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12835781-DS-10 | 29,039,914 | Dear Mr. ___,
You were admitted to the hospital for a hydropneumothorax, which
is a collection of air and fluid next to your lung. You were
seen by our Interventional Radiology team who placed a chest
tube to drain the fluid and air. The chest tube was eventually
clamped and then removed. You tolerated the procedures well.
Once you leave the hospital, continue to take all of your
medications as prescribed. We did not make any medication
changes.
It was a pleasure to take care of you.
Sincerely,
Your ___ team
Dear Mr. ___,
You were admitted to the hospital for a hydropneumothorax, which
is a collection of air and fluid next to your lung. You were
seen by our Interventional Radiology team who placed a chest
tube to drain the fluid and air. The chest tube was eventually
clamped and then removed. You tolerated the procedures well.
Once you leave the hospital, continue to take all of your
medications as prescribed. We did not make any medication
changes.
It was a pleasure to take care of you.
Sincerely,
Your ___ team | Mr ___ is a ___ year old man with a PMH of SCC of L lung s/p
resection, with recurrence in mediastinum s/p chemo and XRT,
again with development of R upper solitary PET(+) mass s/p
___ CyberKnife stereotactic radiotherapy, sent in from ___
clinic for f/u CXR with worsened R hydropneumothorax, now s/p
___ chest tube placement, drainage, and removal. | 173 | 61 |
18046190-DS-4 | 21,136,359 | Dear Mr. ___,
It was a pleasure taking care of you.
You were admitted to ___ after having a loss of
consciousness/lightheadedness. A number of tests were performed,
and after assessing your heart rhythm, it was thought that the
most likely cause was a problem in the rhythm of the heart that
was slow. You had a pacemaker placed in order to prevent any
similar episode.
Regarding your atrial fibrillation, we have increased your
Eliquis dose to 5 mg twice daily instead of 2.5 mg. This
medication is a blood thinner to help prevent clots.
Moreover, you had a low grade fever 100.5 F once. Multiple tests
showed no evidence of a bacterial infection.
- Monitor your blood pressure every other day and at different
times and write them on a paper. Give that paper to your primary
care doctor or cardiologist.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in one day or 5 lbs in a week.
We wish you the best,
Your ___ care team | The patient was admitted for an episode of syncope. After taking
history On admission, his EKG showed: RBBB, LAFB and 1st degree
av block. EP were consulted and think a pacemaker would be the
best management in this scenario. A PPM was placed on ___
without any complications.
The discussion with them included tachyarrhythmias which seem to
be less likely in his condition. His EP will monitor his ___ for
any tachyarrhythmia.
An echocardiogram showed an improved EF 41 % (compared to ___
% in the past).
Patient received 3 doses of vanco for PPM placement prophylaxis.
Patient had an increased BP during his stay up to 170 mmHg. He
was given lisinopril 5 mg on ___ that was stopped upon
discharge since his creatinine increased from 1.2 to 1.4.
Patient had a low grade fever on ___ at night which might
have been related to a small resolving hematoma. No sources of
infection were seen (BC, Urine culture and chest x ray were
negative for sources of infection).
He aslo had a slight increased in WBC. After discussion with EP
in regards of sources of infection after PPM placement, they are
not concerned about an infection related to the ___ placement for
now and they are okay with discharging the patient today.
Regarding his atrial fibrillation, his eliquis was increased to
5 mg BID instead of 2.5 mg and he was continued on his sotalol.
No changes were done for his heart failure, his EF seemed to be
improved on the echo (30 --> 41%). After discussion with Dr.
___ changes in meds were done. | 172 | 266 |
12862832-DS-21 | 25,803,221 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted because of bleeding from your mouth and
sever pain related to your cancer.
What was done for me while I was in the hospital?
- You had a CT scan of your neck which did not show any invasion
of blood vessels by the cancer
- Your pain medications were adjusted to make you more
comfortable before sending you home
What should I do when I leave the hospital?
- Take all your medications as prescribed
- Make yourself appointments to see your oncologist at ___
___ and our palliative care team at the ___ (see below for
contact information)
- Seek medical attention if you experience recurrent bleeding,
worsening pain, or other symptoms that concern you.
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ year old man with relapsed oropharyngeal
cancer who presents with bleeding from the mouth, increased
pain, and poor nutritional intake. He had a CTA head/neck that
ruled out any tumor invasion of blood vessels, and the bleeding
stopped spontaneously. He was admitted for pain control; seen by
palliative care team; and had his regimen adjusted as below
before discharge. His nutritional intake is poor, but the
patient declined inpatient placement of a PEG tube and preferred
to have this arranged as an outpatient by his oncologist.
#Pain control
Outpatient pain regimen not providing adequate control.
Palliative care team consulted. Increased fentanyl patch to
100mcg. Started gabapentin 300mg TID for neuropathic pain.
Continued home magic mouthwash. Plan to see ___ care in
clinic for follow up.
#Poor oral intake
Has had very poor PO intake secondary to pain with swallowing.
Seen by our inpatient nutrition team and found to be at risk for
malnutrition. Given multivatimin with minerals, thiamine, Ensure
supplements. G-tube/PEG tube has been discussed as outpatient,
though patient was not amenable until now. Per patient
preference, deferring G-tube/PEG placement to
outpatient setting.
#Oropharngeal cancer
Scheduled to be discussed next week in multi-disciplinary tumor
board per patient. Outpatient oncologist and ENT made aware of
admission via email. Scoped by ENT in the ED and CTA performed;
no concern for vascular invasion by tumor. He will follow up
with ENT at ___ in early ___ in clinic.
#Hypothyroidism
Continued levothyroxine 100mcg daily
#Bleeding from mouth
Source unclear, likely provoked by valsalva, seen by ENT who
felt
like patient could have been discharged to home from a bleeding
standpoint. Imaging not consistent with a bleed from a major
vessel and he is no longer actively bleeding. CBC remained
stable throughout the admission.
-Contact: wife ___
-Code status: full code (confirmed) | 151 | 293 |
13151205-DS-6 | 20,588,914 | Dear Mr. ___,
You were admitted to ___ after
you fainted in your doctor's office. Prior to that, you had been
feeling some chest pressure while going up and down the stairs,
which is unusual for you.
While you were here, we did a CT scan and discovered that there
was a clot in your lung. As you did not feel great on the
Everolimus (Zortress), we decided to stop Everolimus (Zortress).
We then started you on a blood-thinning medication known as
Apixaban (Eliquis) to prevent more clots from forming.
Since we stopped your Everolimus (Zortress), we started another
medication, Mycophenolate Mofetil (Cellcept), to try to prevent
your body from rejecting your liver transplant. You received the
first dose while you were with us, and pharmacy has also
delivered it to your bedside. In addition, we went up on the
dose of your Tacrolimus; it is now 11 mg twice a day. You will
need labs drawn and faxed to Dr. ___ this ___
___.
It was a pleasure taking care of you, and we wish you well.
Sincerely,
Your ___ care team | Mr. ___ is a ___ avid ___ s/p liver transplant in
___ for Hep C cirrhosis complicated by ___ who presents with
syncopal episode and chest pressure, found to have unprovoked
right lower lobe segmental and subsegmental pulmonary embolism
and ___.
# Unprovoked Pulmonary Embolus: Segmental and subsegmental PE in
RLL seen on CTA on ___, hemodynamically stable throughout stay.
Everoliumus is typically associated with arterial thrombus.
However, given that patient has had significant fatigue since
being started on everolimus, Cr seemed to have increased after
being started on it, and now he is presenting with with new
episode of VTE, decision was made to stop this medication. As
for risk factors for VTE, the only risk factor that Mr. ___
has is decreased activity level. He is s/p liver transplant (___
not an issue now, no known prior mets). As such, we would
consider this to be an unprovoked PE, and per most recent CHEST
guidelines this would warrant indefinite anticoagulation. Choice
of anticoagulant could be dabigatran, newer anti Xa agents, or
warfarin for patients without cancer. We offered him option of
apixaban versus warfarin given his ___. He was counseled that
this agent does not currently have a reversal agent, but also
that he would not need INR checked, as opposed to warfarin. He
stated that he would rather not have regular INR testing. As for
hypercoagulable work up, this can be discussed as an outpatient
if he is interested, as he just had an acute thrombus.
# s/p OTL in ___: He was switched from Prograf to Everolimus
on ___ due to memory issues. Everolimus was discontinued during
this stay due to concern for side effects and new PE. He was
started on mycophenolate mofetil 500 mg BID on ___, day of
discharge. During his stay, tacrolimus was increased from home 8
mg BID to 10 mg BID due to persistently subtherapeutic troughs.
However, trough was 4.6 despite 10 mg BID, hence he will be
discharged on further increased dose of tacrolimus 11 mg q12H.
Everolimus has no known interactions with tacrolimus so its
discontinuation should not have affected his tacrolimus troughs;
it is somewhat perplexing that he requires such high doses. He
will need repeat labs (LFTs, tacrolimus level, BMP) drawn on
___.
# Chronic RUQ/flank pain: Now with segmental and subsegmental PE
in RLL on CTA on ___. Has had previous CT chest on ___
showing no parenchymal or pleuritic lung disease and no rib
fracture. He was also seen by ___ (cardiologist) on
___ for chest discomfort where it was not felt to be anginal.
MRI ___ with no clear etiology of his pain. Given that he is on
high dose of opoids and was very constipated (resolved with
colonoscopy prep), discussed that pain clinic might be
appropriate for management of his chronic pain.
# ___: peak Cr was 2.2 from baseline of 1.1-1.6. He received
bolus IV normal saline and his creatinine improved, 1.4 on
discharge. He will need repeat labs drawn on ___.
# HCV: s/p treatment with Harvoni on ___. Undetectable VL as of
___.
# Overactive bladder: Weak stream, frequency, urgency, and
nocturia since liver transplant. Seen by urology on ___,
thought to be due bladder overactivity and was started on
oxybutynin, which has helped his symptoms. He and his wife
report that his lower urinary tract symptoms started after his
transplant, and would like further investigation. Follow up
appointment was scheduled with urology.
#Latent TB: Hx +PPD. Continued home isoniazid ___ daily and home
pyroxidine.
#Insomnia: Continued home trazadone 100 mg QHS PRN. | 177 | 588 |
12176298-DS-16 | 27,647,301 | Dear ___,
___ was a pleasure taking care of you during your hospitalization
at ___. You were admitted because difficulty breathing and
collapse of part of your lung. You had bronchoscopy with
removal of mucus plugs from your lungs. Subsequently your
collapsed lung opened up. While you were here you finished a
course of treatment for a prior pneumonia.
Please STOP Piperacillin-Tazobactam (Zosyn). You have finished a
course of this antibiotic for pneumonia during this admission.
Otherwise we have made no changes to your medications. | ___ with hx of squamous cell Pancoast tumor s/p right upper
lobectomy with chest wall resection and vascular reconstruction,
with post-op respiratory failure s/p tracheostomy, admitted for
RLL collapse noted at rehab facility.
.
# RLL Collapse: Patient was having difficulty weaning from
ventilator at rehab facility and was noted to have RLL collapse
on CXR. Patient had bronchoscopy which showed mucus plugging in
RLL as well as purulent secretions in the RML and RLL. BAL was
performed in the right lower lobe and was sent for routine gram
stain, culture, and fungus culture. Secretions were
aggressively suctioned and removed. Post-bronch CXR showed
expansion of RLL. Patient will benefit from continued aggressive
sectioning and pulmonary toilet at rehab. Patient completed her
course of Zosyn for Achromobacter species with course ending on
___.
.
# RLL PNA: Patient previously grew resistant Achromobacter from
sputum samples requiring Zosyn therapy with course completed on
___.
.
# Pyuria: Patient has been on maintenance zosyn therapy for PNA
as above. UA with many WBCs and few bacteria. Zosyn was thought
to cover for any potential UTI. Urine culture pending at the
time of discharge.
# Hypertension: Continue furosemide and metoprolol
# HLD: continue simvastatin
. | 88 | 200 |
11534190-DS-3 | 22,426,859 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Weightbearing as tolerated right lower extremity, no hip
precautions
Treatments Frequency:
Staples to be removed at 2-week follow-up appointment | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right periprosthetic hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for surgical fixation of the right
periprosthetic hip fracture, 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
weightbearing as tolerated in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 580 | 260 |
16485876-DS-19 | 23,826,329 | Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted to the hospital for weakness due to the spread of
cancer to your spine. Your symptoms improved with steroids and
radiation. You will continue to get steroids and radiation
treatments while you are in rehab. You were also found to have
cancer in your brain and will follow up with Dr. ___ in the
brain tumor clinic as scheduled. | BRIEF SUMMARY
=============
___ year old male with a history of multiple medical problems
including prostate adenocarcinoma with prominent small cell
features s/p radical prostatectomy in ___, small
cell/adenocarcinoma of the lung s/p R VATS/upper lobectomy ___ and chemotherapy, s/p prophylactic WBRT ___, known bone
metastases of unknown primary who presents with back pain
Xseveral months and RLE weakness/numbness X 3 weeks with
inability to bear weight in the last few days. Patient is found
to have cord compression in the t- and l-spine and new brain
mets on MRI.
ACUTE ISSUES
============
# Cord compression: The patient presented with lower extremity
weakness and was found to have saddle anesthesia and poor rectal
tone on exam. MRI showed compression of the spinal cord due to
bony metastases in the spine. No surgical intervention was
warranted given the diffuse nature of the disease. The patient
received daily radiation and high dose steroids and had return
of some function of his right lower extremity. He will complete
a steroid taper as an outpatient and will complete a total of 10
radiation treatments (last day ___. He was discharged
on a 3-week taper as follows: 4 mg BID ___, 4 mg PO daily
x 4 days, 2 mg PO daily x 4 days, 2 mg PO every other day x 4
days.
# Brain metastases: The patient was found to have metastatic
lesions in the brain. He was asymptomatic from these lesions but
an MRI was done to assess for further CNS spread given the
disease of the spinal cord. The patient is s/p prophylactic
whole brain radiation in ___. He will follow up in clinic
with Dr. ___ on ___ for repeat MRI and consideration for
possible cyberknife.
# DMII: Hyperglycemic 200s-300s this admission due to h/o DM2
and high dose steroids for cord compression. Per endocrine
recommendations, increased sliding scale and long acting
insulin. Will need blood glucose closely monitored as steroids
are tapered.
# LFT abnormalities: Mild transaminase elevation (50s-80s).
Viral hepatitis serologies were negative. Pt without abdominal
complaints, possibly medication induced from high dose
dexamethasone. Liver metastases possible.
CHRONIC ISSUES
==============
# Prostate cancer with small cell features, small
cell/adenocarcinoma of the lung s/p resections, bone metastases.
Case re-reviewed by ___ pathology and it was thought that the
tumor was primary prostate cancer with small cell features.
# CAD s/p LAD stent: Patient is not on ASA due to history of
thigh bleed (date unclear). He was continued on diltiazem,
diovan, isosorbide mononitrate.
# COPD, OSA on CPAP - Patient was continued theophylline and
CPAP.
TRANSITIONAL ISSUES
===================
-Daily spine radiation: Except weekends, last day ___
-Hyperglycemic this admission due to DM2 and high dose steroids.
Will need close blood glucose monitoring while steroids are
tapered.
-Patient discharged on PO dexamethasone taper. Please notify
outpatient neuro oncologist Dr. ___ ___ if
develops lower extremity weakness or other concerning
neurological symptoms
-Patient's daughter was provided with brain MRI report
-Patient will see Dr. ___ in brain tumor clinic ___ for
brain MRI and Cyberknife consideration
-Patient has follow up appointment scheduled with outpatient
medical oncologist Dr. ___ for ___
CODE STATUS: Full Code | 73 | 507 |
19907318-DS-11 | 22,468,325 | You were admitted with abdominal pain and found to have
pancreatitis, or inflammation in your pancreas. It is unclear
as to why you developed pancreatitis. You have improved
rapidly, and you will be discharged today. You can continue on
a full liquid diet, and start to eat more foods as you feel
better. Since you are eating a bit less, we are cutting down
the amount of insulin that you are using.
Please check your blood sugar before meals, and record the
readings. If you are unable to do so, the ___ can check your
blood sugar when they come to see you.
You have a cyst on your pancreas, and so you will need to return
on ___ for an endoscopic ultrasound so that we may get a
better look at the cyst and then figure out if it needs to be
drained.
If your pancreas is inflamed it is important to avoid alcohol. | ACUTE/ACTIVE PROBLEMS:
#ACUTE PANCREATITIS
Appears to be idiopathic, as ___ is s/p CCY, has no clearly
offending medicines, triglycerides are low.
___ does have a pancreatic cyst seen on imaging; discussed with
advanced endoscopy team and they advised f/u with Dr ___
EUS, which was arranged prior to discharge.
___ was started on a clear liquid diet and advanced to full
liquids, and ___ preferred to remain on full liquids to "take it
easy".
His abdomen remained soft, ___ felt that the oxycodone that ___
used for back pain treated his mild abdominal pain as well.
DARK STOOLS: Guiaic negative, ? due to pepto bismol use at
home, not anemic on arrival to ED.
ATRIAL FIBRILLATION CHA2DS2VASC =4
? complicated by splenic infarct
Resumed Coumadin in house; confirmed with outpatient providers
that ___ Home Calls manages his Coumadin dosing. | 162 | 132 |
11142491-DS-10 | 28,833,979 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. As you know, you were admitted under observation
status because of calf pain. You were found to have a hematoma
in your left soleus muscle. Your hematoma remained stable on
repeat imaging and you had no evidence of compartment syndrome.
You were cleared by our physical therapy service and were
medically safe for discharge home.
Because of your hematoma, your warfarin (Coumadin) was briefly
held. It was restarted on ___. Your discharge dose is 5 mg
daily. Unfortunately, you declined to take warfarin on the day
of discharge. We strongly advised you to take warfarin in order
to treat your DVT and prevent serious complications of DVT,
including a blood clot traveling to your lungs. Please continue
warfarin at 5 mg daily when you go home. It is very important
that you have your INR rechecked on ___.
We made the following changes to your medications:
- CHANGE coumading (Warfarin) to 5 mg daily
- STOP Percocet
- START Vicodin | Ms. ___ is a ___ woman with DM and a three week history
of calf pain. She was found to have a RLE DVT on ___ and was
started on coumadin with an enoxaparin bridge. She represented
with left calf pain and was found to have a left soleal
hematoma.
ACTIVE ISSUES
1. Left Soleus Muscle Hematoma: Patient was found to have a
soleal hematoma in the setting of anticoagulation for a RLE DVT.
Her left calf pain preceded the hematoma, which raised concern
for tendonitis vs. tendon rupture, given that she was taking a
fluoroquinolone at the time she started a vigorous stretching
regimen for her calf pain. She underwent an MRI, which did not
show evidence of tendon rupture. Her anticoagulation was briefly
held. She was monitored for clinical signs of compartment
syndrome, which did not develop, and her pain was controlled
with Vicodin. She was seen by the physical therapy department
who cleared her for discharge home with a cane, which was
provided. She underwent a repeat LLE ultrasound on the day of
discharge showing stability of her hematoma, and she was
medically safe for discharge home. When her MRI final read
returned after discharge, it advised follow-up imaging to ensure
that the hematoma was not provoked but an underlying focus of
metastatic disease, given no traumatic etiology of hematoma was
identified on history. These recommendations were communicated
to the patient and to her PCP by Dr. ___.
2. RLE DVT: Patient was diagnosed with a RLE DVT on ___. She
was seen by Dr. ___ of ___ on day of admission.
DVT was thought to be provoked given recent inactivity, and no
further hypercoaguability work-up was advised. Prior to her
appointment with Dr. ___ self-discontinued raloxifene
given concerns it could be contributing to a hypercoaguable
state. Patient was advised to continue anticoagulation for three
months. Her anticoagulation was briefly held in the setting of
working up new left soleus hematoma. On ___, patient was
advised to restart warfarin at 5 mg daily (a reduction from the
7.5 mg daily she had taken prior to admission, at which time her
INR was > 3). She declined to take 5 mg due to concern about
further bleeding but agreed to take 2.5 mg after extensive
discussion. On ___, the day of discharge, patient was advised
to take 5 mg of warfarin. She refused to take warfarin in any
dose. She was counseled extensively on the risks of not treating
DVT, including pulmonary embolism. She demonstrated the capacity
to refuse medications. She was encouraged to restart warfarin
after discharge and to follow-up with the ___
clinic for monitoring of her INR. We explained that given the
stable size of the hematoma even with a therapeutic INR and the
benefit>risk of treating her DVT that she should remain on
coumadin and that she has close PCP ___ that she was medically
ready for discharge on ___.
3. Hematuria: Patient reported gross hematuria on the morning
___. She declined to provide a urine sample, stating that the
hematuria had only occurred once and, as an NP, she did not
think a UA was necessary. She was counseled on the importance of
investigating hematuria. She agreed to provide a urine sample on
___, which was negative for blood.
4. Anxiety: The patient was tearful at times and very worried
about her medical conditions. She said many times that she was
not interested in speaking with social work.
CHRONIC ISSUES
1. History of MRSA: MRSA was cultured from a left superficial
breast cyst in ___. Per hospital policy, patient was maintained
on contact precautions.
2. Diabetes Mellitus: Last A1c 6.9% on ___. Continued on
glargine, ISS, enalapril, and pravastatin.
3. GERD/Duodenal Ulcer: Continued pantoprazole 40mg daily.
4. Hypothyroidism: Last TSH 2.5 on ___. Continued
levothyroxine 100 mcg daily.
5. Osteoporosis: Continued calcium and multivitamin.
TRANSITIONAL ISSUES
- Needs follow-up imaging after resolution of hematoma to ensure
it was not caused by an underlying soft tissues mass
- Encourage patient to restart warfarin and continue
anticoagulation for 3 months for provoked DVT
- Encourage close monitoring of INR with ___
clinic | 172 | 683 |
18743813-DS-10 | 20,689,768 | You had a the leads extracted on your pacemaker (which was
removed in ___ because they were infected. You were
started on antibiotics and blood cultures were followed closely
because you had a fever after the extraction. A PICC Line was
placed when your blood cultures were negative for 72 hours after
your fever, and you will continue with IV antibiotics for six
weeks. Your last dose will be on ___ unless modified by
Infectious Disease at your follow up appointment.
You will follow up with Outpatient Infectious Disease (appt.
info below). You will have weekly labs sent to the ___
___ at ___. This will consist of a CBC with
differential, BUN, Creatinine, ESR and CRP. This will ensure
your blood counts, kidney function and inflammatory markers are
followed closely while you are on antibiotics.
You will follow up with Dr. ___ on ___
(appt. info below)
You should also follow up with your PCP ___ 30 days or if
your headaches continue or worsen. A prescription for Fioricet
has been provided.
Care of the ___ site and restrictions will be provided by your
Infusion Services who will perform dressing changes.
Activity restrictions and care of the incision site are included
in your discharge instructions.
You have been given an updated list of current medications.
It has been a pleasure to have participated in your care. If you
have any questions that are related to your recovery from your
procedure or are experiencing any symptoms that are concerning
to you, please call the ___ HeartLine at ___ to speak
to a cardiologist or cardiac nurse practitioner. | The patient was admitted ___ for an infected pacemaker
pocket following his generator removal on ___. At that
time, he had a TMAX of 100.5 with swelling and discomfort at the
pocket site. The wound was opened and drained by Plastic
Surgery, pus was seen. He was started on empiric antibiotics
which consisted of Vancomycin 2 grams IV in the ED, then 1.5
grams every 8 hours. Blood and wound cultures were sent.
Preliminary wound culture showed coag positive staph aureus and
he was changed to Cefazolin 2 grams every 8 hours. Infectious
Disease was following the patient. They recommended a 4 week
period of IV antibiotics, with a date for PICC line insertion 48
hours after blood cultures had especiated with a final culture
or his last daily culture following his fever were negative.
His inflammatory markers were followed every two days.
He underwent extraction of the leads on ___ and developed a
post operative fever to a TMAX of 102.4. He was given a one
time dose of Vancomycin and Ceftazadime. Blood cultures were
redrawn and were especiating Gram + cocci in clusters. ID was
reconsulted and recommended continuance of Cefazolin and repeat
cultures daily. His TMAX was 100.9 on ___ and cultures were
again drawn. These were followed closely and it was decided to
continue with antibiotics for a six week period following the
first culture post fever which remained negative for 48 hours
(this was the ___ 5 am culture). He had no further fevers,
with a tmax of 99.4, and continued to take Fioricet PRN for his
headaches. MRI was done following complaints of persistent
headache which revealed only paranasal sinus disease. His CRP
was declining at the time of discharge. ESR were send out labs
and were not finalized until post discharge. A PICC line was
successfully inserted on the day of discharge and he was
discharge to home with infusion services. He will have weekly
labs faxed to Infectious Disease outpatient clinic to include
CBC w/differential, BUN/Creatinine, ESR and CRP. He will be
seen in follow up and an appointment scheduled prior to his
discharge (included in discharge worksheet). He will have early
follow up with Dr. ___ as well. | 263 | 385 |
13188363-DS-24 | 24,879,827 | * You were admitted to the hospital with bleeding from your GJ
tube and rectal bleeding. The gastroenterology service had to
remove the GJ tube ___ order to do an endoscopy and they found
that the tissue was friable and there was a small opening at the
old staple line of the stomach. You remained hospitalized for
surgery to reconnect your esophagus to your stomach and had
multiple post op problems causing a very long hospitalization
and multiple surgeries.
* Due to the friable tissue ___ the stomach and bleeding history,
your systemic anticoagulation was stopped and an IVC filter was
placed ___ radiology to prevent any clots from migrating. This
can be removed when it is no longer necessary. Your Xarelto was
stopped
* You should continue your tube feedings so that you receive
100% of your caloric needs and you can eat soft foods as
tolerated.
* Continue to increase your activity to get stronger and improve
your endurance.
* You should shower daily to clean your wounds and just pat dry.
The left neck wound can remain uncovered as long as its dryng
up.
* You will need to return to see Dr. ___ ___ the out
patient clinic as well as the plastic surgery team and
Cardiology for pacemaker checks. | Mr. ___ was evaluated by the Thoracic Surgery service ___ the
Emergency Room and admitted to the hospital for further
evaluation of his coffee ground drainage from his G tube and his
melena. The gastroenterology service was consulted and took him
to the GI unit for an endoscopy. The GJ tube had to be removed
first and a scope was inserted into the tract which demonstrated
some dehiscense of the gastric staple line and the tissue
appeared very friable, some bleeding. A g tube was placed ___
the tract with plans for ___ replacement of his GJ tube the
following day. His hematocrit was stable but anticoagulation
had to stop ___ light of the findings.
After a long discussion with the patient, vascular surgery and
___, plans were made to place a GJ tube ___ ___ along with an IVC
filter. These 2 procedures were done on ___ without
difficulty. He returned to the surgical floor and was evaluated
by the General Surgery service as plans for a colon
interposition needed to be persued sooner than later given the
endoscopic findings. A colonoscopy was done on ___ to
assure that there was no pathology ___ the colon that would
preclude using it for surgery. The test demonstrated a normal
colon.
His GJ tube was functioning well with the G port to gravity and
the J port for feedings. No crushed meds were given via the J
tube so as not to risk clogging the tube and the G portion must
remain vented given the small area of dehiscense. He continued
on Vancomycin, Micafungin and Cefepime which was treating his
intrathoracic fluid collection which grew ___ albicans and
___. ___ early ___ during this time period, he also had
an acute kidney injury for which nephrology was consulted. His
fluid status was optimized and the most likely etiology was felt
to be contrast nephropathy; this ___ improved gradually over
time.
Surgery was planned for ___ after extensive discussion with
the patient, his family, and consulting services including
medical ethics and social work. ___ the interim period his major
issues were related to chronic pain and psychiatric conditions,
perhaps heightened by concerns regarding his upcoming surgery.
After multidisciplinary discussions, the patient was maintained
on Valium and Seroquel along with Oxycodone and Gabapentin.
On ___ he was brought to the operating room and underwent
right thoracotomy and completion esophagectomy, takedown of
cervical esophagostomy, retrosternal gastric
conduit and cervical esophagogastric anastomosis, with left
sternocleidomastoid muscle buttress to anastomosis, and
jejunostomy tube placement. The surgery was uncomplicated.
However, during the operation a high degree of heart block was
noted and treated with epinephrine. For full details please see
the operative note by Dr. ___. Post-operatively he was
brought to the ICU for further management. Given his intra-op
cardiac findings and continued arrhythmia ___ the ICU setting,
cardiac electrophysiology was consulted. Temporary pacing wires
were placed on the evening of POD0 due to continued concerning
arrhythmia ___ the post-op setting. This arrhythmia and complete
heart block later appeared to resolve to a physiologic LBBB and
pacing wires were removed on ___. On ___ his tube feeds were
advanced to goal, his operatively placed NG tube was removed,
and he was extubated. On ___ he then became tachycardic,
respiratory status declined such that he required reintubation,
and his neck drain was found to have an amylase of 5131,
suggestive of a leak from within the operative site. On
___, he had 2 brief episodes of asystole with immediate
CPR and ROSC and temporary wires were replaced. A chest tube was
placed at bedside on ___ for R pleural effusion.
On ___, the patient was brought back to the operating room for
T tube and wound vac placement ___ an effort to stent the area of
breakdown that had been leading to salivary leakage into the
neck wound. He was brought back to the ICU post-operatively.
From a pulmonary perspective, he was found to have increased
secretions and resistant Klebsiella pneumonia and antibiotic
therapy was adjusted appropriately with infectious diseases
involvement. The patient was weaned to extubation on ___. Local
wound care continued and he was able to be transferred to the
thoracic surgical floor on ___. He had initially had some
post-operative delirium, but as this improved the patient had
increasing episodes of agitation and aggression, including
verbal abuse toward staff and psychiatric codes, while on the
surgical floor. Psychiatry was re-involved and medications were
adjusted per their recommendations. Despite continued careful
neck wound care with involvement from the wound nurse team, the
patient continued to have significant leakage of neo-esophageal
secretions from the neck wound. He was therefore brought back to
the operating room on ___ for an EGD and neck exploration. The
mucosa appeared healthier than prior and the stomach was
re-secured around the T tube and the wound bed debrided.
The patient then returned to the surgical floor. He was seen by
___ and noted to have no further ___ needs at that time, given
that he had now recovered to the point of ambulating
independently. Wound care continued. Cardiac electrophysiology
continued to see the patient and evaluate his temporary
pacemaker since its replacement on ___, with eventual
discontinuation of pacemaker on ___. Of note, during this time
on the surgical floor the patient was intended to remain NPO
with nutrition delivered via tube feeds delivered by the J tube.
However, despite understanding of his diet order the patient was
noted to be noncompliant and was frequently found to be
ingesting liquids including water and apple juice. Psychiatry
was again consulted and remained unclear to what extent these
behaviors were rooted ___ long-standing impulsive and
self-destructive behavior vs. residual delirium. A rehab
facility screen was initiated ___ late ___.
