weeks). If you were taking
Aspirin prior to your surgery, take it at 325 mg twice daily
until the end of the 4 weeks, then you can go back to your
normal dosing.
9. WOUND CARE: It is okay to shower after surgery after 5 days
but no tub baths, swimming, or submerging your incision until
after your four (4) week checkup. Please place a dry sterile
dressing on the wound after aqaucel is removed each day if there
is drainage, otherwise leave it open to air. Check wound
regularly for signs of infection such as redness or thick yellow
drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated with walker or 2
crutches. Wean assistive device as able. Posterior
precautions. No strenuous exercise or heavy lifting until follow
up appointment. Mobilize frequently.
Physical Therapy:
Weight bearing as tolerated with walker or 2 crutches. Wean
assistive device as able. Posterior precautions. No strenuous
exercise or heavy lifting until follow up appointment. Mobilize
frequently.
Treatments Frequency:
Please monitor left hip incision closely for signs and symptoms
of infection (drainage, erythema)
Wound check daily
Ice to operative extremity | The patient was admitted to the orthopedic surgery service with
concerns of left hip infection. A left hip aspiration was
performed which showed 19 cell count, 6.0 hct, 25 polys. There
was no concern for deep prosthetic joint infection. Patient was
started on prophylaxis IV antibiotics.
Her hospital course was unremarkable.
Her pain was controlled with a combination of IV and oral pain
medications. The patient received Aspirin 325 mg twice daily
for DVT prophylaxis starting. Her surgical incision was without
active drainage, ecchymosis with improving pinkness surrounding
incision. Her staples were removed on ___. She was started
on IV Ancef. The patient was seen daily by physical therapy.
Labs were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Walker or two crutches, wean as able.
Please take Keflex ___ four times daily for 14 days upon
discharge for left hip cellulitis.
Ms. ___ is discharged to home with services in stable
condition. | 518 | 207 |
19419426-DS-9 | 23,269,393 | Dear ___,
___ was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had 2 weeks of
confusion and right-sided weakness. You were transferred here
from ___ due to concern that you may have had a mass in
your brain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you had a study called an MRI to look closely
at your brain. This determined that you may have had a stroke
or may have had a mass in your brain causing swelling and your
symptoms of right-sided weakness and confusion.
- Your providers here reached out to your past providers as well
as your family. A meeting was held and it was determined that
pursuing further diagnostic evaluation and invasive treatments
was not congruent with your goals of care. Your code status was
changed to do not resuscitate/do not intubate, and the focus of
your health care was changed to focus on comfort.
- You were screened for hospice facilities and you were
discharged to home hospice.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take your medications as needed for your own comfort.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
====================
___ female with a history of transverse colon mass with
tissue diagnosis of schwannoma, anemia who presented with 2
weeks of worsening confusion and right-sided weakness to
___, transferred to ___ for neurosurgical
evaluation once CT showed left-sided vasogenic edema concerning
for malignancy. Here, MRI of the brain showed findings that may
have been compatible with either stroke, underlying malignancy,
or both. Based on the patient's goals of care, it was determined
that even with the least invasive treatment and the best
prognosis she likely would not want to undergo evaluation.
Patient was made DNR/DNI and was discharged to hospice. | 207 | 101 |
18635178-DS-11 | 24,745,210 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall sustaining left sided rib fractures. Because of
your diagnosis of normal pressure hydrocephalus, you were seen
by the neurology team. The CT scan of your brain showed stable
size ventricles. The neurology team did not recommend any
interventions in the hospital as your function is at baseline.
You should continue to take precautions with activity (use a
cane/walker and ask for assistance as needed). Please continue
to follow up with your outpatient neurologist Dr. ___
further considerations. Your breathing and oxygenation were
closely monitored and remained stable. You were given pain
medication to help decrease the discomfort of rib fractures. You
are now doing better, breathing adequately, and pain is better
controlled. You are now ready to be discharge to home to
continue your recovery.
Please note the following discharge instructions:
* Your injury caused Left sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ 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). | ___ is an ___ man with a history of NPH who
was admitted to the Acute Care Surgery Service on ___ after
a fall sustaining left sided rib fractures. Given the diagnosis
of normal pressure hydrocephalus, the patient was seen by the
neurology team. A CT head demonstrated stable sized ventricles.
The neurology team did not recommend any interventions in the
hospital as the patient was at his baseline function and did not
wish to pursue invasive options such as placement of a VP shunt
or lumbar puncture. Physical therapy evaluated the patient and
recommended precautions with activity (cane/walker, assistance
as needed). The patient was instructed to follow-up with his
outpatient neurologist Dr. ___ further considerations.
During his hospitalization, his breathing and oxygenation were
closely monitored and remained stable. At the time of discharge,
he was tolerating a regular diet and his pain was
well-controlled on oral agents. He was discharged to home in
stable condition on ___. | 390 | 160 |
18892158-DS-11 | 20,639,519 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___.
Why was I admitted to the hospital?
===================================================
- You were very confused, and actually found down at home. This
was probably caused by alcohol you were drinking, as this can
cause severe confusion and illness in patients with liver
disease.
What was done for me in the hospital?
===================================================
- You were initially admitted to the intensive care unit for
monitoring of your mental status.
- You were given a unit of blood because your blood counts went
down a little bit, but you didn't have any active bleeding.
- You were started on a medication called lactulose. This
medication helps you poop out extra toxins that your liver
cannot clean because it is sick.
- You were started on your home water pills (torsemide and
spironolactone), but these doses were lowered because we think
they were too strong for you.
What should I do when I leave the hospital?
===================================================
- The most important thing to do is to NOT drink alcohol. This
means not even one beer, glass of wine, or cocktail. NO ALCOHOL.
Any alcohol could cause you to get confused, have worsening
liver disease, and even die.
- Please take lactulose so that you have 3 bowel movements per
day. This will help prevent confusion.
- Please follow up with your liver doctor, ___.
What are the reasons I should return to the hospital?
===================================================
- If you feel confused or if any of your family members are
concerned you are confused.
- If you have fevers, chills, abdominal pain, leg swelling,
black stools, or blood in your stools or vomit.
We wish you the best of luck in your health!
Warmly,
Your ___ Care Team | Mr. ___ ___ year old man with HCV/EtOH cirrhosis with
history of SBP, varices, HE, volume overload, and portopulmonary
HTN, who presented with hepatic encephalopathy. His course was
complicated by acute on chronic anemia.
#Grade III hepatic encephalopathy
The patient was found very confused and hard to arouse at home.
He was transferred from an outside hospital for concern for
hepatic encephalopathy initially admitted to the MICU. In the
MICU he was initially given lactulose enemas then transitioned
to oral lactulose and rifaximin. He required Haldol in the first
layer admission and was placed on Precedex this was discontinued
after a few hours. It is believed that his hepatic
encephalopathy was precipitated by alcohol use as the patient
reported that he had been drinking 1 beer per week and his
family is very concerned that he was drinking more. His tox
screen was
also positive for cannabinoids which was also thought to be a
contributing factor. Patient was eventually transitioned to the
floor on oral lactulose and rifaximin and was alert and oriented
×3 during his time of the floor. He was only discharged with
lactulose, with plan to get insurance approval for rifaximin as
an outpatient.
#Transaminitis
#Elevated CK
Patient initially presented with AST 267 ALT 54 and a CK level
9656. The AST: ALT ratio was consistent with alcohol consumption
though his alcohol level drawn in outside hospital was negative.
His LFTs down trended throughout his hospital stay and his CPK
improved with fluid administration.
#Portopulmonary HTN
Patient was diagnosed in ___. Echo done in ___ showed some improvement in his pulmonary artery pressures.
He was without dyspnea and on room air throughout his hospital
stay and was continued on sildenafil and macitentan.
#Coag negative staph bacteremia
The patient coag negative staph bacteremia in 1 out of 5 blood
cultures drawn on admission. He was initially started on
vancomycin but this was discontinued when his further blood
cultures did not return positive and speciation suggested
contaminant.
#HCV/EtOH cirrhosis
Meld 13 on admission. Decompensated by hepatic encephalopathy,
ascites, SBP, varices and portopulmonary hypertension. He is
currently deactivated on the transplant list pending further
dental evaluation, and now pending involvement in alcohol
relapse prevention. His diuretics, torsemide and spironolactone,
were restarted. These doses were lowered to 10 mg torsemide and
25 mg spironolactone at discharge given that at the higher doses
he was making a lot of urine and there was concern this would
lead to volume depletion. He was maintained on home
ciprofloxacin weekly (liver OK with this dose) for SBP
prophylaxis. | 281 | 411 |
17905598-DS-8 | 25,617,407 | 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 LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily until your follow up with Dr. ___
___ CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Please see instructions below for pin care.
Physical Therapy:
non-weight bearing left lower extremity
Treatments Frequency:
BID daily pin site care: 50-50 hydrogen peroxide-water mixture
applied to pin sites with q tip.
Change dressing around pin sites every 2 days | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left ankle external fixation, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ (___) per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 185 | 256 |
10555770-DS-4 | 24,921,021 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having trouble breathing, and felt dizzy
- You were found to have blood clots in your lungs causing
strain on your heart, and transferred here
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received blood thinning medication (heparin) through the
IV
- Your breathing improved and you were transitioned to blood
thinner injections (Lovenox)
- You also were found to have anemia, low red blood cell counts,
and low iron. This is often caused by chronic low level blood
loss.
- Causes of these blood clots were investigated
- You had colonscopy that showed a polyp.
- You had endoscopy that showed stomach irritation (gastritis)
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Give yourself Lovenox injections twice a day, rotating
injection sites.
- There were parts of the colon not entirely visualized on
colonscopy, so you should schedule a repeat colonscopy in 2
months to take a better look, and possibly remove the polyp
- You should have cancer screening for breast and cervical
cancer, and possibly endometrial, ovarian, and other cancers
based on the discretion of your primary care doctor.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY
========
Ms. ___ is a ___ year-old woman with no significant past
medical history who presented with three days of dyspnea and was
found to have bilateral submassive pulmonary embolism. She has
been hemodynamically stable with no DVTs, started on heparin and
transitioned to Lovenox. Anti-Xa levels checked and appropriate.
She was also found to have iron deficiency anemia, and underwent
EGD/Colonoscopy which were negative for malignancy. Etiology of
thrombophilia remains unknown.
ACTIVE ISSUES:
===============
# Unprovoked bilateral submassive pulmonary emboli
The patient presented with dyspnea for four days with CTA
demonstrating bilateral submassive PEs with mild troponin
elevation, EKG c/w RH strain; bilateral dopplers negative.
Transthoracic echocardiography with increased RA pressure and RV
dilation. Vascular was consulted and recommended heparin, no
role for thrombolysis. She received heparin and was transitioned
to Lovenox, given DOACs not thoroughly studied for her BMI.
Etiology of thrombophilia unclear although some concern for
malignancy raised given no cancer screening in ___ years. No
other evidence of provocation. No PMH or FMH of clots. Did not
pursue thrombophilia workup as patient age> ___, no family hx
VTE, no recurrent VTE, and no splanchnic or cerebral VTE, no
arterial VTE (___, ___. Scheduled for f/u with
vascular medicine and hematology. Symptomatically improved with
anticoagulatoin, and weaned off oxygen. Satting 94% on RA on
discharge, high ___ with ambulation.
# Malignancy screen
No cancer screening in ___ years. No abdominal, gastrointestinal
symptoms, vaginal bleeding, or weight loss; in fact, reporting
100lb weight gain in past ___ years. However, mild bloating over
the ___. Underwent menopause at age ___, LMP ___. Reports
hx intermittent small volume BRBPR, family hx polyps in middle
age and colon cancer in ___, though ___ here with only a small
non-bleeding polyp (unable to completely visualize d/t
incomplete prep) and EGD with mild gastritis. She will schedule
a follow-up colonscopy in 2 months for possible polyp removal
and better visualization. Started pantoprazole 40mg PO daily for
14 day course. On bimanual exam, she had a small and firm
uterus, no adnexal masses were felt but exam limited by body
habitus. TVUS demonstrated 4mm uterus, however not completely
visualized and ovaries not visualized. Further cancer screening
deferred to outpatient primary care team: mammography, cervical
cancer screening, consider CT abdomen for ovarian, pancreatic,
intestinal malignancy. However, she does not have elevated
calcium which may be a sign o malignancy, and, she has had no
weight loss, but rather a 100 lb weight gain in the past few
years.
# Iron Deficiency Anemia
Hb low, with microcytic but normal RDW. Low ferritin at 11 with
normal transferrin. Suspected chronic low level GI bleed,
however EGD and ___ reassuring against this. Possible
intermittent gastritis with bleeding, although reportedly quite
mild; no blood at present. Also possibly intermittent polyp
bleeding, as pt mentioned intermittent small volume BRBPR. Had
menses until ___ yr ago, but this would not evidence in iron
deficiency anemia one year after menopause.No absorptive
deficiency clinically, and celiac negative. Daily CBC monitored
without drop. Pt received IV iron 125mg x 3d.
CHRONIC ISSUES:
================
# Healthcare maintenance
Has not seen physician in decades, was feeling well. Patient is
obese with family history of coronary artery disease. Patient
advised to have age-appropriate cancer screening as above. A1C
5.5. Lipids wnl.
TRANSITIONAL ISSUES
===================
[ ] Started on Lovenox for minimum of ___ months, likely
indefinite i/s/o unprovoked PE. Scheduled with vascular medicine
to determine length of treatment.
[ ] Needs cancer screening: minimum of normal screening
(mammography, pap smear). Consider more thorough imaging if
screening otherwise unrevealing such as CT Abdomen to assess for
ovarian, pancreatic or intestinal malignancy I/s/o bloating and
unclear etiology of thrombophilia in otherwise active patient.
[ ] Recheck CBC in 1 month. Gastritis treated with PPI and
treated with IV iron so would expect significant improvement in
Hb. If not improved, would consider push enteroscopy.
[ ] On labs drawn here, lipids noted to be wnl and A1c 5.5%
Greater than ___ hour spent on care on day of discharge.
# CODE STATUS: Full
# CONTACT: ___ ___) | 224 | 663 |
13269859-DS-37 | 21,110,091 | It was a pleasure looking after you, Ms. ___. As you know,
you were admitted to the ICU for DKA. You were treated with
insulin drip and resuscitated with intravenous fluids. The
sugar levels were markedly elevated and the ___ service
helped to manage the sugar levels, with adjustments made to your
insulin regimen.
Due to your depression and recent alcohol use, you were seen
by the Psychiatry consult team, and they recommended that you be
enrolled in an outpatient partial treatment program. We had
also recommended inpatient treatment at a ___
facility, but you refused voluntary admission. Hopefully, with
these issues addressed, any future ___ episodes can be avoided.
.
Please see your physicians as listed. It is critical that you
keep all your appointments and follow-up.
.
Please take your medications as listed.
. | ___ with poorly-controlled type 1 diabetes presenting with
vomiting found to have diabetic ketoacidosis with unclear
precipitant and acute kidney injury.
# DM1, poorly controlled with complications (neuropathy,
retinopathy)
# Diabetic Ketoacidosis: Patient presented with glucose 751,
ketonuria, polyuria, polydipsia, and anion gap of 37 with
metabolic acidosis (pH 7.04). Her WBC was elevated to 13.3 with
87% neutrophils. Infectious sources were ruled out with negative
CXR, normal UA, negative influenza, negative UCx and negative
BCx. ECG was stable from prior and troponins were 0.02. LFTs,
amylase and lipase were normal. She was started on an insulin
infusion until her anion gap was less than 14, at which point
she was restarted on a basal and sliding scale insulin regimen.
She was also aggressively rehydrated with IV fluids with good
response. She was followed by the ___ consult service and
some adjustsments were made to the doses of both her basal and
sliding scale insulin. She will have close follow-up with
___ on discharge and she was also provided with a script for
urine ketone strips on discharge. Ultimately, her DKA was felt
to be due to non-compliance in setting of depression and EtOH
use. Hopefully, with treatment of her EtOH abuse and
depression, her blood sugar control will improve.
# Acute Kidney Injury: Baseline creatinine is 0.5-0.6. She
presented with creatinine 1.5 in the setting of severe
dehydration from DKA (BUN:Cr > 20). This was not felt to be due
new diabetic nephropathy recent negative urine protein in
___ and normal creatinine prior to this prestation,
although she does have a history of microalbuminuria but this
dates back to ___. Her creatinine improved back to her baseline
with aggressive rehydration as above. Her home lisinopril was
held in the setting of acute kidney injury.
# EtOH Use: heavy alcohol user. Last drink ___. Denies
drinking for the past two weeks but we were unable to
corroborate this information. She was monitored for signs of
alcohol withdrawal and did not experience any. She was placed on
folate, thiamine and a multivitamin with minerals. Social work
and Psychiatry were consulted. Her PCP had hoped that she could
be placed in a ___ facility, however, per Psychiatry
evaluation, she was not deemed to be sectionable and the patient
also refused voluntary admission. Therefore, Psychiatry
recommended outpatient partial treatment program. The patient
was screened by ___ and recommended enrollment in SOAP at
___, as well as enrollment in a community
support program via Vinfen. The patient will complete intake at
___ on ___ at 10 AM.
# Depression: continued mirtazapine and Effexor. Seen by
Psychiatry as above.
# Anemia: patient at baseline. Ferritin is c/w iron-deficiency
anemia. Pt denies any FH of colon CA and denies
BRBPR/melena/weight loss/change in BM. She reports that she
still has regular menses, which is the most likely cause of her
iron deficiency. She reports non-compliance with her iron
supplements. She was restarted on iron supplementation during
admission. She should have repeat iron panel and Hgb/Hct
checked as an outpatient. | 141 | 513 |
18526154-DS-16 | 25,617,516 | Dear Mr. ___,
You were admitted to ___ for
increasing fatigue and fevers. You were seen by neurosurgery,
and a CT head did NOT show an acute infection from your recent
surgery. You were admitted to the oncology service for further
workup of your symptoms.