On ___, Mr. ___ underwent a neck exploration, pectoralis
flap coverage, and STSG given continued leakage from his
anastomosis (please see operative report for additional
details). He was kept intubated and sedated for several weeks
following ___ order to allow for engraftment of the flap given a
baseline level of delirium as well as need for ongoing
procedures. ___ particular, Mr. ___ underwent several bedside
EGDs which demonstrated a small area of breakdown of the
anastomosis anteriorly. This fistula continued to be productive
of copious secretions through the medial portion of his
pectoralis flap and a salivary drain stent was subsequently
placed to aid with healing. This appeared to markedly decrease
the quantity of his secretions. He also had a dehiscence of the
medial side of his flap and additional sutures were placed to
repair the defect. He was additionally treated with antibiotics
(vancomycin) for a slight cellulitis adjacent to the flap which
appeared to improve once better control of his fistula was
obtained. Throughout this time, Mr. ___ remained otherwise
hemodynamically normal and tolerating tube feeds via his Jtube.
He was briefly extubated ___ late ___ prior to being
reintubated for a repeat EGD. He remained intubated and ___ the
ICU post procedure given continued need for additional
procedures and to ensure optimal stent placement and NPO status.
Over time, the edema from the flap closure was decreasing but he
still had some drainage medially. He returned to the OP on
___ for additional sutures to close the wound and
application of a Prevena dressing. That was the final
intervention on the flap. The drainage gradually decreased and
he had a chest/abd CT scan which ruled out a leak. He began
sips of clear liquids and although he had some drainage from the
medial flap, it gradually slowed over time. Dressing were
removed, his diet was advanced to soft but he had one small
tract draining liquid and air from the medial upper flap. He
remains on tube feedings, getting 100% of his caloric needs as
his oral intake is modest at best. His flap appears healthy as
does the STSG from the right thigh. He last returned to the
Operating Room for some additional sutures on ___ and since
then he has remained strict NPO. His dressing is dry and for
that reason he will continue to remain NPO until he sees Dr.
___ ___ follow up. This will allow more time for healing
of the fistula.
His cardiac issues included high grade AV block, a left bundle
branch block and parozysmal atrial fibrillation. A temporary
pacing wire was ___ place with plans to place a permanent
pacemaker when all of his surgical issues resolved and
antibiotic therapy was completed. He underwent placement od a
dual chamber pacemaker on ___ and removal of the screw ___
lead. He subsequently had some sinus bradycardia ___ the ___ on
___ with non capture of the ventricular lead. He returned
to the cath lab of ___ for revision and has since that time
has done well. His pacer site is healing well and he will get a
follow up appointment with Dr. ___ also ___ the device
clinic.
Behavorial and psychiatric issues have been long standing pre op
and continue now though he is much more reasonable and managable
now. He has been followed by the psychiatric service throughout
his stay and most recently has been weaning from his Seroquel.
The chronic pain service helped with weaning him off of IV
narcotics but he will need to continue weaning his short acting
opiods. He has multiple complaints of back pain and hip pain
prior to admission and was on a significant amount of Oxycodone
and Oxycontin before this illness. He will eventually need a
pain management clinic to help with weaning. He has not received
Seroquel ___ weeks but it is listed as a prn. His most recent
change was increasing his Gabapentin to 900 mg at hs and
scheduling Tylenol. He cannot get any crushed medications down
the J tube so as not to clog his "lifeline".
His tube feedings were changed a few days ago to Nepro at 60
cc's/hr from Jevity 1.5 at 55 cc's/hr as his phosphorous and
potassium were elevated. His BUN was also 36 and the amount of
free water was increased to 100 cc's q 4 hrs. He should have a
chem 10 checked on ___ to follow.
He was discharged to rehab on ___ for management of his J
tube feedings, maintaining NPO and increasing his activity. See
follow up appointments listed on page 1. | 209 | 1,721 |
11449283-DS-28 | 21,412,839 | Ms. ___,
You were admitted to the hospital with a pneumonia. You were
treated initially with broad antibiotics, and subsequently with
one antibiotic, levofloxacin, which you should continue through
___.
You imaging also revealed an abnormality in your lung, the
management of which you have discussed with Dr. ___. | Ms. ___ was admitted to the hospital with pneumonia and new
suspicious nodules seen on chest CT. She was initially covered
broadly for HCAP with Vanc, cef, azithro given recent
hospitalizations. Once afebrile 72 hrs, she was narrowed to
levoquin monotherapy to complete a 7 day course.
She will followup with Dr. ___ in one week for further
imaging/management of the new lung lesions. | 48 | 63 |
18172623-DS-21 | 26,725,964 | Dear Mr ___,
It was a pleasure meeting you and taking care of you during your
recent hospitalization at ___.
Unfortunately, you were admitted to the hospital because you had
an aspiration event that caused inflammation in your lungs and
caused your oxygen levels to drop dangerously low.
You were treated with antibiotics for both your lung infection
and the wound on your left leg. The wound on your leg was seen
by Vascular Surgery and a wound vac was removed, and you were
continued on your antibiotics.
While you were in the hospital, your oxygen levels dropped, and
you were transferred to the ICU and treated for a pneumonia that
was probably related to aspiration. Your oxygen levels and chest
X-ray improved, and you were transferred back to the regular
hospital floor.
Because you were very somnolent, some of your pain medications
were stopped or reduced, and then, when your oxygen levels and
somnolence improved, some of these medications were added back.
Chronic aspiration remained a constant problem throughout your
admission and was the cause of two significant drops in your
oxygen levels. You were seen by the speech and swallow team, who
instructed you in safe methods of reduce the risk of aspiration,
though these methods will not eliminate aspiration entirely.
After an in-depth discussion of the risks of recurrent
aspiration and low oxygen, including the risk of needing
intubation (a breathing tube) in the event of a severe
aspiration event, you opted to continue to eat with minimal
dietary modifications because you felt strongly that it was
important for your quality of life.
It has been a pleasure to be involved in your care!
Your ___ Care Team | This is a ___ year old male with past medical history of prior
pontine stroke, chronic dysphagia, CAD, chronic pain on chronic
opiate regimen, chronic R lower extremity osteomyelitis admitted
___ with acute hypoxic respiratory failure secondary to
aspiration pneumonia, course complicated by type II NSTEMI,
recurrent aspiration events attributed to acute metabolic
encephalopathy secondary to opiate regimen combined
with chronic dysphagia, stabilized and able to be discharged to
rehab
# Acute on Chronic Hypoxic respiratory failure
# Dysphagia with recurrent aspiration
Patient initially presented to ___ with hypoxia
to mid-80s on 2L, then was transferred to ___. CXR was
concerning for new LLL PNA. Given recent healthcare exposure,
he was treated with broad spectrum antibiotics given concern for
resistant organisms. Given known dysphagia, there was high
suspicion for aspiration as etiology. The patient was evaluated
by Speech & Swallow team during his admission and determined to
be at very high risk of recurrent aspiration. Their impression
was that all oral intake was deemed risky based on review of a
video swallow study performed this admission. This was discussed
at length with the patient and daughter, including the risks of
recurrent aspiration which include severe hypoxemia, pneumonia
or even death. Course was notable for recurrent aspiration
events--in particular these were felt to occur during settings
of encephalopathy due to his sedating pain regimen (see below).
Etiology of aspiration was felt to be multifactorial from
dysphagia ___ prior stroke and opiate induced encephalopathy.
In setting of several discussions, the patient and his
daughter/HCP ___ repeatedly stated that they understood
these risks but that "him being able to eat whatever he wants"
is vitally important to his quality of life so they wished to
continue with him receiving a regular diet (understanding that
when aspiration events occur and hypoxemia results, that
nutrition will need to be temporarily paused while his
respiratory status is stabilized, with reintroduction to diet as
possible). Of note, his course was complicated by recurrent
aspiration events with resulting hypoxemia that would
subsequently resolve over hours. In above discussions, patient
and daughter agreed he wanted to remain full code.
# Acute toxic encephalopathy secondary to opiates
# Chronic Leg pain, bilateral
Significant somnolence was a substantial issue for him during
this admission, and also a significant contributor to his risk
of aspiration. Felt to be secondary to his pain medication
regimen which included high doses of methadone as well as
oxycodone and baclofen and gabapentin, as prescribed by
outpatient pain physician and PCP. During his admission his
oxycodone was discontinued, gabapentin dose reduced, and
methadone dose reduced. We increased his Tylenol dose and added
lidocaine patches to his legs. He should NOT be restarted on
duloxetine (Cymbalta) due to intolerance per his daughter. His
pain remained well controlled and his encephalopathy resolved.
# Hypertension: Patient had labile blood pressures this
admission, with both episodes of hypertension and hypotension.
His regimen was uptitrated to lisinopril, carvedilol. If
requires additional anti-hypertensive agents in the future,
would consider spironolactone, amlodipine, isosorbide dinitrate
/ hydralazine
# Chronic R Leg Osteomyelitis: The patient was recently admitted
at ___ on ___ for a right calf wound debridement with
VAC placement. Wound cultures were positive for polymicrobial
MDR growth (including pseudomonas and MSSA) and patient was
discharged to his rehab facility on IV Zosyn. This admission,
his wound was evaluated by vascular surgery who felt that it was
healing well and that the VAC could be removed and wound could
be treated with daily dressing changes with 4x4 gauze and tape.
VAC removed ___. He will follow up with Dr. ___ on
___ ___s infectious disease clinic on ___. Per the
recommendations of the infectious disease team, he should
continue Zosyn until ___ (start date ___.
# NSTEMI: In setting of aspiration and hypotension (as above),
he was found to have elevated troponin to ___epression/elevation of Twave changes. TTE showed mild regional
left ventricular systolic dysfunction with severe hypokinesis of
the basal inferior and inferolateral walls. The remaining
segments contract normally (LVEF = 45-50 %), overall felt to be
c/w ischemia in PDA distribution. He seen by cardiology who
recommended medical management for NSTEMI. Optimized blood
pressure as below. He should follow up with his outpatient
cardiologist.
# ___: His course was complicated by ___ with peak creatinine of
2.0 on ___, which improved to baseline of 0.9 by day of
discharge. Deemed to be prerenal given improvement with IVF. | 275 | 743 |
18551091-DS-43 | 23,990,906 | Mr. ___,
You were admitted to the hospital due to volume overload. This
is related to your ___ failing. You were aggressively diuresed
here in the hospital with intravenous lasix and then we
transitioned you to oral torsemide. You will need continued
monitoring of your weight at home as well as continue on a low
salt diet and a 2 liter fluid restriction. You will likely need
intravenous lasix again in the future but our ability to use
this medication is limited by your blood pressure.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your discharge weight is 51.8 kg (114 pounds).
We wish you all the best. It was a pleasure taking care of you
here at ___. | The following issues were addressed over the course of the
hospital stay:
# Dyspnea secondary to acute diastolic CHF exacerbation given
elevated JVP, crackles, increased ___ edema, elevated JVP and
weight gain (61.8kg from 54.4 kg on prior). Cause is most likely
due to his end stage diastolic ___ failure that is
progressive. Trop is negative with no significant EKG changes or
chest pain. No increased cough or sputum production to suggest
COPD exacerbation. This patient was treated with a lasix drip at
5 mg/hr and then transitioned to PO torsemide 20 mg/day. His
discharge weight was 52.5 kg. He also had a diagnostic and
___ thoracentesis which revealed trasudative effusion
negative for malignancy on the right side. Approximately 3.5 L
drained and patient did not require oxygen upon discharge.
However, it is expected that this pleural effusion will
reaccmulate given this patient has end stage ___ failure.
There is known effusion on the left, but given this is small
this risks of the procedure outweigh benefits and it is the hope
that continued PO diuresis will also improve this effusion. He
should continue taking his weight daily at home, maintain a 2g
sodium restriction per/day as well as a 2L fluid restriction.
# Hyponatremia: Likely hypervolemic hyponatremia from volume
overload and chronic in nature. Discharge sodium was 134.
# ___ secondary to poor perfusion in setting of CHF
exacerbation. Cr improved to 1.1 upon discharge with our
aggressive diuresis.
# Atrial fibrillation: Rate poorly controlled but limited by
hypotension. Metoprolol was increased to 150 mg/day (up from 100
mg/day) here in house. HR's remained in ___ but patient
could not tolerate a higher dose of beta blockade.
His warfarin was held in house x 2 days due to hemoptysis and
ozzing from thoracentesis site. Of note on addmission his INR
was subtherapetic at 1.6. He will need close INR follow-up upon
discharge. He was not bridged with heparin given his bleeding
risk is higher comparied to his daily stroke risk. Dr. ___
___ for anticoagulation was contacted regarding this matter.
# Severe Aortic Stenosis: Lengthly discussion took place between
Dr. ___ outpatient cardiologist), Dr. ___
(___) and Dr. ___
cardiologist) regarding management of this patient in house.
This ___ aortic valve peak gradient is not large (39 mm
Hg) and he has moderate aortic stenosis with valve area of 0.8
cm2. Given this circumstance it was felt that this patient
would not benefit greatly from an invasive procedure such as
balloon valvuloplasty or TAVR procedure and the risks of stroke,
___ attack, bleeding and infection are greater than
potentional benefits especially given . All parties agreed upon
this decision and it was discussed with ___ son and HOP in
addition to the patient.
#COPD: Does not appear to be in acute exacerbation. Wheezes are
likely cardiac. Received IV solumedrol in ED x 1 but given
___ white count stabilized and improved without
antibiotics or prednisone an acute exacerbation was not
supported.
#HTN: Diltiazem was discontinued as ___ BP was stable in
the 90's/50's here in house.
**Please note: This patient is at very high risk for hospital
readmission given his goals of care are full intervention.
Extensive discussion with the ethics committee as well as
pallative care took place over the course of this admission. It
is estimated that this ___ life span is ___ year and we
would support comfort care. However, this patient and his son do
not agree with this approach. At this time, we cannot offer CPR
and Intubation. It is the policy of the ___
___ that no patient should be forced to undergo, nor
should any physician or health professional be forced to
provide, an intervention that
is ineffective or harmful. A medical intervention is ineffective
if there is no reasonable likelihood that it will achieve a
medical benefit to the patient. A medical intervention is
harmful if the likely suffering or risk of other harm caused by
the intervention grossly outweighs any realistic medical benefit
to
the patient.
-------------------- | 123 | 664 |
15191302-DS-12 | 22,467,245 | Mr. ___,
You were admitted to ___ initially for infection of your bile
duct. This caused E. coli bacteria to grow in your blood. You
underwent a procedure called ERCP to relieve the infection in
the bile duct and were treated with antibiotics for the bacteria
in the blood. This infection has improved. While you were here,
you underwent further testing for the potential pancreatic
cancer and multiple myeloma. The results of your biopsy are
pending at the time of discharge, and the cancer doctors ___
___ likely next ___ to discuss the results.
Instructions:
- Inject Lovenox 80 mg every 12 hours to reduced your risk of
stroke with atrial fibrillation. We are using this instead of
warfarin for now given the possibility of needing surgery for
the pancreatic cancer
- Take metoprolol XL 100 mg daily
- Take ciprofloxacin 500 mg every 12 hours for the next 3 days
starting tomorrow | # Cholangitis with E. coli bacteremia/sepsis: ___ w/ CAD, HTN,
DL, MGUS, Polymyalgia rehumatica (off steroids), pAF on VKA,
BPH, MGUS and pancreatic mass concerning for cancer (with
osseous lesions c/f mets vs IGA MM) who p/w 1 day onset of N/V
and epigastric abdominal pain. He was found to have cholangitis
and underwent ERCP ___ with notable pus in existing plastic
stent. This was removed, and a covered metal stent was placed.
Blood cultures from ___ grew E. coli. He was treated with
Unasyn, but this was changed to ceftriaxone based on
susceptibilities. Repeat cultures on ___ were negative,
finalized. He had no further fevers and remained
hemodyncamically stable. | 148 | 110 |
11826927-DS-17 | 26,912,443 | You came to the hospital with headache and dizziness. This was
likely from your chronic shingles infection at your R eye. After
careful examination, it did not appear that you had an
infection. You also had significant itchiness that we have
controlled with a medication called fexofenadine. You have been
restarted on a medication called amitryptiline to help you with
your eye pain.
Your CD4 count was rechecked in the hospital. The level is 6.
This is dangerously low and puts you at risk for
life-threatening infection. This could be improved if you decide
to start anti-retroviral therapy. There are antibiotic
medication that you can take to help prevent these infections
called Bactrim and Azithromycin. You have started these
medications while you were in the hospital. You should continue
to take these medications at home.
You have follow-up appointments with all of your doctors listed
below.
It was a pleasure taking care of you, Ms ___. | ___ year old F with history of AIDS (last CD4 count 6), ESRD on
HD, herpes zoster ophthalmicus c/b post-herpetic neuralgia
presenting with worsening right facial pain with blurry vision,
dizziness, and hypotension.
# Hypotension and dizziness: She was initially admitted to the
ICU with relative hypotension (baseline SBPs ___ and
tachycardia with leukopenia, thereby meeting SIRS criteria.
Since it was unclear if her hypotension was secondary to a
septic process, she was covered broadly with Vancomycin and
Cefepime to cover a ?line infection vs. CNS infection and
acyclovir to prophylactically cover a reactivation of herpes
zoster of her face. She seemed to respond to 3L NS, maintaining
SBPs in low ___, with occasional dips into the ___ without
symptoms. Given her eosinophilia, her cortisol level was
checked to rule out adrenal insufficiency and it was low/normal.
Subsequent stim test showed no adrenal disease. She was seen by
the Renal team and it was decided to stop all antibiotics given
that her BPs were close to her baseline. It was felt that her
increased dose of gabapention may have contributed to her
feeling unwell. She was then transferred to the medical floor.
BP's were stable on the floor, but dropped to 60's-70's systolic
while on dialysis. Patient was asymptomatic and BP's recovered
with 200cc NS bolus. Patient was discharged with normal baseline
systolic BP in 80's-90's.
# Headache with facial itching and blurry vision/Post-herpetic
Neuralgia: She presented with an acute on chronic headache with
acute worsening in the setting of discontinuation of gabapentin.
Although there was a negative fluorescein exam in the ED, we
also asked the Ophthalmology team to evaluate her vision given
her prior history of eye involvement. They did not feel that
there were any acute concerns. Patient was prescribed
fexofenadine for her prurtitis. She also has a presumed
diagnosis of post-herpetic neuralgia. She was represcribed
amytriptiline which she reported has worked for her in the past.
# Rash: Clinically suspicious for eosinophilic folliculiits in
setting of HIV. No vesicular lesions noted, without concern for
disseminated herpes zoster. Primarily has post inflammatory
hyperpigmentation to trunk and extremities, although ? some
active lesions on scalp. Given proximity to facial lesions, with
? herpes zoster reactivation, her pruritus was managed with
fexofenadine 180mg qam, downtitrated to 60mg BID on transfer to
the floor. She was discharged with a prescription for this dose.
# ESRD on dialysis: ESRD ___ HIV on ___ dialysis. She was
continued on sevalemer and cinacalcet.
# Atrial fibrillation: She had one episode of afib during fluid
bolus in ED. Continued management with ASA 325mg daily, without
rate controllers.
# AIDS: CD4 count of 6, off HAART in setting of non compliance.
Her risk for increased frequency herpes zoster reactivation off
HAART is certainly elevated. She had stopped her TMP-SMX and
azithromycin prophylaxis, so we restarted it on admission. She
was given Rx for these meds at discharge.
Transitional Issues
-The patient has ___ appointments with her PMD Dr ___
Dermatology.
-She will also continue her prior dialysis schedule of ___ | 154 | 504 |
10326564-DS-17 | 22,832,697 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Activity as tolerated
- Pneumatic boots in bed
- Right lower extremity: Partial weight bearing
- Encourage turn, cough and deep breathe Q2h when awake
Physical Therapy:
- Activity as tolerated
- Pneumatic boots in bed
- Right lower extremity: Partial weight bearing
- Encourage turn, cough and deep breathe Q2h when awake
Treatments Frequency:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: Please change dressing daily or as needed to keep clean
and dry. OK to leave incisions open to air once non-draining.
Site: R knee
Description: staples with slight errythema @ incision site,
+edema.
Care: keep wound clean and dry, continue to monitor surgical
site for signs and symptoms of infection.
Site: R thigh
Description: staples c/d/i
Care: keep wound clean and dry, continue to monitor surgical
site for signs and symptoms of infection. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for retrograde intramedullary nail,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#2. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is partial weight bearing in the
right lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge | 263 | 236 |
15271206-DS-2 | 24,428,278 | Dear Ms. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to abdominal pain and
nausea/vomiting after eating food. You were treated with
medications to treat nausea and to reduce stomach acid, and your
symptoms improved.
After discharge, please establish care with your new primary
care physician (below). | Ms. ___ is a ___ year old woman, recently moved from ___, now
presenting with abdominal discomfort.
#Abdominal discomfort:
She initially presented with epigastric discomfort and
nausea/vomiting after eating. This was thought to be secondary
to a viral gastroenteritis. Lipase normal. Tylenol level
negative. She received symptomatic management with ondansetron
and maalox/benadryl/lidocaine PRN. She was started on ranitidine
for empiric treatment of GERD/gastritis. She was tolerating PO
intake on regular diet prior to discharge.
#Hepatitis likely NASH: AST/ALT elevated to the 100s/200s;
steatosis visualized on RUQ ultrasound but no cholelithiasis.
Hepatitis serologies unremarkable. Encouraged losing weight
(morbid obesity) and establishing care with PCP at ___ for
follow-up and further workup.
#Possible PCOS: She reported irregular periods, hirsutism, body
habitus, and had echogenic evidence of fatty liver. It is
possible that she has underlying PCOS. Workup of this issue was
deferred to the outpatient setting (see below). | 56 | 144 |
15361438-DS-6 | 20,638,608 | You came to the hospital with headache. You were found to have
meningitis and you were started on antibiotics. Your infection
improved. However, we do not know the specific bacteria that was
causing your infection, and so you will be discharged on 2
antibiotics. An MRI of your neck also showed an infection called
discitis that will require intravenous antibiotics for several
weeks. This will be done at your rehab facility.
Additionally, you had a pneumothorax (collapsed lung) during
this hospitalization, but you did not require a chest tube. The
pneumothorax resolved on its own and you were breathing well
without the use of supplemental oxygen.
While in the hospital, you had chronic foot pain. Unfortunately,
no podiatrist was able to see you. You can follow up with a
podiatrist after your rehab stay or can ask your doctor at rehab
for a podiatry appointment.
Please see your Infectious Disease Appointments Listed Below
Please see medication changes below.
START Vancomycin IV X 6weeks
START Ceftriaxone IV X 6 weeks
START Diphenhydramine PRN insomnia
START Hydromorphone (Dilaudid) ___ mg PO/NG Q4H:PRN pain
STOP Tramadol
STOP Trazodone
It was a pleasure taking care of you Mr ___. | ___ with PMHx substance abuse, Hep C, treated Hep B, h/o
endocarditis presents with worst headache of his life and
altered mental status, concerning for infectious process,
confirmed meningitis on LP, repeat LP 72 hours later showing
resolution of WBC with a monocytic predominance.
#Headache- Patient admitted to floor with headache and altered
mental status. There was high concern for meningitis, especially
given neck stiffness and tenderness on exam. Vancomycin,
ceftriaxone, ampicillin, and acyclovir started empirically. Due
to elevated INR and access difficulties, LP was not performed
until approximately 28 hours after initiation of Abx, but still
revealed elevated WBC with neutrophil predominance (See
Results). HSV PCR negative and Acyclovir d/c'ed. Repeat LP 72
hours later showed some resolution of WBC count but no
lymphocyte predominance, making bacterial meningitis most
likely. CSF cultures showed no growth. Given low likelihood of
Listeria meningitis, ampicillin was discontinued and the pt will
continue on IV vancomycin and ceftriaxone for 2 weeks.
#Discitis - Given persistent neck pain, MRI C-spine performed to
rule out paraspinal abscess. It instead showed signal changes
and enhancement at C3-4 and C5-6 discs suspicious for discitis,
which is likely being treated at same time as meningitis.
However, discitis requires longer treatment course. He will
require an additional ___ weeks of antibiotics (remaining on the
same agents, vancomycin and ceftriaxone) after he finished his
final 2 weeks of meningitis therapy (with dose-reduced
ceftriaxone- please see discharge medications). The patient has
follow-up appointments in ___ clinic for the next 2 months.
#Encephalopathy/Cirrhosis
Unclear how much lactulose patient was receiving at outside
facility. Presented with asterixis and altered mental status.
LFT's elevated and consistent with alcoholic hep picture. He was
restarted on lactulose here and mental status improved. He will
be discharged on lactulose. RUQ ultrasound showed dilated
pancreatic duct with normal CBD and low volume ascites. It also
showed cirrhosis of the liver. MRCP was recommended, but this
was not done in-house.
#Hyponatremia
Patient appeared euvolemic on exam. As per prior records,
baseline Na in low 130's. Picture was concerning for siADH
especially given possibility for acute neurologic process. ___
have been a cause for altering mental status. Urine lytes
revealed siADH process. Sodium rapidly improved with treatment
of meningitis and fluid restriction.
#Metabolic Acidosis
Bicarb 15 on presentation with low AG. Patient denied history of
diarrhea or recent NS administration. Likely has RTA from
associated comorbid conditions. However, this improved while in
house without direct intervention.
#PTX
Patient had small pneumothorax after attempt at central line
placement early in AM ___. Unchanged after 12 hours. It
completely resolved without intervention, after repeat CXR ___.
#Chronic pancreatitis
Patient was continued on home pancreaze
Transitional Issues
-Consider outpatient MRCP given RUQ ultrasound findings
-Patient will continue to receive IV Abx at Rehab Institution
-The patient has follow-up appointments with ___ clinic in
___ and ___.
-Patient had L foot pain while in house that appeared
neuropathic. On day of discharge, this pain radiated up to his
calf. ___ doppler ruled out DVT. The patient will plan to see a
Podiatrist while at Rehab or after discharge from that facility. | 186 | 502 |
15066377-DS-10 | 26,174,104 | Dear Mr. ___,
You were seen at ___
Why where you here?
==================
- You were transferred here from ___ for a possible blood
clot in your lungs (pulmonary embolism). You were originally
seen for chest pain.
What did we do for you?
=======================
- A CT scan of your abdomen did not show any blood clots in your
lungs
- Because of your chest pain, you also had a pharmacologic
stress test and that showed mildly decreased left heart function
and some mild coronary artery disease. We do not think this has
contributed to your chest pain. You should continue to work on
controlling your blood pressure, diet, and weight loss to help
your heart.
- You had a barium swallow study that showed mild reflux
disease.
- You were given medications to control your pain, which is
probably from gas pain.
What do you need to do?
=======================
You should follow up with your regular doctor. Please call and
make an appointment within the next 7 days.
You should follow up with the gastroenterologists. They will
make an appointment for you to have further work-up and should
call you with appointment times. If you do not here from them,
please call at ___.
You should talk to your primary care doctor about referral to a
cardiologist.
You should return to the hospital for worsening chest pain,
shortness of breath, palpitations, lightheadedness or dizziness
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team | Mr ___ is a ___ yo M ___ DVT, PE on Coumadin, AAA s/p repair,
urinary retention, s/p lap cholecystectomy presenting from ___
___ for chest pain.
#Abdominal cramping and distention: Patient had lap chole on
___, and was having abdominal distention and muscle cramping.
An abdominal xray was obtained on ___ since the patient had not
passed gas or had a bowel movement since the surgery. It was
reassuring without evidence for a bowel obstruction. Later that
day, the patient passed gas, so he was started on an aggressive
bowel regimen. His abdominal pain was controlled on
cyclobenzaprine, simethicone, Tylenol, and oxycodone. Surgery
cleared him for discharge
#Chest Pain: The patient reports that his chest pain is
non-radiating, non-exertional, and it improved with belching and
movement. He had negative trops and no EKG changes, so there was
a low suspicion for cardiac origin. Most likely post-operative
pain combined with chronic chest pain. Possible component of
GERD or esophageal spasm given CT findings and history. Low
suspicion for AAA pathology given negative CTA. A pharm stress
test was performed and showed LVEF 49%, mild inferior fixed
perfusion defect, changes c/w cardiomyopathy. He was started on
metoprolol succinate 37.5 mg qd for CV risk and it was well
tolerated. It was felt that his CP was ___ esophageal spasm
given CT findings and speech and swallow recommended GI consult.
GI recommended barium swallow, which showed mild GERD, and would
continue workup as an outpatient.
#History of PE: Patient reports a history of multiple DVTs and a
PE. He was started on warfarin greater than ___ years. His
warfarin was stopped on ago but told he needed life long
anticoagulation which was stopped on ___ for surgery. He has
been bridged with fondaparinaux (Arixtra) to warfarin in the
past. He was started on a ___ bridge to warfarin on
___. His warfarin was changed to 5 mg daily given stable inr of
1.4 and not increasing. Will require close f/u as outpatient.
PCP made aware.
#BRBPR: on ___ had episode of some bright red blood on enema
tube, no blood in his stool. Hb stable throughout admission, pt
felt well. Blood felt to be trauma ___ enema tube. Should follow
up if any further bleeding.
#BPH/Urinary Retention: Patient has had a history of urinary
retention which worsened since his recent surgery and he has
been self catheterizing every 6 hours, which was continued in
the hospital. Additionally his Keflex UTI prophylaxis was
continued.
#GERD: continued on Omeprazole 20 mg PO Q24H
#Asthma: continue home fluticasone BID
#HTN: continued on home dose of lisinopril. started on metop
12.5 mg po TID
CODE: Full confirmed
EMERGENCY CONTACT HCP: Wife ___ cell ___ | 238 | 443 |
12310099-DS-4 | 26,014,804 | Dear Mr. ___,
You were admitted because you were having mouth pain, decreased
ability to tolerate food and water, fever, and weakness. Your
pain is caused by irritation in the mouth which is a very common
side effect of chemotherapy. We gave you medication to help with
the pain and you were able to tolerate food. We also gave you IV
fluids since you appeared dehydrated.
Your fever was likely caused by a pneumonia seen on your chest
Xray. We started you on antibiotics to treat this infection. We
will discharge you with medication to help control your pain so
that you will be able to continue to eat and stay hydrated as
well as antibiotics, which you will take through ___.
Thank you for allowing us to be a part of your care,
Your ___ treatment team | Mr. ___ is a ___ year old gentleman with a history of rectal
cancer s/p chemoradiotherapy in ___, now metastatic to liver
and likely right occipital lobe on Modified FOLFOX6+Bevacizumab
presenting with fever, mucositis, and inability to tolerate PO
intake with CXR concerning for pneumonia
# Community acquired pneumonia: Mr. ___ presented with fever
and cough, with CXR suspicious for pneumonia. He was started on
Levofloxacin for treatment of community acquired pneumonia. He
remained afebrile without leukocytosis throughout his hospital
stay. He will continue to take Levoloxacin through ___.
# Mucositis: Mr. ___ presented with mucositis, secondary to
chemotherapy and decreased PO intake as a result of the pain.
His symptoms were controlled in the hospital with viscious
lidocaine, cephasol, and dilaudid. He was able to tolerate PO
intake and is discharged with viscious lidocaine, cephasol,
oxycodone.
# Right sided chest pain: Mr. ___ presents with a ___ day
history of right sided anterior chest pain, which was worse with
inspiration and was not reproducible on exam. The concern for PE
was low as he was not tachycardic, did not have ___ swelling
noted on exam. The more likely etiology is secondary to hepatic
metastasis as noted on CT on ___. He endorsed improvement
with lidocaine patch, which would not be expected with PE.
# Hyponatremia: Likely hypovolemic hyponatremia, resolved with
IVF | 136 | 222 |
16970810-DS-18 | 20,356,668 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | Patient was admitted to the CVICU for SAH, mycotic aneurysm
work-up. He was followed by the neurosurgery service, started on
nimodipine for vasospasm prevention, IV antibiotics,
anticoagulation was held. He underwent TEE which was negative
for vegetation or clot. Follow-up CT angiogram was negative for
mycotic aneurysm, trivial SAH. Per neurosurgery service he was
restarted on Coumadin, nimodipine and antibiotics were
discontinued. He transferred to the floor. There he remained
neurologically stable, headache free. His Lopressor was adjusted
for rapid afib at times. His urine culture from ___ was
positive for ___ colonies, he was asymptomatic with
stable WBC count. A repeat urine was obtained with the plan to
start antibiotic in the outpatient setting if needed. Patient
was deemed sage for discharge to home on HD 3. Follow-up
appointments arranged. No need for neurosurgery follow-up. | 115 | 137 |
12068298-DS-21 | 29,050,785 | Dear Mr. ___,
You were hospitalized at ___ after a gunshot wound to your
left arm and abdomen. You underwent an emergency exploratory
laparotomy to look for injuries to intrabdominal organs from the
bullet. We found that no vital organs were injured. Your arm and
abdominal wounds were cleaned throughly in the operating room as
well. You have recovered nicely from your surgery and are now
ready for discharge. Please see the following for
post-hospitalization care.
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.
Sincerely,
___ Acute Care Surgery | The patient was admitted to the Acute Care Surgery service on
___ after presenting with a gun shot wound to right lower
quadrant. The patient underwent exploratory laparotomy, which
went well without complication (please refer to the Operative
Note for details). After a brief, uneventful stay in the PACU,
the patient arrived on the floor on NPO/IV fluids, and IV PCA
for pain control. The patient was hemodynamically stable.
The patient was alert and oriented throughout hospitalization.
The patient reported weakness of his right leg, numbness of his
right anterior thigh and difficulty bearing weight on the right
lower extremity. Neurology service was consulted given his
findings on physical examination. The patient was recommended to
use ___ brace to right knee for quadriceps support,
crutches, and ultrasound of right leg, which did not demonstrate
a compressive hematoma.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: 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
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 297 | 317 |
16367633-DS-6 | 23,105,301 | Dear Ms. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
You were seen at the hospital for your abdominal pain and
diarrhea, which left you dehydrated.
WHAT HAPPENED IN THE HOSPITAL?
You were given IV fluids to help with your dehydration. You had
imaging that showed no sign of infection or other cause of your
pain. You were treated with pain medication.
Your imaging showed some fluid around your liver. This can have
many causes, some of which are serious, however, there was not
enough fluid to be drained according to the interventional
radiologists, so you were monitored, and no fluid was drained.
WHAT SHOULD I DO WHEN I GO HOME?
Please take your medications as prescribed and follow-up at your
outpatient appointments.
We wish you the best in your health.
-Your Care Team at ___ | Ms. ___ is a ___ w/ PMH of HTN, HLD, recent admission for
colitis, hx of pancreatitis, who presents with three days of
worsening abdominal pain and elevated lactate, c/f viral
gastroenteritis.
#ABDOMINAL PAIN WITH N/V/D + ELEVATED LACTATE: The differential
for this presentation is broad and may include
colitis/diverticulitis or recurrent gastroenteritis. Vomiting
and diarrhea had resolved on admission so stool studies were not
sent. Pancreatitis was deemed less likely given lipase WNL and
imaging not consistent with this condition, though it is
possible to have a normal lipase in the setting of underlying
chronic pancreatitis. Found to have ascites of unclear etiology
(see below). Elevated lactate appeared ___ dehydration that
resolved with IV fluids. CT AP DID not reveal a cause of her
abdominal pain. Pain was managed with Tylenol, simethicone,
Maalox, tramadol for breakthrough as well as IV fluids as
needed.
#ASCITES: Unclear etiology. Steatosis of liver on imaging.
Paracentesis was attempted twice, but no pocket was found with
interventional radiology
#UTI: Symptomatic. Started on 3 day course of PO cipro.
#PRURITUS: Drug rx due to oxycodone given in the ED. Recieved
Benadryl PRN.
#DIABETES: Holding home metformin. ISS
#DEPRESSION: Continue home sertraline
#HYPERTENSION: Patient hypotensive on admission, will hold home
Lisinopril and Diltizem
#HL: Continue home Atorvastatin | 149 | 209 |
13560498-DS-11 | 24,685,940 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You were more short of breath
What happened while I was in the hospital?
- You were given diuretics (water pills) to remove extra fluid
from the lungs
- You were treated for a pneumonia
- We discussed your condition with your family and we all
decided it would be best to transition your care and keep you
comfortable
What should I do once I leave the hospital?
- We will continue to care for your here in the hospital and
keep you comfortable.
We wish you the best!
Your ___ Care Team | SUMMARY:
============
___ with COPD (severe emphysema, home 5L NC), significant PH
(presumed G2/3, but mostly Group 3), prior PE, and GERD, who
presented with worsening hypoxemic/hypercarbic respiratory
failure ___ RV failure with massive RV dilation precipitating LV
cavity obstruction and hypoxemia ___ pulmonary edema and pleural
effusions. She was hospitalized in the ICU required high-flow
nasal canula and was aggressively diuresed but her respiratory
status was not improving. Her course was also complicated by
atrial fibrillation with RVR that was difficult to control and
acute kidney injury. She also developed delirium after
administration of benzos for anxiety. Despite diuresis and
attempts to wean oxygen, this was unsuccessful and after
discussions with her family the decision was made to transition
her to comfort measures only. She was enrolled in inpatient
hospice here at ___. | 127 | 133 |
14271401-DS-6 | 26,090,544 | You were admitted to ___ with shortness of breath and this is
from congestive heart failure as well as your obesity
hypoventilation and sleep apnea. It is critical that you use
your bipap regularly and take your medications regularly,
particularly your diuretics. You also had wheezing over the
past few days, so we have put you on steroids as well as
breathing treatments every 8 hours. | Assessment and Plan:
In summary this is a ___ with history of diastolic CHF, severe
pulmonary hypertension, obesity hypoventilation syndrome, OSA
(on BiPAP however noncomplaint), and COPD on 2LNC (FEV 1 41% in
___, restrictive ___ disease who initially presented on
___ with SOB and hypoxia as well as hypotension.
It was felt that her dyspnea was due progression of her
cardiopulmonary disease to late stage as well as a
decompensation of her cor pulmonale.
She was initially in the ICU on NIPPV and initially required
vasopressors. She was transferred to the medical floor.
OSA: Non compliant with Bipap at home; better compliance in the
hospital. Counselled at length on need for regular use.
Obesity Hypoventilation: VBG shows a compensated metabolic
acidosis with marked hypercarbia (Pco2 of 83). She frequently
sleeps during the day but is easily arousable. SHe still has
desaturations with little ambulation. She is on four liters of
oxygen on the floor; normally uses 2 liters.
COPD: Patient with productive cough and wheezing on ___, so
she was started on prednisone 60 mg daily as well as standing
nebulizers for her COPD. Her prednisone should be tapered at
___. She was also started on a standing expectorant.
She requires 4 L of oxygen on the floor to maintain her oxygen
saturation in the low 90 percent.
CHF: She was seen by the ___ cardiologist who described her
as having severe cor pulmonale secondary to her OSA and obesity
hypoventilation. Her torsemide was increased to 80 mg daily.
I/O were difficult to control because of her incontinence. Her
weight on discharge was 300 lbs.
# Anemia: Chronic in nature and currently stable. No evidence of
bleeding.
# HLD: continue pravastatin
# HTN: Continue coreg. Her ___ should be restarted at rehab as
her bps have improved.
# DM: Sliding scale in the hospital; can resume metformin and
sliding scale at Rehab.
# Goals of Care: I tried at length to discuss with Ms ___
the severe nature of her cardiopulmonary disease and
progression. She was not receptive to this conversation. If
her functional and cardiopulmonary status do not continue to
improve, would also involve her outpatient doctors in this
conversation. She has f/u with ___ cardiology next week;
please also schedule followup with her pulmonologist Dr ___
at ___. | 68 | 405 |
10330091-DS-9 | 27,344,689 | Patient was admitted with bowel necrosis and perforation. She
was seen by surgery and deemed inoperable. She was made CMO in
the emergency department and passed away shortly after arriving
to the floor. | Ms. ___ was admitted to the Hospital Medicine service with
unsurvivable ischemic bowel. She was provided with comfort
focused care, including a morphine gtt titrated to comfort. Her
family remained at her bedside and she passed away a couple of
hours after arriving to ___.
Dr. ___ the family/HCP/NOK and they declined
autopsy.
PCP - Dr. ___ via email of admission and death. | 33 | 63 |
13473495-DS-43 | 24,227,223 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital for abdominal pain. A scan of
your belly was normal with no new process. You were found to be
12kgs above your last weight. You underwent aggressive HD and
much of the excess fluid was removed. You improved.
In addition, you had a positive blood cx on admission (1 of 4)
that is a likely contaminate. Given your history of bacteria
growing in your blood, we will treat you for 14 days with
Vancomycin.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo M with ESRD on HD through R chest tunneled line, DM on
insulin, and early ___ admission for MRSA bacteremia on
vancomycin who was admitted for abdominal paind and found to be
volume overloaded.
# ESRD/Volume overload:
He was extremely volume overloaded upon admission to the
hospital, with a 12kg weight increase compared to his prior
admission in ___. He received HD on ___,
and ___, and ultrafiltration on ___ and ___ via his
tunneled HD line. He lost > 10 kg over the course of his stay.
His overall fluid overload improved, with decreased edema,
particularly in his hands. He was stringently volume restricted
to < 1.5L daily during his stay. He was continued on his
nephrocaps, calcium, and vitamin D repletion.
# CoNS Bacteremia:
He had a single positive blood culture from ___ with coagulase
negative staphylococcus in 1 of 4 bottles. The other initial
cultures and subsequent surveillance cultures remain no growth
to date. His positive blood cultures are most likely a
contaminant. He had been therapeutic on vancomycin (goal of
___ treatment for MRSA bacteremia at his prior admission
(last dose was on ___. He has not been having
fevers/chills, measured fevers, or elevated WBCs. His tunneled
HD line was pulled and reinserted at his prior admission after
blood cultures became negative (on ___. ID was consulted
during this admission and they felt that he should get 10 more
days of vancomycin (last dose ___ with HD, but that a TEE is
not advisable given the inherent risk with intubation which
would have been needed given his obesity. He needs vancomycin
locks for HD. His last dose of vancomycin here was 750mg on
___. Goal vancomycin trough ___. Last dose of vancomycin
for this course should be ___ at HD. Recommend surveillence
cultures following completion of antibiotics.
# CAD:
He has not had any chest pain throughout his stay. His blood
pressures were well controlled. He was continued on his home ASA
and metoprolol.
# DMT2:
He was treated with 5 units NPH BID (before breakfast and then
before dinner) and an insulin sliding scale and his blood sugars
were very well-controlled throughout his admission (70s-130s).
# Afib:
He was continued on his home digoxin and metoprolol for his
atrial fibrillation. He was therapeutic on his warfarin (2mg)
throughout his stay, with INR between 2.2 and 2.7.
# Asymmetric swelling of hands:
He initially presented with asymmetric swelling of his hands,
which has since improved significantly with elevation of his
left hand. He was not having any pain and was therapeutic on
warfarin throughout his stay. He did not have any blood draws or
ivs placed on his left arm. The thrill of his AVF on his left
arm remained palpable throughout his stay. He has an appointment
scheduled for ___ with Dr. ___ addition to LUE U/S at
that time as well).
# Anemia:
He has a mild macrocytic anemia, but is essentially at his
baseline, most likely due to his ESRD. Epo titration was
continued with HD.
# Gout, chronic pain, and abdominal pain:
He initially presented with LLQ abdominal pain that has improved
significantly during his stay. CT scan done in ED did not reveal
any obviosu cause of his pain.
His pain could be due due to volume overload superimposed upon
chronic pain. He was continued on his home fentanyl,
amitriptyline, and lidocaine patch. He was also continued on
home allopurinol. He was given oxycodone for pain instead of his
home dilaudid.
# Constipation:
He was not constipated during his hospital stay. His home
regimen was continued (senna PRN, dulcolax PR if senna
ineffective, saline enema if both ineffective).
# Sleep apnea:
He had not been on CPAP at rehab, although he had been on it at
home prior to entering rehab last ___. He was put on
telemetry overnight. He remained in Afib, but had no other
events. | 107 | 649 |
10088937-DS-12 | 20,696,600 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for flash pulmonary edema (fluid in your lungs) caused
by high blood pressure. We have adjusted many of your
medications to try to get your blood pressure under better
control. Please see the attached list of medication changes.
Please have blood work done on ___ or ___. The results
should automatically be faxed to your PCP. | ___ hx of OSA on CPAP, DM2, HTN, HLD, TIAx2 presents with an
episode of SOB and bradycardia.
.
# Dyspnea, now resolved: Pt's description of "trying to breathe
through water" consistent with flash pulmonary edema. Per pt,
CXR at ___ was normal. CXR at ___ shows no evidence of
pulmonary edema, but dyspnea resolved prior to pt's admission
here, so pulmonary edema still most likely etiology of dyspnea.
Edema likely ___ poorly controlled HTN. Recommend outpatient
stress test to ensure no underlying coronary artery disease as
cause for flash pumonary edema once BP well controlled.
.
# Sinus bradycardia: Responded to atropine at OSH. Ddx includes
high vagal tone/vagal episode (especially given h/o syncope)vs
beta blocker overdose. No evidence of ischemia on EKG, troponins
negative X 2, electrolytes normal. Decreased dose of carvedilol
from 6.25mg BID to 3.125mg BID. ECHO shows normal systolic
function.
# Hypertension: History of SBP > 200. Presented with SBP 170s.
Decreased home carvedilol as above in setting of bradycardia,
increased benicar from 20mg daily to 40mg daily, started
amlodipine 10mg daily. Gave pt lasix 20mg BID PO on ___ with
net urine output of 4 liters over 24 hrs. Pt states that he
takes his lasix as directed at home, but this is questionable
given net urine output of 4 liters. Discharged on home lasix
20mg daily. If pt continues to be refractory to therapy, can
consider evaluation for secondary causes, although most likely
etiology is OSA and metabolic syndrome.
.
# Thrombocytopenia: LFTs normal, but pt has h/o fatty liver
disease. ___ be ___ splenic sequestration as pt has h/o
splenomegaly on imaging and chronic thrombocytopenia with plt 79
in ___, 112 in ___.
.
# Dyslipidemia: TC 148 LDL 68 HDL 34 ___ 410. Continued home
pravastatin, omega 3.
.
# Type II Diabetes, non-insulin dependent: Last HbA1c 5.3 in
___. Complicated by neuropathy. Maintained on sliding scale
insulin this admission, discharged on home metformin.
.
# OSA: Continued home CPAP during admission.
.
## Transitional issues:
- recommend outpatient stress test in the next ___ weeks
- please check CHEM7 this week as pt had several medication
changes this admission
- increased home benicar from 20mg qd to 40mg qd
- started pt on amlodipine 10mg daily
- decreased home carvedilol from 6.25 to 3.125mg BID due to
bradycardia (HR in ___
- if hypertension continues to be refractory, pt should be
evaluated for secondary causes | 75 | 399 |
11852337-DS-8 | 24,380,680 | Dear ___,
You were sent here after you were found to have a blood clot in
your leg. We started you on a blood thinner. You were also found
to have an enlarged lymph node in your pelvis. You had a biopsy
of this lymph node.
We are sending you home on a blood thinner called xarelto. You
should take this medication twice a day for the next ___ days.
After that you will need a new prescription for 20mg of xarelto
to take once a day. You should take this medication with a large
meal. If the biopsy shows any recurrence of your endometrial
cancer, please talk to your primary doctor about switching back
to lovenox.
Please follow up with your primary doctor and with Dr. ___
___ gynecology (see below for your appointments). | ___ yo with history of stage IB grade 2 endometrioid endometrial
cancer s/p TLH-BSO ___ and adjuvant vaginal cuff
___ transferred to ___ from ___ with newly
diagnosed DVT and CT imaging of pelvic sidewall lymp node, for
which she was
transferred due to concern of recurrent malignancy. | 132 | 49 |
16546330-DS-25 | 22,054,590 | You were admitted to the hospital with right upper quadrant
pain. You underwent imaging and you were reported to have
cholecystitis. You were taken to the operating room where you
had your gallbladder removed. You are recovering nicely from
your surgery and you are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
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 | The patient was admitted to the hospital with right sided
abdominal pain. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. Ultrasound imaging
showed a distended gallbladder with shadowing
gallstone at the fundus. She was also noted to have a mild
elevation in the white blood cell count. Based on these
findings, the patient was taken to the operating room where she
underwent a laparoscopic cholecystectomy. Operative findings
were notable for a severely inflamed gallbladder. The patient
was extubated after the procedure and monitored in the recovery
room.
The post-operative course was stable. The patient was
introduced to clear liquids and advanced to a regular diet. Her
vital signs remained stable and she was afebrile. Her
incisional pain was controlled with oral analgesia. The patient
was discharged home on POD #1 in stable condition. An
appointment for follow-up was made with the acute care service. | 816 | 160 |
13758099-DS-3 | 27,918,465 | Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted to the hospital after you
presented with bleeding from your AV fistula after your dialysis
session. You underwent a study that showed that part of the
fistula was narrowed. The radiology doctors performed ___
procedure that opened up your narrowed fistula. You also had a
few episodes of chest pain that improved with nitroglycerine.
Given this and your visit to the emergency room in ___ with
similar symptoms, we elected to perform a cardiac stress test,
which showed some possible areas of your heart that wasn't
getting good flow. The cardiology doctors ___ and
recommended a procedure to look at the blood vessels of your
heart (called cardiac catheterization). They performed this and
saw that your heart vessels were open, which is good news. They
did find that your heart does not pump as well as it should,
which was also seen on other tests in the past. You should
follow up with a heart doctor to talk about other things that
can be done to improve your heart's function.
You were evaluated by the physical therapists who recommended
that you would benefit from additional rehabilitation.
You were started on metoprolol 25mg XL daily upon discharge. We
also discontinued your clonidine medication. Please continue to
take all your other medications as instructed.
It was a pleasure to care for you during this hospitalization.
Sincerely,
Your ___ Care Team. | ___ with PMH significant for ESRD on HD ___ (last received
the day of presentation), HTN, HLD, h/o R MCA and basal ganglia
stroke w/ L hemiparesis now on aspirin/plavix, T2DM who presents
from his HD session for a bleeding fistula s/p balloon
angioplasty of L stenotic AV fistula with subsequent improvement
and tolerance of HD, whose hospital course was c/b chest pain
s/p cardiac catheterization showing clean coronaries.
#Stenotic L AV Fistula s/p Balloon angioplasty: Patient
initially presented with bleeding L AV fistula in the setting of
HD cannulation. The fistula first started bleeding after they
withdrew the needle and persisted for about 1.5 hours despite
continuous pressure, with an EBL of 200-300ccs. Due to a concern
for possible
pseudoaneurysm or stenosis, EMS was called to the dialysis unit
and patient was brought to ___. At ___, patient was
evaluated by the transplant surgery team who recommended ___
fistulogram to further evaluate. ___ has not had any bleeding
from his L AV Fistula since arriving at ___. Patient
subsequently underwent successful ___ Fistulogram and is now s/p
balloon angioplasty for a stenosed fistula (no evidence of
pseudoaneurysm). ___ has been tolerating HD without any bleeding
or difficulty. As a result, the transplant surgery team signed
off and recommended continuing HD per pre-admission schedule.
Per ___, patient may benefit from further balloon angioplasty in
the outpatient setting to further open up the stenosis.
#Chest pain: During this admission, patient also developed chest
pain, likely demand ischemia in the setting his acute bleeding
and possibly missed home medications while being admitted to the
hospital. Upon admission, patient was unable to re-endorse any
home medications and we called multiple facilities in an attempt
to obtain his home medications, which we successfully confirmed
with his PCP. ___ did not have any EKG changes (baseline LBBB,
but negative by scarbossa's criteria). Troponins were
0.47-->0.5-->0.58-->0.68, but this was difficult to interpret in
the setting of ESRD. Patient underwent a nuclear stress test
which was negative for reversible perfusion defects, but did
show fixed defects, increased LV cavity size and severe systolic
dysfunction with global hypokinesis and EF 25%. Patient was
evaluated by the inpatient cardiology team who recommended
cardiac catheterization, which was performed on ___. ___ had
clean coronaries but myocardial bridge and dynamic compression
of his LAD during systole, which cardiology believes may be
related to his chest pain. Patient remained chest pain free for
several days (since restarting of his medications), and was
chest pain free on the day of discharge. Per inpatient
cardiology recs, we started him on metop 25mg XL, which ___
tolerated. Patient will follow-up with Dr. ___
in the outpatient setting.
#Acute blood loss anemia on chronic anemia ___ ESRD: Patient
initially presented with acute blood loss anemia from his L AV
fistula in the setting of already being anemic from chronic
ESRD. ___ lost 200-300ccs of blood, but his Hgb subsequently
stabilized and did not require any transfusions. Patient was
given EPO during HD while ___ was inpatient. ___ has not had any
bleeding episodes since admission. On discharge, patient's Hgb
was 10.5.
#ESRD on HD: Patient has ESRD and is on HD ___. After
successful ___ balloon angioplasty of his L AV fistula, patient
immediately was restarted on HD and tolerated it well. Patient
was followed by the inpatient dialysis team and was continued on
nephrocaps per renal recommendations. Patient also received Epo
during HD sessions while inpatient. ___ will continue his
outpatient HD schedule upon discharge.
#compensated chronic systolic CHF: Patient with hx of sCHF and
newly found EF of 25%
on recent stress test, which was lower than his estimated LVEF
on recent TTE oin ___ (35-40%). Patient remained euvolemic
during this hospitalization and was on RA. We continued his home
lasix on discharge, as well as his aspirin, lisinopril. We also
started him on metop 25mg XL daily. ___ will follow-up with
outpatient cardiologist Dr. ___. Due to his low LVEF, patient
may benefit from ICD. Patient's discharge dry weight was 71.9kg.
#T2DM: We continued patient on his home insulin regimen as well
as ISS while ___ was inpatient. ___ was discharged on his home
regimen.
#HTN: We continued patient on his home antihypertensives during
this admission and his BP ranged between 90/40s-150s/70s. Please
note, as described above, patient was discharged on metop 25mg
XL. Due to this, we discontinued his clonidine on discharge.
Patient's BP was 110s/60s on discharge.
#H/O R MCA and basal ganglia ischemic stroke: Patient has a
history of R MCA and basal ganglia ischemic stroke now with with
chronic L hemiplegia. We continued patient's home aspirin,
plavix and atorvastatin.
#GERD: we continued patient home omeprazole.
#HLD: we continued patient on home atorvastatin.
#BPH: we continued patient on home finasteride.
============================================================== | 240 | 782 |
18699523-DS-19 | 25,487,364 | You came to the hospital because you had abdominal pain. The
pancreas specialists saw you and assessed you and felt that your
pain was not related to your pancreas, that you have some belly
spasm. We treated your pain with pain medications. The ERCP
doctors recommended ___ some new mediations which may help
your pain.
please START citrucel 1 tab at night with ___ glasses of water
(you can get this over the counter)
please START Alish probiotic daily (you can get this over the
counter)
please STARTLevsin .12mg q12H PRN spasm
Please follow up with your GI doctor.
Happy first birthday to your son! | ___ year old woman w/ h/o sphincter of Oddi dysfunction s/p total
of 4 ERCPs w/ sphincterotomy presents w/ abdominal pain.
#Abdominal Pain: Pt has chronic abdominal pain and has previous
dx of sphincter of odi dysfunction requring ERCP
sphincterotomies. She has felt relief of pain after her last
ERCP but three weeks she had pain again. Her LFTs, lipase were
wnl and RUQ u/s showed common bile duct dilation which she has
had on prior imaging. Her lipase and LFTs are all wnl which is
reassuring. ERCP was consulted and they felt this was abdominal
spasm and not related to her pancreas because of normal labs.
She was kept NPO and given IVF for 24 hrs and we managed her
pain with dilaudid 2mg q4H prn
and tylenol prn. She was also given miralax for bowel regimen
while on narcotics. She was then switched to a normal diet and
patient was able to take in PO well. She will follow up with her
pancreas doctors. It weas recommedned pt try Hyoscyamine 0.125
mg PO Q12H PRN for abdominal spasm.
#Depression/anxiety:
-continued escitalopram
-continued lorazepam .5 mg BIDprn
#Tobacco:
- gave nicotine patch | 100 | 186 |
15637056-DS-11 | 22,416,110 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain. You had an ultra sound that showed
gallstones and your blood work was concerning for an obstructing
stone. You had an ERCP that visualized no blockage of your
common bile duct but several stones in your gallbladder. Because
these stones are causing you pain, you were taken to the
operating room for a laparoscopic removal of your gallbladder.
After surgery, your blood work is improving as anticipated.
You should continue to follow up with your primary care provider
on ___ basis for further work up of your elevated liver
studies, specifically your bilirubin level. You have further lab
results pending and we will review it with you at your follow up
appointment.
You tolerated the procedure well and are now ready to be
discharged to home to continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
Service on ___ with abdominal pain radiating to the right
shoulder with onset after a fatty meal. He had and abdominal
ultrasound that showed cholelithiasis without evidence of
cholecystitis. His white blood cell count was normal, his liver
enyzmes and total bilirubin were elevated. He was admitted to
the surgical floor for further evaluation of his abdominal pain
and abnormal liver enzymes.
On HD2 he underwent ERCP that showed a normal common bile duct
and no intervention was preformed. Given that he was symptomatic
with abnormal liver studies it was recommended that he have a
cholecystectomy and liver biopsy on this admission. The findings
were discussed with the patient and his parents and informed
consent was obtained for a laparoscopic cholecystectomy but
declined a liver biopsy at this time. Hepititis panel and
haptoglobin sent. He was referred to his primary care provider
to further evaluate underlying causes of elevated bilirubin and
liver enzymes.
Pain was well controlled on oral medication. 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.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Follow up appointments were scheduled. | 824 | 290 |
12330994-DS-27 | 22,278,634 | Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were having diarrhea, and you had a blood clot in your
fistula.
WHAT HAPPENED WHILE I WAS HERE?
- The radiologists performed a fistulogram, and the blood clot
in your fistula was removed.
- You received one session of dialysis. The dialysis session had
to be stopped early because you were having chest pain. Your
chest pain resolved on its own and your EKG did not have any
concerning changes.
- A stool sample was sent, and we found that you still had
microsporidia in your stool. You were started on albendazole and
Flagyl for treatment of this infection.
- An ultrasound of your liver was concerning for a blood clot in
the blood vessels of your liver. The radiologists performed a
procedure to take a closer look at the blood vessels of your
liver, which showed that the blood vessels were clear.
WHAT SHOULD I DO WHEN I GET HOME?
- Please take all of your medications as instructed.
- Please go to all of your scheduled doctor's appointments.
- Please get your labs checked as instructed and get a repeat
ultrasound of your liver next week.
We wish you the best!
Sincerely,
Your ___ Liver Team | ====================
SUMMARY
====================
___ y/o man with alcoholic cirrhosis s/p DDLT ___ and s/p
deceased donor renal transplant ___, with delayed graft
function (recently deemed to be failed), on HD ___ with
recent admission for profuse diarrhea found to have
microsporidia who presented with watery diarrhea recurrence and
clotted graft.
====================
ACTIVE ISSUES
====================
#DIARRHEA
The patient presented with acute on subacute diarrhea, s/p
recent hospitalization and broad infectious work-up which was
positive for microsporidia. He completed a course of albendazole
(s/p x4 weeks, last day ___ per patient his diarrhea did not
improve with treatment. Additionally, in the setting of changing
his immunosuppresants he feels his diarrhea became significantly
worse. The most likely etiology for his ongoing diarrhea was
thought to be persistence of microsporidia, given the positive
stool culture. He was started on albendazole and Flagyl for
treatment of the microsporidia. A stool sample was sent to the
CDC to assess for resistant microsporidia strain, as a resistant
strain would necessitate a medication requiring special CDC
approval. Of note, he did have a weakly positive CMV viral load.
However, after conferring with the ID team, it was decided to
defer initiation of antivirals for now. He will get weekly CMV
viral loads to monitor. Other infectious stool workup was
negative, including C. diff and norovirus. His diarrhea improved
on the albendazole and microsporidia, so he was discharged with
plans for close follow up with both transplant hepatology and
transplant ID.
#TRANSAMINITIS
#ETOH CIRRHOSIS S/P LIVER TRANSPLANT
The patient has a history of alcoholic cirrhosis s/p liver
transplant. Recent liver biopsy (___) was negative for acute
rejection. Potential etiologies of his transaminitis included
rejection vs hypoperfusion in the setting of hypovolemia vs
infection. RUQ U/S was concerning for "reversal of diastolic
flow in the main hepatic artery, as well as absent diastolic
flow in the distal branches of the hepatic arteries" consistent
with possible rejection. CTA abdomen showed filling defect of
right hepatic artery and linear filling defect of distal main
hepatic artery at bifurcation, concerning for thrombosis vs.
stenosis. Hepatic arteriogram showed patent but tortuous course
of proper hepatic artery, with delayed filling of hepatic
parenchymal branches. At time of discharge, planned for repeat
ultrasound for assessment of hepatic vasculature in 1 week.
#NORMOCYTIC ANEMIA
#ANEMIA OF CHRONIC DISEASE
The patient developed worsening normocytic anemia as low as 7.4,
from his baseline of ___. Iron studies were consistent with
anemia of chronic disease, but there were also likely
contributions from CKD and infection. He was transfused 1u PRBC,
and his Hgb subsequently remained stable.
#END STAGE RENAL DISEASE ON HEMODIALYSIS
#FAILED DECEASED DONOR RENAL TRANSPLANT
#AV GRAFT CLOT, RESOLVED
The patient was found to have a clotted graft at dialysis on
___. He underwent fistulogram with angioplasty on ___,
resulting in patency of the fistula. He received HD on ___,
which had to be stopped early due to development of chest pain
(see below). He continued to make >300cc UOP per day without
receiving further dialysis, his electrolytes remained stable,
and he had no e/o volume overload on exam. Therefore, he did not
receive further dialysis while inpatient.