CT chest showed changes (ground glass opacities) in your left
upper lobe. There was concern for a lung infection, and you were
started on levoquin. Due to your recent steroid use, there was
concern for an atypical pneumonia (PCP). You had a bronchoscopy
that did not show definitive growth. However, your blood work
was positive for beta glucan, an antigen that is elevated in PCP
___. You were started on IV bactrim and oral prednisone.
You were transitioned to oral bactrim and should continue this
treatment for a total of 21 days (complete on ___. After
you finish this course of bactrim, you will need to remain on
PCP ___. You will discuss this at your Infectious
Disease appointment this week. You were also put on high dose
steroids for your PCP. These need to be tapered down (see below)
according to steroid taper.
During your stay, you were also found to have abnormal
electrolytes. It is believed that your low sodium is due to an
inappropriate production of a diuretic hormone (SIADH) because
of your pneumonia as well as high dose bactrim. You were seen
by Nephrology (Kidney) doctors and were started on a 1L fluid
restriction, salt tabs as well as a medication called tolvaptan
to increase your sodium. We hope that once you stop high dose
bactrim your sodium levels will return closer to normal and you
may be able to stop tolvaptan. You will need close monitoring of
your sodium and have your labs drawn next week. Your kidney
doctors ___ determine if you need to continue on tolvaptan.
You were also found to be lightheaded while you were in the
hospital. You were found to have orthostatic hypotension (your
blood pressure dropped when you stood up). This is likely from
medication as well as being sick. You were started on a
medication called midodrine to help. As your PCP pneumonia
improves and some of the medication you were recently started on
can be stopped, hopefully your dizziness will improve and you
can stop midodrine. Please follow up with your Nephologist and
PCP about needing to continue this medication. If you find your
blood pressure is high (>150/100), you should alert your
physician and discuss stopping midodrine.
Lastly, you were found to have urinary retention during this
hospital visit. It may be from your recently started medications
or from an enlarged prostate. You were shown how to use a
straight catheter to intermittently remove urine from your
bladder. If you continue to have difficulty voiding or have
blood in your urine after you return home, you should follow up
with a urologist.
If you experience confusion, lightheadedness or dizziness you
should call your physician.
You are being discharged home, and should follow up with Dr.
___ disease), Dr. ___, Dr.
___ and pulmonology.
We wish you the best,
The ___ Care Team
STEROID TAPER:
___: 20 mg daily
___: 15 mg daily (take 3 5mg tabs)
___: 12.5 mg daily (take 2 5mg tabs, 1 2.5mg tab)
___: 10 mg daily (take 2 5mg tabs)
___: 7.5 mg daily (take 1 5mg tab, 1 2.5mg tab)
___: 5mg daily (take 1 5mg tab)
___: 2.5 mg daily | Mr. ___ is a ___ male with 40 pack year
smoking history, CAD, PE ___, on Lovenox), metastatic
NSCLC (adenocarcinoma) KRAS/EGFR/ALK mutation negative s/p
Carboplatin/pemetrexed, s/p CK to brain metastases, s/p
chemoradiation to L hilar mass, most recently s/p L frontal mass
resection (radiation necrosis) who presents with fever and SOB
and found to have PCP ___.
# PCP ___: CXR without clear
consolidation,
CT showed ground glass opacities in LUL and inc R hilar LAD.
Radiation Oncologist (Dr. ___ consulted, possible radiation
pneumonitis though atypical picture and would recommend bronch
for optimal cultures. Bronch done by Pulmonary, cultures
negative
including PCP however ___ elevated. ID
consulted and recommends treatment for Bactrim. Fevers have
improved. Gallactomannan serum and bronch negative. Finished 10d
course of Levaquin 750mg on ___. Patient being discharged on
Bactrim 3 DS tablets every 8 hours for ___ course, to be
completed ___ with prednisone taper: 40mg
daily x 6 days, 20mg daily x 11 days, followed by slow taper.
Patient will be followed by ID ___ for initiation of PCP
___.
# Hyponatremia: Likely due to SIADH from pulmonary disease and
bactrim for PCP treatment, as urine osmolality elevated.
Continuously
decreasing Na with fluid challenge. Started on tolvaptan 30mg
daily with sodium improvement. Being discharged home on 1L fluid
restriction, BID salt tabs, and tolvaptan. Patient scheduled
for renal followup ___.
# Orthostatic hypotension: Patient reported feeling dizzy with
standing. Orthostatics positive for significant BP decrease. Pt
had been on fluid restriction, did not respond to fluid bolus so
volume status does not seem to be cause. Adrenal insufficiency
would be treated with patient's prednisone for PCP. Likely due
to
autonomic instability due to illness and chronic deconditioning.
Started on midorine 10mg TID. Evaluated by physical therapy to
be stable to ambulate with ___ need ___ floor bed due
to DOE with stairs.
#Abdominal Pain: Patient reported new abdominal pain in the
___ region. States that he has not had a BM in several
days. Feels constipated. States some improvement with BM this
am.
Has history of abdominal surgeries. KUB showed possible large
bowel obstruction, CT neg for obstruction and clinically pt's
did
not appear to have obstruction. Decreasing pain throughout day
and with BMs.
# Lower Extremity Rash, Resolved: Appears like livedo
reticularis
given ___ purple reticular appearance. Can be associated with
vasculitis and infection. Hepatitis serologies and ___
negative.
# Metastatic NSCLC, adenocarcinoma: ___ CT chest/abd/pelvis
stable (L hilar mass, RML mass, R adrenal nodule). Currently not
on chemotherapy. Gabapentin and oxycontin/oxycodone for pain
control.
# Pulmonary Embolism:Continue Lovenox 80 mg SC BID, dose change
if wt falls below 75kg.
# Gout: Continue allopurinol
==================== | 563 | 401 |
19941011-DS-18 | 22,616,408 | Patient admitted with cachexia, fever and malaise. History of
IVDU. Demanded IV narcotics on floor. Found to be stealing from
other patients on floor. Echo performed with no e/o
endocarditis. Blood cultures negative to date. Patient demanded
to leave AMA. She understood the risks and left shortly
thereafter. | ___ with h/o depression, hep C, and polysubstance abuse who
presents with malaise and fevers, being evaluated for
endocarditis but left AMA.
**Of note, on the day that pt left against medical advice, she
was found in the room of another patient, going through the
other patient's purse. She had stolen a debit card and cash.
When confronted, she denied she stole the items, and claimed
them hers. However, it was confirmed that these items did not
belong to her (as the name on the debit card was not hers), and
they were returned to the owner. The ___ police department
was called, and the patient's whose debit card was stolen
decided not to press charges. She was ushered back to her room,
where she had a sitter, until she decided to leave against
medical advice. It was explained to her that she was being
evaluated for a potentially life-threatening infection, and she
was also explained the risks of leaving without the evaluation
being complete. The patient understood this and relayed the
risks back to the team. | 48 | 179 |
13926282-DS-23 | 27,098,054 | You were admitted for evaluation of your worsening pain /
bloating after meals. You underwent a colonoscopy, which was
unremarkable. You also underwent an MRE, which did not show any
concerning findings. there was no inflammation on biopsy of
your colon. You were followed closely by the GI service, who
made some changes to your bowel medications.
You likely have hypersensitivity causing abdominal discomfort
that we would like to treat with a combination of medications.
You saw GI in the hospital | ___ y/o F with PMHx of anxiety, insomnia, sarcoidosis on MTX,
idiopathic gastroparesis, GERD, and chronic abdominal pain of
unclear etiology, who presented with worsening abdominal pain
and weight loss. GI involved.
# GASTROPARESIS
# ACUTE ON CHRONIC ABDOMINAL PAIN
# WEIGHT LOSS
GI involved. Etiology likely severe IBS, hypersensitivity. She
has many complaints of pain and symptoms that do not seem to
have a physiological explanation. For example, rapidly after
taking benefiber she had severe abdominal pain. She had an exam
when she was speak with her hospitalist and Dr. ___ GI
physician, percussed her abdomen and this caused no pain
whatsoever, but when she was not distracted and the hospitalist
lightly percussed her abdomen it caused severe pain. She seemed
to have benefited with less abdominal cramping from bentyl but
she disliked taking this med and it was stopped.
Per GI recommendations, initially stopped her
gastrointestinally-active meds to see how she feels without
them, as it is currently not clear what is helping or hurting
her. Colonoscopy performed with unremarkable findings. MRE
unrevealing as well. Pt was maintained on a bland diet, and
antacid medications were slowly reintroduced (first Maalox, then
ranitidine). Both will be continued at discharge. She was also
seen by GI staff specializing in Motility disorders, Dr.
___. She has past abnormal gastric emptying study and
Dr. ___ will try to obtain Domperidone. Her EKG qtc was
measured at 480msec.
# ANXIETY / INSOMNIA: Per report, difficult to control, has
responded poorly to antidepressants in the past, has been on
high doses of benzodiazepines and sleep aids for a long time.
Continued on home doses of Zolpidem, Zaleplon, Clonazepam. She
follows with an outpatient psychiatrist. She may benefit from
mindfulness, meditation or other mind-body therapy.
# SARCOIDOSIS: Not currently an active issue. Continued on
methotrexate 20 mg PO ___ and low dose prednisone. | 82 | 321 |
19246661-DS-5 | 23,093,201 | Dear Ms ___,
You were admitted for severe abdominal pain and right shoulder
pain. The pain is likely related to the ablation you received
the day prior to the onset of the symptoms. We scanned your
chest and abdomen and only found changes in your liver which are
EXPECTED changes after an ablation. You were also very
constipated and required an aggressive bowel regimen since you
were requiring a lot of pain medications which slow down your GI
tract. Please continue to stay active, hydrated with water and
you can take the colace and senna to help you have regular bowel
movements. You have scheduled appointment with your primary care
doctor on ___. Be sure to make the scheduled appointments
with Dr. ___ the transplant team. | ___ w/PMHx HCV/ETOH cirrhosis, HCC s/p RFA on ___ presents
with RUQ pain + dyspnea x 2d.
#Abdominal pain: Pain likely related to RFA which took place the
day before onset of symptoms. Imaging showing expected postop
changes in liver and pt with mild worsening of transaminitis.
Post-procedure hepatic capsule distention also likely referring
to R shoulder. Patient w/constipation (last BM over 1wk ago)
which may be contributing to pain. No documented fevers in
transfer note (tmax of 100.1). She did not fulfill SIRS criteria
and did not have a fever while on the medical floor. Her blood
and urine cultures were no growth to date.
Overnight, patient did not require IV opiates and controlled
with oral oxycodone. Patient passed bowel movements before
discharge which was the first in a week as per patient's
history. She was given senna and colace on discharge in addition
to PO oxycodone. She will has scheduled ___ with PCP and
will need to continue close ___ with transplant team and
primary hepatologist Dr. ___.
#Hypoxia, pleuritic chest pain: PE and MI not likely causing
pleuritic chest discomfort given negative CTA and enzymes/EKG.
Pt does have R sided pleural effusion which is likely related to
RFA. At this point, R sided pleural effusion and RUQ abd pain
likely contributing to symptoms. Blood cultures were no growth
to date and patient had no documented fevers while at ___. She
was ordered to have incentive spirometry as pt with likely
atelectasis. Her O2 saturations improved and at time of
discharge, she was was 96% on room air at time of discharge.
#Anemia, pancytopenia: Patient with 8pt hct drop since ___, now
hct of 34.7, normocytic. Patient given IVF at OSH and may be
dilutional. No bleeding noted in RFA op report. ___ have acute
suppression of bone marrow secondary to inflammation from
procedure. Subcapsular hematoma s/p RFA not seen on prelim
report of imaging. Patient was consented for blood products
preemptively but did not require transfusions. Hct at time of
discharge increased to 35.7.
#HCV/EtOH CIRRHOSIS: HCV treated ___ yrs ago with IFN, stopped as
pt developed diffuse rash. Without history of decompensation.
Renal function remains at baseline (baseline Cr 0.7). No
coagulopathy. Establishing care with transplant team currently.
#VARICES: Last EGD ___ showed small (grade 1) varices at the
lower third of the esophagus. Not on nadolol.
#HCC: ___ MRI: 2.6 x 3.0 cm arterial enhancing lesion
with washout is compatible with hepatocellular carcinoma within
hepatic segment 7. ___ had US/CT-guided RF ablation of segment
7 HCC, cluster probe, 3 overlapping ablations.
Patient will need ___ MRI in approximately four weeks.
# Chronic lower back pain: Has history of chronic pain related
to back surgeries including laminectomy. Continued Lidoderm
patch daily. | 126 | 447 |
11132535-DS-17 | 23,054,916 | Instructions: Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had shortness of breath and chest tightness.
====================================
What happened at the hospital?
====================================
-You were found to have an exacerbation of your heart failure.
You had too much salt and water built up in your body which
caused breathing symptoms. We also saw in your blood work that
your kidneys were injured by the heart failure exacerbation.
-We gave you IV medications that got rid of the extra salt and
water. Your kidney function and breathing normalized.
-Unfortunately you developed a pneumonia while here, in the
right lower lobe lung. You improved quickly with antibiotics.
You will need to take the antibiotic for 7 more days.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Take Augmentin for 7 more days, then stop, to finish treatment
of the pneumonia.
-Take your home torsemide medication as you were already
directed to do, prior to this hospital stay. There were no
changes made to your existing medication except to STOP taking
spironolactone until instructed otherwise (because your blood
pressure was normal without taking this, and if you took it now
it can make your blood pressure too low).
-Your new dry weight is 93.71 kg (206.6 lb) upon discharge
today.
-Weigh yourself every morning, call your cardiologist's office
immediately if you notice any weight that goes up more than 3
lbs from a prior value.
-You must absolutely adhere to use of your BiPAP machine at
night. On day of discharge today, you did not have any falling
asleep episodes because you used it all of last night correctly.
This got rid of any carbon dioxide build up that can happen with
your sleep apnea.
Pay attention to your symptoms. If you experience any of the
following, it could mean more build up in your carbon dioxide
levels that could be dangerous, you would need to call your PCP
office to ask to be triaged. And you need to call ___ ESPECIALLY
if you experience lethargy or confusion at any time.
___ sleep
___ up choking or gasping
___ headaches, dry mouth, or sore throat
___ up often to urinate
___ up feeling unrested or groggy
___ thinking clearly or remembering things or
confusion
Some people with sleep apnea don't have symptoms, or they don't
know they have them. They might figure that it's normal to be
tired or to snore a lot.
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team | ___ year old female with history of chronic hypoxic respiratory
failure/COPD on 2L NC, atrial fibrillation on apixaban, chronic
diastolic heart failure with pulmonary HTN/RV dysfunction,
recurrent DVTs, OSA on CPAP, NIDDM2 with neuropathy, gout, HTN
who presented with lethargy and found to have acute CHF
exacerbation.
# Lethargy, metabolic encephalopathy (resolved)
Concern in ER for overuse of oxycodone, but no significant
improvement with naloxone. VBG was without significant
hypercarbia.
Mental status since arrival to floor is full (oriented x3,
recites days of week backwards), she is only fatigued. She says
this has occurred
related to CHF exacerbations before.
-However, on ___ she was transiently confused with nonfocal
neurologic exam. Question if related to ___ chronic hypercarbia
and exacerbated by the new aspiration PNA. The confusion
resolved entirely by the afternoon that day.
-COntinue home oxycodone
-On day of discharge, the patient was the most alert and awake
and interactive I have ever seen ___ during this hospital stay.
This is likely from the patient being fully compliant with BiPAP
the evening prior. I have called the patient's daughter ___
after the patient gave permission and gave ___ update with
request for ___ to convince ___ mother to be compliant with all
___ meds and BiPAP at home.
# Chronic hypercarbic respiratory failure
# Pulmonary hypertension
# Acute on chronic diastolic CHF (resolved)
# Cardiorenal syndrome, ___ (resolved)
Weight was 101 kg on admit. Cr elevated on admission (1.6)
from
normal baseline (0.9) and mildly more hypoxic than normal, with
dyspnea. CXR was without clear overload, though known history of
pulmonary hypertension & RV dysfunction. She had held torsemide
for past few days prior to admit, due to nausea/vomiting in last
few days, and
also received IV saline for the self limiting viral
gastroenteritis on ___ and ___
in the ED. Altogether, she had acute CHF exacerbation as a
result.
- Completed IV diuresis on ___. Renal function normalized.
Resumed home torsemide. ___ dry weight is 93.71 kg (206.6 lb)
upon discharge today. She had diuresed about 18 pounds since
admission.
- Held off on repeat TTE, most recent was ___
#Pneumonia
-Developed shaking chills with CXR showing RLL pneumonia on
___ morning. Got IV unasyn and felt much better. Discharged
with 7 days of augmentin
#OSA on CPAP
-COntinue home BiPAP qhs
# Gout
Notes recent exacerbation in bilateral ___ & ___ DIPs. On exam,
slight erythema but no warmth, pain or tophi.
- No evidence of cellulitis in either foot on exam
- Continue colchicine
- Continue home allopurinol
# Depression
- Continue sertraline & bupropion
# Chronic low back pain
- Continue oxycodone, though with caution
# Paroxysmal atrial fibrillation
- Continue metoprolol succinate & apixaban
# Hyperlipidemia
- Continue atorvastatin
# Type II diabetes mellitus with neuropathy
Stopped insulin at home (by self) prior to past admissions, in
early ___ & is off therapy for diabetes. A1C 7.1% during most
recent admission.
Greater than 30 minutes was spent on discharge planning and
coordination. | 415 | 448 |
18758871-DS-5 | 21,041,294 | Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE HEMORRHAGIC STROKE, a condition where a
blood vessel providing oxygen and nutrients breaks and bleeds
into the brain. The brain is the part of your body that controls
and directs all the other parts of your body, so damage to the
brain from being deprived of its blood supply can result in a
variety of symptoms.