#CHEST PAIN
#TACHYCARDIA
The patient developed new transient left-sided chest pain
radiating to the neck while at HD on ___. It resolved without
intervention, EKG was without ischemic changes, and trops were
negative. Suspected demand cardiac strain in the setting of
fluid shifts during HD. PE was felt to be less likely given lack
of hypoxia or evidence of right heart strain on EKG. PNA was
felt to be unlikely give resolution of symptoms without
intervention. Chest X-ray showed no acute cardiopulmonary
abnormality and TTE was without focal wall motion abnormalities.
==================
CHRONIC ISSUES
==================
#HISTORY OF SEIZURES: Continued keppra 1gm daily; 500mg q3x/week
with HD
#DEPRESSION: Continued home Sertraline 50mg daily and
Mirtazapine 15mg daily
#S/P LIVER TRANSPLANT: Continued home prednisone 5mg and
azathioprine 75mg, as well as atovaquone for ppx
Core Measures
# CODE: Full
# CONTACT: ___ (Wife) Phone number: ___
===================== | 205 | 639 |
16095794-DS-3 | 26,449,119 | You were hospitalized for thrombocytopenia (low platelet count)
due to ITP. Hematology was consulted, and you were treated with
high-dose steroids and IVIG. Your platelet count is improving.
You will need to blood draws at any ___ facility on ___ and
___, which Dr ___ will order and follow up. | ___ year old woman with lupus complicated by recurrent
thrombocytopenia here with severe thrombocytopenia and increased
menstrual blood loss.
# Severe thrombocytopenia/ITP:
Pt was found to be hemodynamically stable, but with some areas
of small spontaneous hematomas. Pt had headaches, for which she
underwent CT head in the ED given PLT 5k; fortunately there was
no evidence of bleed. Pt was hospitalized on the Medicine
service for further evaluation and management. She was monitored
with Neuro signs throughout her hospitalization, which remained
stable. ___ Hematology consulted, and pt was started on
Decadron 40 mg IV q day. Given PLT count that downtrended to <
5k, pt was also treated with IVIG x 2 days. Her PLT count
improved, and was 84k at the time of discharge.
Given her vaginal blood loss, she was started on oral iron, per
Hematology recs. She was also started on senna and colace to
minimize constipation while on iron.
HIV and HCV were tested during this hospitalization, which were
both negative.
# Lupus -
- continued plaquenil 400 daily
# HTN
- continued HCTZ
- maintained SBP < 160
FEN - regular diet
Code - full
Dispo - d/c'd to home, with outpt hematology follow up | 51 | 208 |
19596788-DS-4 | 24,528,317 | Dear ___,
You were admitted to ___ and
underwent Gelfoam embolization of the right hepatic artery for a
liver bleed. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix.
*Please understand that there is no need for anti-coagulation,
since during your hospitalization, it was determined that your
risk of bleeding outweighs your risk of coagulation. | ___ was seen and admitted to the hospital on ___
for 24 hours of
acute onset of abdominal pain. Patient was seen in an outside
hospital and found to have a large hematoma behind the liver
with hemoperitoneum. The patient was on Coumadin for a prior
pulmonary embolism. The patient's vital signs were been stable.
On arrival we were notified of the patient's INR was 6.
Given her acute onset and spontaneous hepatic bleed and
perihepatic hematoma with active extravasation on CT, she was
taken to Interventional Radiology for empiric Gelfoam
embolization of the right hepatic artery. She was consented,
prepped, and tolerated the procedure well. She was then admitted
to the TSICU on ACS, with serial hematocrits and abdominal
exams. An abdominal MRI done on ___ showed no hepatic mass
that was associated with the abdominal hematoma. They
recommended a repeat liver MRI in 3 months.
Once she was stable, she was transferred from the TSICU onto the
floor. There, she was seen by hematology for her genetic
hypercoagulabilty on ___. They recommended that given that
she is a heterozygote for the prothombin gene
mutation, and the deep venous thrombosis that she had was
provoked, she should not need life-long anticoagulation. In
addition, the plasminogen-activator 1 inhibitor deficiency is a
bleeding risk, not a thrombotic risk. The risk of bleeding
life-long anticoagulation outweights any benefit. They concluded
that she could go home without any lifelong anti-coagulation
therapy.
She was also seen by pain management for management of her
chronic/acute pain, as well as her Suboxone status. They
recommended decreasing the amount of medication, re-evaluation
with her PCP Dr ___ discharged from the hospital. She
was instructed that if she had any questions regarding pain, she
should call the ___ Pain ___ at
___.
On ___, she was tolerating a regular diet, pain was
adequately controlled, and she expressed desire to go home to
see her family. At this time, she was off her anticoagulation
medications, was abulating without difficulty, voiding without
difficulty, and was medically cleared by ACS service, with
stable vital signs. She was given discharge paperwork,
prescriptions for outpatient medications, and instructions on
what to do if her abdominal hematoma recurs. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 134 | 385 |
18572264-DS-13 | 22,567,848 | Dear Ms ___,
You were admitted to the hospital for chest pain. We did some
tests that showed some damage to your heart, but a cardiac
catheterization did not show any blockages of the large arteries
to your heart. It is possible that you have some tiny blockages
in the smaller arteries that we cannot treat with stents. You
should continue taking your blood pressure and cholesterol
medications, exercise regularly and lose weight to improve your
cardiac health. Please follow up with your primary care doctor
and your cardiologist for further evaluation.
No changes were made to your medication regimen. | Ms ___ is a ___ with CAD (s/p BMS ___ to ramus), difficult
to control HTN, HL, Depression and chronic LBP who presented to
ED complains of chest pain.
# CHEST PAIN:
Patient presented with exertional chest pain and found to have
elevated troponins with non-specific ST changes (felt to be
overall unchanged when compared to prior EKGs) concerning for
NSTEMI. Given known h/o CAD with cardiac cath in ___ showing
70% and 30% lesion in the ramus intermedius (s/p BMS) and
relatively recent stress MIBI (___) with upsloping ST
segment depression on EKG in the inferolateral leads, this was
concerning for coronary thrombosis. The patient underwent
cardiac catheterization which showed no evidence of
angiographyically-significant flow limiting coronary disease
with patent stents in the high first diagonal. The patient
subsequently underwent echocardiogrophy which revealed normal
biventricular systolic function and no other structural
abnormalities, although imaging was suboptimal overall. The rise
in patient's troponins was felt perhaps secondary to
microvascular disease. Patient was continued on Atorvastatin,
ASA, and Nifedipine. Further consideration could be given to
starting a nitrate if she continues to experience exertional
chest pain. She was counseled regarding lifestyle modifications,
including weight loss. Patient was chest pain free with down
trending troponins prior to discharge. She was instructed to
follow up with her PCP and cardiologist for further evaluation.
# ___:
Patient has hx of Stage III CKD thought possibly to be
associated with chronic analgesic vs. hypertensive
nephrosclerosis. Patient's Cr elevated to 1.4 on admission,
possibly pre-renal in etiology. Nephrotoxic medications were
held in the inpatient setting. Creatinine Normalized to 1.0
following IVF hydration.
# HTN:
Remained stable. Patient was continued on her home NIFEdipine CR
90mg PO DAILY, and Lisinopril 80 mg PO DAILY
# Hypothyroidism:
Continued home Levothyroxine Sodium 112 mcg PO DAILY.
# Depression:
Followed by Psychiatry, remained stable. Continued home
antidepressants traZODONE 75 mg PO HS, BuPROPion (Sustained
Release) 150 mg PO BID, and Fluoxetine 80 mg PO DAILY.
# Chronic LBP:
Continued home regimen of Lidocaine 5% Patch 1 PTCH TD DAILY,
TraMADOL (Ultram) 50 mg PO Q8H:PRN pain, Hold Tizanidine 4 mg PO
BID:PRN pain, Acetaminophen 650 mg PO Q8H:PRN pain.
# GERD:
Continued Omeprazole 20 mg PO BID. | 99 | 385 |
10162298-DS-22 | 29,455,384 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted with woresening cough and
shortness of breath. You were seen by the pulmonologists who
helped manage your care while you were hospitalized. You had an
echocardiogram (ultrasound of your heart) which showed normal
function. Your pulmonary artery pressure was high. You can
discuss this further with your pulmonologist. You also had a CT
of your chest which showed a possible new pneumonia. You were
started on antibiotics to treat pneumonia and you will need to
continue these antibiotics for 2 weeks total.
Finally, your steroids are being tapered down. You should take
40mg of prednisone tomorrow, then decrease your dose by 10mg
every three days until you get to 10mg. Then continue to take
10mg of prednisone. | This is a ___ y/o female with pulmonary sarcoid, re-presenting
with ongoing shortness of breath at rest, dyspnea with minimal
exertion, and cough.
#Pulmonary Sarcoidosis
#Pneumonia, bacterial
Ms. ___ was admitted from pulmonary clinic with subacute
shortness of breath, dyspnea on exertion and cough. She was
managed with the help of the pulmonary consult team. It was
thought her continued symptoms were due to infection (viral,
bacteria or PJP), worsening sarcoid or possible right sided
heart failure ___ the setting of significant pulmonary disease.
The patient underwent an Echocardiogram which showed preserved
biventricular systolic function with moderate pulmonary
hypertension. Induced sputum was negative for PJP, but was
positive for Strep Pneumonia. RVP was negative- culture is
pending on discharge. The patient also had a CT chest without
contrast which showed new left lower lobe consolidation
concerning for pneumonia. Given these findings, the patient was
started on Augmentin for a 14 day course. The decision was made
not to start HCAP coverage given patient was overall non-toxic
appearing and induced sputum sample was positive for strep
pneumonia. Finally, given no evidence of worsening sarcoid on
her CT scan, her steroids were also tapered. She will be
discharged on 40mg and will decrease my 10mg every 3 days
stopping when she gets to 10mg. She will transition her care to
Dr. ___ discharge.
#PJP prophylaxis
Discussed with ___ attending, Dr. ___ regarding
options for PJP prophylaxis. The patient has a number of drug
allergies and will likely need to be on high doses of steroids
___ the future. The patient was set up with outpatient follow up
with Dr. ___.
#Paroxysmal atrial fibrillation
The patient was currently ___ NSR, seems unlikely to be cause of
her symptoms. She had no evidence of paroxysmal atrial
fibrillation while hospitalized.
#Hyponatremia
The patient presented with mild hyponatremia which improved with
IV fluids. | 134 | 300 |
19818243-DS-14 | 23,897,629 | Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having chest pain.
Your heart was monitored and your electrocardiogram and blood
tests were reassuring. You had an echocardiogram and a stress
test which were also reassuring.
Your INR was slightly high and therefore you warfarin dose was
held on ___. You should resume taking 2 mg daily tomorrow. You
should have your INR checked on ___.
You should continue to take the rest of your medications as
prescribed and follow up with your doctors as ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is an ___ w/ symptomatic severe AS s/p ___
TAVR, dilated cardiomyopathy, T2DM, HTN, prior nonhodgkins
lymphoma s/p chemo and XRT with recurrence s/p chemo who
presents with chest pain.
#Chest Pain: ECG without ischemic changes. Troponins negative
x3. Chest pain resolved spontaneously. Possible MSK component
given bruising over chest wall and tenderness to palpation.
However, given risk factors, could not exclude cardiac etiology.
He had a nuclear pharm stress which showed no evidence of
reversible ischemia making cardiac etiology less likely. He
remained chest pain free. He was continued on ASA, plavix, beta
blocker, statin.
# Atrial Flutter: The patient developed paroxysmal A-fib,
A-flutter with variable block, and ___ periodic 2nd degree AV
block with Wenkebach conduction after his recent core valve
placement. He was started on anticoagulation. He was noted to
have pre-syncopal episodes with prolonged sinus pauses and
therefore underwent pacemaker placement. Pacemaker was
interrogated during admission. He was continued on warfarin. INR
was supratherapeutic on day of discharge and dose was held on
___. He was instructed to take 2 mg on ___ and to have his
INR drawn on ___ and adjust his dose as directed by his MD.
# Severe aortic stenosis s/p Core Valve TAVR: Pt. with hx. of
severe aortic stenosis with recent clinical
decompensation, NYHA class III symptoms. The post-operative
course was complicated by new paroxysmal atrial fibrillation,
new ___ degree AV conduction delay w/ Wenkebach, and hematoma
formation
at the femoral access site. A repeat echo during admission
showed EF of 30% and ___ bioprosthesis with normal
gradient and trace aortic regurgitation. He was continued on his
current medication regimen.
# Coronary artery disease: Pt. with hx. of silent MI and CAD
s/p CABG in ___. Cath in ___ revealed three patent grafts
but 70% stenosis in the SVG to the PDA, now s/p DES. The
patient to be continued on Aspirin and Plavix during this
hospitalization. He was also continued on Metoprolol Succinate
25mg, simvastatin and Losartan
# Type 2 diabetes: held home oral medications and treated with
HISS
# Chronic dysphagia: soft diet during this admission
# Hypothyroidism: continued home levothyroxine
# B12 deficiency: continuted B12 supplementation
transitional issues:
- INR was supratherapeutic on day of discharge. patient will
need to have his INR closely followed and warfarin dose may need
further adjustment
- patient appeared euvolemic at time of discharge. monitor
cardiopulmonary exams and daily weights. lasix dose may need
adjustment
# CODE: full (confirmed)
# CONTACT: Patient, ___ (daughter) ___ | 113 | 424 |
17218741-DS-19 | 21,812,473 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had a seizure
What happened while I was admitted to the hospital?
-You were evaluated by the neurologists who felt that your
seizure was caused because you ran out of your clonazepam
-Your found to have a C. difficile infection in your intestines
and you were started on antibiotics to treat it
-You became nauseous and started vomiting because your
intestines had slowed down as a result of the C. difficile
infection
-Your tube feeds were slowed and you were evaluated by the GI
doctors who recommended ___ medication changes
-Your intestines were allowed to rest and then your tube feeds
were restarted
-Your lab numbers were closely monitored and you were continued
on your home medications that were thought to be appropriate
during your hospital stay
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
-Please complete antibiotic course for c difficile infection
We wish you the very ___!
Your ___ Care Team | Ms. ___ is a ___ year-old woman with a history of scleroderma
(diffuse systemic cutaneous), esophagitis with esophageal
stricture, HFpEF (EF 55%), interstitial lung disease, bowel perf
s/p colostomy in ___, polysubstance use disorder on
methadone, and anxiety, who initially presented for possible
witnessed provoked seizure at home thought to be in the setting
of running out of her clonazepam, was admitted for abdominal
pain, and subsequently found to have a fulminant C. difficile
infection complicated by ileus.
ACUTE ISSUES
============
# Fulminant Cdiff colitis complicated by ileus
The patient complained of abdominal pain and constipation on
admission. There was evidence of large stool burden and
inflammation near ostomy site on CT abd/pelvis. The patient then
developed explosive diarrhea night of ___ and tested positive
for C. difficile infection. Patient was initially treated with
p.o. vancomycin 125 mg with a planned 10 day regimen. However,
she subsequently developed nausea, vomiting, and worsening
abdominal pain and was diagnosed with an ileus based on serial
abdominal imaging. Her antibiotics were changed to high-dose
p.o. vancomycin and IV metronidazole. GI was consulted made
recommendations for further management of ileus. Patient's tube
feeds were transiently held and she was kept n.p.o. to
facilitate bowel rest. Her tube feeds were then advanced as
tolerated along with her diet. Patient was encouraged to chew
gum and was asked to ambulate multiple times a day. With such
supportive measures as well as antibiotics, the patient began to
improve. Her nausea and vomiting ceased and her abdominal pain
became much closer to her baseline chronic abdominal pain.
Patient's PEG tube site was noted to be mildly erythematous and
this area was evaluated by nursing and GI who recommended
mupirocin ointment to prevent infection.
# Provoked seizure
Patient presented to the hospital with a history of possible
witnessed seizure at home. Neurology was consulted and felt that
this was most likely in the setting of benzodiazepine withdrawal
as the patient had run out of her clonazepam and had not taken
it for 2 days prior to presentation. A noncontrast head CT was
reassuring as there is no obvious mass or organic cause of her
seizure. Patient was also placed on a video EEG that did not
demonstrate seizure activity. MRI head showed nonspecific
findings that should be followed up within 36 months with
repeat MRI. Patient was continued on her 3 times daily
clonazepam regimen and did not have any other recurrence of
seizure or altered mental status during her hospital stay.
Patient was counseled on the fact that she could not drive for 6
months because of her seizure per ___ law.
Patient we need to follow-up in outpatient neurology clinic
after discharge.
# ___
Patient initially complained of chest pain on presentation.
Unclear etiology of chest pain. The chest pain was thought to be
possibly related to the patient's scleroderma, as she had known
esophagitis and esophageal stricture, as well as interstitial
lung disease. The patient also had HFpEF (EF 55%, non-ischemic
stress cardiomyopathy), so cardiac etiology was possible but her
ischemic workup was negative and her troponins were negative ×3.
Her home lisinopril and metropolol were held given diarrhea and
relative hypotension during her hospital stay.
CHRONIC ISSUES
==============
# Polysubstance use disorder
# Anxiety
Patient was continued on home doses of fluoxetine, mirtazapine,
clonazepam, methadone.
# Scleroderma (diffuse systemic cutaneous)
Noted. Complications, if applicable, as stated above.
TRANSITIONAL ISSUES
===================
[] Benzodiazepines: Patient should avoid any sudden
discontinuation of home benzodiazepines as this might provoke
another seizure
[] PPI: Consider discontinuation of home PPI as it increases the
risk of C. difficile infection
[] Driving: Patient cannot drive for 6 months per ___
law because she suffered a seizure
[] Repeat MRI: Repeat MRI in 36 months for further evaluation
of nonspecific enhancement to better correlate with seizure
semiology
[] Neurology follow-up: Patient to follow-up in first-time
seizure clinic
[] PEG Tube Site: Mupirocin ointment for 2 weeks (last day
___, please evaluate for resolution of superficial
infection
[] Surgery follow-up: After completion of C. difficile
treatment, patient should follow-up with surgery to discuss
colostomy takedown
[] GI follow-up: Patient should be evaluated in outpatient GI
clinic to discuss need for esophageal dilation
[] Rheumatology follow-up: Patient to follow-up with outpatient
rheumatology providers for further management of systemic
sclerosis
[] Will complete 14 day course of Vancomycin - Rx provided.
[] Compazine PRN nausea.
[] Held Metoprolol and Lisinopril given lower blood pressures.
Please restart as appropriate as an outpatient.
#CODE: FULL CODE (presumed)
#CONTACT: ___ (HCP, father) ___ | 187 | 724 |
12774149-DS-10 | 20,807,728 | Ms. ___,
It was a pleasure meeting and caring for you during your most
recent hospitalization. You were admitted from your rehab
facility with fevers. You also had a short period of time where
your oxygen level dropped. This resolved without any
intervention. We learned that you have been having increased
episodes of urination. We checked your urine and found that you
were having a urinary tract infection. We treated you with an
antibiotic and you were discharged back to your rehab facility.
We wish you a speedy recovery.
All the best,
Your ___ Care Team | BRIEF SUMMARY STATEMENT: Ms. ___ is an ___ year old ___
and ___ female with PMH significant for COPD (no
PFTs in ___ system, baseline sats 89-91% on ___ home O2,
several admissions for exacerbations most recently ___,
multiple episodes of pneumonia including aspiration pneumonia
(___), aortic mural thrombus (on coumadin since ___,
prior strokes, HTN, CAD, pAFib with CHADS2 of 5 who presents
from her rehab facility with transient hypoxemia and fevers
despite ongoing treatment for CAP on levofloxacin. Pt. was
found to be without cough, SOB, or increased O2 requirement
(baseline 89-93% on ___ NC). CXR was notable for stable
bibasilar infiltrates seen on prior OSH studies. Pt. did note
increased urinary frequency and worsening of baseline
incontinence with a UA consistent with ongoing UTI. Pt. was
started empirically on ceftriaxone. Urine culture revealed MDR
E.Coli resistant to ceftriaxone. After discussion with ID,
given uncomplicated nature of acute cystitis, pt. received a one
time dose of fosfamycin for treatment. She remained
hemodynamically stable and was discharged back to her rehab
facility. | 98 | 182 |
18780646-DS-10 | 27,571,922 | Dear ___,
You were admitted to ___ with a severe infection of your
scrotum. You were found to have significant kidney injury and
low blood pressure.
While in the hospital, blood, urine and skin cultures were
obtained. Imaging tests were performed that demonstrated severe
inflammation of your scrotum, perineum and groin. You were
treated with IV antibiotics and pain medication. You were also
treated with IV fluids to treat your kidney and your blood
pressure.
Your heart monitor demonstrated a slow heart rate while you are
sleeping. We recommend you follow up on this with your primary
care doctor and discuss having a sleep study.
We discussed with you the risks of transitioning to an oral
antibiotic at this time. Given the severity of the infection we
recommended that you stay at the hospital for additional doses
of IV antibiotics. However you have maintained you would like to
leave.
Upon leaving the hospital, please take Bactrim 2 tablets every
morning and every night. Please take the augmentin every morning
and night. If you develop worsening pain, fevers, swelling,
worsening sweats please return to the hospital.
It was a pleasure taking care of you at ___!
- Your ___ Care Team | Summary statement:
___ yo M with a history of HIV who presents with left sided
scrotal swelling and pain found to have exam and imaging studies
consistent with significant left-sided epididymo-orchitis and
scrotal cellulitis along, ___, signs concerning for sepsis.
#CODE: Full, confirmed
#CONTACT: ___ (friend), ___
TRANSITIONAL ISSUES:
- Patient has follow up appointment on ___,
ekectrolytes and creatinine should be monitored at that visit
given recent ___ and ___ dose Bactrim therapy
- Patient discharged on 4 day course of oxycodone
- A follow-up ultrasound in ___ months time is recommended to
assess the stability of the left crescentic hypoechoic
peritesticular thickening.
- Patient with asymptomatic bradycardia found to have Mobitz I
Wenckebach while asleep, consider sleep study while outpatient
- TI: thyroid u/s, TSH
-Outpatient evaluation of normocytic anemia as etiology remains
unclear
#Scrotal Skin infection
Patient presented from clinic with tense scrotum with left side
size of grapefruit, with leukocytosis, fevers, hypotension and
___. Urology was consulted and ultrasound performed which did
not demonstrate gangrenous infection. He was initially treated
with vanc/zosyn and then transitioned to vanc/ceftriaxone.
Patient initially did not have significant clinical improvement
and infectious disease was consulted. A CT demonstrated
significant infection of the perineum and scrotum and ___
gangrene could not be ruled out. Patient was started on
clindamycin. Vancomycin dosing was also adjusted given improved
kidney function. Patient had interval improvement with
downtrending leukocytosis and fever curve and improvement in
erythema and size of scrotum. A wound culture of superficial
ulcer demonstrated MRSA. Given the severity of the infection we
recommended that patient stay at the hospital for additional
doses of IV antibiotics. The patient insisted upon leaving on
___ and was able to communicate possible risk of worsening
infection, loss of tissue and death. He will be discharged with
oral regimen with ID recommendation of augmentin and Bactrim. He
will also be discharged with short course of oxycodone and with
close follow up at ___ ___.
___
#Hypovolemic hyponatremia
In setting of sepsis. Improved with IVF resuscitation.
#Asymptomatic Bradycardia
#Type I ___ ___ AV block
Identified on telemetry while patient was sleeping.
Asymptomatic. Increased suspicion for underlying sleep apnea
given body habitus. Consider cardiology evaluation and sleep
study as an outpatient. | 196 | 360 |
19969118-DS-21 | 27,973,799 | Dear ___,
___ was a pleasure taking care of you during your most recent
hospitalization. You were admitted for increased depression,
fatigue, and mental haziness. You were evaluated by neurology
and psychiatry in house. You were felt safe for discharge. MRI
of head showed no acute intracranial process.
Please take of your medications as prescribed.
Please followup with your physician ___. | ___ female with PMH ___, MS, and depression,
admitted for gradual decompensation with complaints of increased
mental "fogginess", fatigue, leg cramps, and increased
depression ___ suicidal ideation. Patient states that these
complaints have been present since ___, ultimately
leading to her passive suicidal thoughts. Patient was evaluated
by Neurology who confirmed a nonfocal neuro exam and recommended
MRI, which showed no acute intracranial findings. Presentation
was not consistent with MS flare. Patient with depression and
anxiety, evaluated by Psychiatry and started on lexapro. | 58 | 84 |
19640899-DS-11 | 28,161,837 | Dear Ms. ___,
It was our pleasure participating in your care. You were
admitted on ___ for severe shortness of breath. Because of
your heart failure, you were retaining fluid and the fluid in
your lung was making it hard to breath. We tried giving you very
strong medications via your IV but these medications were unable
to remove enough fluid from your lungs and legs. You were
started on dialysis while inpatient and will continue as an
outpatient at ___ on ___,
___, and ___.
You were also found to have a lung nodule in your CXR. Your PCP
has already ordered at CT scan so that we can get more
information about this.
If you have any worsening or concerning symptoms, please let
your doctors ___.
Again, it was our pleasure participating in your care. We wish
you the best of luck | Ms. ___ is a ___ woman with a history of DM II, RA,
HTN, and CKD V with two recent admissions for PNA/COPD/dCHF. She
presents again with shortness of breath and volume overload.
.
# Volume overload secondary to Acute-on-Chronic diast CHF: The
patient's initial presentation (as with her prior recent
admissions) was consistent with volume overload secondary to
CHF. She was seen by ___ cardiology who recommended
aggressive diuresis. Despite attempts with metolazone, Lasix
160mg and multiple doses of chlorothiazide, we were unable to
successfully diuresis her. She was initiated on dialysis during
this admission with a tunneled line placed on ___. Venous
mapping showed poor venous access on the left side so the
fistula was placed on her right radiocephalic arteriovenous
fistula on ___. PPD and hepatitis serologies negative. She
will be receiving dialysis T/H/S at ___ Dialysis.
.
# CKD V: Patient has stage V CKD presumably due to HTN/DM. Given
she was unable to be effectively diuresed with aggressive
medication dosing, she was evaluated by Nephrology and
ultimately initiated on dialysis as per above. She will be
receiving dialysis T/H/S at ___ Dialysis.
# MGUS: Per Atrius records, the patient had iron deficiency
anemia treated with PO iron and a diagnosis of MGUS (M spike
seen on SPEP in ___ but has not had follow-up evaluation.
Repeat SPEP during this admission again showed monoclonal IGG
kappa of 1172 which, along with trace light chains, makes her
generally low risk for progression. Given that it will be
difficult to follow based on her clinical exam and basic lab
work because of her other comorbidities, she might benefit from
repeat SPEP/UPEP yearly.
- Hematology follow up is recommended. Discussed with patient
.
# Lung Nodule: Incidentally noted. Follow up CT recommended.
This was discussed with the patient.
.
.
CHRONIC DIAGNOSES:
------------------
# Hypertension: Continued home labetalol. She was started on
Imdur during this admission. ___ need to be titrated as
necessary.
.
# Rheumatoid Arthritis: Continued prednisone and Tylenol with
codeine prn.
.
# T2DM: Last A1C 7.1%: Insulin glargine increased from 5 to
10units QAM. She was placed on gentle insulin sliding scale for
additional coverage but will be discharged on the Lantus 10
units qam. This may need to be titrated as an outpatient
.
# Hypercholesterolemia: Continued home pravastatin.
.
. | 142 | 383 |
16801891-DS-10 | 26,859,598 | Dear Ms. ___,
You were hospitalized at ___.
Why did you come to the hospital?
=================================
- You came to the hospital because you were having trouble
breathing and we were concerned that you were having an asthma
attack.
What did we do for you?
=======================
- We gave you albuterol nebulizers and IV steroids to help treat
the asthma attack.
- Your breathing improved, so we discharged you with flovent
inhalers as well as a five day prednisone course.
What do you need to do?
=======================
- Please take prednisone 60mg per day for a total of five days
of steroids. Day 1 = ___. Day 5 = ___.
- Please follow-up with your primary care doctor. Please call
the office to try and schedule a sooner appointment.
- Please talk with your primary care doctor about getting
pulmonary function tests (PFTs) to better assess your asthma.
- Please continue to take your Dulera and your Flovent two times
per day.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team | ___ Admission Course ___:
___ year old F with PMH of asthma presenting to the ED with
tachypnea concerning for asthma exacerbation.
Patient was admitted from the ED for an acute asthma
exacerbation. Patient was not hypoxic and there was little
concern for a pulmonary embolism given patient's appropriate
oxygen saturation. While in the emergency room the patient
received 3 Duoneb treatments, magnesium as well as a dose of IV
Methylprednisolone. Upon transfer to the ___ the patient did
not require any oxygen supplementation and there was no concern
for airway compromise. Patient was transitioned to oral
prednisone 60mg on ___ and prescribed a 5 day course.
Patient was also prescribed Flovent 110mcg 2 puffs daily and
Dulera 100-5mcg BID for management of moderate to severe asthma.
Peak flow was 350 at time of discharge. | 166 | 134 |
19563570-DS-25 | 27,325,833 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted with a urinary tract infection, acute
kidney failure and severely elevated potassium levels. This was
most likely caused by poor oral intake and urinary tract
obstruction. You were treated with intravenous fluids and
medications which you tolerated well. You also had a foley
catheter to drain your bladder for 24 hours. Your potassium
level has returned to normal. Your kidney function is now
recovering.
When you return home, it is very important that you continue
eating and drinking. You will take an oral antibiotic to
continue to treat the urinary tract infection. You will also
need to continue to self-catheterize with clean technique, but
you will now need to self-catheterize every other day until you
see your urologist.
Your glyburide dose has been decreased and it is important that
you take only 1.25mg twice a day and continue to monitor your
blood sugars at home. Please call your PCP if you notice that
your fingerstick levels are too low (less than 70) or too hight
(greater than 220).
If you start to have fevers/chills, confusion, or decreased
amount of urine, please seek medical attention. | ___ with PMH CAD, HTN, DM, CKD, and ureteral strictures
requiring intermittent self-catheterization, admitted with URI
symptoms and poor PO intake found to have ___, hyperkalemia and
non anion gap metabolic acidosis. He reports not having
performed straight catheterization on regular schedule and had a
UA consistent with infection.
ACTIVE ISSUES:
# Acute renal failure on Chronic Kidney Disease:
History of CKD (baseline Cr 1.3-1.4). He presented with Cr 3.3,
K 6.3 and non-anion gap metabolic acidosis. FeNa was 1.39%,
urine Na 39, FeUrea 30.23%. His acute kidney injury was
multifactorial from pre-renal azotemia (caused by poor po intake
and relieved with fluid bolus) and post-renal obstruction (hx of
strictures and urinary retention requiring foley placement
during inpatient stay). Interestingly, as described by the
renal consulting service, the urinary obstruction lead to a
distal RTA type IV where the back flow of obstruction caused
pressure in the collecting ducts and eventually compromised
secretion of H and K and thus leading to non-anion gap metabolic
acidosis. Notably, his renal function improved with IV fluids,
and foley catheter to relieve obstruction. US showed no
dilatation of the renal pelvis or ureters. He was able to void
on his own after foley was removed. At discharge Cr 1.7 and K4.7
and both were trending downward. He was instructed to perform
clean technique self-cath 4x weekly rather than twice. He will
follow-up with urology and nephrology.
# Hyperkalemia: K to 6.3 in the setting of ARF. No peaked T
waves on EKG. No cardiac complaints. ___ ___ with urinary
obstruction and RTA4. The hyperkalemia resolved with kayexalate,
IV insulin + dextrose, lasix, calcium gluconate, and foley to
relieve urinary obstruction.
#Non anion Gap Metabolic ___ urinary obstruction
phenomenon that leads to dysfuction of the collecting duct,
causing retention of H and K alone. Was treated with sodium
bicarb.
# UTI
Patient did not complain of dysuria etc, but his UA showed
pyuria concerning for UTI vs prostatitis. Pt would not agree to
rectal exam thus differentiation difficult. UTI was considered
more likely because of self-caths and urinary retention. Urine
culture was mixed flora only. He was treated with IV
ceftriaxone and switched to 10 day cipro 500mg po. Patient was
also instructed on sterile technique for performing
self-catheterizations.
# URI
Patient presented with cough, body aches and fatigue concerning
for URI. Additionally, his wife was getting over a serious URI.
Influenza antigen tests were negative for influenza A and B. At
time of discharge his symptoms had resolved, so no further
intervention needed.
# Altered mental status
On presentation the patient was lethargic, and family reported
he had altered mental status including confusion and refusal to
eat. This was likely delerium secondary to UTI, ___ and uremia.
With resolution of acute problems the patient's mental status
returned to baseline.
# Pulmonary nodule.
Patient had a CXR that showed a nodule in anterior mediastinum /
anterior left lung. This is stable compared to CXR since ___,
but outpatient CT recommended to better evaluate. | 208 | 506 |
16273894-DS-10 | 24,017,449 | Dear Ms. ___,
It was a pleasure taking care of you during this
hospitalization. You were readmitted to ___
___ for worsening yellow/green drainage from your
back wound. Your wound was cleaned out in the emergency room by
the Chronic Pain team and you were started on intravenous
antibiotics. A scan of your back showed that the infection was
superficial. With antibiotics, your fevers stopped, your back
pain improved, and the blood counts that measure infection
(white blood cell count) improved. Prior to discharge, you were
switched to oral antibiotics and you will need to complete a 7
day course of antibiotics (last day ___.
You are now safe to leave the hospital. Please ___ with
your doctors as ___ and take all your medications as
prescribed. You have a month's supply of pain medications at
home. | ___ with HLD, GERD, depression, spinal surgery x 10 (most
recently s/p removal of infected spinal stimulator device on
___ presents with purulent drainage from back wound and
superficial abscess on CT.
==============
ACTIVE ISSUES
==============
# Wound drainage and subjective fevers: The patient presented
with purulent drainage from midline wound site with CT showing
superficial abscess. She underwent bedside debridement by the
Chronic Pain team in the Emergency Room. The reason for this
abscess was most likely the presence of stitches after prior
procedure preventing appropriate drainage, and less likely due
to resistant organism (MRSA) given prior wound cultures growing
MSSA or hardware infection (screws). Upon admission, patient
was febrile to Tmax 102 and tachycardic to HR 120s with
leukocytosis to WBC 27 on ___. The patient was initially
started on IV Vancomycin with resolution of fever and
tachycardia, normalization of WBC, and improvement in back wound
drainage. The patient was switched to PO Bactrim DS BID on
___ to complete a 7 day course of antibiotics (last day
___ and remained febrile for over 36 hours prior to
discharge. The patient has scheduled ___ with her PCP ___
___ and has home ___ for wound care.
# Acute on chronic low back pain: At the time of admission, the
patient was on both short-acting oxycodone prescribed by her PCP
and PO hydromorphone prescribed by her Chronic Pain specialists.
These were continued initially per the recommendations of the
Chronic Pain service while the patient reported back pain
increased from her baseline. Her breakthrough Dilaudid was
discontinued on ___ given improvement of back pain. The
patient's home tizanidine and gabapentin were also continued.
No narcotics were prescribed at the time at discharge, as the
patient's husband filled a month's supply the ___ prior to
admission.
===============
CHRONIC ISSUES
===============
# Depression: Continued home sertraline.
# GERD: Continued home omeprazole and ranitidine.
# HLD: Continued home simvastatin.
====================
TRANSITIONAL ISSUES
====================
MEDICATIONS
- STARTED on Bactrim DS BID for 7 day course of antibiotics
(last day ___
- The patient has a 1 month supply of pain medications at home
(filled by her husband)
OTHER ISSUES
- The patient has PCP ___ scheduled on ___
- The patient has ___ for wound care and dressing changes | 143 | 373 |
13990946-DS-4 | 21,605,620 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain found to
have pancreatitis from elevated triglycerides. You were treated
with fluids, pain medications and a procedure called pheresis to
remove the triglycerides. Your symptoms improved and you were
able to eat a low fat diet with improved pain.
You will need to follow-up with the gastroenterology team and
after discharge for ongoing management and work-up of your
pancreatitis. You will need to follow-up with ___ clinic for
follow-up appointment of your triglycerides this ___,
___. Please follow-up with your primary care doctor next
week for repeat lab work.
It was a pleasure taking care of you,
Your ___ Care Team | Mr. ___ is a ___ with PMHx necrotizing pancreatitis who
initially presented with a chief complaint of epigastric
abdominal pain, nausea, and vomiting. His labs were notable for
an elevated lipase and a negative serum EtOH. His CT
abdomen/pelvis revealed evidence consistent with pancreatitis in
addition to his previous pancreatic necrosis. He was admitted at
___ in ___ of this year with necrotizing pancreatitis
from EtOH after which he quit drinking. He was found on this
admission to be tachycardic with lipase ___bdomen
pelvis showing diffuse peripancreatic fat stranding and edema
with multiple adjacent fluid collections decreased since ___.
He had a hypodense area concerning for pancreatic necrosis. He
was given dilaudid and fluid and admitted to the MICU. In the
MICU, patient was found to have severe hypertriglyceridemia to
the 7000s(in ___, triglycerides were 207) for which he
underwent pheresis with improvement in his triglycerides to the
700s. He was noted to have anemia felt to be due to fluid
resuscitation and thrombocytopenia possibly due to underlying
liver disease. He has also had sinus tachycardia likely
exacerbated by pain as well as direct hyperbilirubinemia for
which he underwent MRCP which showed ___ strictures and his
bilirubinemia was felt to be related to possible chronic liver
disease.
He was transferred from the ICU to the floor, admitted with
acute pancreatitis secondary to hypertriglyceridemia s/p
pheresis complicated by hyperbilirubinemia and anemia. Patient
with minimal abdominal pain on discharge. Alk phos will need to
be monitored on discharge in addition to LFTs. Arranged for
___ clinic follow-up on ___. Discussed importance of
monitoring diet and avoiding alcohol (reports has
not drank alcohol since ___, however has been eating a diet
that may have had more fatty foods). Patient also reported two
year episodic dizziness and given history, head CT and carotid
ultrasound was completed in addition to ECHO. His dizziness
improved during hospitalization and he was told to follow-up
with his PCP for further evaluation. Gastroenterology followed
during hospitalization and will see him in follow-up. | 111 | 334 |
15608916-DS-19 | 23,698,718 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
shortness of breath and found to have a worsening of your heart
failure with new pleural effusions (fluid outsides of your
lungs). We treated you with intravenous diuretics (medications
to help remove the fluid) with some improvement in your
breathing.
After extensive discussion with your family and you, the
decision was ultimately made to focus your care on your comfort.
We stopped all medications and interventions that were not
directed at your comfort.
Wishing you well,
Your ___ Care Team | Ms. ___ is a ___ y/o woman with H/O CAD, hypertension,
diabetes mellitus, hyperlipidemia, sinus node dysfunction now
s/p PPM, HFpEF, breast cancer s/p left breast mastectomy and
radiation in ___ presenting with shortness of breath, dyspnea
on exertion, cough, and orthopnea, found to have acute on
chronic diastolic CHF. Hospital course complicated by NSTEMI,
bilateral pleural effusions, moderate pericardial effusion, and
change in code status to DNR/DNI and CMO.
# Goals of care: Given acute change in functional status and
overall clinical status, several goals of care conversations
were held with the patient's daughter (HCP) and patient.
Decision was ultimately made to focus care on comfort, with
patient transitioned to DNR/DNI (___) and made CMO (___).
Family decided no further procedures/painful interventions,
including thoracentesis, and patient was only continued on
medications for symptom relief.
# Hypoxemia, acute on chronic diastolic heart failure, bilateral
pleural effusions: Patient presented with acute shortness of
breath, new O2 requirement to 4 Lpm via NC, NT-Pro-BNP elevated
to 2448, and significant fluid overload on exam, consistent with
CHF exacerbation. She was diuresed with furosemide IV with good
response but no significant improvement in O2 requirement or
reduction in pleural effusions. Echocardiogram on ___
showed LVEF >55% with mild symmetric LVH and moderately sized
circumferential pericardial effusion with no specific
echocardiographic signs of tamponade physiology. Interval
increase from small to moderate pericardial effusion compared to
TTE on ___. After discussion with family and patient,
thoracentesis was felt to not be within goals of care. She was
transitioned to PO diuretics, but given worsening PO intake was
ultimately discharged with no diuretic regimen and on CMO.
# Failure to thrive: Multifactorial in the setting of
progression of medical comorbidities, clinical status, and
likely contribution from depression. She was continued on her
home escitalopram. Mirtazapine was attempted for appetite
stimulation and mood modulation but subsequently stopped. Her
appetite has continued to worsen with poor po intake.
# NSTEMI: Patient with intermittent episodes of left sided chest
discomfort since last discharge. Troponin-T peaked at 0.48, EKG
without new ischemic changes. Repeat TTE with preserved EF, no
wall motion abnormalities. PMIBI on ___ showed no perfusion
defects. Patient was medically managed with Heparin gtt x 48 h,
ASA 81 mg, atorvastatin 80 mg, and initiation of metoprolol
succinate.
# Pericardial effusion: Echocardiogram showed small-moderate
pericardial effusion, interval increase compared to prior on
___. No evidence of tamponade physiology.
# Leukocytosis: Patient with persistent leukocytosis (peak WBC
14) without signs or symptoms of acute infection, no fever or
chills. Likely stress response.
# ___ on CKD: Prior baseline Cr of 1.4, elevated to peak of 2.4.
Initially secondary to likely cardiorenal, improved with
diuresis. Did worsen in the setting of likely over-diuresis.
Ultimately stabilized to Cr of 1.9, which likely represents new
baseline. Home ACE-I held given ___. | 93 | 463 |
19966115-DS-8 | 23,669,560 | Dear Mr. ___,
You were admitted to the hospital because of swelling in your
legs. It was felt that the swelling in your legs was not because
of your heart. Your leg swelling was thought to be from "stasis
dermatitis" a condition where swelling in your leg results from
decreased flow of fluid back to the heart. It is treated with
compression stockings and leg elevation. Your kidney function
was also slighltly diminished due to dehydration and we have you
IV fluids and it improved before discharge. You had a sore
throat, cough, and congestion. You were tested for the flu and
this test was negative. Your symptoms improved prior to
discharge. You were assessed by physical therapy who felt that
you would benefit from rehabilitation.
Sincerely,
Your ___ Team | ___ yo M with a PMH of ___ disease, HTN, DM, Spinal
stenosis, and bilateral TKR's who presents with bilateral ___
edema with erythema consistent with stasis dermatitis.
# Lower extremity edema likely secondary to stasis dermatitis:
Mr. ___ was noted to have lower extremity edema that was
symmetric and erythematous to the midshins. BNP was obtained
that was within normal limits to assess the likelihood of heart
failure exacerbation as contributor to patient's symptoms though
no prior history of CHF was noted. Mr. ___ had echocardiogram
on day of discharge to evaluate his cardiac function in the
setting of known OSA and predisposition to right sided heart
failure. Echocardiogram showed moderate aortic stenosis with
preserved global biventricular systolic function and borderline
pulmonary hypertension in the setting of known OSA.
It was felt that his lower extremity edema was from stasis
dermatitis from venous insufficiency. He was treated with leg
elevation and compression stockings. Lasix was discontinued
Amlodipine was also discontinued given that it was felt that it
could be contributing to lower extremity edema. His lower
extremity edema improved with leg elevation and compression
stockings.
# URI symptoms:
Mr. ___ presented with chronic cough, but inconsistent with
reporting if cough is worse at this time. He remained with
oxygen requirement, leukocytosis, and CXR was without evidence
of pneumonia. On hospital day 2 Mr. ___ developed congestion,
rhinorrhea, and sore throat. He was tested for influenza that
was negative. He was treated symptomatically with tylenol and
lozenges. His congestive symptoms improved prior to discharge.
#Dysuria
Mr. ___ endorsed dysuria prior to admission. He was noted to
be on bactrim chronically for UTI precention. UA at time of
admission was negative for infection. Bactrim was continued per
prophylactic home dose. Mr. ___ has upcoming urology
appointment with Dr. ___ on ___.
# Acute on chronic renal failure (baseline creatinine of
1.4-1.6)
Mr. ___ presented with creatinine of 1.6 BUN/Cr > 20 and
consistent with pre-renal process and FENa 1.85% more consistent
with intrinsic process and is likely to be mixed process given
underlying CKD with acute insult. Patient noted to take 20 mg
daily lasix which likely contributed to some degree of pre-renal
insult. Creatine improved to 1.4 with fluid challenge and
cessation of lasix and hydrochlorothiazide.
#Hypertension
Mr. ___ had systolic SBP of 140-160. Initially
HCTZ-triamterene and amlodipine were held given ___ and ___
extremity edema. It was felt that given his comorbidities
including hypertension, diabetes, and CKD lisinopril was started
at 20 mg and HCTZ-triamterene and amlodipine were stopped. His
blood pressure goal would be 130/80 given his age and
comorbities include CKD and diabtes.
# Knee pain s/p bilateral TKR:
Mr. ___ presented with worsening knee pain. He had right knee
pain at time of admission though prior to admission had been
seen by his orthopedist who felt there was no indication for
surgical intervention and had recommended pain management and
outpatient physical therapy. X-ray of right knee at time of
admission did not indicate any new injury and knee on exam does
not appear to have evidence of infection. He was evaluated by
physical therapy who felt he would benefit from rehabilitation.
His pain was controlled with tylenol and tramadol.
#Normocytic Anemia
Chronic and stable. Mr. ___ ferritin was noted to be 25 and
consistent with iron deficiency anemia. Should consider
outpatient colonoscopy. He was started on daily ferrous sulfate
with bowel regimen.
#OSA
Continued on bipap. Echocardiogram showed borderline pulmonary
hypertension likely secondary to OSA.
# DM II complicated by neuropathy:
ISS continued.
gabapentin continued for neuropathy
# ___:
Continued carbidopa-levodopa, entacapone, pramipexole
# HLD:
Contued simvastatin.
# BPH:
Continued tamsulosin.
# Code: DNR, ok to intubate
# Emergency Contact: ___ (Dtr) ___, ___ (Wife)
___ | 132 | 628 |
17006856-DS-22 | 20,796,768 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
necase your G-tube fell out. While you were unable to take
medications by G-tube, we gave you IV medications. The G-tube
was replaced on ___ by the ___ team.
Please follow-up with your doctors as ___ and take all
medications as prescribed.
Best of luck in your future health,
Your ___ Team | ___ yo F with a history of IPH resulting in paresis of her
extremities, bedbound at baseline with PEG for
medications/nutrition, history of alcoholic cirrhosis presents
with dislodged G-tube, found to have an ileus.
# Displaced gastric tube: initially secured with a foley, ___
replaced the gastric tube on ___. Tube feeds and per-Gtube meds
were restarted on ___.
# Ileus: Evidenced by dilated loops of bowel on CT and seen
again on imaging during her ___ replacement of the G tube. The
new g-tube was put to light suction overnight and her abdominal
tenderness resolved.
# Hypercalcemia. Patient found to have asymptomatic
hypercalcemic to Ca ___ on admission, improved to 10.9 with IV
fluids. PTH checked and low at 8. 25 Vit D level sent and
pending at the time of discharge. Please consider further
work-up for hypercalcemia including PTHrp and 1,25 Vit-D level.
# Oral thrush: Started on nystatin.
# Status-post IPH: Home meds initially were held while NPO.
Restarted on ___. No active issues other than pain from
contractures during this admission.
# Cirrhosis: alcoholic origin. Home meds were initially held
while NPO but then restarted on ___.
=========================
TRANSITIONAL ISSUES
=========================
MEDICATIONS CHANGES
- STARTED on Nystatin for oral thrush
FOLLOW-UP
- Patient found to be hypercalcemic to Ca ___ during this
admission (10.9 on discharge). PTH low at 8. 25 Vit D level sent
and pending at the time of discharge. Please consider further
work-up for hypercalcemia including PTHrp and 1,25 Vit-D level.
- Please check calcium level on ___ | 65 | 247 |
14033331-DS-48 | 25,650,141 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for
blood cultures that grew bacteria. At this time, we believe you
had a line infection, and so your prior dialysis catheter was
removed and you had a new one placed on this admission. Your
dialysis was continued subsequently without complication. We
performed an ultrasound of your heart valves that did not show
infection.
Our kidney doctors ___ your ___ wounds, which are
the result of calciphylaxis, and do not feel there is a need for
surgical intervention at this time.
You were having some chest pain when working with ___. We believe
this is mostly musculoskeletal in nature. We monitored your
cardiac enzymes, and while they were elevated, you did nto have
any EKG changes and it is unlikely that you are having a heart
attack. | ___ F with ESRD on MWF HD, chronic L heel ulcer, chronic ABD wall
wounds, on chronic Bactrim and history of calciphylaxis who
presents from her SNF for Staph bacteremia found to have a HD
tunnel site infection.
# Methicillin-R Staph epi bactermemia: Likely source was tunnel
site infection, although abdominal wounds would have also been a
source. Vanc was dosed by ___ during her line holiday, and
dosed with HD as appropriate. Repeat cultures on admission and
throughout hospitalization were negative. TTE did not note
vegitations, but was a technically limited study. ___ did not
show vegetations. Pt should have vancomycin dosed at HD through
___ to compelte a 14 day course of treatment for bacteremia.
# ESRD ___ DM/HTN on HD
She was given a line holiday from ___ until ___.
Electrolytes were closely monitored. Tolerated HD on ___. Can
resume ___ schedule as previously.
# Calciphylaxis
She has multiple open abdominal wounds from calciphylaxis which
were evaluated by the wound nurses, who felt there was
potentially a superimposed infection and recommended general
surgery consult. Sodium thiosulfate had been tried previously
but was unable to be tolerated due to nausea and vomiting.
# CAD s/p CABG ___ (s/p MI (___): Continued Atorvastatin
10 mg PO QPM and Clopidogrel 75 mg PO and betablocker. On day
prior to discharge had chest pain that was likely MSK in nature
as it was reproducible on palpation. EKG was unchanged. Troponin
0.15-0.17, but with flat CKMB.
INACTIVE ISSUES
# DM:c/b hypoglycemia: placed on an insulin sliding scale
in-house
# HTN: continued home metoprolol
# ASTHMA: continued albuterol
# CVA: continued clopidogrel
# Diastolic CHF: inactive issue. continued metoprolol
# seizures: inactive issue. continued keppra
TRANSITIONAL ISSUES
--Please continue vancomycin with HD until ___ to complete a 14
day course of treatment
--Please continue ___ HD
--Given many recent hospitalizations and pt's wishes to be at
home, would continue goals of care discussion as outpatient.
During this hospitalization, palliative care was consulted but
pt was not ready to have these discussions yet
# Emergency Contact: ___ (sister), phone number:
___ | 140 | 351 |
11602538-DS-6 | 26,007,873 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
What brought you into the hospital?
- You were admitted because you had chest pain and difficulty
breathing.
What was done for you in the hospital?
- You were found to have fluid around your heart and fluid
around your lungs. We had the rheumatologist see you and they
were unsure what this was from. It was likely a viral infection
that caused your symptoms. While in the hospital you received
medications to get rid of your fluid overload. Your were
diagnosed with acute pericarditis and we started you on
steroids. We also did a thoracentesis to remove the fluid around
your lungs.
-You were also found to have an irregular heart rhythm called
atrial fibrillation.
What should you do after leaving the hospital?
You should keep taking prednisone 40 mg for 2 weeks (last day:
___. Your primary care doctor ___ decide how long
you will need to be on steroids. Please go to the follow up
appointment with PCP and nephrology.
We wish you the best,
Your care team at ___ | ___ y/o woman with history of hypertension, NIDDM2, CKD4, HLD,
and left-sided breast cancer s/p mastectomy who was admitted for
sternal chest pain, shortness of breath and cough for 2 weeks
likely from viral pericarditis.
#Pericarditis
Patient with two weeks of sudden severe stabbing pain starting
in left shoulder, migrating to sternum, worse with inspiration
and associated with SOB, cough, fatigue. PE was ruled out by V/Q
scan and there was a low suspicion of ACS due to the lack of EKG
changes and stable troponin. Chest x ray showed bilateral
pleural effusions and bedside US showed pericardial effusion. A
TTE showed normal EF and valves and small-moderate pericardial
effusion, that together with an elevated inflammatory markers,
suggested acute pericarditis. She was started on prednisone 40
mg. Rheumatology was consulted for possible serositis; however,
per rheumatology, there was no suggestion of systemic rheumatic
disease such as SLE, drug-induced lupus or RA. Patient will be
discharged on prednisone taper with follow with PCP to taper
over 3 months and repeat TTE, CXR and repeat ESR, CRP, and CBC.
Last TTE before discharge showed a small pericardial effusion
without signs of tamponade.
#Pleural Effusions
#Shortness of Breath
Patient reports that SOB started about the same time of her
chest pain. X-Ray showed moderate left and small right pleural
effusions. Patient had mild signs of volume overload that were
treated with diuresis with lasix IV. Repeated chest x-ray showed
that there has been decrease in the left-sided pleural effusion
with a tiny right-sided pleural effusion. IP was consulted for
diagnostic thoracentesis from left pleural effusion. Pleural
liquid suggestive of transudative. She will need follow up
results of pleural fluid cytology in the outpatient setting.
Patient with improvement of her symptoms at discharge, without
signs of volume overload.
# AFib
Patient with new onset afib with RVR at admission. In sinus
rhythm during hospitalization with episodic asymptomatic atrial
fibrillation. At discharge, she was in sinus rhythm. Management
with metoprolol. Patient with a CHA2DS2-VASc=5. Warfarin was not
started because of concern for bloody conversion of her
pericardial effusion. However, once her pericardial effusion
resolves, then she can be started on warfarin.
# Sinus Pause: Patient had asymptomatic sinus pause on telemetry
for <10 seconds. Her beta-blocker was decreased to 25 mg BID.
# Hypertension: pt with BP of 188/83 on admission. Treated
initially with losartan 100mg, metoprolol 50mg bid and
amlodipine 5mg qd. Losartan was discontinued because of
increased creatinine and amlodipine was increase to 10 mg for
adequate pressure control.
#Acute on chronic kidney disease
Patient with elevation of creatinine level comparing with
baseline. Likely due to overdiuresis. Diuretics and losartan
were discontinued during hospitalization.
CHRONIC/STABLE PROBLEMS:
# DM2: on diabetic, low salt diet at home. ISS was initiated due
to the start of prednisone but she did not require any insulin.
# Gout
- Continued home allopurinol ___ qd
# HLD
- Continued home simvastatin 20mg qPM
TRANSITIONAL ISSUES | 180 | 471 |
13109578-DS-10 | 27,985,972 | Dear Ms. ___,
You were admitted to the ___ due to abdominal pain
and leg weakness. When you presented to the emergency department
you blood work showed a high white count concerning for
infection. We tested your urine and it was concerning for
infection. We also did a CT scan to look at your small and large
intestines. It showed changes concerning for irritation in the
walls of your colon, a condition called diverticulitis. We gave
your small bowels a rest and started you on two antibiotics
flagyl and ciprofloxacin that will treat the irritation in your
colon. You should continue taking these antibiotics for a total
of 14 days (start day: ___ end day: ___. You also
met with the surgeons while you were in the hospital, they said
there was no need for surgery now. However, please talk to your
primary care physician, ___ scheduling an
appointment with a surgeon.
You were found to have a urinary tract infection. The
antibiotics that you are using to treat the diverticulitis will
also treat this infection.
You presented with leg weakness especially in your left leg. We
did an XRay of your hips and pelvis that showed arthritis in
your left hip. We tested for a clot in your left calf, it was
negative, there was no clot. Please be sure to keep your
appointment with orthopedics (listed below).
Please take 1 mg of warfarin tonight ___. Call Dr. ___
at ___. You should have your INR drawn on ___,
___.
Thank you for allowing us to participate in your care.
___ care team | ___ woman with hypertension, DM, CKD, as well as history
of diverticulitis who presented with generalized lower extremity
weakness, dysuria and lower abdominal pain, found to have acute,
uncomplicated sigmoid diverticulitis, as well as a potential
urinary tract infection.
# ACUTE UNCOMPLICATED SIGMOID DIVERTICULITIS. Patient with
leukocytosis and lower abdominal pain, with few episodes of
diarrhea prior to admission. CT abdomen/pelvis confirms this
diagnosis. Continued on metronidazole 500 mg PO q8H and
ciprofloxacin 500 mg PO q12h. She was pain-free and tolerating a
regular diet prior to discharge.
# ACUTE URINARY TRACT INFECTION. UA positive on admission.
___ UCx grew Klebsiella pneumoniae, which was pan-sensitive.
She was treated with cipro for sigmoid diverticulitis, which was
appropriate coverage for this UTI.
# HYPERTENSION. initially hypertensive, then remained
normotensive on home BP meds of lisinopril and metoprolol.
# DIABETES MELLITUS. Hgb A1C 8% in ___. Complicated by
retinopathy and vascular disease. On metformin at home,
maintained on ISS while in-house.
# HYPERLIPIDEMIA: Continued home ezetimibe.
# DEMENTIA, MILD: Continued home donepezil.
# GERD: Continued home ranitidine.
# HYPOTHYROIDISM: Continued home levothyroxine.
# CHRONIC KIDNEY DISEASE, STAGE III: Continued calcitriol,
lisinopril and calcium/vitamin D supplementation.
=============================
Transitional Issues:
=============================
- Patient should take 1 mg warfarin on ___. Patient should
then continue with normal home dose schedule of warfarin. INR
check on ___.
- Moderate left hip osteoarthritis noted in XRay of the
pelvis/hips bilaterally. Moderate hypertrophic spur and moderate
effusion on the left.
- Discharged with ___iprofloxacin 500 mg BID/flagyl
500 mg TID (start date: ___ end day: ___
- Colonoscopy should be completed once acute diverticulitis is
resolved
- Follow up with general surgery regarding surgical management
of diverticulitis
- Full code
- Contact: daughter, ___, ___ | 268 | 296 |
16533040-DS-19 | 29,035,176 | Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neurology wards of the
___ so as to investigate the cause for your worsening right
sided weakness and slurred speech. Through a series of physical
examinations, laboratory tests and brain imaging tests, we were
able to determine that your symptoms were likely due to blocked
blood vessels in the left side of your brain, around the area of
your previous stroke (which caused similar symptoms). These
likely occurred as a consequence of hypertension, high
cholesterol levels and a history of tobacco abuse.
- We have started you on some medications to reduce the risk of
future strokes including
ASPIRIN 81mg daily
SIMVASTATIN 20mg daily
NORVASC or AMLODIPINE 2.5mg daily
- It is important that you follow up with a primary care doctor
to ensure that we continue to address your medical risk factors
for stroke. We have set up a referral for you to see two places.
** ___ Center
___
___
TTY#: ___
** ___ Elder Services
Hours: ___ - ___ 8:00am-5:00pm
___, Unit 10
___
___
Telephone: ___ | Mr. ___ was admitted to the Neurointensive care unit and the
Neurology wards of the ___ for
acute on chronic right sided weakness and new dysarthria and
word finding difficulties. Per the HPI as above, he noted the
acute onset of these symptoms as well as a right facial droop
that his family noted. He only presented to the ED because his
other daughter happened to be coming to the ED as well. He was
found to have a slight anomia, a right hemiparesis involving
face, arm and leg. Stat neuroimaging studies revealed the
presence of encephalomalacia in the left basal ganglia
(indicative of his old infarction) and CTA showed the presence
of a stenosed M1 on the left, suggestive that his new symptoms
may be related to hypoperfusion. TPA was thus deferred.
He was admitted to the NeuroICU initially on a heparin drip. His
examination remained stable overnight and he did well. A1c
returned mildly elevated at 6.5 and his LDL returned back
slightly elevated at 80. To initiate medical management of his
intracranial stenosis, he was started on aspirin, simvastatin
and a low dose of amlodipine to control hypertension but avoid
excess hypotension.
Due to his lack of insurance, we were not able to arrange
scheduled follow up for him. Our social workers were able to
organize a referral for him to see physicians at the ___
___, and he received a prescription through
___ to receive free medications for the time being. He and
his family were educated about stroke, and the importance of
modifying his risk factors.
At the time of discharge, he displayed intermittent contractures
of the right hand (which he says are chronic) in the background
of a mild right hemiparesis (including face). His language
function was normal save for a very mild anomia that is not out
of proportion to his prior lack of education. There was no
dysarthria. He was able to ambulate independently and was ruled
to be safe for discharge by our physical therapists. | 199 | 335 |
17397202-DS-3 | 22,363,612 | Dear Ms ___, you have been admitted here as you developed 2
episodes of right leg weakness worisome for TIA(transient
Ischemic Attact)which is due to decreased blood perfusion to
specific part of your brain, although all of your symptoms
resolved, you are still at risk of developing stroke, in that
case symptomes are more permanent. To evaluate the cause of your
TIA, we performed MRI and MRA of your brain to see if there is
any narrowing of blood vessels there.We also performed Echo as
heart problem can be the origin of clot formation which can
travel to brain and cause TIA and stroke. We did not change any
of your medivation except for ASA which we increased the dose to
325 mg daily. As other possible cause of your symptome could be
low brain perfusion because of low blood pressure, we decreased
the dose of your HCTZ to 12.5 mg daily. | ___ year-old right-handed woman with hx of thrombocytosis from
JAK-2 mutation and HTN who presents with 2 episodes of transient
right hemibody symptoms, now resolved. Negative stroke work up
St. ___ after the first episode. Neurological exam is
currently normal. OSH NCHCT shows no acute abnormalities. Given
that these symptoms could be TIA, admitted for further workup.