Hemorrhagic strokes can have many different causes, so we
assessed you for medical conditions that might raise your risk
of having stroke. In order to prevent future strokes, we plan to
modify those risk factors. Your risk factors are:
- Diabetes
- Hypertension
We will look for other causes once we can get an MRI (after the
shrapnel is removed from your hand). Other possible causes
include: a vascular malformation, stroke caused by a clot that
then bleeds, a condition called "cerebral amyloid" that happens
as we age and weakens blood vessels, or possibly a mass or
infection of some kind. We will be able to see these after the
blood is cleared away (~6 weeks) and once we are able to get an
MRI.
We are changing your medications as follows:
- STOP metoprolol.
- STOP hydrochlorothiazide.
- HOLD aspirin for now, until you see Dr. ___.
- HOLD atorvastatin for now, until you see Dr. ___.
- START carvedilol (Coreg) 6.25mg TWICE PER DAY. This will
replace your metoprolol.
- START amlodipine 10mg ONCE PER DAY. This is another medication
to lower your blood pressure.
- INCREASE lisinopril to 40mg DAILY.
- START cyclobenzaprine (Flexeril) up to THREE TIMES PER DAY AS
NEEDED for neck muscle stiffness and pain.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ old right-handed man with a past
medical history of HTN, hyperlipidemia and DMII on an insulin
pump who presented with confusion, acute onset face, arm and leg
weakness and fall, found to have a right frontal IPH with mild
surrounding edema.
#Neuro: Monitored in ICU with SBP goal <150, for which he
required uptitration of home medication (See #Cardiology). Exam
improved from L-sided plegia to weak withdrawal antigravity in
LUE and LLE with noxious stimuli. Hypertonic fluids were not
indicated. CTA was without vascular abnormality. Possible
etiologies include unvisualized vascular abonormality,
mass/tumor, hypertensive bleed, or amyloid. MRI brain W/WO
contrast was postponed due to shrapnel in left ring finger.
Radiology did not clear him for MRI. An appointment was made for
evaluation with hand surgery on ___ to remove this foreign
body. He was ordered for MRI in 6 weeks. Other stroke risk
factors: A1c 6.6%, LDL 66.
- Goal SBP <150. Continue antihypertensives as below.
- Follow-up at orthopedics/hand surgery at ___ ___
floor) on ___ to remove shrapnel in left hand so you
can get MRI on ___.
- MRI ordered to be completed at about 6 weeks following stroke
(___) and at before your appointment with stroke
neurology (Dr. ___ on ___. Call ___ (#1)
to schedule MRI at ___.
- STOP aspirin and atorvastatin for now, until follow-up with
Dr. ___.
# Cardiology: Goal SBP <150, for which he was restarted on home
lisinopril and uptitrated to 40mg DAILY. His home metoprolol XL
25mg was switched to carvedilol 6.25mg BID. Amlodipine 10mg was
also added.
- SBP goal <150.
- CONTINUE carvedilol 6.25 BID
- CONTINUE lisinopril 40mg BID (home 20mg)
- CONTINUE amlodipine 10mg DAILY
# Respiratory: OSA, for which he was non-compliant on CPAP.
- Continue CPAP
# GI: He passed bedside swallow, but occasionally noted to have
some difficultly swallowing pills, so formal SLP evaluation was
done and cleared him for pureed (dysphagia) diet with nectar
prethickened liquids, 1:1 supervison, meds crushed in
applesauce.
# Endocrine: IDDM, for which he was started on Lantus and RISS
per ___. At home, he is on an insulin pump; A1c 6.6%. ___
recommended staying off insulin pump for now, as his plegia
precludes him from operating the device safely.
- Insulin sliding scale per included instructions.
- If you need to schedule this patient for a follow up at the
___, please contact ___
Appointment ___ or email
___ for immediate
response. Please state that the patient is discharged from the
___. Urgent appointment for those new or discharged on insulin
for first time can be scheduled to occur within ___ days and
other appointments are within ___ weeks.
# Neck pain:
- Cyclobenzeprine 5mg TID
========================================
___ Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No | 390 | 536 |
15189906-DS-6 | 22,714,916 | Mr. ___-
You were admitted after a fall at home. Initially you had pain
that limited your mobility, and you worked with our physical
therapists. After two sessions you improved enough that you were
cleared for home.
You will have follow-up with your ophthalmologist tomorrow. | ___ with CAD/CABG, AF, glaucoma, R cataract surgery on ___ off
warfarin presents with mechanical fall and difficulty ambulating
Fall: Mechanical related to poor lighting and his recent eye
surgery. He had extensive CT imaging which was negative. In the
Emergency department he was evaluated by ___ but he was not
cleared for home. On repeat evaluation, his back pain (secondary
to the fall) was improved and he was able to work with ___ again.
He was cleared to return home.
Right lumbar back pain: No clear fracture on imaging - He was
treated with tylenol and low dose oxycodone for breakthrough.
ARF: On admission his creatinine was 1.5, with a baseline of
___. He was hydrated with IVF and his creatinine was 0.9 at
discharge.
Cataracts s/p surgery: Surgery was on ___, which he tolerated
well. He was continued on all eye drops as before. He was
re-established with an ophtho appointment for ___.
AFib: Continued Metoprolol. Resumed outpatient medications on
discharge.
CAD/CABG: Continued home regimen of aspirin, BB, and statin. | 44 | 171 |
17028437-DS-25 | 20,767,201 | Dear Ms. ___,
It was a pleasure to care for you at ___. You were admitted
for recurrent abdominal pain which was previously attributed to
urinary tract infection. You did not have any bacteria in your
urine or anything to suggest you have a urinary tract infection
right now. A CT scan of your abdomen shows chronic inflammation
of the bladder, unchanged from your last admission. While
inpatient, your pain was well controlled on Tylenol. We suggest
following up with a urologist, a specialist in medical issues
regarding the bladder.
___ were also evaluated for a cough during this hospitalization.
At first we were concerned for food going into your lungs but
evaluation by a Speech pathologist who felt that you were
swallowing safely. A CT scan did not show infection or
inflammation of the lungs. We recommend continuing to take your
inhalers as prescribed.
Please continue to take all medications as prescribed and follow
up as scheduled with your doctors. ___ you experience worsening
of symptoms, inability to urinate, stabbing back pain, fever or
chills do not hesitate to call your doctor.
Wishing you the best of health moving forward,
Your ___ team | Ms. ___ is a ___ year old lady with history of dementia, DM2,
HTN, OSA (on nocturnal O2), several recent admissions for
abdominal pain(last discharged ___, ___ for abdominal
pain, found to have chronic cystitis on CT with ___
pyuria. She had recently been treated for UTI with 3days of
ceftriaxone as well as a course of nitrofurantoin. Her urine
culture was negative this admission and her suprapubic pain was
well controlled on acetaminophen and bowel regimen. She had
intermittent cough inpatient concerning for aspiration but was
evaluated by speech and swallow who felt she could safely
tolerate a regular diet. CT chest unrevealing of infiltrate or
pneumonitis, with incidental discovery of a thyroid nodule and
several small pulmonary nodules. Thyroid function tests were
within normal limits. Home ___ was recommended and was set up
prior to discharge.
# Abdominal Pain/Chronic Cystitis: Regarding history of
abdominal pain, during prior admissions prior to ___,
her abdominal pain was thought to be in the setting of her
urinary tract infections. She was admitted twice in ___ for abdominal pain.Of note, urine culture from previous
admission was contaminated with epithelial cells and she still
received adequate treatment with ceftriaxone and then a course
of macrobid. On prior admission, her CTA showed evidence of
atherosclerotic disease so amlodipine was decreased from 10 mg
to 5 mg to prevent transient hypotension that could exacerbate a
component of mesenteric ischemia. On presentation, patient with
continued cystitis on CT and pyuria. Patient endorses frequency
but no dysuria. Given improved pain, recently completed course
of antibiotics, no fever, or leukocytosis, no antibiotics were
administered outside of 1 dose of ceftriaxone in ED. Urine
culture returned negative for infection. Suspected to also be a
component of constipation. Pain improved with tylenol and proper
bowel regimen. Patient was suggested to follow up with urology
given chronic inflammatory changes around bladder on CT
Abd/Pelvis
#Cough: Patient with intermittent, ___ cough,
allegedly of several months. No fever/leukocytosis/hypoxia.
Persistent retrocardiac opacity on CXR was further evaluated
with CT chest with redemonstration of prior bilateral lower lobe
atelectasis seen on CT A/P. There was not evidence of
pneumonitis or infection on CT chest. Patient was evaluated with
bedside swallow and suggested for regular diet with thin
liquids. Patient and son were instructed on use of Albuterol MDI
with spacer to help alleviate symptoms of her cough and
hopefully prevent potential abdominal rectus strain.
#Diarrhea: One day of C.difficile negative loose stool which
resolved. | 192 | 408 |
10838334-DS-23 | 24,307,114 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you had bloody bowel
movements.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While in the hospital, you had more bloody bowel movements.
- You were briefly in the ICU and received blood transfusions.
- A colonoscopy was performed, which was normal.
- You most likely bled because of diverticulosis (outpouches in
your intestine), which has now resolved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-We recommend you continue eating a high fiber diet and staying
hydrated.
-If you develop bloody bowel movements again, please come back
to the emergency room.
We wish you the best!
Sincerely,
Your ___ Team | BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ male with past medical history of
diverticulitis, internal hemorrhoids, CAD, HTN, BPH s/p TURP,
and hyperlipidemia who presented with bright red blood
per rectum and transient hypotension. He was briefly monitored
in the MICU and received 2u pRBCs during hospital stay. CTA
showed no active extravasation and extensive pancolonic
diverticulosis. Colonoscopy was normal. The bleeding was
suspected to be from resolved diverticular bleed. He was
discharged in stable condition with close outpatient follow-up.
TRANSITIONAL ISSUES
===================
[] Outpt cardiac monitoring for burden of flutter/fib
[] Continue risk/benefit discussions re: anticoagulation for
AFib
[] Repeat CBC as outpatient at PCP follow up in 1 week
(___). Discharge Hgb was 8.5.
ACUTE ISSUES
============
#Acute blood loss anemia
#Syncope
#Lower GI bleed
Presented with large volume BRBPR and presyncope, although he
remained hemodynamically stable. CTA was without active
extravasation. He received 2U PRBCs, and was monitored in the
MICU after bleeding stopped where his vitals remained stable.
Colonoscopy showed moderate non-bleeding diverticula, which were
thought to be the source of bleeding. Discharge Hgb was 8.5.
#pAF
#?CAD
Intermittent A fib/flutter while on tele in the ED. He does have
a documented history of CAD but has not followed with cardiology
recently. CHADSVASc2 = ___, would benefit from anticoagulation
but likely needs outpt monitoring to determine burden or whether
this was just triggered in the setting of acute illness. ASA
81mg was stopped given increased bleeding risk and minimal
effect on stroke reduction with AFib.
#Asymptomatic pyuria
s/p cipro in the ED, urine culture was contaminated. He was
asymptomatic and did not receive antibiotics.
#HTN - Held home lisinopril in setting of active bleed.
#HLD - Continued atorvastatin
# CODE: Full confirmed
# CONTACT: ___ (wife) ___ | 148 | 278 |
16865976-DS-6 | 28,141,622 | Dear Mr. ___,
You were admitted to the ___ after having an episode of
syncope, or fainting. You underwent various tests which showed
that you likely had a "vasovagal episode." A vasovagal episode
may occur if you stand up too quickly; it can also happen if you
strain too hard during a bowel movement or during urination.
Please avoid standing too quickly. Additionally, please
continue taking the medications prescribed to help prevent
constipation.
You were also found to have an abnormality in the aorta. It
remained stable and has likely been present for a long time. It
is important to keep your blood pressure and heart rate under
control to prevent any complications.
Finally, we strongly encourage you to continue safe practices at
home, including using a walker and working with physical therapy
to improve your balance and mobility.
It was a pleasure taking part in your care,
Your ___ Medicine Team | ___ y/o male with PMHx of psoriatic arthritis p/w syncopal event
in setting of straining to have a bowel movement, noted to have
C2 spine fracture, unclear chronicity, and aortic hematoma
incidentally noted on OSH imaging, admitted to ICU for frequent
BP monitoring with goal SBP <120 and further imaging for C-spine
fracture. His ICU course was uneventful save for transisent
hypotension to sys 80's with resolved with holding home anti-HTN
medications and 1 L IVF. He was transferred to floor once blood
pressure consistently controlled.
# Syncope. Strongly suspected vagal event in setting of
straining to have a bowel movement given HRs 40-50s on EMS
arrival. HRs normalized to 70-80's on ICU. EKG showed afib which
was chronic per records with out any rapid ventricular rate
during course. Pt's EKG also with RBBB and LAFB so increased
susceptibility to vasovagal syncope. Pt monitored without issues
in MICU. However, given lack of prodrome before syncopal event,
and patient's longstanding HTN and atrial fibrillation, stroke
workup with carotids, ECHO and lipid panel was done. Echo was
grossly normal with preserved EF >55%
# Hypotension: Though secondary to hypovolemia on admission.
Patient's BP improved to systolic 110's from systolic 80's after
1 L IVF in MICU. His home carvedilol, Lasix, spironolactone and
lisinopril was held.
# C2 fracture, age indeterminate: Noted on OSH CT C-spine
imaging, unclear chronicity of fracture. Evaluated by
ortho-spine in the ED. C-spine not yet cleared. No neurologic
deficits on exam or increased pain. MRI spine performed which
suggested no acute process. C-collar was removed.
# Aortic hematoma: Incidentally noted on OSH CTA. Mild high
density thickening of lateral and posterior descending aorta
suspicious for intramural hemorrhage/hematoma without evidence
of rupture or dissection. Evaluated by vascular surgery in the
ED, and felt not to be candidate for immediate intervention.
Blood pressure goal was <110 in ICU. Patient's blood pressures
remained very labile throughout stay and at discharge, patient
was not continued on home spironolactone, furosemide, or
lisinopril.
# Leukocytosis. Pt with slight leukocytosis but no clinical
picture to suggest infection (felt to be ___ stress
demargination). Labs were followed and chest x-ray was
reassuring.
# Atrial Fibrillation. Previously on Coumadin but discontinued
some years back per patient preferences, now rate controlled. We
held hold carvedilol in setting of hypotension above initially.
# diastolic CHF. Given hypotension above home lisinopril, coreg,
spironolactone, lasix was held on ___.
# GERD. We continued home omeprazole.
# COPD. Continued home medications.
# DM2. Placed on ISS with no issues.
# Prophylaxis: Pt placed on subcutaneous heparin for DVT
prophylaxis.
TRANSITIONAL ISSUES
===================
-aortic hematoma incidentally noted on scan; please work on
blood pressure and heart rate control to prevent complications;
started on statin, continued on carvedilol to help reduce risk
-patient up to 140s SBP and HR >130s with exertion; may need
further uptitration of beta blocker to reduce risk of
complication from aortic hematoma
-held lisinopril, Lasix, spironolactone in setting of low BPs
and orthostatics; LVEF appears improved on recent TTE to >55%;
can restart medications as indicated
-patient with anemia; no clinical e/o bleed; consider further
workup keeping in mind patient's advanced age | 154 | 514 |
15904250-DS-14 | 24,380,917 | Ms. ___,
It was a pleasure taking care of you during your recent
hospitalization. You were admitted with chest pain and there was
concern you had a heart attack. You were transferred to ___
___ and we did a heart catherization that showed no new
blockages. You may have had a very very small heart attack but
nothing large. Your echocardiogram was repeated and showed your
heart is not functioning any worse than before, though as you
know you do have heart failure and it has not been functioning
normally for quite some time.
We also noticed some redness on your legs and we started an
antibiotic in case you possibly had a skin infection. I know
this redness you noted before because of your vein graft. We
will send you home with 2 more days of an antibiotic called
bactrim.
It is important you follow up with your PCP and your
cardiologist. You should have your kidney function checked in
___ days, later this week, and Dr. ___ she ___ follow up
on those labs and then you will see both her and Dr. ___
___ week.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ woman with hx of AV block s/p PPM, CAD s/p CABG
___, PCI in ___, HTN who presents with NSTEMI, currently s/p
catheterization that did not show new occlusive disease. | 198 | 31 |
16129427-DS-6 | 27,790,760 | -You should continue taking the antibiotics as prescribed, until
your prescription is complete.
-You should continue to frequently flex and extend your right
fingers and thumb to prevent stiffness. Your wound can be left
open to air or you may apply clean, dry dressing daily if the
wound is draining.
-Elevate your right arm above the level of your heart as much as
possible.
-You may shower and let warm, soapy water run over your hand
wound. Dry thoroughly and apply dry dressing to wound if
needed.
-No swimming or soaking in tub until wound has closed.
-Wear a glove when engaging in activities that could contaminate
your wound (such as diaper changes).
-If your hand wound begins to worsen after discharge home with
an acute increase in swelling or pain, please call the hand
clinic and report this (___).
.
Medications:
* Resume your regular medications unless instructed otherwise.
* 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.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication to prevent constipation. You may
use a different over-the-counter stool softener if you wish.
* 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.
.
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 wound, chest pain, shortness of breath, or
anything else that is troubling you. | The patient presented to the ED on ___ with signs of right
thumb cellulitis after a dog bite. She was admitted to the
plastic surgery service for IV antibiotics, pain control, and
observation.
.
Neuro: The patient's pain was well controlled with PO Tylenol
and Ibuprofen, and she did not require PO or IV opiods
throughout the admission.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient tolerated a regular diet and had no issues
voiding.
.
ID: The patient was given IV Unasyn in the ED and after
admission. She remained afebrile with all vital signs stable
throught the admission.