Given the weakness primarily involved R leg with minimal other
deficits, could be in territory of ACA infarct.It also could be
because of thrombocytosis or change in BP. For TIA work up, we
performed ECHO with bubble study, head MRA, MRI, we could not
find any abnormal finding . As she had 1 episode of low BP at
that time and she states that she did not drink enough amount of
fluid her symptom could be secondary to low perfusion pressure.
Also in work up tests we found platelet level of ___, which
can cause TIA ,we contacted her Hematologist and she will
perform BMA and consider starting Hydroxy urea. We increase the
Aspirin dose to 325 mg to prevent TIA in future. | 152 | 184 |
14789632-DS-8 | 25,324,627 | Dear Mr. ___,
It was a pleasure caring for you! You came to the emergency room
because you were feeling unwell and had blood in your ostomy
bag. You were admitted to the hospital because you lost blood
from your stool and your blood counts were low.
For your low blood counts you were given blood transfusions. The
bleeding from your colostomy stopped and your blood counts were
stable so you were able to go home.
We have made a follow-up appointment for you with a
gastroenterologist (a stomach and colon doctor). We have also
made an appointment to follow-up with your primary care doctor
on ___. Prior to your doctor appointment you will need to
have some blood work done. We have printed you a prescription
for this blood work so that you can have it done at a lab
convenient to your home.
It was a pleasure caring for you!
Sincerely,
Your Medical Team | Mr ___ is an ___ year old man with a history of ___
gangrene c/b bowel perforation s/p end colostomy and chronic
parastoma hernia c/b multiple prior colonic GI bleeds,
cirrhosis, diastolic CHF, A-fib (not on anticoagulation), who
presented with profuse bloody output from his colostomy bag and
was admitted for acute blood loss anemia.
# Acute blood loss anemia:
# GI-Bleed: Patient presented with profuse bloody output from
his ostomy. Hgb was 6.2. He received 2uPRBCs with increase in
Hgb to 7.4. The etiology of the bleed was most likely due to
known angioectasias and friable colonic mucosa noted in previous
colonoscopy in ___. Patient also is being treated for C-Diff
which may be a contributing factor. The patient was evaluated by
acute care surgery recommended conservative medical therapy
given that the patient is a high risk candidate for surgical
restoration (CHF, cirrhosis, age, large hernia). The possibility
of varices in the setting of cirrhosis was also discussed with
hepatology service. They did not recommend scope given no
varices seen on previous scope. If the patient continues to
bleed he should undergo CTA to evaluate for varices. The patient
remained stable and without bleeding for over 24 hours. He was
able to ambulate without symptoms of anemia. His Hgb at time of
discharge was 7.2. The patient will be scheduled to have a
follow-up CBC as an outpatient after he leaves the hospital.
# C. DIFF Colitis: Was diagnosed at ___.
Patient was continued on oral vancomycin while inpatient.
# Atrial Fibrillation: Patient's home metoprolol was held in the
setting of a GIB. His metoprolol was continued upon discharge.
The patient is not anticoagulated due to recurrent GIB. Digoxin
was continued.
# COPD: Continued home advair
# Diastolic Heart Failure: Held Lasix/Spironolactone iso GIB,
restarted on discharge
# Diabetes: Insulin Sliding Scale while in house
# Peripheral Neuropathy: Continued Gabapentin
=====================
TRANSITIONAL ISSUES:
=====================
MEDICATION CHANGES:
[ ] None, continue home medications
DISCHARGE HGB: 7.2
DISCHARGE PLT: 76
DISCHARGE WBC: 2.6
ITEMS FOR FOLLOW-UP:
[ ] GIB/Anemia: Patient will need follow-up of Hgb/Hct in ___
days after discharge. ___ need outpatient transfusions for
ongoing blood loss anemia.
[ ] GIB: Patient to follow-up with gastroenterology as an
outpatient. Consider use of short chain fatty acid enemas.
[ ] GIB: If patient has ongoing bleed, he will need a CTA to
evaluate for variceal bleed in the setting of cirrhosis.
[ ] Leukopenia: WBC count 2.6k at discharge in the setting of
cirrhosis, please follow-up CBC in ___ days after discharge.
[ ] Thrombocytopenia: Platelet count ___ in hospital. Please
follow-up with CBC in ___ days to make sure platelets are not
trending down.
[ ] C-DIFF: Positive test at ___ Patient to
continue his course of PO vancomycin.
[ ] Cirrhosis: MELD 9 (Cr 0.8, bili 0.4, INR 1.3, Na 138). No
previous evidence of varices on EGD and colonoscopy. Patient to
follow-up with gastroenterology as an outpatient.
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
Code: Full Code | 156 | 496 |
19890966-DS-21 | 21,589,441 | Dear Ms ___, you have been admitted here with numbness in
your left side concerning for stroke.
Performed MRI of your brain did not show that you have any new
infarction. We also performed MRI of your neck which did not
show any significant finding and in the simple words your MRI of
the head and neck did not show any new abnormality.
We did not change any of your medications and did not add any
medication.
Your symptoms resolved spontanously without any medication or
intervention.
Please take your medication as instructed. | After performed ___ in the emergency room, did not show any
visible abnormal finding, Ms ___ was admitted to neurology
stroke service for overnight observation and MRI of the head.
The symptoms improved after 4 hours and she was back to her
baseline.
The patient was seen in the morning , with her neurological exam
at her baseline.
___ MRI did not show any abnormal finding in the DWI, FlAIR or
gradiant ECHO.
As she was found to have mildly hyperactive reflexes, with
upgoing toes, MRI of the neck was requested.
MRI of the neck did show mild degenerative disease but without
cord compression.
The patient was discharged home at her baseline without any new
focal sensory finding.
On the day of discharge she was awake, alert and oriented x3,
without focal finding in the cranial nerve, sensory or motor
exam.
Performed UA did not revealed any infection.
We did not changed any of her medication and she was discharged
home without any complication. | 88 | 155 |
14048212-DS-17 | 21,823,921 | You were admitted to the antepartum floor for management of a
sickle cell crisis and fever. You were transfused a unit of
blood and your hematocrit remained stable. You developed a fever
while you were here, with no obvious source. Your fever work up
was unrevealing. Continue to stay hydrated and take pain
medication as needed at home. | ___ y/o G2P0 with Hgb SS disease admitted at 17w2d with sickle
cell pain crisis. Her pain was initially managed with a Dilaudid
PCA then transitioned to po Dilaudid. Her hemoglobin on
admission was 8.3 and dropped to 7.0 on HD#2 after IV hydration.
She was transfused 1 unit of PRBCs with improvement of her
hemoglobin (7.5). Prior to discharge, her hgb had dropped again
to 6.3, however, she strongly desired discharge home. Hematology
followed her while she was here.
.
On HD#2, she developed a fever (102.2) with no identifiable
source. She had a negative CXR, urine culture, and blood
culture. Repeat CXR on ___ was concerning for possible
cardiomegaly and ? pericardial effusion, however, she had a
normal echocardiogram. ID was consulted and recommended empiric
Ceftriaxone. She was treated from ___ through ___. She was
afebrile at the time of discharge.
.
Ms ___ had no obstetric issues during this admission. She had
a reassuring ultrasound on ___ in the ___. She will have close
outpatient follow up. | 58 | 166 |
19683840-DS-18 | 27,241,632 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted with a blockage of your
bile ducts and an infection associated with this blockage. You
underwent a procedure called an ERCP and had a stent placed in
your bile duct. | ___ y/o ___ speaking female with recently diagnosed
gallbladder cancer metastatic to the liver, HTN, and CKD, who
presented to ___ with abdominal pain and elevated LFTs, s/p
ERCP with stent exchange on ___ who presented with cholangitis
and septic shock. She was treated with fluids, pressors, and
antibiotics with improvement. | 47 | 51 |
10885062-DS-21 | 27,615,701 | Dear Mr ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abnormal liver tests
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received testing for you liver, which revealed that
alcohol use was most likely responsible for the abnormal liver
tests
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments, as below.
- Please let you primary doctor know or go to the ED if you feel
like you are going to harm yourself
We wish you the best!
Sincerely,
Your ___ Team | Mr ___ is a ___ y/o M with PMH significant for alcohol use
disorder who was initially admitted to inpatient psychiatry
facility for suicidal ideation, then transferred for abd pain
and abnormal liver function tests concerning for ETOH hepatitis.
There were also reports of possible hematemesis but he had none
here and had normal RBC counts. Workup was consistent with EtOH
hepatitis, which slowly improved with supportive care. Psych
evaluated patient and deemed that he no longer was a risk to
self and was safe to be discharged home with follow up as an
outpatient. | 113 | 96 |
16224237-DS-16 | 27,373,667 | Dear Ms. ___,
It was a pleasure to care for you during your admission here,
Why was I admitted to the hospital?
- You were brought in because you had a fall at home
- In the emergency room, they saw that you had a lot of fluid
around your lung, as well as an abnormal heart rhythm that made
your heart beat too slow
What happened while I was admitted?
- You had CT scans of your head and neck, which showed some
small fractures in your neck bones, but no bleeding.
- You had a drain placed around your lung to remove the fluid.
- You had a pacemaker placed into your heart to keep your heart
beating at a normal rate.
What should I do when I leave the hospital?
- Please take your medications as listed and follow up with your
appointments as listed below.
- Please do not take any NSAIDs (ibuprofen, aspirin) for 4 weeks
because it may cause bleeding around your pacemaker.
- Please do NOT have any MRI scan for 3 months or before talking
with your cardiologist because of your new pacemaker.
Once again it was a pleasure caring for you, and we wish you all
the best!
Sincerely,
- Your ___ Team | Ms. ___ is a ___ F with PMHx dementia (A&Ox1 at baseline),
HTN, Osteoporosis, currently living at an ALF, who presented
after fall with headstrike, found to have incidental large L
sided pleural effusion with midline shift s/p pigtail placement
as well as bradycardia to ___ secondary to new dx of CHB, now
status post PPM placement ___.
ACUTE ISSUES:
=============
# Complete Heart Block
Patient presented with syncope and was found to be in complete
heart block in the ED. Troponin elevation was mild and
medications with bradycardic side effects were initially held.
She had multiple pauses up to 12 seconds long and was briefly on
pressors. She ultimately had placement of PPM by EP. She is
planned for follow-up in device clinic 1 week from discharge.
Etiology was ultimately not definitive.
# L Sided Pleural Effusion
Patient has had increased dyspnea on exertion the past few
months, in the ED she had a chest x-ray which showed complete
left-sided whiteout with midline shift. Pigtail catheter was
placed and she was also noted thereafter to have a pneumothorax
felt likely to be alveolar pleural fistula. Her pleural effusion
was exudative, cytology X2 was negative but concern for
malignancy was still high. After failing to transition to
waterseal she underwent endobronchial valve placement,
thoracoscopy with pleural biopsy and tunneled Pleurx catheter
placement. Biopsy was pending at time of discharge. Follow-up
with IP was scheduled. Some mild erythema +/- purulence at site
of pleurX cathether, improved with augmentin, discharged on 10d
course.
# Fall
Fall with headstrike, unk LOC, CT head negative, C spine notable
spinous process fractures. In the setting of new diagnosis of
complete heart block as above, possibly related to symptomatic
complete heart block vs mechanical. No murmur/post-ictal
confusion noted. TTE without aortic stenosis.
# Osteoporosis
# C spine fractures
Noted mildly displaced spinous processes C4, C5, and C6, though
without neck pain. Patient self-cleared c spine.
# Pericardial effusion
Moderate effusion seen on TTE, no evidence of tamponade. Repeat
TTE showed decreasing effusion.
# UTI
Leukocytosis, positive urinalysis, worsened mental status,
treated with 3 days of CTX with improvement in mental status and
resolution of leukocytosis.
CHRONIC ISSUES:
===============
# HTN
Hypertensive to 180s - 190s systolic in ED. She remained
normotensive without her lisinopril, and in the setting of her
recent fall, her lisinopril was held until follow up.
# HLD
Continued home pravastatin 40 mg QHS.
# Toxic metabolic encephalopathy
# Dementia
Patient with increasing delirium while inpatient in setting of
fall, complete heart block, and ICU stay. Continued home
Memantine 5 mg QD and donepezil 5 mg QD. | 197 | 420 |
11470105-DS-11 | 22,388,424 | Dear Mr. ___,
You were hospitalized due to symptoms of speech difficulty and
weakness resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
CHF
previous MI
We are changing your medications as follows:
Please continue on CMO medications including Morphine, Zyprexa
prn, and Lorazepam prn.
It was a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team | Mr. ___ presented with altered mental status, aphasia, and
right sided weakness concerning for stroke as well as facial
twitching concerning for status epilepticus. he was admitted to
the Neuro ICU and started on Keppra as well as Aspirin. Facial
twitching was seen to stop. Pt was found to have elevated
troponins suggestive of NSTEMI as well as C. Difficile
infection. Due to patient appearing significantly ill,
discussion was held with family on ___ and it was decided that
patient would be placed on comfort measures. He was evaluated by
Palliative Care and started on Morphine standing as well as
Lorazepam and Zyprexa prn. He was transferred to hospice care. | 155 | 111 |
14155218-DS-15 | 25,919,586 | Dear Mr. ___,
You were transferred to ___ for
evaluation and treatment of an incarcerated inguinal hernia, for
which you were taken to the operating room and underwent surgery
to repair the hernia. 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 for follow-up
care. You may schedule an appointment by calling ___
during duty hours.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs as tolerated.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Please contact the Acute Care Surgery Clinic at ___ to
schedule your follow up appointment in ___ days. | The patient was admitted to ___ ACS service with signs and
symptoms of bowel obstruction and CT imaging concerning for
right inguinal hernia incarceration, 2 weeks after right
inguinal hernia repair at an outside hospital. The patient was
made NPO, an NGT placed, and serial abdominal exams performed in
addition to laboratory workup and hemodynamic monitoring. After
several hours in observation the patient was taken to the OR
where he underwent right groin exploration, ifntraabdominal
laparoscopy with reduction of small intestine and bowel
obstruction, with a preperitoneal anterior approach to repair
the peritoneal defect.
After the surgery he was taken to the PACU where he remained
stable and without complications. He was then transferred to the
floor where he was maintained on IV fluids until able to
tolerate PO intake. He voided without difficulty and developed
bowel sounds by POD1.
He was discharged home on POD2 in stable condition after
tolerating a regular diet, voiding appropriately, and achieving
adequate pain control. | 760 | 161 |
11068569-DS-19 | 29,841,434 | Dear Ms. ___,
WHY WAS I ADMITTED?
- You became short of breath and had some increasing swelling in
your legs
- This was caused by a condition called heart failure where the
blood is not pumped forward well enough so it begins to back up
into the lungs and the rest of the body
WHAT HAPPENED WHILE I WAS HERE?
- You were given IV diuretic medications to help you urinate off
the extra fluid
- You responded well to this medication, and your breathing and
swelling improved
- You were transitioned to an oral version of this medication
- When your breathing and swelling was improved, you were
discharged home
WHAT SHOULD I DO WHEN I LEAVE?
- Please attend all of your follow up appointments as scheduled
for you
- Please take all of your medications as prescribed
- Please weight yourself daily and call your doctor if your
weight increases by more than 3 pounds
It was a pleasure to care for you during your hospital course.
Your ___ care team | The patient is a ___ woman with morbid obesity and
multiple abdominal surgeries, recent admission for pyelo and
___, admitted with progressive dyspnea and edema concerning for
new heart failure. | 161 | 30 |
11690403-DS-15 | 21,177,711 | Dear Ms ___,
You were hospitalized due to symptoms of language difficulty
secondary to a transient ischemic attack, a condition in which a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot temporarily.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
We are changing your medications as follows:
Adding aspirin
Increasing the dose of Crestor
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
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Ms ___ was admitted for an episode of language difficulty.
This episode lasted about ___ minutes, and there was no
evidence of infarction on her head CT. She was not able to
tolerate an MRI, and therefore, it was not done. She underwent
carotid ultrasound that did not demonstrate any significant
stenosis. She was thought to have had a TIA given the
constellation of symptoms and rapid resolution. At the time of
discharge, the etiology was unknown given that her telemetry did
not show any episodes of atrial fibrillation and her carotid
ultrasound did not show significant stenosis. Throughout her
hospitalization, it was noted that her memory was very impaired,
and therefore, we recommended outpatient neuropsychology testing
and dementia workup. | 243 | 120 |
15538743-DS-9 | 24,081,498 | Dear Mr. ___,
You presented to ___ on ___ with complaints of increasing
drainage from your biliary drain which was placed on ___.
You were admitted to the Acute Care Surgery team and were
transferred to the surgery floor for IV hydration, antibiotics,
pain control and for further monitoring of your gallbladder and
drain.
On ___, you had a cholangiogram study done which was
concerning for a small gallbladder leak. You also had an
ultrasound of your abdomen which confirmed your tube was in the
correct position. On ___, you had an ERCP where a gallstone
was removed and a stent was placed to help facilitate drainage.
You tolerated this procedure well and were advanced to a regular
diet the following day. Please note that the ___ clinic will
call you with an appointment to have your stent removed in 4
weeks.
You were transitioned to oral antibiotics and pain medicine
which you tolerated. You have ambulated frequently, are able to
tolerate a regular diet and are now medically cleared to be
discharged to home with visiting nurse services to help manage
your drain. An appointment has been made for you to follow-up
with the Acute Care Surgery team. Please follow-up with your
primary care provider ___ 2 weeks.
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.
General 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).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | ___ y/o M s/p PTBD placed on ___ who presented to ___ on
___ with complaints of increased drainage output as well as
emesis. On HD0, he had an EKG done which revealed normal sinus
rhythm. He had an ultrasound which showed no intrahepatic
biliary duct dilation and the PTBD to be in the correct
position. He also had a T-tube cholangiogram which was
concerning for a small bile extravasation. The patient was made
NPO, placed on IV fluids, IV antibiotics and had a foley placed
for urine output monitoring. He was admitted to the Acute Care
Surgery team and was transferred to the surgery floor for IV
hydration, drainage output monitoring and for further
gallbladder imaging.
A urinalysis and urine culture were sent which were negative. On
HD1, the patient underwent an ERCP with sphincterotomy and stone
removal. The patient tolerated this procedure well with no
adverse events. He was kept NPO overnight and placed on a twice
a day proton pump inhibitor. His foley was removed. He was
advanced to a regular diet the following day and switched to po
antbiotics and pain medicine which he tolerated well.
The patient was alert and oriented throughout the
hospitalization. The patient remained stable from a
cardiovascular and pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
The patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
made with the Acute Care Surgery clinic and the patient stated
he would prefer to find a Primary Care Provider after discharged
from the hospital. | 550 | 378 |
15837926-DS-10 | 24,062,703 | Dear Mr. ___,
You were hospitalized due to symptoms of <> resulting from an
ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
<> Dissection due to injury
We are changing your medications as follows:
<> Start taking aspirin and plavix daily
Headache plan:
[ ] Headache management: Continue tylenol ___ mg every 6 hours
as needed, and nortriptyline 10 mg every night
[ ] Follow up with Neurosurgery
[ ] Follow up with Neurology
[ ] Outpatient speech therapy
Please take your other medications as prescribed.
Please follow up 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 | BRIEF SUMMARY:
Mr. ___ is a ___ year old man with PMH of concussion two
weeks ago ( hit in head by a medicine ball which he was tossing
above his head) who presented with acute onset dysarthria and
right sided weakness. CTA found L carotid dissection and clot
extending from the ICA intracranially to the M1 segment of the
MCA. He was intubated due to persistent vomiting. He received
TPA and was taken for angio for L ICA clot retrieval and three
stents were placed in tandem. Brain MRI showed subacute infarcts
involving the left basal ganglia, left insular cortex and left
frontal lobe in an MCA distribution. He significantly improved
clinically with resolution of his dysarthria and right sided
weakness (apart from mild pronation of RUE). He later developed
a severe headache, Repeat Ct showed small subarachnoid
hemorrhage in left frontal area, which remained stable on follow
up images. He will be discharged on aspiring and plavix daily.
Exam at time of discharge with minimal deficits: right lower
facial weakness, right mild pronation, no aphasia, ambulating
independently.
=============================================== | 312 | 180 |
18816555-DS-12 | 21,809,436 | Dear ___,
___ was a pleasure taking care of you. You were admitted to the
___ because you were having
severe back pain. You were given some medications to help with
your symptoms and an MRI of your lower back showed degenerative
changes of your spine that were causing some pressure on your
nerves. You will need to have physical therapy after you are
discharged, which can be arranged by your primary care
physician.
During your hospitalization, you were also found to be diabetic,
with very high blood sugars. Your HbA1C, which is a measure of
you blood sugar over the past 3 months was also very high. For
this reason, you were started on oral medications for your
diabetes, as well as a dose of insulin you will have to take at
bedtime. You will need to follow-up with your primary care
physician to monitor your blood glucose.
Wishing you a speedy recovery,
Your ___ Care Team | Mrs. ___ is a ___ year-old woman with history of ovarian cancer
s/p debulking and chemotherapy, kidney stones s/p lithotripsy,
hypothyroidism and recent UTI presenting with acute on subacute
low back pain.
# Low Back Pain/Lumbar Radiculopathy: Patient reporting 3 weeks
of low back pain with acute worsening radiating to her right and
left lower extremities. No red flag signs or symptoms. Had a CT
scan 6 weeks ago that did not show any acute processes. On
admission, patient was hemodynamically stable. Physical exam was
remarkable for positive straight leg raise bilaterally. Patient
was started on acetaminophen, ibuprofen, and cyclobenzaprine for
pain control. Given history of ovarian cancer, metastatic
disease was a concern, but symptoms were more consistent with
radiculopathy. MRI of the L-spine showed a mild posterior disc
bulge of L3-L4 which minimally narrows the left sub foraminal
recess with mild facet hypertrophy, and a mild posterior disc
bulge of L4-L5 with minimal narrowing of the subforaminal
recesses and a mild facet hypertrophy with minimal right greater
than left neural foraminal narrowing. Renal US was done given
her history of renal stones that was unremarkable. Patient was
seen by ___ who recommended out-patient follow-up given her
ability to ambulate alone.
# Type 2 Diabetes Mellitus: Patient was also found to have be
hyperglycemic throughout her hospital stay. Patient is not known
to be diabetic prior to admission. HbA1C was done on ___ was
9.9. ___ was consulted and recommended starting the patient
on Lantus to 24 units QHS, Glipizide 10mg BID w/ breakfast &
dinner, and Metformin 500mg BID w/ breakfast & dinner. If
tolerated well & no GI distress, plan to increase by 500mg
weekly to max dose of 1,000mg BID w/ breakfast & dinner. Patient
was educated regarding her new diagnosis and her new regimen for
diabetic control. Patient was also reporting blurry vision for
prolonged period of time likely related to her diabetes. CT head
negative. Patient requires out-patient follow-up with
ophthalmology.
# Hypothyroidism:
- Continued Levothyroxine 125 mcg PO/NG DAILY
***TRANSITIONAL ISSUES***
- MRI lumbar spine reassuring without signs of mets, cord
compression, or significant nerve compression. Has L3-l4, L4-L5
mild posterior disc bulge.
- Patient would likely benefit from physical therapy as an
out-patient.
- Consider initiation of ASA 81mg and statin given new diagnosis
of diabetes
- Patient with newly diagnosed diabetes with HbA1c 9.9 d/ced on
Lantus, Metformin, and Glipizide as above. Requires close
follow-up and increase on her metformin over the next 2 weeks
per recommendations above.
- Patient written scripts for lancets, strips, and needles for
her new diagnosis of diabetes. Please ensure she continues to
have sufficient supplies going forward.
-Plan to follow-up with ___ for new diagnosis of diabetes
-Patient having blurry vision, has follow-up appointment at
___ on ___.
-Patient has had elevated LFTs since ___, continue to
monitor as an out-patient
-Code: Full
-Contact: ___, ___ | 154 | 470 |
10454455-DS-22 | 23,440,043 | You presented with recent weight loss as well severe
constipation. You were disimpacted in the ED and placed on
medications to help you have bowel movements. You also had an
irregular heart rhythm called atrial fibrillation. You were
placed on medications to help with your heart rate.
You were seen by the psychiatry, neurology, Occupational
Therapy, physical therapy, social work, and nutrition services
to help with your depression, memory, and ability to function
safely on a daily basis. Ultimately, after much discussion with
you and your brother you were sent to rehab for further
treatment.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ y/o F with PMHx of HTN, HLD, COPD, DM2, who presented with
constipation and altered mental status. CT in the ED notable for
large stool burden in the rectal vault with possible stercoral
colitis. She was seen by surgery and underwent manual
disimpaction in the ED. ED course was also complicated by afib
with RVR, for which she was started on diltiazem. Of note, she
also has had a subacute decline in mental status and nutritional
status over the past month (with similar admit for same earlier
this year). There was concern for altered mental status and
possible neurocognitive disorder vs. pseudodementia.
#Atrial Fibrillation with RVR. Found to be in afib w/RVR. Rate
controlled on diltiazem. CHADS2-VASC score elevated so discussed
with patient and her brother who agreed to start anticoagulation
with Coumadin. She received first dose of Coumadin 5mg ___.
TSH was normal and Echo was unremarkable. Afib likely
contributed by poor nutrition and low BMI.
#History of anorexia, unclear if currently active
#Severe malnutrition, BMI 13- Seen by psychiatry who reported
previous history of anorexia nervosa. Psych believes here
current status does not meet the definitive criteria of anorexia
nervosa but note that her mood and concern for how her eating is
affecting her health is contributing to her poor diet. She
continued to report issues with swallowing and ___ abdominal
pain. Seen by S&S who did not appreciate any deficits. She also
noted concern that eating would make her constipated. She was
continually noted to have poor oral intake during this
hospitalization. Would monitor calorie counts following
discharge. Likely will difficulty eating is multifactorial
though probably mostly related to underlying mood/psychiatric
conditions.
#Delirium
#Possible neurocognitive disorder
#Depression, anxiety- Etiology of recent worsening mental status
was thought to be partially delirium in the setting of
constipation vs. pain.But her presentation was notable for a
more subacute decline in mental status with concurrent weight
loss and failure to thrive at home.DDx included neurocognitive
decline vs. eating disorder vs. depression. Neurology felt that
she likely had a fluctuating delirium due to poor nutritional
status and a possible pseudodementia due to depression, and they
did not find evidence of a clinically advanced neurodegenerative
process, but feel that she should have a full neurocognitive
assessment once her medical condition improves.
Psychiatry felt she may have a neurocognitive disorder, as well
as some delirium that may have resolved. They also think she may
have unspecified depressive and anxiety disorders. They do not
believe she has anorexia nervosa by definition but
her mood and concerns certainty negatively affect her eating
habits. She was resumed on remeron 7.5mg QHS. She should
continue to see psychiatry as an outpatient for further
titration of her medications.
She was evaluated by ___ and OT who both felt that she should be
discharged to rehab
-OT stated "Pt demonstrates difficulty with recall and
attention-based tasks today, as well as appropriately planning
out/executing hand placement of clock when given task. Given
pt's performance with these tasks today as well as previously
poor performance with medication management tasks with OT
evaluation in ___, recommend pt have assistance with IADL
tasks such as medication management and cooking at this time.
Anticipate pt will require 24 hour supervision and continued OT
services upon discharge. Should 24 hour supervision not be
available, recommend pt discharge to rehab. Pt will require
continued follow-up for mobility/OOB ADL." Discussed above
findings with patient, her family, and psychiatry who agreed
that rehab was the best option for the time being and would need
further assessment prior to discharge from rehab to assess
ability to safely return home to independent living.
#History of T2DM- 24 hours of fingerstick blood glucoses shows
no significant hyperglycemia that would require treatment, so
stopped fingersticks
#Prior constipation, stercoral colitis, with mild ongoing
abdominal discomfort
-She was seen by surgery and underwent manual disimpaction in
the ED. She was continued on a bowel regimen with the goal of
having a daily bowel movement, though she often refused her
bowel regimen medications. She did have BM day prior to
discharge. She should be encourage to take her medications on a
daily basis to prevent further constipation.
#Reported dysphasia- Given patient's report of food getting
stuck at her manubrium, she was seen by speech and swallow who
recommended a soft diet with thin liquids, but otherwise just
aspiration precautions. She has not been observed to have any
problems swallowing according to the nurses, nor have I seen any
issues
# HTN: Holding home losartan given initiation of dilt and
acceptable BP control
# COPD: on home tiotropium, advair, Flonase, albuterol prn
# GERD: on home omeprazole | 108 | 754 |
19040887-DS-15 | 22,583,309 | Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for coughing up blood from your lungs.
What was done for me in the hospital?
- You underwent a bronchoscopy to help clear your air pipes and
stop the bleeding you had in your lungs.
What should I do when I leave the hospital?
- You should take all medicines as prescribed.
- You should follow up with your primary care doctor ___ Dr.
___.
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team | PATIENT SUMMARY:
================
This is a ___ year old woman with a known neuroendocrine tumor of
bronchus intermedius s/p IP tumor debridement on ___ presents
with
hemoptysis, now clinically stable without further hemoptysis.
#Hemoptysis
#Pulmonary Neuroendocrine Tumor
In early ___, the patient presented with cough and fever,
and had a CT chest that showed RUL and RLL collapse. She
underwent bronchoscopy with tumor debridement at ___
___ with Dr. ___ was diagnosed with a
neuroendocrine carcinoma. She was referred to ___ ___ for
rigid and flexible bronch, bronchial wash, cryotherapy,
electrotherapy, and EBUS with transbronchial aspiration. She
tolerated that procedure well, but returned with hemoptysis 2
days later. On ___ (this admission), she underwent flexible
bronchoscopy by interventional pulmonology, with cryoablation of
the bleeding site. The patient tolerated the procedure well, was
HD stable in the PACU, and was given Codeine for residual
tracheal pain. She was discharged on a 10d course of Augmentin
for a presumed post-obstructive pneumonia. She also received a
script for 5 days of codeine.
# ASTHMA:
Continue budesonide-formoterol 160-4.5 mcg/actuation inhalation
DAILY (held while inpatient). | 101 | 174 |
17739375-DS-13 | 29,205,808 | Dear ___ you for coming to the ___
___. You were admitted to the hospital because you fell. We
did many xrays which did not show any fractures. Because of your
fall you are being placed in an ___ facility. We did not
make any chnages to your medications. | ___ with severe alzheimers and recent fall.
.
#S/P fall: She was found on the ground with evidence of fall and
facial ecchymoses. She underwent very thorough radiologic
evaluation which did not show any acute fractures. Spine films
did show some vertebral height loss of unclear time frame but
not likely acute. Falls and inability to self care are related
to severe alzheimers (see below).
.
#Alzheimers disease: She has severe alzheimers and has been
living only with her husband who is still actively working. She
is alone for long periods of time which is likely no longer
safe. Her husband had been working on placement prior to this
admission. Because she is not safe at home she is being admitted
to a long term care facility for further management. She takes
namenda at home. She did receive one dose of olanzapine here for
delirium.
#Fever: She has had low grade fevers up to 100.9 here. She does
have a mild cough but no other localizing symptoms. Her CBC, UA,
and CXR were normal. She did have evidence of mastoid air cell
effusion. Her low grade fevers are most likely form a viral
upper repiratory infection. If her fevers worsen or she devlops
other signs of infection she should be evaluated by the
physician on call at the facility.