.
Prophylaxis: The patient did not require systemic
anticoagulation as she was able to ambulate without assistance
and encouraged to do so frequently.
.
At the time of discharge on HD#2, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. She was discharged home with instructions for
followup and wound care, and all of her questions were answered
prior to discharge. | 304 | 197 |
19761356-DS-18 | 21,898,274 | Call the Acute Care Surgery clinic or return to the Emergency
Department if you have:
- worsening abdominal pain not relieved by medication
- persistent nausea or vomiting
- inability to eat or drink
- inability to pass flatus or have a BM
- fever greater than 101
- any other symptoms that are concerning to you
You will need to see a Gastroenterologist after your acute
infection resolves. This can be arranged through a referral
from you PCP, ___.
Your blood pressure was extremely high while you were admitted
to the hospital. We resumed all of you home medications but
also had to start Hydrochlorothiazide 25mg daily to help control
your blood pressure better. You should follow up with your PCP
to have your blood pressure checked. | Mr. ___ was transferred from ___ with abdominal
pain and a CT scan (without PO contrast) that showed dilated
small bowel and questionable extraluminal air. Since he was
stable, a repeat CT scan with PO contrast was done to better
evaluate his bowel. This repeat CT scan showed long segment
ileitis and no free air.
The patient was admitted to the floor with an NGT. He was kept
NPO with IVF. On the morning of HD2, his NGT (which had low
output) was discontinued secondary to discomfort. He was
transitioned to clear liquids and had decreased pain and
tenderness on exam. He had regular flatus and BMs.
On HD 3, he tolerated a regular diet. He was voiding and
ambulating independently. His pain had resolved, and he was
non-tender on exam.
Of note, the patient had consistently high blood pressures up to
200 systolic and 100 diastolic during his hospital stay. He has
a history of poorly treated HTN. While NPO, he received IV
hydralazine as needed for blood pressure control. All of his
home blood pressure medications were resumed, and 25 mg of
hydrochlorothiazide daily was added for better blood pressure
control. The patient was encouraged to follow up with his PCP
for continued blood pressure management and with a GI doctor for
work-up of his ileitis. | 123 | 227 |
16643075-DS-27 | 24,820,211 | It was our pleasure to care for you at ___. You were admitted
for a skin infection on your belly. We also found that you had
a bladder infection. We treated these infections with IV
antibiotics which will be continued at rehab. You were provided
a long-term IV line to allow IV antibiotics to be given.
We made the following changes to your medications:
- INCREASE furosemide to 40mg daily until you see Dr. ___
- RESTART aspirin
- START miconazole powder for rash
- START vancomycin IV until ___
- START morphine to be taken every 6 hours as needed for pain | ___ male with morbid obesity here with with right sided abdominal
pannus cellulitis.
# Right flank cellulitis: Patient with cellulitis of pannus.
There is no crepitus or fluctuance and the perineum is without
signs of cellulitis on exam, CT scan and ultrasound. Patient
without systemic symptoms of infection including fever,
tachycardia, leukocytosis. Surgery evaluated patient in
emergency department and have low concern for necrotizing
fasciitis and they followed the patient on the floor. Patient
was started on IV vancomycin and ceftriaxone and after 24 hours
the erythematous border receded. Patient was then switched to
PO bactrim and dicloxacillin, however given concern for
absorption IV antibiotics were restarted on ___ (vancomycin and
Unasyn). The erythema and swelling continued to slowly improve.
PICC was placed ___ to allow long-term antibiotic therapy. The
Infectious Disease team was consulted to aid in antibiotic
selection and duration of therapy. On their advice, Unasyn was
discontinued ___. Vancomycin therapy will continue for another
14 days from ___, until ___. They believe that the dependent
regions of the pannus will be reached by antibiotic therapy, but
agree with continued monitoring.
# Pain: Thought to be due to cellulitis. We initially started
patient on his home standing tylenol and tramadol and then
switched him to PO oxycodone. When this did not work, we
switched to IV morphine and then to PO as the patient tolerated
PO intake. Continued to complain of poorly-controlled leg pain
above knee, no evidence of spreading infection. This may be due
to radiculopathy from lumbar spine, to be investigated as
outpatient given chronic presentation.
# Lower extremity edema, worse per PCP ___. Likely fluid
overload, ___ is negative. We increased Lasix to 40mg PO qd
throughout the stay.
# Bacteriuria/pyuria: Despite no dysuria, E coli grew from
urine. Patient did complain of increased urinary frequency which
he attributed to Lasix. The antibiotics used for cellulitis
would cover this infection as well.
# A fib: Rate-controlled with metoprolol. CHADS score 1 for
hypertenision, off coumadin. We continued metoprolol tartrate
100mg BID while inpatient in place of home succinate, switched
back on discharge.
# Metabolic alkalosis: Continued mild alkalosis, likely ___
diuresis.
# Constipation: No BM for several days, resolved ___.
# HTN: Remained normotensive. We continued home Lasix,
metoprolol as above.
# GERD: Continued home omeprazole.
# OSA: Previous diagnosis, home CPAP broke so he has not been
using it.
# Transitional:
- consider renewing CPAP for OSA
- Nutrition consultation
- consider investigation of possible lumbar radiculopathy if
left leg pain continues after resolution of infection | 100 | 440 |
14761733-DS-19 | 20,963,171 | It was a plseaure taking care of you while you were in the
hospital. You were admitted for evaluation of your shortness of
breath and found to be in an abnormal heart rythym called atrial
fibrillation which caused fluid to accumulate in your lungs.
You were started on a medication called diltiazem to control
your heart rate. You were also treated for a urinary tract
infection and will need to continue to take antibiotics for the
next few days. Our occupational therapists felt that you
benefit from some time at a rehab hospital. | ASSESSMENT & PLAN: ___ yo with alzheimers dementia who presented
with acute onset shortness of breath and found to have afib with
RVR. Patient was rate controlled with diltiazem and also
treated for a UTI with resolution of her symptoms.
.
# Atrial Fibillation with RVR: Patient was found to be in atrial
fibrilation with a ventricualr rate to 140s and evidence of
pulmonary edema on chest xray. Prior to transfer to ___ the
patient was attempted at rate control with metoprolol without
effect and was transfered on diltizaem. He was continued on
diltiazem while inpatient and had her dose titrated to a
dominant heart rate of 60 to 80 BPMs. This was achieved using a
daily dose of 240 mg and she was converted to long acting
formulation of 240 mg with sustained effect. Patient had a
CHADS2 score of 3 (given unclear history of a past TIA), but the
decision to anticoagulate was deffered to the outpatient setting
given the unknown duration of afib and her history of frequent
falls at home. She was discharged on aspirin 81 mg daily. A
cardiology follow up appointment was scheduled for the patient
prior to discharge to rehab.
.
# ACUTE DIASTOLIC HEART FAILURE: Patient was noted to have
pulmonary edema on chest xray causing hypoxia which was felt
secondary to rapid ventricular rate and poor diastolic filling
and therefore no indication for ace inhibitors. The patient was
rate controlled as above and diuresed to a presumed dry weight
of 114.5 lbs. She was able to ambulate with out desaturations
at the time of discharge. Interval chest xray showed
improvement in pulmonary edema without complete resolution of
her pleural effusions. Repeat CXR is advised in ___ weeks to
assess for interval change. It was decided not to perform a
thoracentesis inpatient as the patient had some degree of acute
on chronic encephalopathy from dementia.
.
# Hypoxia: Was felt secondary to acute congestive heart failure.
Improved with diuresis and rate control. Patient able to
ambulate on room air at the time of discharge.
.
#UTI: patient was found to have a positive UA and negative
Urine culture though may have had antibiotic exposure prior to
collection of urine culture. Initially complained of urinary
frequency and was treated with ceftriaxone and converted to PO
bactrim 1 tab DS to complete a 5 day course scheduled to end on
___.
.
#DEMENTIA: patient with established cognative impairment
related to her dementia, daughter raised concerns for patient's
safety at home as now appears to be requiring 24 hour care. Her
mental status was stable while inpatient though occasionally
aggitated responding to redirection. A cognative neurology
appointment was scheduled for the patient for further
evaluation.
. | 97 | 460 |
12777122-DS-4 | 21,527,816 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
- You initially came to the hospital because of elevated glucose
levels.
What happened during your hospitalization?
- You were treated in the ICU for your high glucose levels which
improved with insulin.
- Images of your chest and abdomen, as well as tests of your
urine and blood did not show any signs of infection.
- You were seen by diabetes specialists who helped determine
your insulin doses.
- You were seen by psychiatry specialists who recommended you
follow up as an outpatient.
What should you do when you leave the hospital?
- Continue to take all of your medications as prescribed
- Follow-up with your primary care physician within one week
- Please keep all of your other scheduled health care
appointments
Sincerely,
Your ___ Care Team | ___ with PMH of T1DM and chronic abdominal pain recently who
now presented with nausea and vomiting, found to have an anion
gap concerning for DKA. Patient was transferred to the MICU and
received insulin with resolution of anion gap. Infectious workup
was negative. ___ have been caused by difficulty accessing food
and medications at home. She is suspected to have gastroparesis
and is being referred to GI.
ACTIVE ISSUES:
==============
#Diabetic ketoacidosis
Patient presented in DKA in the setting of noncompliance with
insulin with possible contribution from recent nausea/vomiting.
Infectious work up in the MICU was unremarkable. She was treated
with IV fluids and a insulin drip. Her A1C was 12.3%. Per ___
clinic recommendations, the patient was transitioned to 18U
Lantus qAM, Humalog 3 units qAC, and a sliding scale. Social
work consulted and gave patient information about home delivery
of medications.
[] Arrange medication home delivery
[] ___ Diabetes follow-up requested
#Nausea/vomiting
#Acute on chronic abdominal pain
Patient presented with acute on chronic abdominal pain and
inability to maintain PO intake with no new travel or sick
contacts. LFTs and lipase normal and abdominal exam was benign.
Likely secondary to gastroparesis, as patient improved with use
of Reglan. Alternatively, the patient states she saw worms in
her stool and was concerned she could have a parasite although
she has never left the ___. Stool O&P sent and pending
at time of discharge. She was transitioned to PO diet as
tolerated and outpatient evaluation with GI for possible
gastroporesis was arranged.
[] Outpatient GI followup for gastroparesis workup. Patient
given script for Reglan to bridge her to this appointment
[] Follow up stool O&P
# Potential personality disorder
Per report, patient has a diagnosis of psychiatric disorder that
may be oppositional defiant disorder. According to ___ records,
patient not followed by psychiatry but has history of requiring
Haldol and Ativan for chemical restraint during one ED visit.
She states she previously saw a counselor but is not currently
interested in one. During current admission, patient endorsed
poor medication compliance out of fear of going to the pharmacy
and bad prior experiences with the healthcare system. Patient
was evaluated by psychiatry who felt she has chronic PTSD and
nonspecific neurocognitive disorder. They recommended outpatient
follow up, but she declined seeing behavioral health at this
time. Given resources for follow up.
[] If patient is amenable to Behavioral Health counseling,
please consider referring to:
___ ___ at ___ floor, ___ Suite
___
Phone: ___
___
___ for Mind Body Medicine at ___ Floor
___
Phone: ___
Fax: ___
# Iron deficiency anemia
Patient with Hgb 9.7 on ___, previously 12.4 on admission on
___. Labs consistent with microcytic anemia, likely iron
deficiency anemia. No obvious source of bleeding. She was
treated with ferrous gluconate 125mg IV for 2 days.
[] Recheck iron studies and CBC as outpatient
# Hypokalemia
Intermittently requiring potassium repletion. Resolved.
# Dental disease
Patient lost tooth during hospitalization. No evidence of active
infection.
[] Refer to Dental | 138 | 485 |
16409774-DS-3 | 27,782,830 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted for
evaluation and treatment for shortness of breath in the setting
of dilated congestive heart failure and superimposed pneumonia.
You underwent CXR and CT scan, both indicated signs concerning
for pneumonia. You were started on antibiotics on your HOD#1.
Your blood and urine cultures came back negative, and a workup
for atypical pneumonia was negative. You completed a course of
7 days of antibiotic treatment in the hospital. You were also
given diuretics to help with the pulmonary edema, which was
causing your respiratory distress. You underwent renal
ultrasound and CT scan, which showed proximal stenosis of at the
junction of the renal artery and iliac artery. The stenosis
resolved after CO2 angiography and balloon angioplasty. You
will be discharged with torsamide and will need to return to get
your blood drawn so we can monitor your creatinine level. You
will be followed closely by renal transplant, who will monitor
your kidney's function and decide whether to perform a renal
biopsy. We wish you well.
Best Regards,
Your ___ Medicine Team | Mr. ___ is ___ with ESRD s/p renal transplant ___, CAD s/p
CABG ___, afib, PVD who presented ___ worsening SOB for four
days.
# SOB secondary to CHF: Patient had pulmonary edema likely due
to dilated CHF in the setting of CKD, complicated by pneumonia.
Patient was put on IV Lasix (IV 80mg), supplement O2, and fluid
restriction (<1L). CXR and CT scan confirmed findings
concerning for pneumonia. Patient was started on empiric
vancomycin and cefepime (___), as well as penumonia workup
(per ID recs) for atypical pneumonia. Before he was discharged,
patient has completed 7 days of Abx. His symptoms have
completely resolved. all EKGs yielded no evidence of ischemic
changes.
# PNA: CXR and CT scan showed findings concerning for PNA. Per
ID's recs, started the patient on empirical Vanc/Cefepime
(___). Pneumonia work up showed negative legionella.
Patient remained afebrile and showed no signs of sepsis.
Completed 7 days of cefepime and was completely asymptomatic
when he was discharged.
# ESRD: Patient continued to have elevated Cr. Rapamycin was
started on HOD #2 and Tacrolimus was discontinued on HOD #3 per
transplant team recs. Blood pressure was controlled by
metaprolol and amlodipine. Patient underwent renal ultrasound,
which raised the concern for renal artery stenosis. on HOD #6
patient underwent CO2 angiography, which showed proximal
narrowing at the junction of renal artery and aorta.
Intervention by balloon angioplasty took place. Follow up renal
ultrasound showed patent vessels. Patient's Cr has been slowly
trending down. On discharge, his Cr was 3.1. He also had
contraction alkalosis and hypokalemia after diuresis. He will
be dischraged on 40mmeq supplements and furosemide was
discontinued. His potassium, creatinine, and INR will be
closely monitored after he is discharged. He should avoid any
nephrotoxic meds. No current renal biopsy is scheduled, patient
will be re-evaluated in his upcoming appointment on ___.
# Afib: patient was triggered 2x for V-tach while he stayed on
the floor. Consistent findings of diffuse non-specific ST-T wave
changes, intraventricular conduction delay, and low QRS voltage
in the limb leads. Was seen by cardiology and digoxin was
discontinued.
# immunosuppression: Patient was transitioned from tacrolimus to
___. will continue to follow transplant team's recs wiwth
MMF, rapamune, and FK. Rapamune level on discharge was 8.7
(target range is ___. Continue with bactrim and
valganclclovir for prophylaxis. | 202 | 415 |
10156068-DS-2 | 24,238,743 | You were admitted to the hospital with abdominal pain. You had
a cat scan done of your abdomen which showed appendicitis. You
were taken to the operting room where you had your appendix
removed. You are now preparing for discharge home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites. | ___ year old gentleman admitted to the acute care service with
abdominal pain. Upon admission, he was made NPO, given
intravenous antibiotics and underwent radiographic imaging which
showed a dilated fluid-filled appendix with a proximal
obstructing appendicolith consistent with acute appendicitis.
With these findings, he was taken to the operating room where he
underwent a laparoscopic appendectomy. His operative course was
stable with minimal blood loss. He was extubated after the
procedure without incident.
On POD #1, he was started on a regular diet. His intravenous
antibiotics were discontinued. His intravenous analgesia was
changed to oral agents.
His vital signs are stable and he is afebrile. His hematocrit
is stable at 41. He is voiding without difficulty. He has
maintained an oxygen saturation of 97% on room air.
He is preparing for discharge home with instructions to follow
up with the actue care service in 2 weeks. | 266 | 158 |
10182665-DS-7 | 29,411,152 | You were admitted with nausea, vomiting, headache and
uncontrolled hypertension thought to be a side effect from your
protocl medication, cideranib. Both your protocol medications
were held and we adjusted your BP medications, with improved
control of the blood pressure and symptoms. You should continue
this dose of blood pressure medications and monitor your BP and
symptoms. Please contact your oncologist if you have repeat
symptoms. restart your protocol drugs this pm.
MEDICATION CHANGES:
-Stop Nifedipine
-Start Amlodipine 10mg po 5pm
-Fioricet ___ po prn headache | ___ y/o Fw ith Stage IIIC Ovarian ca with recent recurrence,
admitted on cycle 2 day 13 of Protocol ___, with Cediranib
(VEGF inhibitor) and Olaparib with headache, intractable
nausea/vomiting and uncontrolled hypertension.
.
# Nausea/vomiting/Headache: Likely related to uncontrolled BP,
hypertensive urgency. Held protocol drugs, and titrated BP
meds, now much improved after BP control.
-Nifedipine was changed to amlodipine as nifedipine can cause
HAs, dose of amlodipine 10mg to be taken at night and lisinopril
in the morning
-prn fioricet, antiemetics
.
# Uncontrolled hypertension: particularly elevated diastolic
pressure. VEGF inhibitors known to cause HTN, so protocl drugs
were held during admission.
- MRI to evaluate for PRES syndrome was negative
- BP now better controlled, continuing with Lisinopril 40mg
daily, and changed nifedipine to amlodipine 10mg at night. Pt
should continue to monitor BP at home.
.
# Diarrhea: also known side effect of Cediranib, monitored off
drug. Decreased in quantity since admission, pt will cont to
monitor and inform primary oncologist as outpt.
.
# Polycythemia: could be related to Cediranib as noted after
starting drug. carboxyhemoglobin normal, repeat value hct
better could have been some component of dehydration, cont oupt
f/u
.
# Ovarian Ca: hold protocol meds, seen by primary oncologist
here, to restart meds tonight | 86 | 208 |
16094649-DS-25 | 20,659,389 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for abdominal distension.
What was done for me while I was in the hospital?
- Fluid was removed from your abdomen.
- Your diuretic medication doses were increased.
- Chest x-ray showed a loculated pleural effusion. You will need
to follow-up with Interventional Pulmonology for this.
What should I do when I leave the hospital?
- Continue to take your medications as prescribed.
- Keep all of your scheduled follow-up appointments.
- Your furosemide (Lasix) dose was increased to 40 mg daily. You
can take two (2) 20 mg tablets for a total daily dose is 40 mg.
- Your spironolactone dose was increased to 100 mg daily. You
can take two (2) 50 mg tablets for a total daily dose of 100 mg.
- You are getting 2 new prescriptions, but you do not need to
fill these until your old ones run out.
If you need to refill your prescriptions before your appointment
with your doctor, please call Dr. ___ at
___.
Sincerely,
Your ___ Care Team | SUMMARY:
====================
___ female with a PMH of Child Class C NASH cirrhosis
(diagnosed by biopsy ___, stage 4 fibrosis) with portal
hypertension c/b variceal bleeds, SBP with MDR E Coli, with a
recent hospitalization in ___ for spontaneous bacterial empyema
s/p IV ertapenem, who presented with worsening abdominal
distension in the setting of medication non-adherence. | 194 | 54 |
14984395-DS-18 | 25,730,723 | Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having shortness of
breath. While you were here you had some fluid removed from your
lungs and had a catheter placed in the lung due to the rapidity
of the fluid reaccumulation.
You had an excisional biopsy of your lymph node which showed
T-cell lymphoma. You underwent chemotherapy which you tolerated
well. You will need close outpatient observation and monitoring
to assess for disease response to treatment.
The following changes have been made to your medication regimen.
Please START taking
Neupogen 1 300mg syringe subcutaneously injected once per day
Colace 100mg by mouth twice per day (stop if having loose
stools)
Senna ___ tabs by mouth twice per day as needed for constipation
Miralax 17g packet by mouth once per day as needed for
constipation
Tylenol ___ every six hours as needed for pain
Oxycodone 2.5-5mg by mouth every four hours as needed for pain
Ativan 0.5mg by mouth every four hours as needed for
nausea/insomnia
Allopurinol ___ by mouth once per day
Please STOP taking
Coumadin - you will need to restart this in the future, however
while you have the pleurex catheter in place you should not be
taking this medication
Otherwise take all medications as prescribed. | ___ yo F with hx of CAD, Afib on coumadin, COPD with concern for
new diagnosis of lymphoma who presents with dyspnea.
.
# Dyspnea - due to bilateral pleural effusions. Other
cardiopulmonary etiologies were ruled out, as was infection.
She had a thoracentesis of the left lung with resolution of her
shortness of breath; the effusion was transudative but
hemorrhagic without malignant cells by cytology. Her pleural
fluid reaccumulated after initiation of chemotherapy and so a
pleurex catheter was placed by interventional pulmonology. This
was capped and drained at discharge; over the 2 days of clamping
prior to discharge, she accumulated very little fluid. The
catheter should be accessed for drainage pending hypoxia and
subjective dyspnea. Please drain pleurex catheter in a sterile
manner ___. If patient complains of pain with
drainage, please stop and reclamp. If less than 50cc of
drainage three consecutive times, please call interventional
pulmonary department. She will follow-up with IP for evaluation
of need for the pleurex.
.
# T-cell lymphoma: s/p excisional and bone marrow biopsies
which are pending at the time of discharge. She also had
biopsies taken at OSH which showed T-cell lymphoma of unclear
cytogenetics. She underwent CHOP chemotherapy (day ___ and
tolerated this well. She was started on neupogen prior to
discharge with good improvement in her WBC count (from 1.7 to
12), to continue neupogen for 5 days total. She was not
neutropenic throughout the hospital course. At the time of
discharge, her T-cell gene rearrangement studies were pending.
.
# CAD: not an issue. Continued on statin and dilt. Her aspirin
was held prior to the thoracentesis and restarted after pleurex
placement.
.
# Afib - CHADS2 is 2. Coumadin was held throughout the admission
for thoracentesis and pleurex placement. This was held at
discharge and will need to be restarted at some point in the
future when the pleurex is removed. | 211 | 333 |
16368567-DS-7 | 21,041,707 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
You may shower and remove the gauzes over your incisions. Under
these dressing you have small plastic bandages called
steristrips. Do not remove steri-strips for 2 weeks. (These are
the thin paper strips that might be on your incision.) But if
they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
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. | ___ with history of coronary artery disease presenting from ___
___ with gallstone pancreatitis.
Pre-hospital course as mentioned above. After a period of
observation at ___ he underwent an ERCP with extraction of an
8mm stone from his distal common bile duct. He underwent a
sphincterotomy and then was observed. He had slow downward
trend in his hyperbilirubinemia and his tenderness started to
improve, although it did not resolve completely. After the
risks and benefits were discussed with the patient, he was taken
to the operating room for cholecystectomy with the understanding
that we would need to perform an open procedure if we
encountered significant inflammation precluding a safe
laparoscopic dissection. The laparoscopic procedure went without
difficulty and the patient went to recovery in stable condition
and was subsequently transferred to the floor where he tolerated
a regular diet and his pain was well-controlled on appropriate
medicines.
He experienced mild shortness of breath and pain in the
post-operative period and he and his wife expressed concern for
going home on ___. Mr. ___ opted to stay overnight
again as an inpatient to further stabilize. It was decided to
discharge him with a prescription for an albuterol inhaler, in
addition to pain meds and colace.
He was discharged from the hospital in good condition and with
appropriate prescriptions and instructions on ___. | 642 | 230 |
10913302-DS-66 | 29,936,731 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital.
WHY WERE YOU ADMITTED:
- You weren't feeling well and we found that you had bacteria in
your blood.
WHAT HAPPENED IN THE HOSPITAL:
- We gave you antibiotics and you got better.
WHAT SHOULD YOU DO AFTER LEAVING:
- Please follow-up with your doctors as ___.
- Please take your medications as prescribed.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to take part in your care!
Your ___ team | Transitional issues
===================
[] Patient was found to have VRE bacteremia during this
hospitalization. Planning approximately two week course of
daptomycin ___ through ___. Patient will obtain weekly
CBC/diff, BUN/Cr, CPK labs while outpatient on dapto to be
followed up by ___ clinic. Getting gentamycin locks @ HD, has
an HD catheter. He will have daptomycin locks for his port,
which he will get intermittently at the ___ his
chemotherapy.
Mr. ___ is a ___ male with AML s/p alloSCT in
___ complicated by chronic GVHD of skin and lungs,
hypogammaglobulinemia, chronic respiratory failure requiring
BiPAP, HFpEF (LVEF 50-55%), ESRD on HD MWF, PE on apixaban, and
recurrent MRSA bacteremia on suppressive minocycline who
presents with fever and shortness of breath i.s.o vancomycin
resistant enterococcal bacteremia.
Acute issues
============
# Fever:
# Acute on Chronic Dyspnea: his symptoms were concerning for
pulmonary
infection, pneumonia vs. viral URI. Imaging was negative for
consolidation. He had baseline dyspnea secondary to sclerotic
changes from skin GVHD. He currently has a port-o-cath and a
chest wall HD line, both of which are sources of infection.
Blood
cultures were positive for enterococcal bacteremia, vancomycin
resistant, and susceptible to ampicillin, daptomycin, and
linezolid. ID recommended daptomycin.
Chronic issues
==============
# AML s/p allo SCT
# Chronic GVHD: He is s/p alloSCT in ___ complicated by
extensive chronic GVHD of skin, lungs, and eyes. He received
INV-Ruxolitinib 20mg PO post HD, and continued to receive home
pulmicort, montelukast, prednisone, acyclovir, atovaquone,
azithromycin, dronabinol, gabapentin, pilocarpine, cyclosporine,
fluorometholone, and artificial tear eye drops. He continued
with his BiPAP during the night.
# ESRD on HD
He continued to receive dialysis on MWF, and continued his folic
acid, vitamin D, vitamin E, and nephrocaps. Renal was consulted
to manage his ESRD.
# Recurrent MRSA Bacteremia
His suppressive minocycline was held while on IV antibiotics.
# Pulmonary Embolism
His home home apixaban was continued.
# Hypogammaglobulinemia: Recently received IVIG on ___.
# Depression/Anxiety: his home venlafaxine and Ativan were
continued.
# Hypertension
# Chronic Diastolic Heart Failure: LVEF 50-55%. Stable. BNP
lower
than prior. His home carvedilol was continued.
# Hypothyroidism
Continued home levothyroxine.
# GERD
Continued home ranitidine
CODE: Full Code (presumed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (girlfriend) ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 86 | 398 |
19438782-DS-22 | 27,804,053 | ATIVITY:
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 6 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.
You may resume sexual activity unless your doctor has told you
otherwise.
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:
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 r 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 heal, 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.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
MEDICATIONS:
You are being discharged on your home medications. In addition
you are being started on IV antibiotics for the infection in
your abdomen. The exact duration of your antibiotic course will
be determined by your infectious disease doctor when you follow
up with her in clinic in 3 weeks time.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness". Your pain
should get better day by day. If you find the pain is getting
worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises. | On presentation to the ED on ___ the patient's vital signs
were stable, labs showed a WBC 20 and Hct 23.5. CT ABD/Pelvis
demonstrated 9.6 x 6.2cm walled-off irregular low density fluid
collection w/ gas and fecal material around the rectal stump.
Another large fluid collection was noted in the extraperitoneal
subcutaneous collection adjacent to the lower abdominal surgical
wound. The patient underwent incision and drainage of the
superficial incision in the ED at the bedside underlocal
anesthesia with expression of ~200 cc purulent fluid. Pt was
started on IV antibiotics Cipro/ Flagyl and was admitted to
surgery. Patient then underwent ___ guided drainage of 15 cc of
purulent fluid from the deeper fluid collection later that day.
A drain was left in place with continuous low output.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with Fentanyl patch, IV
Dilaudid and PO Oxycodone as appropriate.
___: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO and the diet was
advanced sequentially to a regular diet which was well
tolerated. Patient's intake and output were closely monitored.
His labs from rehab at the time of admission showed evidence for
a UTI. Patient was incontinent throughout the hospital stay,
which per him was his baseline status, so given his immobility
and body habitus his urine output was monitored with a candom
cath and retracted penis pouch as appropriate.
ID: The patient's fever curves were closely watched of which
there were none. He was kept on IV Cipro/Flagyl, WBC were
repeated daily, and culture and sensitivites were followed. A
vac dressing was kept in place on the midline wound while the
infra-umbilical incision received dry packing twice daily. Gram
stain of the superficial fluid collection showed 1+ PMH, no
organisms, sparse growth clostridium species not C. Perfringens
or C. Septicum, and rare growth C. Perfringens. Gram stain of
the deepr collection showed 3+ PMH, 2+ GNR, no growth to date.
ID was consulted who recommended IV Meropenem inhouse switched
to IV Ertapenem 1g Q24H as outpatient for at least 3 weeks. A
PICC line was placed on ___ pending the patient's discharge
to rehab on ___.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge on ___ for rehab, the patient was
doing well, afebrile with stable vital signs. The patient was
tolerating a regular diet, making adequate ostomy output, and
his pain was well controlled. The patient received discharge
teaching and follow-up instructions and verbalized understanding
of and agreement with the discharge plan. | 644 | 487 |
11592242-DS-21 | 28,530,980 | 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:
- touch down weight bearing on the right lower extremity with no
precautions.
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 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
touch down weight bearing on the right lower extremity with no
hip precautions. Hip and knee may be range of motion as
tolerated.
Treatment Frequency:
dressing may be left on until soiled or it falls off. When it
falls off the incision may be left open to air. | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction and
percutaneous pinning, 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. The
patient was monitored on a CIWA scale throughout his admission
and required no benzodiazapenes for withdrawal support.
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
touch down weight bearing in the right lower extremity, and will
be discharged on enoxaparin 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. | 323 | 280 |
15990037-DS-8 | 28,348,448 | Dear ___,
___ was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were confused and you fell.
What happened in the hospital?
- You were found to have very high blood pressure. We changed
your blood pressure medicine until your blood pressure was
better.
- We did head imaging because you were confused, and these did
not show a new stroke.
- Your INR was also found to be too low. It remained low despite
giving you warfarin.
What should you do once you leave the hospital?
- Continue to take your blood pressure medications as we have
prescribed
- Work hard at rehab trying to get your strength back
- Attend your appointment on ___ for a ultrasound and
appointment with Dr. ___ to discuss removing your PD catheter.
- New Medications:
Isosorbide MONOnitrate
Labetalol
- Changed Medications:
Acetaminophen dose decreased
Losartan dose increased
- Stopped Medications:
Isosorbide DInitrate
Metoprolol Succinate
We wish you the best!
Your ___ Care Team | ===============
PATIENT SUMMARY
===============
Mrs. ___ is a ___ woman with history of atrial
fibrillation (on Coumadin), ESRD on HD (___), CVA in ___,
history of DVT, and recent admission for ___ bacteremia ___ to
pneumonia who presented from the ___
after several unwitnessed falls on ___, who was found to
be hypertensive (SBP 220s), altered, and volume overloaded -
overall concerning for hypertensive emergency - with hospital
course complicated by difficult to control HTN and a
subtherapuetic INR.
============= | 190 | 77 |
19299113-DS-17 | 23,200,913 | Dear ___,
You were hospitalized with increased ostomy output and vomiting.
For this, you were treated with antibiotics. While you were in
the hospital, you developed a myasthenic crisis and became very
weak. You became so weak that we had to intubate you to help you
breathe. We treated you with IVIG and Plasmapheresis and you
slowly got better. You are in the process of being slowly
wheened of the ventilator to breath on your own. Rehabilitation
will assist with this process.
You should be sure to take all of your medications and keep your
appointments.
It was a pleasure taking care of you,
Your ___ Care Team | TRANSITIONAL ISSUES:
=====================
[] Arrange for follow-up with primary care provider and primary
neurologist outpatient.
[] Pyridostigmine restarted then held due to concern for
possible active disease per Dr. ___, Neuro-Muscular
Specialist.
[] Increase Azathioprine to 50mg BID on ___ (started 50mg QD on
___.
[] Weekly LFT/CBC while on azathioprine for 1 month, then
monthly for 3 months, then Q3 months.
[] Monitor weekly B12, treat with IM if level is <400. Last
treated with IM on ___.
[] Outpatient neurologist ___, MD,
___, will need to be seen by at neurologist at
rehab.
[] Continue to treat patient's anxiety and depression is
interfering with patient's goals of care.
[] Monitor phosphorus and replete as needed. | 106 | 112 |
18454110-DS-28 | 27,385,358 | Dear ___,
___ was a pleasure treating you.
You were admitted to the ___
for a fast heart rate. You were admitted to the intensive care
unit and stabilized. Your rapid heart rate was treated with a
medication, and your gastrointestinal infection was treated with
antibiotics. During your hospitalization, you also developed a
build up of fluid in your right lung that required a chest tube
to drain the fluid. This tube was pulled without complication,
and you will go home with supplemental oxygen that should be
worn at all times at 2 liters until your interventional
pulmonology appointment. At that appointment, you can also
request to continue follow up with another preferred
interventional pulmonologist. We wish you and your family the
best. | []BRIEF CLINICAL COURSE:
Ms. ___ is a ___ yo F w/ ESRD on hemodialysis with history
of right sided pleural effusion who presented with tachycardia
and originally admitted to the Medical ICU for concern for
sepsis, stablized overnight and transfered to the medical floor
for further management. EKG confirmed atrial fibrillation with
RVR, and rate was controlled with metoprolol during the course
of this hospitalization. Patient's septic clincal picture likely
secondary to C. diff colitis which patient has had in the past;
she was treated with PO vancomycin and PO flagyl and improved
dramatically by the time of discharge. She received
hemodialysis as scheduled throughout this admission.
.
[]ACTIVE ISSUES:
# Pleural Effusion: The patient has a history of pleural
effusions dating back to ___ in ___ of that year, she
underwent a thoracentesis with 1.5 L drained found to be
transudative. Procedure team did dx/tx tap on ___. The
gram stain of pleural fluid revealed no organisms and cultures
ultimately had no growth. Interventional pulmonology placed a
larger diameter chest tube to suction on ___, and removed
tube on ___ with the patient on a non-rebreather mask
overnight to promote re-expansion of the lung and facilitate
attenuation of the pneumothorax. Chest x-ray the following
morning after the chest tube was removed showed improvement in
the pneumothorax with some fluid re-collection. Per
interventional pulmonology the patient was deemed ready for
discharge with supplemental oxygen to be worn until her follow
up appointment with interventional pulmonology as an outpatient.
.
# Atrial fibrillation with RVR: No prior notes documenting
atrial fibrillation. the patient was tachycardic on arrival and
broke with 1 dose of 25 mg po metoprolol. She was started on
12.5 of metoprolol TID during her ICU CHADS2 score is 3. Her
afib could be from many sources; insufficient intravascular
volume (was likely dialyzed today) versus volume overload
leading to left atrial stretch vs. atrial irritation from recent
femoral catheter placement. Patient with difficult to control
afib overnight on ___, requiring IV lopressor and diltiazem.
During each run of atrial fibrillation, the patient remained
clinically asymptomatic and hemodynamically stable. At
discharge, the patient was on a rate controlling regimen of
metoprolol 50mg PO BID, with a PRN dose of 25mg PO metoprolol as
needed on dialysis days.