#Goals of care: A discussion was held with her husband and
health care proxy. The HCP expressed that the pattient would not
want extraordinary measures and would prefer to be DNR/DNI. If
medical issues arise she is okay to be evaluated and
hospitalized as appropriate.
#Glaucoma: Continued carteolol eye drops
TRANSITIOANL ISSUES
-Trend fevers, evaluation by physician on call as appropriate | 49 | 272 |
19815230-DS-5 | 23,339,111 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital for a brain bleed after a
fall.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were evaluated by Neurosurgery who did not recommend
surgery for your brain bleed.
- You were treated in the ICU for extra fluid in your lungs.
Your breathing improved with dialysis (removed the fluid).
- You had low blood pressures, and you were started on a
medication to take before dialysis to support your blood
pressure.
- You were found to have unstable heart rates that were low and
high. You had a pacemaker placed to help control your heart
rate. You were also started on a medication to help control your
heart rate.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[] Patient has persistently low BPs iso peripheral vascular
disease, so BPs may be unreliable. He mentated well with normal
lactate with BPs in ___. His goal MAP is 55 mmHg.
[] Please consider referral to Psychiatry for management of
anxiety and depression.
[] Varices seen in the upper esophagus w/o evidence of liver
disease on imaging and unremarkable labs. Consider fibroscan or
further workup as an outpatient.
MICU Course
===========
Presented after a fall. Evaluated by neurosurgery on arrival who
did not recommend surgical intervention. He was initially
admitted to the MICU for labs concerning for hypercarbic
respiratory failure. He was also hypotensive requiring levo fed
briefly. The Levophed was quickly weaned off. He was never
intubated or put on BiPAP for his respiratory failure. His blood
pressures were persistently in the ___ systolic. He was
mentating appropriately, with a normal lactate. This is assumed
to be his baseline. He is s/p prednisone burst for presumed COPD
exacerbation ___ s/p azithromycin 500mg x 3 days
(___)
While in the MICU, he was found to have tachy-brady syndrome.
Electrophysiology, cardiac surgery, and interventional radiology
were all consulted. There was an attempted pacemaker placement
for his tachy-brady syndrome on ___ via an attempted
R-femoral venous access. However, the pacemaker was not
successfully placed due to difficult vascular access. The
patient was then transferred to the cardiology floor while
awaiting multidisciplinary discussion between electrophysiology,
cardiac surgery, vascular surgery, interventional radiology with
a approach as to how best to implant the pacemaker.
FLOOR COURSE
============
On the floor, there were continued discussion regarding how best
to place a pacemaker. Consulting teams requested the operative
reports of his prior surgeries so as to better understand his
anatomy, however these unfortunately could not be obtained as it
was unknown where he had had these surgeries. Consulting teams
continued to discuss best approach for providing patient a
pacemaker, with a tentative plan for access through his tunneled
line or possible epicardial leads. He continued to be
tachycardic to the 110s, as well as hypotensive to SBPs ___.
He triggered on the floor multiple times for unstable vitals,
however continued to mentate well, and had normal lactate on
each check. His respiratory status remained stable on his ___
baseline NC requirement. Nephrology attempted perform HD while
on the floor, however patient could only tolerate 1 hr of
dialysis due to significant hypotension. They stated they would
not pursue further dialysis on the floor given his hypotension.
On ___, patient began to have episodes of very symptomatic
bradycardia lasting ___ minutes. He would temporarily lose
consciousness, have HRs in the ___, and then spontaneously
return to his baseline tachycardia and mental status. He had
multiple episodes of this on the floor over the night, with the
last episode requiring a few seconds of transcutaneous pacing.
This prompted his transfer to the CCU. Patient's floor course
was also complicated by significant pain requiring breakthrough
oxycodone, as well as significant anxiety, which seemed to
worsen his symptoms.
CCU COURSE
==========
In the CCU, patient was monitored while awaiting pacemaker
placement and continued to have several episodes of slow atrial
fibrillation associated with episodes of presyncope. Through
combined efforts by ___ and EP, patient underwent ___ procedure on
___ to establish venous access through the R groin into the IVC
with plan to undergo Micra pacemaker placement on ___. During
this procedure, ___ performed angioplasty of the R external iliac
which was found to be occluded ___ scarring from prior access of
this vein. A dialysis catheter was placed as a placeholder to
maintain vascular access for pacemaker placement. During this
procedure, patient require both levophed and vasopressin to
maintain adequate BPs in setting of anesthesia. The patient
remained intubated after this procedure and was maintained on
two pressors while sedated. On ___, he had a permanent
pacemaker placed and remained intubated since his procedure
occurred late. He was successfully extubated in the AM of ___.
He was weaned off vasopressin and levophed before transfer to
the floor. He was followed by Nephrology for HD. Of note,
patient continued to have significant anxiety that was acutely
exacerbated by his bradycardic episodes in which patient feels
he's about to die. Palliative care was consulted to help assist
with management of patient's pain and anxiety. He was deemed
clinically stable for floor transfer.
___ COURSE
============
Patient was transferred to the Cardiology service for further
management after CCU course. He was started on rate control with
metoprolol for his atrial fibrillation. BPs and respiratory
status remained stable and volume was managed with HD as he was
transitioned back to ___ HD. | 164 | 757 |
17429794-DS-30 | 25,877,408 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted for abdominal pain and a possible
gastrointestinal bleed.
WHAT HAPPENED IN THE HOSPITAL?
- You were monitored for signs and symptoms of active bleeding.
- A CT scan of your abdomen suggested a possible obstruction.
- You had an Upper Endoscopy which showed narrowing in your
small intestine.
WHAT SHOULD YOU DO AT HOME?
- Eat soft foods in smaller amounts, more frequently.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | BRIEF SUMMARY:
Mr ___ is a ___ y/o man with PMH of AFib, on rivaroxaban,
CHF, Stage IV CKD (baseline Cr ~2.0), PVD (complicated by
chronic recurrent osteomyelitis), DM II, COPD, chronic anemia
(bl Hb 8.4), and recently diagnosed pancreatic head
adenocarcinoma (no chemotherapy/not surgical candidate), who is
presenting from rehab for possible GI bleed and abdominal pain. | 92 | 58 |
16078742-DS-7 | 24,595,972 | Dear Mr. ___,
It was a priviliege to care for you at the ___
___. You were admitted for fever, possibly due to a
combination of a gout flare and sinusitis. Due to your lack of
spleen and risk of serious infection, you were monitored
closely, but it is now safe to be discharged home to complete
your antibiotics and continue the prednisone taper.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team | SUMMARY:
Mr. ___ is a ___ male with history of remote
splenectomy, recurrent sinusitis, gout and hypertension who
presented with fever with suspected acute bacterial sinusitis as
source as well as a gout flare. | 88 | 33 |
19837674-DS-23 | 28,433,990 | Dear Ms. ___,
You came to the ___ for fever after your chemotherapy. You
were treated with antibiotics in the emergency room. We have
not found any evidence of infectious illness. Your fever has
resolved. Although we do not have a clear explanation for your
fever, we felt you are safe to return home. | ___ yo female with a history of multiple myeloma on treatment
with daratumumab who is admitted with a fever.
# ACTIVE ISSUES
The etiology the fever was unclear. Patient received one dose
of Cefepime in the ED. She had non-focal exam and ROS.
Infectious workup was obtained, including CXR, blood and urine
culture, and no evidence of bacterial infection was noted during
this admission. Of note this occurred after her prior infusion
of daratumumab. She was given 1 neupogen injection for ANC of
800 and ANC was up to 2800 at the time of discharge, at which
point she was afebrile without infectious symptoms.
# CHRONIC
Multiple Myelmoma
- S/p C2 Daratumumab ___.
Anxiety
- Continued home nortriptyline, clonazepam, and lorazepam.
HTN
- Continued home atenolol. | 58 | 124 |
16002684-DS-20 | 22,523,911 | Dear Mr. ___,
You were admitted to the hospital with frequent falls, which are
likely due to your chronic gait instability issues. We found no
evidence of infection or heart problems which could be
contributing. Ativan, which you take in the evenings to sleep,
can sometimes cause unsteadiness, and this medication was
discontinued. You were seen by physical therapy, who recommended
using your rolling walker AT ALL TIMES when getting around.
Please follow-up with your primary care doctor and with your
neurologist after discharge and take your medications as
prescribed.
With best wishes,
___ Medicine | ___ male with history of mild dementia and gait
instability, DVT (on apixaban), depression, CAD, PVD who
presents with falls, likely mechanical.
# Falls:
# Possible acute non-displaced L1 fracture:
# Gait disorder, NOS:
Presented from ___ for falls, x 3 on ___,
without clear headstrike or syncope. CT spine showed
non-displaced L1 fracture, no intervention needed per ACS and
neurosurgery in the ED. NCHCT negative. Etiology of falls likely
chronic gait instability (for which he is followed by cognitive
neurology) and inappropriate use of cane rather than rolling
walker. Neurologic exam non-focal, with low suspicion for cord
compression. Orthostatics negative. Tele with occasional PVCs
and sinus bradycardia, but chronotropically responsive without
high-grade block or arrhythmias. TTE of poor quality and unable
to evaluate valves, but no murmur on exam to suggest severe AS.
Low suspicion for UTI, as below. Possible med effect from home
QHS Ativan use; Ativan therefore discontinued. Pain for his L1
fracture was well-controlled with tylenol PRN and a lidocaine
patch. He was seen by ___ and cleared for home with home ___ and
strict use of rolling walker. He should f/u with his outpatient
cognitive neurologist after discharge for further management of
his chronic gait instability.
# Asymptomatic bacteriuria:
UA positive but patient asymptomatic without fever or
leukocytosis. UCx with mixed flora. BCx NGTD. He was briefly
treated with CTX (___), discontinued for likely
asymptomatic bacteriuria.
# Mild cognitive impairment vs dementia:
Chronic, at baseline (AOx3). He should f/u with his outpatient
cognitive neurologist after discharge for further management.
# Hypertension:
Normotensive with negative orthostatics. Home amlodipine and
metoprolol continued.
# Sinus Bradycardia:
# Frequent PVCs:
Mild, asymptomatic sinus bradycardia on home metoprolol dose,
with frequent PVCs when metoprolol was held. Chronotropically
responsive with exertion and therefore unlikely contributing to
falls. Home metoprolol continued on discharge.
# Mild acute hypoxia:
Sats 88% on room air in ED, mid-90s on 2L on admission. CXR with
possible mild pulmonary edema without evidence of PNA, for which
he received Lasix 10mg IV on admission with resolution of
hypoxia. He was quickly weaned to RA without further hypoxia or
evidence of pulmonary edema or volume overload. Appeared
euvolemic on discharge.
# Chronic RLE DVT:
Given trace R>L leg asymmetry, repeat ___ performed showing
non-occlusive thrombus in R popliteal vein, similar to ___
and therefore likely chronic. No e/o new/acute DVT. He was
continued on his home apixaban 2.5mg BID. Of note, he
technically does not meet criteria for dose-reduced apixaban;
suspect dose was reduced as outpatient in setting of frequent
falls. Discharged on home reduced-dose apixaban, with further
consideration of resumption of full-dose apixaban deferred to
outpatient PCP.
#Depression:
Home escitalopram reduced to 20mg PO daily (from 30mg PO daily)
at pharmacy's recommendation.
#BPH:
Continued home finasteride.
#Insomnia:
Continued home melatonin. As above, home QHS Ativan was
discontinued, as it may have contributed to his falls.
#Umbilical hernia:
Has been enlarging but remains reducible and non-tender. Saw
surgery ___ pt is declining intervention at this time.
Continue to address as outpatient.
# Chronic ___ edema:
# Venous stasis:
Without prior diagnosis of CHF. R ___ with chronic DVT, as
above. As above, he received Lasix 10mg IV on admission for
possible pulmonary congestion but did not require further
diuretics. No significant lower extremity edema at the time of
discharge. Would continue with lower extremity elevation and
TEDS as outpatient.
# Contacts/HCP/Surrogate and Communication: Son ___
___ is HCP (form on file at ___
# Code Status/Advance Care Planning: FULL - MOLST on file
(please
** TRANSITIONAL **
[ ] ensure patient uses rolling walker at all times
[ ] consider increasing apixaban to full dose; left to
discretion
of PCP
[ ] ensure f/u with outpatient cognitive neurology for mild
cognitive impairment and gait instability
[ ] QHS Ativan discontinued given possible contribution to falls
[ ] escitalopram dose reduced per pharmacy recommendations | 92 | 611 |
19104245-DS-14 | 22,951,860 | Dear Mr ___,
It was a pleasure taking care of you at ___
___!
Why was I in the hospital?
You were in the hospital because you were found on the ground at
home.
What happened to me the hospital?
You were seen by the neurologists; they were unsure if you had a
seizure. We increased your dose of Depakote to help control
seizures. We also started a medication called Metoprolol because
your heart was beating quickly.
What should I do when I leave the hospital?
You should continue taking all your medications, including the
new medication called Metoprolol. You should use a walker to
prevent you from falling.
Best wishes,
Your ___ team | ___ male past medical history COPD, schizophrenia, MCA
stroke ___, ETOH abuse, Afib not on ACA, dementia (AOx1 at
baseline, yells, cusses), epidural hematoma and seizures who
presents after being found down at his nursing home with
continued lethargy admitted to medicine for further work-up.
# Toxic metabolic encephalopathy
# Right sided weakness
Patient found down, unresponsive initially, but started talking
after arriving to the hospital. Most likely caused by mechanical
fall complicated by confusion of being in trash can. Initial
concern was for CVA, but CT head negative for acute intracranial
process. UA not consistent with UTI and is incontinent of urine
at baseline per nursing home. Chest x-ray was equivocal, and he
was not felt clinically to have pneumonia. Neurology evaluated
the patient, they were uncertain of the etiology. Seizure is
possible given history of seizures and borderline low Depakote
levels, but he did not have any further seizure activity after
arrival to ___. Tox screen was negative. Depakote was
increased to 650mg q8h given low level. He should have repeat
level checked on ___, and should also have neurology follow up
in approximately 1 month.
# Leukocytosis
# LLL atelectasis vs. consolidation
CXR was read as showing left lower lobe consolidation or
atelectasis, although he has no fever, cough/sputum, or
leukocytosis to suggest pneumonia. He was given antibiotics on
arrival but these were stopped shortly thereafter as PNA was
felt unlikely.
# Atrial fibrillation
CHADsVASc 3 (age, stroke history). HR to 120s in ED with stable
BP. He was started on low dose Metoprolol with subsequent
improvement in his heart rate. Notably, he was on Metoprolol
during his last hospital visit in ___, but this was stopped for
unclear reason. He is not currently on anticoagulation (other
than Aggrenox), likely due to history of intracranial bleed.
# ___
Cr 1.3 on arrival to ED w/ baseline Cr 0.8 to 1. Likely
hypovolemic given ketones in urine and high specific gravity. He
was given total 2.5 liters with subsequent improvement in his
Creatinine to 0.9.
# Schizophrenia
# Secondary parkinsonism
# Mood/behavior disorders
Baseline mental status: verbally abusive, curses and yells,
screams, repeats words over and over; does not try to physically
hurt providers. Other than the increased dose of his Valproate
(as above), his home regimen was continued.
# COPD
Continued PRN albuterol.
# Epidural hematoma s/p fall c/b seizures (___)
Depakote increased from 500mg q8h to 650mg q8h.
# h/o CVA
Continued dipyridamole-Aspirin 1 CAP PO BID, spoke with nursing
home and this was the only med discrepancy without conclusion,
unclear if he's receiving 2 caps twice a day vs 1 cap twice a
day. | 107 | 473 |
19231238-DS-31 | 22,716,761 | Dear ___,
___ were admitted with abdominal pain and some confusion.
The abdominal pain was likely from constipation and
significantly improved after starting medications to help with
bowel movements. Please continue to take these medications to
prevent abdominal pain. Some of your confusion is likely from
progression of your underlyning dementia. However, there was
also concern that your kidney disease was contributing. Thus
after discussion with your family, ___ were started on
dialysis(a way to filter the body of toxins that might cause
confusion and other complications). ___ were also started on
some medications to help alleviate some of the confusion.
Please continue to take all medications as prescribed and attend
all follow up appointments.
Sincerely,
Your ___ medical team | ___ with a history of DM, HTN, CHF (EF 50-55% ___, CKD, RCC
s/p left nephrectomy, RAS s/p PCI on ASA (plavix stopped due to
GI bleed in ___ admission) who presents with worsening
altered mental status and abdominal pain.
# AMS/Dementia: Family reports patient has been incontinent,
more abusive verbally and just not being herself. Symptoms seem
to point towards worsening dementia with frontal symptoms w/
intermittent episodes of delirium. Source of AMS is most likely
progression of her underlyning dementia. There could also be a
component of uremia.
CT head from ___ on ___ suggestive of vascular dementia.
Non-con MRI from ___ also consistent with vascular dementia and
parenchymal atrophy. Given BUN>100, assosiated volume overload
and pruritis, there could also be a component of uremia. After
extensive family discussion on ___ ___, it was decided to
proceed with a timed-trial of dialysis in the hope to improve
part of her symptoms that might be due to uremia. Will have
re-evaluation by outpt nephrology in ___ months to re: discuss
viability of dialysis based on course of first ___ months of
dialysis. had tunneled line placed ___. While improving, pt had
some agitation and difficulity with insomnia even days after
initiation of dialysis. Geriatrics was consulted, adn patient
was started on seroquel for insomnia/agitation. D/c'ed
cetirizine/benzonatate/hydroxyzine for possible contribution to
overall agitation.
- Will have MWF dialysis
# Volume overload/hx of dCHF: Pt presented with volume overload
on exam with JVP 10, pitting edema to hip, b/l UE edema,
effusions no CXR. Weight on ___, sig increased from
discharge wt of 72.5kg on ___. Probably a combination of
decompensated dCHF(LVEF 50-55 on ___ and also uremia given
associated AMS and pruritis. Given difficulity with access,
started on torsemide 100mg PO BID on ___ with metolazone once
5mg. Diuretics stopped and volume status managed at dialysis
starting ___. Discharge weight of 74.2kg.
- Will have volume mgmt at dialysis.
# Abdominal pain: Patient presented with c/o abdominal pain. On
exam, there was no tenderness to palpation. Patient has had
significant work up with 2 CT scans in 5 day intervals not
showing any acute findings. Has history of GI bleed, but no
evidence of bleed and no evidence of diverticulitis on CT scan
or ischemic bowel disease causing GI bleed. Source of abdominal
pain likely due to constipation given pain improved with bowel
movements.
# Anemia: Recent admission for GI bleed. there was concern for
GI bleed and patient refused ___ prep. H/H stayed stable
throughout admission. Presence of hemorrhoids. No evidence of
bleeding. Family requesting for colorectal surgery as
outpatient. Was on BID pantoprazole PO, changeed to daily PPI.
# Acute Renal Failure on CKD: initiated dialysis as above. Will
follow up with outpatient nephrologist.
# DMII: Will continue home glargine 8U and ISS. Will closely
monitor for hypoglycemia based on PO intake. BG of 137 this AM.
-continue humalog ISS
-hypoglyemia protocol
-started ___ glargine 8 units on admission
# HTN: Continue antihypertensives:
- nifedipine 90mg BID and hydralazine 75mg TID
- labetalol 200mg PO TID
CHRONIC ISSUES:
# H/o renal artery stenosis s/p angioplasty and PCI:
- Continue ASA 81mg.
- Stopped clopidogrel per Dr. ___
# h/o breast CA:
- per daughter not on tamoxifen, last filled ___ has
been on for ___ years (since ___ confirmed with PCP. No further
tamoxifen indicated.
==============================
TRANSITIONAL ISSUES
==============================
[ ] Should have discussion re: colonoscopy given prior admission
for GI bleed. per report, pt was expected to get ___ after
recent discharge, but declined.
[ ] No lab draws in L arm as much as possible given possible
future use for AV grafts if dialysis becomes permanent
CODE: FULL
Contact: ___(dtr) cell ___ other daughter ___
Son ___ ___ | 120 | 628 |
19955582-DS-6 | 26,593,491 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
Department: GENERAL ___
When: ___ at 1:20 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in
your throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before
your pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | The patient presented to the emergency department and was
evaluated by the Acute Care Surgery team. The patient was found
to have appendicitis and was admitted to the Acute Care Surgery
service. The patient was taken to the operating room on ___
for laparoscopic appendectomy, 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. On ___ the patient was noted to be hypotensive
to SBP of 85-90 with a hct drop to 19.9. She was transfused 2U
PRBC with an appropriate Hct rise to 26. At the time of
discharge the patients Hct was stable at 25.8. 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
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. | 784 | 254 |
15287015-DS-32 | 26,450,147 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I hospitalized?
You were brought to the emergency room because you could not be
awoken by staff at your nursing facility. At the emergency room,
your oxygen levels fell and you were intubated to provide
respiratory support and you were transferred to the intensive
care unit.
What happened during this hospital stay?
You received ventilation and blood pressure support until you
were able to breathe on your own. We continued most of your home
medications. Over a few days your mental status improved.
Thank you for allowing us to be involved in your care, we wish
you all the ___!
Your ___ Team | PATIENT SUMMARY STATEMENT:
Ms. ___ is a ___ F with a history of stiff person syndrome,
muscle spasm seizure disorder, OSA, HFpEF, prior
hospitalizations for hypoxia and altered mental status, now
presenting after being found unresponsive in bed at her nursing
home on ___ and intubation in the ED. Ultimately
transitioned to ___ and discharged to hospice. | 112 | 56 |
12438257-DS-14 | 28,491,990 | Dear ___,
You were admitted to the hospital for an infection of your skin
and soft tissue underneath ___ your L armpit and breast. You were
treated with antibiotics for the infection, and were later taken
to the operating room by the surgeons to remove some of the dead
tissue at the infection site. A vacuum wound dressing is
currently ___ currently ___ place. You also had a peripherally
inserted central catheter (PICC) inserted.
There have been a few changes to your medications. First, you
will receive an antibiotic through the ___ till ___. The
wound vac should be changed every 3 days till follow-up with
your surgeon. Second, you should not take your CellCept until
Dr. ___ you to do so. She will contact you when she
would like you to restart your CellCept.
It was a pleasure taking care of you, Ms. ___. We wish
you the best! | ___ SLE on prednisone, cellcept and plaquenil, who presents with
a five day history of an expanding left flank/axillary/breast
MSSA cellulitis.
#Cellulitis: Pt was noted to have severe erythema, edema, and
induration of the L axilla/lateral breast area. Purulent
discharge was noted ___ the ___ the area, with surrounding
desquamation of the tissue. Discharge and tissue was cultured.
Pt was started on vancomycin, aztreonam, and clindamycin due to
concern given pt's immunosuppression and concern for necrotizing
fasciitis. ID subsequently recommended discontinuing all
antibiotics except for vancomycin, given the low suspicion for
nec fasc given the slow course and improvement on exam. Pt
continued on vancomycin until culture was speciated to MSSA, at
which point she was switched to cefazolin per ID. Given her
penicillin allergy, pt was monitored closely to ensure she did
not have an anaphylactic response. She had no reaction, and
tolerated the cefazolin well. Erythema of the site improved
during the admission; however, potential fluctuance beneath the
central area of necrosis with exudative material vs. fibrinous
material was concerning, and surgical team took pt to OR for
debridement of the area on ___. Pt received stress-dose
steroids given her chronic steroid regimen. After surgery, pt's
pain was well-controlled. Erythema/edema of the site improved
significantly. Wound vac discharge was serosanguinous and scant
___ volume. She had a PICC placed prior to discharge ___ order to
complete her 2-week course of treatment (started ___, end
date: ___. Wound vac was removed prior to discharge, to be
replaced while at rehab every ___ day until follow-up with
surgery (Dr ___.
#SLE: pt has significant disease with loss of digits at
baseline. Pt previously on plaquenil, cellcept and prednisone.
Per discussion with rheumatology ___ and her outpt
rheumatologist, cellcept was held while plaquenil & pred
continued (given potential adrenal crisis). Her lupus remained
stable during the entire admission.
#Right shoulder dislocation: patient had fall ___ weeks back
while ___ ___ with right shoulder dislocation s/p reduction.
Per pt, she is scheduled to see her orthopedist ___ ___ ___
order to be evaluated for potential fixation at the site. Given
likely 2-week course for cellulitis, will likely hold off on any
surgical procedure until abx course is complete (i.e., after
___.
#Anemia: chronic anemia ___ SLE. However, Hct drop to 27.9 from
34.4. Hemodynamically stable, most likely secondary to
procedure. Subsequent Hct check prior to discharge was stable at
___. Will be monitored as an outpatient by her
PCP/rheumatologist. | 148 | 404 |
14020630-DS-22 | 28,533,945 | 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 driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised. | ___ status post Whipple ___ (path: solid-pseudopapillary
neoplasm) p/w crampy abd pain, syncope, mesenteric stranding of
roux limb on CT. A CT scan of the abdomen was obtained on
admission. It showed a heterogeneous appearance to the
Roux/biliary limb with adjacent mesenteric stranding and trace
fluid which is concerning for enteritis. This finding
correlated clinically with her abdominal cramping but did not
justify her vasovagal syncope. That being said, she was
admitted for observation to the ___ surgery service where
she was placed on intravenous fluids. Overnight she did well
and was tolerating a regular diet the next morning. As such,
she was saline locked. She was passing gas and had additional
bowel movements that did not result in additional episodes of
vasovagal syncope. Given her unremarkable hospital course, she
was discharged home later that afternoon after 23 hours of
observation with prescriptions for stool softeners. She will
follow up with Dr. ___ performed the Whipple procedure
initially, as an outpatient. Should she continue to have
abdominal crampiness or should the abdominal symptoms worsen,
she may undergo a serial CT scan to rule out worsening
stranding. | 63 | 196 |
15792940-DS-20 | 29,892,115 | Dear Mr. ___,
It was a pleasure taking part in your care. You were admitted to
the hospital with pneumonia and sepsis and you were monitored in
the intensive care unit. Your symptoms improved rapidly with
antibiotics.
You developed chest pain associated with changes in your EKG and
cardiac labs suggestive of a heart attack. You had a cardiac
catheterization that showed that your chest pain was likely
caused by vasospasm - when the arteries contract. You were
started on a medication to help relax your coronary arteries.
You will need to continue on the antibiotic Levaquin for evelen
more day.
The following changes were made to your medications:
- Started Nifedipine 30 mg daily
- Started aspirin 81 mg daily | Patient is a ___ year-old man who presented to ___ in
the setting of severe spesis and septic shock and pneumonia
transferred to the ___ MICU who improved with fluid
resusciation and pressor support but developed chest pain and
NSTEMI on ___.
#. Septic shock: The patient presented to ___ with
lactate of 7.3 that required a total of 7L of NS and a Levofed
drip. He was quickly weaned off pressors and his lactate
improved to 3.4 on admission to the MICU. Blood cultures grew
gram positive cocci in pairs and clusters that speciated to
pan-sensitive pneumococcus. He will complete a ___s an outpatinet.
#. Severe Sepsis/Pneumonia: The patient reports one week of URI
like symptoms with cough and malaise that acutely worsened with
high fever to 102 overnight. Rapid flu swab at ___ was
negative. CXR at ___ revealed right middle lobe PNA. Patient
received CTX/Azithro at ___. He was started on vancomycin,
ceftriaxone and azithromycin on admission to the MICU. His blood
culture grew Streptococcus Pneumoniae that was pan-sensitive. He
was switched to Levaquin on ___ and discharged with a
plan to complete a 14 day course on ___.
#. Chest pain/Coronary Vasospasm: On the morning on ___,
patient developed chest pain that was improved with sitting
forward. EKG showed non-contiguous ST elevations initially
suggestive of pericarditis. He was given morphine 2 mg iv x 1
and ibuprofen 800 mg po without releif. His chest pain resolved
after 1.5 hours. Repeat EKG showed improvement in ST changes.
Cardiac enzymes became elevated to troponin 1.25, CK-MB 53. He
was then started on a heparin drip, aspirin 325 mg po daily,
metoprolol 12.5 mg po TID and loaded with plavix 600 mg po.
Echocardiogram showed mildly depressed global systolic function
and abnormal septal motion and no pericardial effusion. Cardiac
catheterization revealed no CAD and generalized slow flow
(particularly in spastic OM2 and 3 branches) that improved with
IC NTG and IC Nicardipine. The diagnosis of coronary vasospasm
was attributed to the findings of his cardic catheteriztaion and
he was discharged on Nifedipine 30mg daily. | 120 | 345 |
10081525-DS-15 | 28,566,281 | You were admitted to the hospital after you had fallen down some
stairs. You were found to have a splenic laceration and left
sided rib fractures. You were taken to the operating room where
you had your spleen removed. You were monitored in the
intensive care unit. Your vital signs have been stable and you
are slowly recovering from your fall. You are preparing for
discharge home with the following instructions: | The patient was admitted to the hospital after a fall. In
emergency room, found to have a + FAST. Upon admission, he was
made NPO, given intravenous fluids, and underwent radiographic
imaging. Chest x-ray imaging showed left displaced posterior
rib fracture, but no evidence of pneumothorax. By torso cat
scan, he was found to have a splenic laceration. He was
reported to have isolated episodes of hypotension and he
received a unit of packed red blood cells. He was transferred to
the Trauma ICU for close monitoring.
On HD # 2 he was taken to the operating room where he underwent
an exploratory laparotomy and splenectomy. The operative course
was notable for a 2 liter blood loss in the abdominal cavity.
The abdomen was packed in all 4 quadrants. Once the hemorrhage
was controlled, the packs were systematically removed. A
___ tube was placed for bowel decompression. The
patient was extubated after the procedure and transferred back
to the intensive care unit for ongoing monitoring. During this
time, he was reported to have ST changes on his EKG and
troponins were cycled, initially at .13 but subsequently trended
down to .01.
He was transferred to the surgical floor once hemodynamically
stable in the ICU. His vital signs continued to be closely
monitored along with serial hematocrits have been monitored with
a current hematocrit of 26. The ___ tube was removed on
POD 3 once bowel function returned and his diet was slowly
advanced.
He was noted with intermittent drops in his oxygen saturations
associated with thick green sputum and productive cough. CXR was
done showing bibasilar atelectasis worse on the left and
unchanged on the right and a new small left pleural effusion.
CTA of the chest was also done to assess for pulmonary emboli
and this was ruled out. The CTA also showed chronic obstructive
airway disease. Given his exam and greenish sputum production he
was started on ___ugmentin. Incentive spirometry was
encouraged in addition to scheduled nebulizers, chest ___ and
cough and deep breathing. His oxygen was weaned and his room air
saturations were 90-92% without any symptoms of dyspnea. A
follow up CXR on day of discharge showed overall improvement as
well. Upon further discussion with patient it was discovered
that he had a long tobacco use history consisting of 4
packs/day.