.
# C.diff colitis: Patient met ___ SIRS criteria on admission,
with a source originally presumed to be pulmonary, given the
findings on her CXR. Her lactate down trended with fluid
resuscitation with PRBC overnight on admssion. She qualified
for HCAP coverage given her visits to dialysis sessions.
Alternative infectious sources in the urine, as well as in the
stools (endorses one episode of diarrhea) were also entertained,
and a C. diff was sent. Atypical PNA would be unlikely to
present in this fashion. C. diff assay was positive. The
patient had a history of C. diff several years prior. The
patient was placed on PO flagyl and PO vancomycin given that the
severity of her colitis was enough to warrant an ICU admission.
The patient's diarrhea improved substantially after a few days
of therapy. At the time of discharge, the patient was on day 10
of 14 total with the vancomycin/flagyl combination therapy. She
was discharged with a prescription for 4 additional days of
therapy.
.
# Anemia: HCT baseline in low 30's and becomes symptomatic with
HCT < 30. Her etiology is secondary to her ESRD, and she has had
HCTs up to 39. HCT consistently >35 once transferred out of the
MICU. She did not require any transfusions while on the
medicine floor.
.
# ESRD: Baseline Creatinine between ___. Patient was maintained
on regular hemodialysis schedule throughout her hospitalization.
We continued Nephrocaps 1 CAP PO DAILY. We continued Sevelemar
2400 mg TID for the first 4 days on the floor. Her phosphate
dropped to 1.3 on ___ and her sevelemar was held. She was
discharged with a prescription for sevelemar
.
#CHF: Her last EF was 65% in ___, and at that time her BNP was
>70,000. She has known AR and MR on echo. BNP on ___ was
___.
.
# Lactic acidosis: Largely resolved. lactate 2.5 on admission,
down to 1.5 on ___ after IVF resuscitation.
.
[]CHRONIC ISSUES:
.
# Hypertension: In the ICU, the patient's home regimen of
amlodipine 5mg PO daily, clonidine 0.2 mg PO TID, hydralazine
50mg PO TID, and isosorbide mononitrate 15mg PO daily held given
baseline pressures around 120-150 systolic, with significant
decrease to 90-110's systolic on hemodialysis days. At the time
of discharge, the patient was taking metoprolol as her sole
anti-hypertensive.
.
# Hyperlipidemia: We continued the patient on her home dose of
Atorvastatin 10 mg PO DAILY.
.
# Glaucoma: We continued the patient on her home dose of Timolol
Maleate 0.25% 1 DROP BOTH EYES BID.
[]TRANSITIONAL ISSUES:
1.) patient is going home with supplemental O2 to facilitate
resorption of pneumothorax. Patient's daughter (caregiver)
instructed to have patient wear supplemental O2 at least until
they meet with Dr. ___ interventional pulmonology; he will
then decide whether continuing supplemental O2 is clinically
appropriate.
2.) patient's anticoagulation was on hold during this admission
given the patient's daughter's concern for GI bleed in the
setting of C. diff colitis, since this has happened in the past.
Outpatient anticoagulation should be considered given her
CHADS2 score is 3. | 127 | 907 |
19831143-DS-17 | 21,450,539 | Ms. ___, you were admitted to the ___
___ with complaints of fevers, chills and cough. You
were found to be having an exacerbation of your
asthma/bronchitis which was likely due to a viral illness.
However, your flu test was negative. You will be treated for
five days with prednisone and with antibiotics. It is important
that you follow up with your Primary Care Doctor and with your
___.
Please see below for your follow-up appointments.
It was a pleasure caring for you and we wish you a speedy
recovery! | ASSESSMENT AND PLAN: Ms. ___ is a ___, PMH Asthma and COPD
presenting with fevers, chills and cough productive of green
thick mucus x 5 days. | 92 | 27 |
16494217-DS-8 | 24,413,879 | Dear Ms. ___,
It was a pleasure to participate in your care at ___. You
were admitted to the hospital with dizziness and found to have
elevated blood sugars and a low INR level. Your hemoglobin A1c
is increased at 11.6%, which indicates that your sugars have
been chronically elevated for at least the last 3 months. For
your increased blood sugars, we increased your glyburide to 10
mg daily, your PCP ___ likely need to add another medication or
start you on insulin after discharge.
Regarding your low INR level, we started you on a heparin drip
and increased your coumadin to 5mg daily, however your INR is
still subtherapeutic. We will have a visiting nurse administer
lovenox injections for the next five days until your INR is
therapeutic.
Please follow up closely with your PCP for further management of
your diabetes and coumadin dosing. | ASSESSMENT & PLAN: ___ yo F with h/o DMT2, dCHF, and afib
presents from clinic with elevated blood sugars to > 500 and
dizziness.
# Hyperglycemia: The patient was admitted from clinic with a
FSBG > 500. She was previously on 5mg glyburide for diabetes.
She reports compliance with her medications, although she does
not usually check her sugars at home. The last A1c in our system
was 7% in ___. Infectious causes were also considered as a
possibility of her hyperglycemia, however CXR, and UA were
unremarkable and nothing on skin exam to suggest cellulitis. A
repeat A1c on admission was 11.6% suggesting long standing
hyperglycemia and uncontrolled diabetes. Her glyburide was
increased to 10mg daily on admission and she was started on a
regular insulin sliding scale. Initiation of Metformin was
discussed however, was not started based on patient's Cr. The
patient is opposed to self administering insulin, thus lantus
was not started during this hospitalization. The patient will
follow up with her PCP to discuss possibly adding another oral
diabetic medication or further discussion of starting insulin.
# Dizziness: The patient reports that her dizziness felt similar
to the symptoms she experienced when her aneurysms were found.
Her dizziness and headache resolved with correcting sugars.
Orthostatic vitals were also negative as well. She was monitored
clinically without recurrence of symptoms
# Afib- The patient's INR on admission was subtherapeutic at
1.2. She usually takes 2.5mg coumadin at home, and denies any
skipped doses. Given her CHADS2 score of 4 and high risk of a
thromboembolic event she was started on heparin drip and
warfarin was increased to 4mg daily on HD ___, and then
increased to 5mg on HD 4. She was discharged on 5mg coumadin
daily with SQ lovenox ___ daily for 4 days as bridge therapy.
___ will draw a repeat INR on ___ and fax the results to
her PCP who will titrate her coumadin dose as need. At discharge
her INR was 1.5. She was continued on metorprol for rate
control.
# Acute on CKD: The patient was admitted with Cr. of 1.7
(Baseline 1.3-1.5). Her Cr improved with fluids and remained at
baseline during her hospital course. Cr at discharge was 1.3
CHRONIC STABLE ISSUES
# chronic dCHF: No evidence acute exacerbation. continued on
home metoprolol, digoxin, atorvastatin, valsartan, and HCTZ,
furosemide
#HTN - continued on valsartan, HCTZ
# Hypothyroid: continue home levothyroxine
TRANSITIONAL ISSUES
# follow up with PCP for optimization of diabetes regimen
#INR to be drawn by ___ on ___
# full code | 145 | 423 |
15014952-DS-19 | 28,763,244 | Dear Mr. ___,
You were admitted to ___ because you had dizziness and a slow
heart rate. Your dizziness improved after you received IV
fluids. We monitored your heart rhythm overnight. Your heart
rhythm was slower than it is normally, but you had no additional
episodes of dizziness.
You should continue to take your home medications with no
changes. Please follow up with your primary care doctor and your
cardiologist.
It was a pleasure taking care of you!
Your ___ Team | ___ male with a past medical history of hypertension,
hyperlipidemia, A. fib on Coumadin, prostate cancer who presents
with dizziness in setting of emesis.
# CORONARIES: unknown
# PUMP: Mild MR, moderate TR LVEF>55%
# RHYTHM: Slow afib
#Dizziness: Patient with dizziness/lightheadedness in setting of
active emesis. No LOC or headstrike. CT head unremarkable.
Patient evaluated by Neurology in ED with no evidence of stroke.
Symptoms improved with IVF and no other intervention. Symptoms
likely secondary to vasovagal response in setting of emesis and
not primarily cardiac etiology.
#Bradycardia: Patient with slow atrial fibrillation on EKG.
Basline HR 60-80, although EKG from ___ demonstrated HR 48.
Patient monitored on telemetry overnight. Maintained HR ___
during the day and 43-50 overnight. Unlikely patient's
bradycardia is contributing to dizziness and patient with
adequate blood pressures to maintain perfusion.
#Emesis/Nausea: Patient with emesis and nausea prior to
presentation. Denies abdominal pain or diarrhea. Symptoms now
resolved and patient is taking in adequate PO. Consistent with
viral gastroenteritis.
#Atrial fibrillation: Patient with known history of atrial
fibrillation. Currently in slow afib. On warfarin, not on nodal
blockade. Continued on Warfarin. Of note, patient follows with
___ clinic. Per OMR note from ___ patient
was on WARFARIN (COUMADIN) dose should be: 2.5mg ___,
___ and 3.75mg four days. However, patient
reports he was taking 2.5mg ___ and 3.75mg ___
he was continued on this regimen.
#HTN: Hypertensive with SBP 180 on presentation. Home Nifedipine
XL 30mg.
#HLD: Pravastatin 5mg
#CKD: Cr at baseline (1.7-1.8).
#Radiation proctitis
Patient with mild radiation proctitis. It was initially treated
with argon plasma coagulation and now Canasa suppositories three
nights a week. Symptoms are well controlled with no rectal
bleeding.
# CODE: Full confirmed
# CONTACT: HCP: son, ___, ___ and Daughter
___ ___ | 77 | 287 |
16177747-DS-22 | 25,792,432 | You were admitted to the hospital for a seizure and sickle cell
crisis. Your pain was treated with dilaudid and then with your
regular pain medication (oxycodone). Your seizure was treated by
increasing your dose of Keppra. On discharge neurology
recommeded adding a medication called trileptal with plans to
slowly wean you off the keepra, the instructions are listed
below. You should also increase you dose of folic acid to 4 mg
daily. You had a CT scan of your brain which did not show any
bleeding. You had an MRI of your brain that did not show any
ischemia (area of your brain not getting enough blood).
You should follow up with your primary care doctor ___
below) and should also follow up with a hematologist to begin
treating your sickle cell disease and decrease the frequency of
crises and the chances for having more bleeding in your brain.
Week 1
Keppra -take 2 (1000 mg) tablets in the am, take 3 (1500)
tablets at night
Trileptal- take 1 tab (300 mg) in the morning
Week 2
Keppra -take 2 (1000 mg) twice a day
Trileptal- take 1 tab (300 mg) twice a day
Week 3
Keppra -take 1 (500 mg) tablets in the am, take 2 (1000 mg)
tablets at night
Trileptal- take 2 tab (600 mg) in the morning and 1 tab (300 mg)
at night
Week 4
Keppra -take 1 (500 mg) twice a day
Trileptal- take 2 tab (600 mg) twice a day
Week 5
Keppra -take 1 (500 mg) in the morning
Trileptal- take 3 tab (900 mg) in the morning and 2 tabs (600
mg) in the evening
Week 5
Keppra -stop
Trileptal- take 3 tab (900 mg) twice a day | Summary:
___ year old man with a history of sickle cell disease, IPH in
___ of this year with subsequent seizure disorder presents
with headache and facial twitching, now pain and seizure free
since last night. | 278 | 35 |
10959084-DS-18 | 29,944,848 | Dear Ms ___,
It was a pleasure taking care of you. You were admitted to ___
for fevers and confusion, which were most likely caused by a
urinary tract infection. While you were here, you received
antibiotics for your infection. Your fevers and confusion got
better, so you will go back to your rehab center.
We wish you all the best in the future!
Sincerely,
Your ___ Care Team | BRIEF SUMMARY STATEMENT:
=============================
___ woman with a history of dementia (non-verbal at baseline),
___, anxiety, CVA, hip fracture c/b septic joint in
___, and recurrent UTI's, who presented from her nursing home
with fever, with U/A from ___ showing >100,000 ESBL E. Coli. She
was initially given a dose of Gentamicin, which was transitioned
to Meropenem on ___, and Ertapenem on ___. Plan to complete a
7-day course. Her mental status waxed & waned between responsive
only to sternal rub (mostly in the morning) to alert &
responsive to voice but still nonverbal (mostly in the
afternoon). Wound care was consulted for a large, deep sacral
ulcer (see recommendations in transitional issues); decision was
made not to undergo surgical debridement, as this would cause
significant pain & ulcer is unlikely to heal. Palliative care
was consulted, and decision was made to feed the patient for
comfort, rather than placing an NGT for tube feeds. | 65 | 153 |
11913943-DS-19 | 21,566,350 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with nausea, vomiting, and abdominal pain. You had a CT scan
that did not show any acute intra-abdominal processes. You blood
work showed that you were dehydrated. You were made given IV
fluids and bowel rest. Your abdominal pain resolved and your
diet was slowly advanced to regular which you tolerated well.
Your hydration and labs improved. Your heart was closely
monitored for signs of stress. Your troponins, a marker of heart
injury, were initially elevated but decreased. Your EKG was
unchanged.
You are now tolerating a regular diet, your abdominal discomfort
is improved and you are ready to be discharged to home to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | The patient was admitted to the Acute Care Surgery Service on
___ with nausea, vomiting, and abdominal pain. A CT scan
did not show any acute intra-abdominal processes but laboratory
workup revealed elevated WBC and lactate. The patient was made
NPO, maintenance IVF administered as well as analgesic
medication. The patient received serial abdominal exams and his
vital signs closely monitor for any hemodynamic instability. On
___ the patient had an episode of heartburn/chest discomfort
which was worked up for cardiac etiology but this was rules out.
On day three of hospitalization the patient resumed ambulation
and had flatulence. The abdominal pain had resolved and the
decision was made to assess the patient's tolerance to oral
intake. The following day the patient experienced an episode of
diffulty breathing and wheezing which was resolved with
albuterol nebulizer. An incentive spirometer was issued and
pulmonary toiletry encouraged.
The patient tolerated a liquid diet following and this was
advanced to a regular diet without issues. By ___ the
patient was tolerating a regular diet and his laboratory values
had normalized. He was discharge home with self-care
instructions, follow-up appointments and a bowel regimen. He was
also prescribed albuterol for his occasional wheezing/breathing
difficulty and asked follow up with his PCP. | 316 | 208 |
17271724-DS-14 | 23,692,859 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for high levels of potassium and heart
failure. You also needed urgent dialysis.
What was done for me while I was in the hospital?
You had dialysis to reduce the amount of fluid in your body and
lower your potassium levels. You also had a tunneled line placed
so you could receive dialysis, You received 3 sessions of
dialysis and did well. You received tests for your chest pain
which showed that you did not have a heart attack.
What should I do when I leave the hospital?
- Weigh yourself every morning, and call your doctor if weight
goes up more than 3 lbs.
-Please go to your follow up appointments as scheduled in the
discharge papers.
- Please monitor for new/or worsening symptoms. If you do not
feel like you are getting better or have any other concerns,
please call your doctor to discuss or return to the emergency
room.
Sincerely,
Your ___ Care Team | Ms ___ is a ___ year old woman with HTN, history of SLE, recent
diagnosis of heart failure with reduced EF (28%), and CKD
complicated by hyperkalemia who presents with acute on chronic
systolic heart failure exacerbation and persistent hyperkalemia
requiring initiation of hemodialysis.
TRANSITIONAL ISSUES
[ ] Please follow up Vitamin D levels after 8 weeks of 50,000
units once weekly
[ ] Will need follow up with infectious disease for positive PPD
[ ] needs f/u regarding tunneled line dialysis access placement,
and interested in peritoneal dialysis
[ ] Bicarbonate and torsemide were discontinued
[ ] Re-initiate goal directed heart failure therapy as she
continues to adjust to HD.
[ ] Unable to tolerate hydralazine due to hypotension
ACUTE ISSUES
# CKD Stage V
# Hyperkalemia
# Metabolic Acidosis
CKD may be related to previous dx of SLE, longstanding HTN,
reduced kidney reserve due to previous nephrectomy in setting of
renal artery stenosis. Renal function has continued to decline
and given electrolyte abnormalities, primarily hyperkalemia,
indication for urgent HD leading to patient receiving tunneled
line dialysis access (___) and first 3 sessions of HD
inpatient (___). Patient did well overall with stable BPs,
electrolytes, and fluid status. Brief episode of hypotension and
syncope during first HD session but resolved with minimal fluids
and did not recur. Plan to continue phosphate binder
(sevelemer), nephrocaps, vit D 50k units/week. Plan for
outpatient HD sessions beginning ___.
#Positive PPD
PPD site indurated to 28 mm. During interview with interpreter,
pt states she received all childhood vaccines including BCG but
has not had reaction to PPD before. Renal consulted and CXR
obtained, which demonstrates no evidence of active TB infection.
Identified OP dialysis center that will accept based on results.
Should follow up with ID to investigate possibility of latent
infection.
# Acute on Chronic Systolic Heart Failure with reduced EF (28%)
# Non-ischemic cardiomyopathy
# Acute pulmonary edema
Prior to admission, pt had been worked up with TSH wnl, HIV neg,
HBV exposed and immune, HCV neg, tox screens neg, and mild Fe
deficiency with anemia of chronic disease/ SPEP and UPEP
demonstrate normal K:L ratio. Coronary angiogram has not been
performed due to renal function but has been started on CAD
regimen. Volume was initially controlled with Lasix 120 mg
boluses and ultimately hemodialysis. She was unable to tolerate
her beta blocker due to orthostasis, and this should be
addressed as an outpatient as she continues to adjust to HD.
# Chest pain
Has had chronic pain beneath left breast. Patient describes
concerning features such as pounding CP coming on during
exertion, is brief and resolves with rest, and associated with
SOB and diaphoresis. Multiple EKGs and troponins do not indicate
evidence for ischemia. Pain is reproducible on exam, indicating
MSK component. Furthermore, pain is responsive to Lidocaine
patch and also improved after Omeprazole. ___ be component of
GERD or excess gastric acid in the setting of reduced PO intake.
Nuclear stress in ___ showed Uniform myocardial perfusion
with global hypokinesis. Continue to use Lidocaine and
Omeprazole as needed. | 173 | 495 |
10490455-DS-13 | 20,539,733 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital due to abdominal pain and
constipation.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you had a CT scan to look for
any causes of constipation. Your CT scan showed that you had a
large amount of stool and also showed that you had small kidney
stones. To help with constipation, you received a number of
enemas, suppositories, other medications to help you with bowel
movements. These treatments helped you have better bowel
movements and your pain improved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take Colace and senna for constipation.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with a history of HIV and
AIDS as well as anal condyloma, Major Depressive Disorder
requiring recent hospitalization who presents with abdominal
pain and constipation with concern for constipation and anal
inflammation as etiology.
# Abdominal Pain
#Constipation
Patient presented reporting significant constipation as trigger
for abdominal pain. Initial concern for anal pathology (history
of anal condyloma, hx radiation ___ ?anal cancer) as etiology
of pain, however CT (___) demonstrated rectal thickening (known
finding), no obvious mass, no SBO, and a significant amount of
stool in the rectosigmoid. Trigger for constipation is unclear
as no reported changes to diet, no increased opiods. He was put
on bowel regimen: standing Senna 17.2mg BID, Bisacodyl 10mg PR,
Miralax 17g daily, and enemas. Oxycodone was reduced to 15mg q6h
prn from home 30mg q4h prn, and received a dose of
methylnaltrexone. By time of discharge, patient's abdominal pain
had improved, abdomen was less distended, and he was having BMs
without help from enemas.
# Nephrolithiasis:
CT scan ___ also showed 3mm stone present in left ureter with
minimal
ureteral dilatation and pelvic fullness. Renal function was at
baseline. Initial concern that stones could correlate with acute
presentation. However, in the setting of small stones,
uncharacteristic pain for nephrolithiasis, and improvement of
abdominal pain after BMs, unlikely that these stones were
contributing. He received IV fluids, pain was controlled with
acetaminophen, and Lidocaine patch. | 136 | 234 |
19251999-DS-9 | 21,101,316 | It was a pleasure caring for you at the ___
___. You were admitted for gastroenteritis and kidney
failure. Your gastroenteritis resolved on its own, and was
likely a viral infection. We believe your kidney failure was the
result of both dehydration (from the gastrointestinal illness)
and from too high levels of tacrolimus in your blood. We stopped
tacrolimus for now until you see your liver doctor. In the
emergency department, you had an abscess drained - we did not
start antibiotics but please seek care if you begin having
fevers or chills or if the area looks more erythematous. It is
extremely important that you follow-up with both your primary
care doctor and your new liver doctor here.
.
We made the following changes to your medications:
We STOPPED tacrolimus (until you are instructed to restart by
your liver doctor)
We STARTED celexa (citalopram) for depression
.
Your follow-up information is listed below. | Hospitalization Summary:
___ w/ history of orthotopic liver transplant for autoimmune
hepatitis in ___ on ___ transferred from ___
___ with N/V/D (resolved on admission) and ___.
.
# ___: Patient presented with a Cr of 2.7. U/A was unremarkable.
Abd U/S showed normal appearing kidneys. Bl was discoverd to be
1.0 from records sent from ___ - Cr was 1 in
___. She was given IVF and Cr began to improve. Tacrolimus
level was sent and returned greater than assay, was downtrending
on discharge to 21. Cr was 1.4 on day of discharge. The patient
was instructed to discontinue tacrolimus until meeting with her
new hepatologist in early ___.
.
# N/V/D: Likely viral gastroenteritis had started 5 days PTA.
Symptoms were completly resolved by HD#1.
.
# Vulvar abscess: Patient gives history c/w hidradenitis
suppurativa. Abscess was I&D'd in the ED. Packing was removed
and the patient was not started on antibiotics as the area did
not look infected. No fevers and no leukocytosis.
.
# s/p orthotopic liver transplant: Pt reports transplant was for
autoimmune hepatitis in ___ at ___ in
___ (Dr. ___. She has been living in ___ for 6
months without hepatology ___. She reported 1 episode of
rejection early after transplant but none recently. Records were
obtained (records should be scanned in outside hospital
records). Records showed recurrence of autoimmune hepatitis in
the graft. Patient was taking 2 mg BID tacrolimus, 10 mg
prednisone, and 500 mg BID of cellcept on admission. Liver was
curbsided re: tacro level > assay and recommended holding tacro
until close hepatology ___. HepC was sent and was negative. Abd
U/S was unremarkable. She was discharged on prednisone and MMF.
.
# Anemia: MCV = 91, Hct 33 and was stable. Nl iron studies
though with borderline ferritin.
.
# Psych: Patient reported h/o anxiety, depression, and ADHD (was
apparently on adderall, klonopin, and antidepressant in the past
but with no new PCP to prescribe these meds). She was started on
celexa 10 mg per day and scheduled with PCP ___ at ___ clinic.
.
# Social: Recent h/o domestic violence with husband. A patient
___ alert was enacted and social work c/s was obtained.
.
Transitional Issues:
- code status was full code
- contact was with the patient
- patient will need close follow-up for mgmt of her
immunosuppressants and liver transplant
- ___ for resolution ___
- ___ for anxiety, depression, ADHD | 152 | 411 |
17264362-DS-5 | 28,930,363 | Dear ___,
It was a pleasure caring for you during your admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
-Your admitted to the hospital because you had abdominal pain
caused by a clot in your superior mesenteric vein.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-While you were in the hospital we had the interventional
radiology team remove the clot from your superior mesenteric
vein. You also underwent a transjugular intrahepatic
portosystemic shunt (TIPS) procedure due to your underlying
liver disease.
WHAT SHOULD I DO WHEN I GO HOME?
-Please stick to a low salt diet and monitor your fluid intake
-Take your medications as prescribed
***You were newly prescribed apixaban which is a blood thinner
to help prevent further clots.***
-Keep your follow up appointments with your team of doctors
Thank ___ for letting us be a part of your care!
Your ___ Care Team | ___ is a ___ year old male with past medical history
notable for Hep C (diagnosed ___, untreated), alcoholic
cirrhosis complicated by hepatic encephalopathy and upper GIB,
found to have esophageal varices (s/p banding ___, on
nadolol) who presented with abdominal pain to ___
___, found to have non-occlusive SMV thrombosis with
mesenteric ischemia, and transferred to ___ for further
management. He underwent catheter directed tPA, thrombolysis and
TIPS placement with interventional radiology without any acute
complications. He was started on heparin drip and transitioned
to apixaban upon discharge.
TRANSITIONAL ISSUES
======================
[ ] He was started on a loading dose of apixaban during his
hospital stay. He will transition to 5 mg twice daily on ___
and need follow-up with hepatology regarding decision of
long-term management of his anticoagulation.
[ ] Please ensure follow up with Dr. ___ the next 4
weeks.
[ ] Please ensure follow up with Dr. ___ on ___
___ 11:30 AM regarding treatment of his hepatitis C. He
is also non-immunized against hep B and will need to be
vaccinated.
[ ] Patient was started on a seven-day course of topical
erythromycin for folliculitis to end on ___.
ACUTE ISSUES
======================
# SMV Thrombosis
# s/p catheter directed tPA, thrombolysis
# s/p TIPS
He originally presented as a transfer from ___
with an SMV thrombus. He underwent successful TIPS + chemical
thrombolysis and lysis of his SMV thrombus. Venogram on ___
showed patent and excellent flow through the SMV and the TIPS
stent with final PS gradient 5 mmHg. He was transitioned from a
heparin gtt to Apixiban during this hospital course.
[ ] He was started on a loading dose of apixaban during his
hospital stay. He will transition to 5 mg twice daily on ___
and need follow-up with hepatology regarding decision of
long-term management of his anticoagulation.
# Cirrhosis2/2 HepC and cirrhosis
He underwent a successful TIPS procedure with a final PS
gradient of 5 mmHg. His home nadolol was discontinued as it is
no longer indicated.
[ ] Please ensure follow up with Dr. ___ regarding
treatment of his hepatitis C. He is also non-immunized against
hep B and will need to be vaccinated.
# Eye Folliculitis
During his hospitalization he developed some erythema
surrounding his eyelids consistent with folliculitis. He was
started on a 7-day course of topical erythromycin scheduled to
end on ___.
CORE MEASURES
=================
# HCP: ___ ___
# CODE: Presumed FULL | 162 | 402 |
10738019-DS-21 | 21,286,198 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) 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.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
· Headache is one of the most common symptom after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | Mr. ___ was admitted to neurosurgery step down unit with TBI
after a fall off a ladder.
#TBI
He was started on keppra for seizure prophylaxis x 7 days.
Repeat head CT showed increase in frontal contusions. He was
monitored clinically and his neurologic exam remained
neurologically intact throughout his hospitalization, therefore
repeat CT was deferred. He was started on 3% NaCl with serial
sodium checks and then transitioned to PO salt tabs for
discharge. Sodium goal high normal, instructed to follow up with
PCP for sodium check in the next week. He will follow up with
___ clinic in 8 weeks with repeat head CT.
#Leukocytosis
WBC elevated to 19 on admission. He remained afebrile. CXR
negative for consolidation. UA was negative. WBC was normal at
9.5 at discharge.
#Hypertension
Patient takes lisinopril for HTN. BP was intermittently slightly
elevated to 160s during hospitalization requiring
hydralazine/labetalol with good effect. He was discharged on his
home antihypertensive with instructions to follow up with PCP
for further monitoring.
#Dispo
He was evaluated by ___, who recommended discharge to home. On
day of discharge, his pain was well controlled with oral
medications. He was tolerating a diet and ambulating
independently. His vital signs were stable and he was afebrile.
He was discharged to home in a stable condition. | 447 | 211 |
19428864-DS-14 | 20,694,024 | Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with blood in your urine and you were
found to have a mass in your kidney concerning for cancer. You
were seen by oncology and urology and will need to follow up in
___ clinic. They should contact you with a follow
up appointment.
You were also found to have high blood pressure. You were
started on a medication to treat your high blood pressure. You
should take this medication every day.
Your baby aspirin has been stopped because you are bleeding.
Please discuss with your primary care doctor if you should
resume this medication.
We wish you the best,
Your ___ Care team | Ms. ___ is a ___ PMHx HLD who is transferred from ___
___ for evaluation of HTN, hematuria and new renal mass.
# Renal mass concerning for renal cell carcinoma
# Hematuria
#Acute blood loss anemia.
Patient with symptoms of malaise, hematuria, and unintentional
weight loss concerning for possible renal cell carcinoma in the
setting of new large renal mass. CT torso confirmed the mass and
also noted involvement of retroperitoneal lymph nodes and renal
vein. The patient was seen by urology who recommended MRI which
can be completed as an outpatient. She was also seen by oncology
who felt there was no urgent need for intervention. The patient
will be set up for follow up in the ___
clinic to determine next steps. The patient is aware that her
mass is likely malignant. The patient had ongoing intermittent
hematuria on discharge. Post- void residuals were checked and
were not indicative of urinary retention and h/H was stable.
# Hypertensive urgency
Patient with new onset hypertension likely due to tumor thrombus
in renal vein. She was started on Amlodpine 10mg daily with good
blood pressure control.
# BLE edema
___ negative for DVT at ___. Likely due to mass/obstruction
of venous return/lymphatics. ___ edema improved with
elevation/compression
# HLD.
- Continue home Simvastatin 5 mg daily. The patient will hold
her ASA in setting of hematuria and unclear surgical plan.
# ?depression
Patient recently started on Celexa as PCP concerned that her
anorexia/malaise could be related to depression. However,
patient denies significant depressed mood and stopped taking her
Celexa ___ days ago. Will continue to hold celexa
# Glaucoma
Continued home eye drops | 118 | 264 |
12525411-DS-13 | 23,589,299 | Dear Mr. ___,
You were admitted because you were having weakness and
dizziness, and there was concern that you had a stroke. You also
had large changes in your blood pressure. We performed several
studies to look at your heart and blood vessels for any problems
and your brain to look for a stroke. However, your symptoms
were more likely related to medications or general balance
issues.
Please note we changed your Diovan to be taken in the evening
now, not the morning, also we would like for you to stop taking
the donepezil because it may be affecting your current symptoms.
We changed your insulin regimen to : humalog ___ 18 units at
breakfast and NPH 8 units before bedtime | ___ with history of dementia, ESRD with HTN, DMI, and HLD (off
statin for muscle ache) presenting with complaints of possible
right-sided weakness prior to arrival, in addition to dizziness.
A syncope workup was performed, and his symptoms were determined
to be most likely progression of his general instability.
ACTIVE PROBLEMS
# ? Neurological symptoms - Uncertain etiology, but syncope vs
TIA vs lacunar or cerebellar stroke were considered. Also
medication issues or hypoglycemia possible.
The patient has multiple medical issues including multiple
vascular risk factors. In the ER he was evaluated for a code
stroke for listing to the right while in bed and overall had a
non-focal exam on ED evaluation. Per neurology evaluation, his
history alone does not suggest a stroke. STAT Head CT showed no
bleed given recent fall. Other than perheps his dizziness and
his listing, the patient has not had any new neuro deficits in
the setting of Alzheimer's dementia. There was low suspiscion of
an acute neurological event, but performed MRI to look for
possible lacunar stroke or cerebellar lesion, since patient
exhibited some truncal ataxia/inability to sit still. MRI was
normal. Cardiac wise, patient has been asymptomatic and EKG not
changed much from prior, but pt had mild elevated troponin.
Will check add'l troponin and monitor on telemetry, although low
suspiscion for cardiac event. Likely, this is a progression of
his gait instability and frequent falls, dating back to well
before this admission, and patient will benefit most from
physical therapy
# Hypertensive urgency - On arrival to the floor patient had SBP
in 230s but was asymptomatic. Likely secondary to not receiving
medications day of admission vs labile HTN. BP improved to
190/96 with labetalol 100mg PO and diovan at home dose. Home
medications were restarted, bringing his BP lower than our first
24 goal, to 126/60. His valsartan was then adjusted to be ___
dosed, separated from his metoprolol to help prevent swings.
# Orthostatic hypotension/hypertension - Review of patient's
chart reveals that BP managment has been challenging since at
least ___, with PCP noting ___ history of hypotension and falls.
He also has a previous admission for similar circumstances,
including gait instability, confusion and dizziness. Home
medications were adjusted so that both antihypertensives not
taken in the morning, as they have similar durations of action.
Valsartan switched to ___ dosing to give better 24 hour coverage. | 121 | 397 |
19314266-DS-10 | 24,995,770 | ___ have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. ___ should have ___
bowel movements daily. If ___ notice that ___ have not had any
___ from your stoma in ___ days, please call the office. ___
may take an over the counter stool softener such as Colace if
___ find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as ___
have been instructed by the wound/ostomy nurses. ___ will be
able to make an appointment with the ostomy nurse in the clinic
7 days after surgery. ___ will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until ___ are
comfortable caring for it on your own.
Please monitor the laparoscopic incision sites. These are closed
with dermabond. Please monitor for signs of infection including:
increased redness, increased pain, yellow/white/grey drainage,
fever greater than 100.1, or swelling of the wound. Please call
the office if ___ develop these symptoms.
The ___ will connect ___ to your chemotherapy and the nurses
___ send him home with your portacath accessed. ___ will
continue to have radiation therapy. ___ will have radiation
therapy prior to your discharge today.
___ can continue to take Oxycodone for pain. Do not drink
alcohol or drive a car while taking this medication. Do not take
more than 4000mg of tylenol in 24 hours. Do not drink alcohol
while taking Tylenol. | ___ y/o ___ speaking male with past medical history of
colon and rectal cancer and chronic constipation, currently
being treated with XRT and home infusion of ___, who presented
with abdominal pain and no bowel movements for 3 days.
# Abdominal Pain: Differential diagnosis included obstruction
from solid tumor burden which could be the cause of his
constipation as well. KUB on ___, showed a large
amount of colonic stool extending from the cecum through the
sigmoid colon. There was no free air. Pt was recently admitted
with similar symptoms, which resolved with aggressive bowel
regimen therefore pt underwent aggressive bowel regimen with
daily miralax, mag citrate, fleets enema with standing
Colace/senna. After bowel regimen, pt reported having up to 14
small bowel movements daily. Pt's diet was advanced to clears
and pt tolerated it well. Repeat KUB two day later on ___
showed increased stool burden in the descending colon and rectum
with
mild dilatation of the transverse colon, which could represent
large bowel
obstruction secondary to fecal impaction. Colorectal surgery was
consulted and took the pt to the OR on ___ for diversion and
colostomy. On ___, the patient's foley was discontinued and he
was able to void appropriately. His diet was advanced from sips
to clears and he tolerated this well. On ___, the patient was
passing lots of gas into his ostomy bag, and was able to
tolerate solid food by dinner. On ___, he remained on a regular
diet and continued to pass flatus but was not producing much
stool from his ostomy. We continued to monitor his output, which
began to increase on ___ with small amounts of formed stool in
the ostomy bag. He had ostomy teaching with both an interpreter
and the ostomy nurse present. On ___, he remained on a regular
diet and was passing increased amounts of stool per ostomy. The
patient was seen inpatient on ___ by Dr. ___ his home
chemotherapy was ordered by this provider. ___ services received
all forms necessary to give the patient home chemotherapy per
Dr. ___. He was deemed appropriate for discharge on
___. After receiving radiation therapy.
# Colorectal Cancer: Pt remained on home infusion of ___ as
well as XRT therapy.
Pt's ChemoXRT was administered up until the day before surgery.
The patient resumed XRT POD 4, and also received XRT on POD 5
and again prior to discharge on ___. He will be resuming
chemotherapy as an outpatient following discharge.
# HTN: remained stable and pt not on any antihypertensives at
home | 351 | 423 |
12842039-DS-22 | 20,653,824 | Mr. ___,
You were admitted with black stools concerning for a
gastrointestinal (GI) bleed. And EGD (aka upper endoscopy) on
___, colonoscopy and video capsule endoscopy both on ___ were
negative for acute bleeding. These tests were significant for
esophagitis, changes in the appearance of the tissue at the end
of the esophagus concerning for a condition called ___
ESOPHAGUS (development of metaplasia). Please discuss with your
primary care physician whether to schedule a repeat EGD to
obtain a diagnostic biopsy of the tissue that had the appearance
of ___ esophagus.
The colonoscopy showed hemorrhoids and diverticulosis, which
were not bleeding. The video capsule endoscopy showed minor
blood in the stomach, which we believe is due to mild irritation
of the stomach lining during the EGD procedure.
***We remind you that as of time of discharge, we are
recommending discharge to ___ rehab for further physical
therapy since ___ evaluation showed that you are considerably
below your functional baseline, and you will likely benefit from
inpatient physical therapy. You and your family have declined
this recommendation. In light of this, we are making
arrangements for a home safety evaluation by a ___.
It was a pleasure taking care of you.
-Your ___ team | ___ h/o HTN, CAD, and hepatitis C presents w/melena.
# Acute on chronic blood loss anemia, now stable
# Melena, now RESOLVED
# Hx gastrectomy with gastrojejunal anastomosis
-Drop in H/H from ___ on ___ to 9.___.1 on ___ in
setting of melena. Stable since. s/p EGD ___ and C-scope ___
without source of bleed.
-Set up with video capsule endoscopy on ___ following
C-scope, showed some blood in the stomach, ?trauma due to ___
EGD (which was used to place capsule)
-Of note patient has hx gastro-jejunal anastomosis after
bowel perforation in the setting of prior ERCP
-Held home-dose aspirin 81 and metoprolol throughout admit,
restarted at discharge. Also held furosemide, will cont to hold
as still appears hypovolemic as of ___.
# Grade B esophagitis
# ?___ esophagus
-Findings noted on ___ EGD. Biopsy of tissue concerning for
___ was NOT biopsied since indication for EGD was to
evaluate for a source of GIB.
-Continue with omeprazole 20mg BID.
[ ] Consider outpt GI referral for repeat EGD w/ biopsy to
evaluate for ?___ if consistent with goals of care.
# Multi-articular severe OA with
# Presumed severe exacerbation of left shoulder OA on ___
Left shoulder plain films signif for left left glenohumeral OA
with "bone-on-bone configuration and marked spurring along the
glenoid"; no fracture or dislocation. There is focal tenderness
over the glenohumeral joint. No erythema or effusion to suggest
gout or septic arthritis. Pt was treated with PRN PO tramadol,
oxycodone 5 mg PO x1 and morphine 4 mg IV x1 with minimal relief
initially. By ___, left shoulder pain had resolved.
# Deconditioning
Despite continued ambulation trials throughout the
hospitalization, pt noted with generalized weakness and
deconditioning on ___ ___. Pt was formally evaluated at bedside
on ___ AM by ___, who recommended discharge to ___. Hospitalist
conveyed this recommendation on the phone with pt's daughter/HCP
___ as well as ___ concern for fall risk if pt were
to be discharged directly home. ___ declined this
recommendation and instead elected for discharge home with ___
services for further ___, and she demonstrated understanding of
concern for fall/injury risk.
CHRONIC MEDICAL PROBLEMS
# HTN, CAD: hold aspirin, metoprolol, and furosemide in setting
of GI bleed. Continue simvastatin.
# Mild painless left abdominal ventral hernia: Cont to monitor
clinically. No indication for acute intervention.
Discharge Diet: 2g-Na/Heart-healthy diet
50 mins spent on discharge ___ (>50% time spent counseling
pt @ bedside and daughter/HCP ___ on the phone and
coordinating care). | 199 | 418 |
16395565-DS-7 | 28,391,825 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with a fever of 103 at your rehab facility. You recently had
your gallbladder removed and therefore an infection in your
abdomen was suspected. You had a CT scan that showed an abscess
in the area that your gallbladder used to be. You were given
broad spectrum IV antibiotics. Cultures from the drain were sent
to the lab and then a more specific oral antibiotic was
selected. You are now doing better, tolerating a regular diet,
and having no fevers or signs of infection. Please continue to
take antibiotics as prescribed and follow up in the post
operative clinic at your scheduled appointment date.
You are now ready to be discharged to rehab to continue your
recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water. | Ms. ___ is an ___ yo F history of laparoscopic
cholecystectomy on ___ admitted to the Acute Care Surgery
Service with fever of 103 at rehab facility. CT abdomen showed a
complex 3.7 cm fluid collection in the gallbladder fossa
containing locules of air concerning for an abscess. She was
made NPO, given IV fluids and broad spectrum IV antibiotics and
admitted to the floor for further management.
On HD1 interventional radiology was consulted and placed an 8
___ pigtail catheter into the collection. Samples were sent
for microbiology and revealed staph aureus coag positive.
Antibiotics were narrowed to oral Bactrim due to sensitivity
data. On HD2 the patient received 1 unit of packed red blood
cells for a down trending hemoglobin of 6.5 which she responded
appropriately to 6.8. Blood levels were monitored and remained
stabled.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
The patient was seen and evaluated by physical therapy who
recommended discharge to rehab with which the patient agreed.
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 to rehab. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 523 | 268 |
15500291-DS-13 | 29,989,198 | Dear Mr. ___,
It was a pleasure treating you during your recent admission to
the ___.
You were admitted because you had syncope (you passed out) and
hit your head. A CT scan showed you had a small amount of
bleeding inside your brain, but this bleeding is stable and does
not require neurosurgical intervention. You were cleared from
the surgical team.
While hospitalized, we evaluated you for different causes of
syncope, including orthostatic hypotension (due to being
dehydrated) and cardiac (structural or arrhythmias). We noted
that your blood pressure decreases when you stand up - this
might explain your syncope. You should drink plenty of fluids to
decrease the risk of future episodes. You also received an
ultrasound of your heart, called a TTE (echocardiogram). This
did not show any obvious reasons for you to lose consciousness;
it was consistent with your prior echocardiograms.
What to do next:
-You can consider having a Holter monitor placed to monitor your
heart rate and make sure there are no arrhythmias contributing
to your lose of consciousness. Please discuss this further with
your primary care doctor or your cardiologist.
-We stopped your aspirin because you had bleeding in your head.
Restart your baby aspirin 81mg daily on ___.
-You should get your scalp staples removed by your PCP in about
2 weeks, between ___ - ___.
-You do not need neurosurgical follow-up.
Thanks, from all of us in your ___ care team!
Additional notes from your neurosurgeon team:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | Mr. ___ is a ___ with CAD (s/p 3V CABG ___, DM2,
BPH, HTN, HLD, glaucoma, pernicious anemia and multiple previous
episodes of syncope who presents with unwitnessed syncope with
headstrike at home, with CT-head notable for a stable L-sided
SAH without neurosurgical intervention indicated at this time.
#Orthostatic hypotension: On ___, Mr. ___ was transferred
to ___ for neurosurgical evaluation after syncopal fall at his
assisted living facility. He had had a CT head that did show L
parietal SAH (see details below) and so was transferred to ___
for consideration of surgical intervention. He was initially on
___ service but transferred to medicine when it was felt that
no surgery was warranted. The etiology of his fall was felt to
be due to orthostatic hypotension given positive orthostatic VS
on admission by systolic drop of 30 mmHg when standing. He
received IVF with improvement in orthostasis and was cleared by
___. Orthostasis was felt to be due to poor po intake. Infectious
work up was negative including blood cx, Ucx, and CXR. Other
etiologies of syncope were felt to be less likely; EKG did show
asymptomatic sinus bradycardia to high ___. Telemetry
showed no significant events beyond intermittent sinus
bradycardia when sleeping to low ___. He had TTE that
was unrevealing (see report)- EF >55%, no significant TR, MR;
notable for aortic sclerosis. No evidence of ischemic event
including negative CK-MB and troponin, BNP <300. Of note,
patient was seen at ___ in ___ for persistent dizziness
and syncope and at that time he had EKG, TTE, carotid duplex,
brain MRI which were unrevealing for etiology.
#L Parietal Subarachnoid Hemorrhage: On ___, Mr. ___ was
transferred to ___ for neurosurgical evaluation after syncopal
fall at his assisted living facility. ___ at ___ was
concerning for small left parietal SAH. Repeat CT after
transfer showed stable hemorrhage. Aspirin was held. He was
admitted to the floor for neurologic monitoring. The patient
remained neurologically and hemodynamically stable. He was
transferred from the ___ team to medicine for syncope workup.
Plan to restart aspirin in 1 week (___). No indication for
neurosurgical follow-up.
##DM: on SSI while inpatient; HbA1c 6.8.
##h/o HTN: normotensive during admission; not on any home.
##HLD: Continued home atorvastatin.
##Glaucoma: continued home eye drops.
=================== | 593 | 374 |
13478841-DS-8 | 29,999,498 | It was a pleasure taking care of you at ___.
You were admitted for confusion and delerium. This was due to
the progression of your cancer, which caused you to have a high
calcium level in your blood leading to confusion. We attempted
to correct this, but we were unable to successfully do so.
You are being discharged on the following medication list with
this documention. Please stop all other medications other than
these. | Mr. ___ is a ___ with hx metastatic melanoma c/b prior
episodes encephalopathy and hypercalcemia who presents to the ER
with lethargy, fall, and hypercalcemia concerning for underlying
infection.
.
# Goals of care: patient was admitted with toxic metabolic
encephalopathy secondary to hypercalcemia of malignancy with
possible contribution from infection. He was given adequate
trial of reversal of his calcium as well as treatment for
infection without resolution of his delerium. Throughout he
remained AOx1-2. Due to his persistent delerium, and in light
of his metastatic melanoma, he was made comfort measures only
with home hospice.
.
# Hypercalcemia: Likely ___ underlying malignancy and
contributing to his lethargy. An EKG was obtained and wnl. He
was started on NS at 200cc/hr and given pamidronate infusion.
His calcium decreased to within normal limits but his
encephalopathy did not clear.
.
# Encephalopathy: Pt was noted to be lethargic on admission.
Most likely etiology for his lethargy was hypercalcemia as his
lethargy improved as his calcium normalized. Other etiologies
included possible UTI which was treated with ciprofloxacin.
Treatment of his UTI and calcium did not result in complete
improvement in delerium; other etiologies were ruled out.He did
improve somewhat with less lethargy/improved alertness but some
confusion/disorientation persisted. In discussion with family
and his primary oncologist, the patient was made comfort
measures only with home hospice.
.
# Leukemoid reaction: WBC as recent at ___ was downtrending on
vemurafenib but on admission it was acutely elevated to 79.8 on
admission and then increased to 90 the following day prior to
discharge from the unit. We initially started IV antibiotics out
of concern for a possible cellulitis over the tumor in his left
axilla. The antibiotics were then discontinued the following
day. His Leukemoid reaction was most likely related to his
metastatic melanoma.
.
# Metastatic melanoma: Hx of dx since ___ with evidence of mets
diagnosed recently ___ after complaints of anorexia, weight
loss and axillary pain since ___. Recently started
therapy with vemurafenib. Due to his persistent toxic metabolic
encephalopathy in setting of poor prognosis due to metastatic
melanoma, the patient was made comfort measures only with home
hospice.
.
# Acute kidney injury: On admission the pt's Cr was slightly
elevated above baseline. His Cr improved with IVF and resolution
of hypercalcemia. His medications were renally adjusted. | 75 | 395 |
15994443-DS-5 | 24,246,927 | Dear Ms. ___,
You were brought to the hospital after taking an overdose of
citalopram. This caused you to become very sick and confused.
You were admitted to the intensive care unit. You were found to
have a condition called serotonin syndrome and you received
supportive treatment in the intensive care unit and gradually
improved. You also had a pneumonia which was treated with
antibiotics.
You were seen by the psychiatry team who recommended that you be
transferred to an inpatient psychiatric facility for further
treatment. You will continue to receive care there.
It was a pleasure taking care of you and we wish you the best,
Your ___ Care Team | Ms. ___ is a ___ woman with history of
depression, who presented to ___ after an intentional
overdose of citalopram with resultant seizure and intubation
found to have a prolonged course of serotonin syndrome requiring
extended ICU stay. She was worked up for infectious and
paraneoplastic causes of encephalitis due to her prolonged ICU
course without any evidence of bacterial or viral meningitis.
Preliminary testing for paraneoplastic causes were unremarkable
but full panel pending prior to discharge; however, she improved
dramatically and ultimately her condition was attributed to
serotonin syndrome. While in the ICU she was also treated with a
full course of ceftriaxone pneumonia. Once she was transferred
to the floor she was able to be transitioned from TPN to a
regular diet. She had a mild transaminitis that was attributed
to TPN and was resolving following discontinuation of TPN. She
did have a mild leukocytosis and was treated empirically for 2
days on the floor for potential line infection but cultures were
negative and antibiotics were discontinued with resolution of
leukocytosis. The inpatient psychiatry team was consulted and
recommended ___ and further inpatient psychiatric
treatment given serious suicide attempt. As she was medically
stable without further acute medical problems, she was cleared
for discharge to inpatient psychiatry.
# Toxic ingestion/Citalopram overdose
# Serotonin syndrome:
# Hypoglycemia:
# Rhabdomyolysis:
Patient presented critically ill in the setting of intentional
overdose of citalopram. Toxicology was consulted, recommended
continuing sedation with fentanyl and midazolam, monitoring Qtc
and electrolytes closely. Qtc remained <500. During MICU course,
she became increasingly febrile, tachycardic and rigid with
lower extremity clonus, thought to be ___ serotonin syndrome.
She was treated with sedation, paralytics, esmolol drip, and
cyproheptadine. CT head was negative. Also noted to be
hypoglycemic, thought to be ___ toxic effect from citalopram, so
was started on D5WNS maintenance fluids, which were increased
when found to have elevated CK concerning for rhabdo. Toxicology
and neurology were reconsulted when symptoms lasted more than 7
days with inability to wean paralysis due to recurring autonomic
instability. She had an infectious and paraneoplastic workup
performed and symptoms were ultimately thought to represent
prolonged course of serotonin syndrome. An LP and EEG were
unremarkable. She was ultimately able to be extubated and weaned
off sedation and was transferred to the floor without further
signs or symptoms of serotonin syndrome.
# Pneumonia:
Patient was initially intubated for airway protection in setting
of seizures and confusion. She subsequently developed persistent
hypoxemia requiring increased FiO2 and a CXR was concerning for
evolving pneumonia. She was initially treated broadly for
possible aspiration pneumonia, then transitioned to ceftriaxone
for total 7 day course which ended ___.
# Ileus: Patient was initially not tolerating TF due to high
residuals and following extubation was having significant
nausea. She was not having bowel movements and was determined to
have an ileus. KUB without evidence of obstruction. Symptoms
resolved with aggressive bowel regimen. She was given TPN for
nutrition which was able to be discontinued ___.
#Leukocytosis: While on the floor her WBC increased to 12K on
___, initially with concern for potential line infection given
IJ line, but cultures were without any growth and site of line
without any signs of infection. IJ line was removed on ___. She
is s/p empiric vancomycin ___ while awaiting cultures,
which remained negative >48 hours. A repeat infectious workup
was negative with normal CXR, normal UA, and negative blood
cultures, without any localizing signs/symptoms of infection.
Leukocytosis resolved and vancomycin was discontinued.
#Transaminitis: She developed a mild transaminitis while on the
floor. Workup included hepatitis serologies and RUQUS which were
normal. Transaminitis was thought related to TPN which was
discontinued on ___ with LFTs improving prior to discharge. She
should have repeat LFTs in one week (___) to monitor for
continued improvement.
#Depression/Anxiety: s/p intentional overdose; has been having
panic attacks. Has long standing history of depression. Psych
was consulted during this hospitalization and recommended
inpatient psych placement and ___.
#Panic attacks: She was having intermittent episodes of panic
with shortness of breath and chest discomfort. She was treated
with PRN Lorazepam 0.5mg which worked well for her symptoms.
TRANSITIONAL ISSUES
===================
[ ] Please recheck LFTs in one week (___) to ensure resolution
of transaminitis
[ ] Please ensure outpatient psychiatry follow up
[ ] A mildly complex exophytic cyst is seen arising from the
upper pole of the right kidney and is amenable to follow-up with
ultrasound in ___ year.
#CODE STATUS: Full Code
# Communication:
___ (home) parents
___ (cell) Ray father
___ (cell) mom | 107 | 741 |
12643870-DS-15 | 26,456,705 | Dear Mr. ___,
You were admitted to the hospital after you became confused with
a fever. At the hospital we found you to have a skin infection
which we treated with IV antibiotics. You should continue these
antibiotics after you leave the hospital for 6 days until ___.
Whiel you were in the hospital you continued to complained of
worsening tingeling in your fingers and feeling llike your hands
were wet. The gabapentin you were taking at home was not
working for you. We stoppped your home gabapentin and started
you on a new medication called pregabalin which you also take 3
times a day. Please stop taking the gabapentin when you get
home.
Wishing you all the best. It was a pleasure taking care of you.
Your ___ care team | Mr. ___ is a ___ y/o male with a past medical history of severe
AS s/p mechanical AVR (___. ___ ___ c/b cervical spine
injury, AF (on warfarin), h/o recurrent DVT/PE (on warfarin),
CML (on gleevec) who presented with lethargy, confusion and
weakness. | 136 | 43 |
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