He was discharged home in stable condition on ___ with an
appointment to follow up with his ___ clinic and was also
instructed to follow up with his PCP for pneumonia and
obstructive airway disease. He will have visiting nursing
services who will remove his staples in about 1 week. | 76 | 450 |
11965254-DS-81 | 25,332,406 | Dear ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had nausea, vomiting, and
worsening abdominal pain
What happened while I was admitted to the hospital?
-Were you were evaluated by the gastroenterologist and underwent
a CT scan of your abdomen that did not show evidence of a
Crohn's flare
Your symptoms and pain were managed with IV medications and
your diet was slowly advanced as tolerated
-Your lab numbers were closely monitored and you were given
medications to treat your medical conditions
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
We wish you the very best!
Your ___ Care Team | ___ year-old female with medical history notable for refractory
fistulizing Crohn's disease complicated by multiple abdominal
abscesses (history of carbapenemase producing Klebsiella) s/p
total colectomy, ileostomy and gastrojejunostomy (___) and
ostomy revision, fistula takedown, component separation
(___), recent hospitalization for gastroenteritis who
presented with abdominal pain, decreased po intake for 2 days
found to not have any concerning findings on lab work or CT
imaging. Her symptoms were thought to be in setting of acute
gastroenteritis and she was managed conservatively until
symptoms improved prior to discharge. | 128 | 87 |
16398746-DS-24 | 23,145,620 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted due to concern for low blood pressure. You
were watched over 24 hours and your vital signs remained stable.
We believe that there were a variety of factors that could have
played a role in your hypotension. Your labs indicated that you
were dehydrated on arrival, please maintain good fluid intake. A
Xray of your belly showed you were constipated, and you improved
after having bowel movements on the day of admission, please
take laxatives on a regular basis (instead of as needed). We
spoke with your Cardiologist who recommended stopping once of
your anti-hypertensives, Lisinopril. He will follow-up with you
as an outpatient. Lastly, we were able to schedule an
appointment with Neurology on ___ to assess for autonomic
dysfunction.
Weigh yourself every morning, call MD if weight goes up or down
more than 3 lbs.
Please use the hydrocortisone cream for the hemorrhoids.
Please keep the follow-up appointments made for you.
___ MDs | This is a ___ y/o man with PMHx with history of HIV (CD4 627, VL
undetectable ___ sCHF (LVEF ___, anal cancer s/p XRT and
several episodes of unexplained hypotension requiring MICU
admission presenting with abd pain and hypotension.
# Hypotension/Abdominal Pain: BP normal on admission and after
24 hours of admission. On review of OMR, he has been extensively
worked up for hypotension in the past. Providers who seem to
know him well have concern for intermittent cecal volvulus
causing severe abd pain, leading to shock and HD collapse (see
Cardiology note ___. He was evaluated by CRS (___) and
was felt to have a rather unremarkable CT scan of the abdomen,
no surical intervention was offered. No fever, leukocytosis,
left shift or bandemia to suggest infection on admission. KUB
without obstruction currently but with significant fecal load.
His abdomen was benign on admission and he has no localizing
complaints. Abdominal pain appears to have improved after having
BMs. Another consideration for his hypotensive events is
autonomic dysfunction (given h/o peripheral neuropathy) and
medications (taking extra or non prescribed meds, or
amiodarone/beta blocker preventing a tachycardic response to
dehydration). Labs on admission suggested dehydration (including
___, that responded to fluids). Outpt Card was contacted and
decision was made to discontinue Lisinopril. Neuro appt was
arranged prior to discharge for evaluation fo autonomic
dysfunction. Lastly, patient is undergoing a pharmacy-led review
and reconciliation of the patient;s current extensive medication
list to evaluate interactions. Negative orthostatics on
discharge. Close follow-up with PCP was arranged prior to
discharge.
# Constipation: KUB in the ED with fecal loading, which likely
explained his mild abd pain. BM relieved much of the discomfort.
Instructed to start a regular laxative regimen (instead of prn)
in order to avoid episodes of constipation +/- hypotension.
# sCHF: Non-ischemic; LVEF 40% - on review of OMR, LVEF ___
from ___ is not accurate (see Cardiology notes). He is
currently mildly volume overloaded (BLE edema), though
comfortable on RA. Given reported hypotension in outpatient
clinic, will given gentle IVF per above. Discontinued
Lisinopril, per outpt Cardiologist. Continued home Metoprolol;
continued Amioodarone (pt taking it for ventricular ectopy).
# HIV: CD4 627, on HAART; continued home antiretrovirals.
# ___: Likely mild hypovolemia, s/p IVF, resolved.
# Hypothyroidism: Continued home thyroid replacement.
# PVD: Continued home Plavix/aspirin.
# Depression: Continued home SSRI.
# Hypogonadism: Continued home testosterone cream. | 170 | 402 |
10884861-DS-6 | 23,472,066 | Dear Mr. ___,
You were admitted from the infectious disease clinic because we
were concern that you had another infection. When you were
admitted the gastroenterologist took out your biliary stent. You
were given IV antibiotics and you since improved. Please follow
up with your PCP and infectious disease doctor. | ___ w/ HTN, DMII, cholangitis s/p stent, and cholecystitis
(requiring perc chole tube - now removed), and recurrent
polymicrobial hepatic abscesses (requiring
percutaneous drain - now removed) in ___ presented from ___
clinic for concern of cholangitis and sepsis, s/p ERCP on ___
with stent removal and biliary clearance, who also underwent
cholecystectomy on ___.
#LIVER ABSCESSES
#RECENT CHOLANGITIS, CURRENTLY WITH PLASTIC CBD STENT
#RECENT CHOLECYSTITIS (CONSERVATIVELY MANAGED)
Pt with recent hx of cholangitis with complication of liver
abscess initially presented with signs of severe sepsis
(tachycardia, leukocytosis and lactate). S/p ERCP with stent
removal and clearance of biliary tree. ID following,
recommending initially broadening to Zosyn then de-escalated to
levaquin and fluconazole
post ERCP after biliary stent removal. His fluconazole was
decreased to 200 mg daily due to his decreased creatinine
clearance. He will follow up with his ID doctor Dr. ___ on
___ for further management of antibiotics. ACS consulted, who
recommended cholecystectomy prior to discharge on ___
# HTN
#ORTHOSTATIC HYPOTENSION: resolved with fluids
# ___
Likely ___ to prerenal azotemia from sepsis. Improved with IVF
hydration.
[] Recommend checking outpatient chemistry. If creatinine
clearance improves to >50, can go back up to 400 mg daily.
# Renal cyst:
Multiple mildly complex cortically based renal cysts, measuring
up to 4.3 cm, with the dominant cyst demonstrating septation
with calcification. Bosniak ___ classification. Will need further
work up as it has a 5% chance of malignancy.
Plan
- work up as outpatient
#BPH
- continue Flomax and Proscar
# DM: moderately well controlled DM as outpatient (last A1C in
___ 6.7), but had some high values this admission, likely due
to prolonged NPO periods followed by large meals and difficult
to dose insulin. His metformin and glipizide were held
throughout the hospitalization and he was on insulin. By
discharge***
# HLD: Held simvastatin initially but it can be restarted on
discharge. Continued ASA 81mg daily
# homelessness
Per pt's roommate, he does not want the patient to return to his
current residence. He was seen by ___ who gave him information on
homelessness resources. He will be discharged to ___.
# Renal cyst:
Multiple mildly complex cortically based renal cysts, measuring
up to 4.3 cm, with the dominant cyst demonstrating septation
with calcification. Bosniak ___ classification. Will need further
work up as it has a 5% chance of malignancy.
Plan
- work up as outpatient
#BPH
- continue Flomax and Proscar
# HLD
- Hold simvastatin
- ASA 81mg daily
On ___ the patient was transferred to the Acute Care
Surgery Service for laparoscopic cholecystectomy. Please see
operative report for details. Post operatively the patient was
extubated and taken to the PACU in stable condition.
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.
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. | 49 | 532 |
15497723-DS-15 | 24,004,331 | You were admitted to the hospital due to increased seizure
frequency. We think that this was likely secondary to recently
decreased Keppra vs missed doses from vomiting, possible viral
illness, decreased sleep in the setting of the death of her
sister.
Therefore, we have put you back on Keppra 2000mg BID and
continued your home Vimpat 150mg BID. On these medications, you
had no concerning findings on EEG and your mental status
improved during your hospitalization.
You can follow up as scheduled in our system and get your
scheduled MRI before this appointment as listed below. We have
set up for nursing services to help you with your medications as
this seems to be a problem, at times. | ___ year old female with past medical history of hypothyroidism,
cognitive decline, and seizures followed for significant FLAIR
white matter hyper intensities seen on MRI possibly secondary to
___'s meningoencephalitis. Her initial exam is significant
for some memory inconsistencies and difficulty with two step
commands, possible very mild visual difficulties in left lower
quadrant.
In general, she has many reasons for suspected provoked seizure
- 1.) Decreased Keppra dose vs noncompliance (per daughter she
cannot find the Keppra bottle at home) 2.) Flu like illness 3.)
Vomiting up her AEDs - missing one day's dose of both meds at
least. 4.) Decreased sleep due to distress re: Sister's death.
#Neuro: We replaced her prior Keppra 2000mg BID and Vimpat
150mg BID. She was placed on cvEEG. No further seizures were
noted. Final report was pending at time of discharge. She was
continued on current doses of AEDs. She will follow up with her
primary neurologist and have previously scheduled repeat MRI to
further evaluate ___'s meningoencephalitis
#CV: ___ remained hemodynamically stable was continued on
atorvastatin and amlodipine
#Resp: She remained on SORA
#FEN/GI: She tolerated regular diet
#Endo: Was continued on home levothyroxine
#Psych: Was continued on home citalopram | 118 | 198 |
11091256-DS-21 | 29,378,745 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital.
WHY WERE YOU ADMITTED:
- Your blood count was low.
WHAT HAPPENED IN THE HOSPITAL:
- We gave you medications to help with your pain.
WHAT SHOULD YOU DO AFTER LEAVING:
- Please continue to take your medications as prescribed.
Thank you for allowing us to take part in your care.
Your ___ team | Mr. ___ is an ___ year old male with a past medical history
notable for pAF on warfarin, provoked DVT/PE, aortic stenosis
s/p bovine AVR (___), CAD s/p PCI in ___, hypertension,
hyperlipidemia, metastatic disease likely PNET, recent L
___ B2 periprosthetic hip fracture s/p ORIF of his L
periprosthetic femur fracture on ___ now re-presenting after
fall. He is found to have acute on chronic anemia, evolution of
thigh hematoma, ___, stercoral colitis, and penile abscess. | 60 | 76 |
15589573-DS-13 | 24,187,831 | Dear Ms. ___,
WHY WAS I ADMITTED?
- You had some signs of kidney damage on your lab tests
- You came in to be seen by our kidney specialists and to have a
workup to try to find out the cause of the damage
WHAT WAS DONE WHILE I WAS HERE?
- You were seen by our kidney specialists
- You had a biopsy of your kidney
- This biopsy showed inflammation in the kidney called "acute
interstitial nephritis"
- This was likely due to the motrin that you had been taking at
home
- You were started on high doses of steroids to treat this
- Your kidney function improved, and you were discharged with
close follow up with the kidney doctors
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
-You should avoid taking ibuprofen (motrin)
We wish you the best!
-Your ___ Care Team | The patient is a ___ female with a history of
hypothyroidism and osteoarthritis referred for rapidly
increasing Creatinine concerning for glomerulonephritis. | 144 | 22 |
16883133-DS-3 | 27,334,076 | You were admitted for a leg cellulitis. You responded to IV
antibiotics. You were transitioned to an oral antibiotic called
Bactrim. You should take this for 10 more days. You should
follow up with your PCP ___ ___ weeks. If the infection has not
resolved completely, you may need to take the antibiotics for
longer.
Do NOT scratch your eczema. It may cause a new infection. You
may take Benadryl or other anti-itching medications. You should
continue to follow up with your dermatologist for further
management of your eczema. | ___ year old F>M with a h/o severe excema and previous foot
infections last in ___ now presenting with fevers and
foot swelling c/w cellulitis.
.
#Cellulitis - the pt was started on vancomycin for her
cellulitis. He made slow improvement and required redosing of
her vanco when her trough came back low at 5. With appropriate
dosing, he made more rapid improvement and was transitioned to
Bactrim DS 1 tab po BID. He was monitored overnight after the
transition with continued improvement. ___ Dopplers show no
evidence of DVT. He scratches his skin due to her eczema which
was the likely source of her infection. He was treated with
sarna lotion and benadryl prn. He has been on other lotions in
the past per her dermatologist (ie triamcinolone cream) but he
reports that his ecezema is actually relatively well controlled
at present and is not using any of the creams. His fevers
resolved. Cultures have all been negative to date.
.
She was otherwise continued on her home medications and will
complete at 10 day course of Bactrim. She will follow up with
your PCP for further evaluation. | 95 | 194 |
18267541-DS-16 | 20,535,742 | You were admitted after a seizure. You were found to have very
low sodium levels, likely from drinking water. You sodium level
returned to normal and stayed at normal. The neurology doctors
think that your seizure was caused by the low sodium levels and
you are not at higher risk to have another seizure in the
future. It is important to monitor your sodium levels to ensure
they stay stable. No driving restrictions are necessary unless
your sodium levels are abnormal or you develop seizure or pass
out.
In addition, you had muscle break down cause elevation in your
CK. This was improving prior to discharge. You will be at risk
of kidney injury with the elevated level. Make sure you stay
hydrated with gatorade. If your urine output drops or becomes
dark please drink more fluid or present for evaluation. You will
need to have follow up labs. Because of this your statin was
held as it can contribute to elevated CK. Please discuss
restarting this medication with your PCP.
Your LFTs were elevated which is likely due to muscle break
down. However, you will need to have labs to ensure this
resolves. If this does not resolve, you may need further
evaluation of your liver including possible MRCP (discuss with
your PCP).
You had some vascular plaques suggesting atherosclerosis. Your
aspirin was increased to 325mg daily. Statin is indicated but
should be held until your rhabdomyolysis resolves.
I have updated your PCP on these issues. | ___ with who presents with AMS and likely seizure, found to have
acute hyponatremia secondary to acute water intoxication.
# Acute hyponatemia:
He had significant water intake with acute decrease in serum
sodium. This was complicated by seizure (see below). Nephrology
was consulted and he was initially started on hypertonic saline.
Eventually he started rapidly self correcting which was limited
with D5W. It was possible that a component of SIADH was present
as urine osms were difficult to totally explain with acute water
intoxication. However, his urine osms returned to normal and ADH
returned to appropriate levels. His sodium levels resolved and
with regular diet remained normal. He will have follow up labs
with PCP follow up to ensure continued normalization of his
hyponatremia.
# Seizure:
This was provoked secondary to hyponatremia. Neurology was
consulted and did not think that antiepileptics were indicated.
Furthermore, they did no feel that he was at increased risk of
seizure activity when his sodium was normalized. He had no
further episodes of seizure or neurologic abnormalities while
inpatient. Given his "provoked event" no further restrictions
were placed on his driving as he shouldn't be at increased risk
from general population as documented by neurology. This was
discussed with patient and outpatient provider.
# Rhabdomyolysis:
This was thought secondary to hyponatremia, trauma and seizure.
He was treated with IVFs and his CK rapidly resolved. His CK was
>5000 at discharge however dropping rapidly and he was making
good urine output. He had no evidence of ARF. After discussion
with nephrology fellow they though discharge should be okay
given overall clinical picture. He will have follow up labs to
be sent to PCP. I discussed the risk with the patient and
notified the PCP. His statin was held at discharge but likely
indicated long term. This was discussed with the patient and
PCP.
# Atherosclerosis/vascular plaques:
As evidenced on imaging findings. Neurology was following and
recommended increase in aspirin to 325mg daily. His statin was
held but may be indicated. Both the patient and the PCP were
notified of these findings.
# Anemia:
No evidence of bleed. Likely dilutional. Patient aware.
# CAD: s/p CABG for 3vd.
On aspirin and beta blocker. Holding simvastatin.
He will have outpatient labs and PCP follow up. PCP and patient
were notified of abnormalities. | 243 | 372 |
14303868-DS-14 | 23,861,864 | Dear ___ was a pleasure taking care of you. You were admitted to the
hospital because of low oxygen levels prior to a planned
endoscopic procedure. We also found that you had diffuse edema
(tissue swelling) and weakness.
During this admission we did an extensive evaluation of your
symptoms, with mostly normal results. A CT scan showed no
evidence of blood clots in your lungs. It did should emphysema,
likely related to your history of smoking. There was also a very
small lung nodule that will require a repeat CT scan in 12
months.
An MRCP showed no evidence of a mass in the pancreas, though may
show signs of prior pancreatitis. A repeat MRCP should be
performed in 3 months. A small amount of fluid was also seen in
the pelvis, with no obvious cause, and this can also be followed
up with a repeat CT scan of the abdomen/pelvis in the near
future.
An echocardiogram (ultrasound) was done to check the function of
your heart. It was mostly normal other than decreased pumping of
the right side of your heart. This is likely related to your
COPD.
You will be contacted after discharge to schedule pulmonary
function tests. If you do not hear from the ___ lab in the next
___ days, please call the main ___ number (___) and
ask for the pulmonary function test lab.
The following tests are pending at the time of discharge and
should be followed up by your primary care physician:
- ___ (to check for autoimmune disease)
- tTG-IgA (to check for Celiac disease)
- Urine protein electrophoresis (to check for proteins in the
urine)
- Vitamin B1 (to check for vitamin deficiency)
- ___ Gold (to check for TB)
If I am contacted about any abnormal values for the above test,
I will be sure to contact you directly. Otherwise you can
discuss the results with your primary care physician.
Overall, your smoking is likely playing a large role in your
symptoms, and particularly your low oxygen levels. It is
critical that you consider stopping smoking or else your lung
disease will continue to progress and likely become much more
severe in the near future.
If you have worsening of your symptoms, please contact your
primary care physician or return to the hospital for further
care.
Sincerely,
Your ___ Team | ___ with hx of autoimmune disease, bladder cancer, hypertension,
COPD (no PFTs, not on home O2) presenting with subacute dyspnea
and weakness over 2 months.
# Hypoxia:
Patient presented with incidentally noted hypoxia prior to
scheduled EUS. No prior records regarding COPD history, but
given active tobacco use, diminished breath sounds throughout,
CT findings, and reported history of improvement with Symbicort
and Spiriva, COPD is a likely diagnosis. Hypoxia likely
representes progression of COPD, though concern for accelerated
symptoms recently did raise concern for a superimposed process.
Hypoxia also improved dramatically with nebulizers, and patient
had ambulatory O2 sat >94% by hospital day 3. Given initial
diffuse edema, there was concern for heart failure. However, her
edema improved without any diuresis or other directed treatment,
and TTE was notable only for RV dilation and hypokinesis,
thought to be related to pulmonary bronchospasm. She underwent
CTA that was negative for PE, but did show emphysema and
multiple 3mm pulmonary nodules. Pulmonary was consulted, who
made further recommendations for evaluation of her hypoxia.
While low likelihood, given her history of Pott's disease (many
years ago, fully treated with no recent complications), a
___ gold was sent to rule out TB, and was pending at
the time of discharge. PFTs with MIP/MEP were also ordered to
evaluate for COPD or other pulmonary process. She was discharged
on Symbicort and Tiotropium, along with albuterol inhaler. She
was encouraged to quit smoking, but she says this is unlikely to
happen and is not motivated. Of note, she also declined any
invasive procedure for further evaluation of her pulmonary
nodules, as she said she would not necessarily want to know if
she has lung cancer and would not want chemotherapy. This should
be explored further if her symptoms progress. Ultimately the
most likely cause of her hypoxia and overall symptoms is COPD,
including possibly her cachexia, though if her symptoms persist
or worsen her unusual constellation of symptoms warrants further
evaluation with PFTs, ___ CT, and referral to other
specialists as indicated.
# ___ edema:
No evidence of renal disease based on BUN/Cr. As above, no
evidence of decompensated heart failure such as pulmonary edema
or pleural effusions, elevated JVP. Does have reported hx of
isolated elevation of cardiac biomarker, but without known CAD.
Serum albumin was only marginally low at 3.4. TTE showed likely
RV dilation likely due to pulmonary disease, but overal
diastolic and systolic function was within normal limits. UPEP
was normal. TSH was 5.7, only mildly elevated, and should be
repeated as an outpatient prior to changing her levothyroxine.
Her ___ edema resolved without any specific intervention while
she was in the hospital. The patient felt that it was related to
eating hospital food rather than the "junk" that she had been
eating at home over the mpast several months. It is possible she
has been eating very high sodium foods, though she does not have
clear evidence of heart failure, so this would be unlikely to
fully explain her symptoms. If her edema recurs she should have
further evaluation.
# Pancreatic findings on CT:
Initial concern was for pancreatic cancer versus autoimmune
pancreatitis. However, per radiology and discussion with GI,
___ MRCP was not concerning for either, though did show
signs of chronic pancreatitis. GI recommended deferring EUS for
now based on MRCP findings, and to repeat MRCP in 3 months.
# Hypothyroidism:
Continued on home levothyroxine 150 mcg 6x per week, and 300 mcg
on ___. TSH was 5.7, but no change was made to her
medication in the inpatient setting. Her TSH should be rechecked
as an outpatient.
# Alopecia:
- Continued prednisone 60 mg once per month (did not receive
while inpatient)
# Chronic back pain:
- Continued home vicodin and diazepam
# Hypertension:
- Continued home meds | 375 | 621 |
17948846-DS-9 | 28,037,390 | Dear Mr ___,
It was our pleasure to take care of you during this hospital
stay.
You were hospitalized due to symptoms of right side weakness and
difficulty with your speech resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
irregular heart rhythm, advanced age.
Added Pradaxa 150 mg twice a day, this medication is a blood
thinner and can increase risk of bleeding.
I contacted your primary care doctor and let him know about
this.
Atorvastatin 10 mg daily.
Sulfameth/Trimethoprim DS for 7 days for urinary infection.
We stopped aspitrin.
Please take your other medications as ___
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 | The patient was transferred from ___ hospital after
receiving IV TPA.
He was monitored closely in the ICU and after 24 h was
transferred to the regular floor.
He passed speech and swallow evaluation for regular food.
His stroke risk factors were investigated and he was found to
have atrial fibrillation.
For secondary prevention of stroke, he was started on
Atorvastatin and after discussion with his primary care
physician he was started on pradaxa 150 mg BID.
Aspirin was stopped.
Physical therapy service evaluated the patient and he will be
transferred to acute rehab for further treatment.
Urine analysis showed concern for urinary infection and he was
started on Bactrim DS bid for 7 days with end date of ___.
===========================
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =76 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A | 287 | 304 |
10436108-DS-20 | 23,433,094 | You have undergone the following operation: Thoracic
Decompression With Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You have been given a brace. This brace
is to be worn when you are walking.You may take it off when
sitting in a chair or while lying in bed.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery, do not get the incision wet.Cover it with a sterile
dressing.Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting. 5)TLSO when
OOB
Treatments Frequency:
Remove the dressing in 2 days.If the incision is draining cover
it with a new sterile dressing.If it is dry then you can leave
the incision open to the air.Once the incision is completely dry
(usually ___ days after the operation) you may take a shower.Do
not soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery,do not get the incision
wet.Cover it with a sterile dressing and call the office. | Mr. ___ was initially admitted to the ___ neurology
floor after you fell at work. An MRI of his brain that showed
significant changes to the ___ matter in the brain. Neurology
team thinks these changes are likely caused by your whole-brain
radiation. He had lumbar puncture, and the spinal fluid had
___ blood cells and high protein, which are abnormal findings.
The medical team was concerned for meningitis, though nothing
grew. Cancer cells can cause a carcinomatous meningitis, but the
cytology results on the spinal fluid were also negative. He also
had some green sputum from his cough, and treated with a course
of azithromycin for a presumed bronchitis. A spinal MRI that
showed multiple spinal metastatic lesions: T6 and T12 metastatic
lesions and myelopathic symptoms. He was admitted to the
orthopedic spine team and taken to the operating room on ___
for T6 transpedicular decompression and T5-T7 posterior fusion.
In summary, ___ man with metastatic NSCLC with mets to the bone
s/p chemo (on nivolumab) and radiation (including WBRT) admitted
___ for fall in setting of subacute on chronic worsening of
gait. LP which was negative. MRI brain with diffuse subcortical
___ matter changes, likely consequent to prior whole brain
radiation. MRI spine with metastatic lesions compressing spinal
cord. Went to OR with spine after extensive convo with rad-onc,
med-onc, neuro-onc and patient.He is now s/p T6 transpedicular
decompression, T5-T7 posterior fusion.
Post op course was complicated by pain, acute blood loss anemia,
ileus followed by IBS symptoms of frequent stools and new onset
afib post op. Afib was managed with a low dose metoprolol for
rate control. He is currently in SR with HR in the ___ and a
stable blood pressure. Given his recent spinal surgery and
contraindication to systemic anticoagulation, Cardiology
recommended rate control. This was likely a catecholamine
response in the post-operative state. Pain was controlled with
oral and iv pain medications. labs were monitored closely for
electrolyte imbalances and post op anemia. He is currently
stable. Ileus has improved. Hosptial Course was otherwise
unremarkable. He is cleared for REHAB and should follow up with
his oncologist as an outpatient within 1 week for further care
and planning. | 621 | 365 |
18901481-DS-19 | 22,827,136 | Dear Mr. ___,
You were admitted to ___ and
underwent exploratory laparotomy with repair of your stomach as
well as repair of the artery in your left arm. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
YOUR INCISION:
*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.
YOUR BOWELS:
-Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
-If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
Warm regards,
Your ___ Surgery Team | ___ stabbed in domestic dispute w/ LUQ wound s/p lap->open
exploration w/ gastrorrhaphy and L brachial transection s/p
repair. He initially had profuse bleeding from left biceps stab
wound which was controlled after repair. Per vascular surgery,
he was initially started on hep gtt and aspirin post-op with
eventual removal of hep gtt. His left radial pulse was monitored
with Doppler and pain was controlled with acetaminophen and
oxycodone. He was given prazosin 2mg qhs for nightmares per ___
and also had several OT sessions. He had no BM, though passed
flatus, for several days with additional bowel regimen added
until he had a BM with lactulose on the day of discharge. | 407 | 112 |
16750522-DS-2 | 29,245,686 | Dear Ms. ___,
It was a pleasure taking ___ of you at ___!
You came to us because of slurred speech and weakness. While you
were here, we discovered that you had multiple new strokes, as
well s a new clot in your lung. We were worried that your
anticoagulation was not working. Multiple studies were done, and
we did not discover a shunt between the right and left sides of
your lung, and you did not have additional clots in your lower
legs or abdomen/pelvis. We changed you to a different blood
thinner (lovenox).
You also developed an aspiration pneumonia in the setting of
food going down the wrong pipe, likely in the setting of your
stroke, and you were treated with antibiotics. You had episodes
of confusion in the setting of stroke and infection as well as
some medications that cause sedation, and this was treated with
changing your medications and treatment of the infection. Your
mental status improved, and eventually you were also able to be
upgraded to a different diet!
It is very important that you take all of your medications and
attend all of your follow up appointments, they are listed
below.
Please take ___, we wish you the very best!
Sincerely,
Your ___ ___ Team | ___ year old lady w/schizoaffective disorder on clozapine,
metastatic lung adenocarcinoma w/ brain metastases s/p chemoXRT,
pulmonary embolism on rivaroxaban, admitted with
encephalopathy, LUE weakness & slurred speech, found to have
multiple bilateral CVA and new segmental PE c/f anticoagulation
failure, with course complicated by demand NSTEMI, aspiration
pneumonia, severe protein calorie malnutrition, as well as
delirium in setting of acute illness +/- psychiatric
medications.
# Multiple bilateral CVAs:
On admission the patient was found to have numerous multifocal
infarcts including the bilateral cerebral hemispheres and
cerebellum. Etiology of strokes concerning for embolic shower vs
watershed and embolic strokes, in the setting of
hypercoagulability of malignancy.
Work up including TTE x 2 did not reveal PFO (although she was
unable to perform Valsalva), and TEE was deferred as this would
require anesthesia and would not necessarily change management.
She was monitored on telemetry and no atrial fibrillation was
seen. For anticoagulation and further evaluation of VTE (given
concern for possible PFO), please see below. Home atorvastatin
was increased to 40 mg daily per neurology; also on aspirin 81
mg. She will have follow up with stroke neurology, scheduled for
___.
# Pulmonary embolism on xarelto:
Patient had a recent R lobe subsegmental on ___ (kept on
xarelto) in the outpatient setting. On admission she was found
to have a new segmental RML PE on CTA ___ therefore she was
transitioned from xarelto to a heparin drip. ___ US neg. A CT A/P
venous phase was done to check for burden of clot in the
abdominal/pelvic veins given concern for hypercoagulability and
multiple PEs, but none was found. There was additionally no DVT
on ___ dopplers. Given this, the decision was made to defer IVC
filter (as this wouldn't affect her stroke risk and it is an
extra procedure), and trial her on lovenox. Hypercoagulability
work up was also sent, only notable for mildly low antithrombin
(78)- otherwise factor V and VIII assays normal, protein C/S
functional screens WNL, B-2 glycoprotein negative, cardiolipin
Ab IgG/IgM negative, homocysteine 6.6. She was transitioned from
heparin to enoxaparin, started ___, and tolerated this well
without evidence of bleeding. On discharge, she will be on
enoxaparin 70 mg q12H. Please recheck CBC within 1 week to
ensure stable. ___ consider lupus anticoagulant in outpatient
setting, however unclear if this would necessarily change
management.
# Type II NSTEMI
# Chest pain
On admission patient had a troponin peak to 0.51 thought ___ new
PEs. During the admission she had on & off chest pain, but EKGs
did not show any sign of ACS (perhaps slightly progressive
inferior Q waves). TTE was done w/o wall motion abnormalities.
Troponins downtrended. She also has multiple etiologies for
chest pain (new PE on CTA, PNA, lung cancer), as well as likely
costochondritis given reproducible TTP +/- pleuritis given PEs,
as worsens w/ anxiety. This was improved with lidocaine patch.
She was continued on aspirin, statin and a heparin drip, which
was transitioned to enoxaparin as above. Stress test and cath
were deferred given comorbidities as well as desire to avoid
triple anticoagulation.
# Metastatic lung cancer with brain met: Followed by Dr. ___
at ___. S/p chemoXRT as well as resection of one brain met (one
remaining). Had been planned for possible initiation of
pemetrexed. Of note, the pt has a reported brain met remaining
but we cannot see the met on our MRI brain. She was set up with
follow up with Dr. ___ on discharge, email sent to update.
# Aspiration PNA
Patient was found initially to be mildly hypoxic and imaging was
c/w aspiration PNA thought ___ encephalopathy and chronic
aspiration (mild-moderate oropharyngeal dysphagia seen on
video). She was started on unasyn. However, repeat imaging
showed worsening of pneumonia and she had increased secretions,
so antibiotics broadened to zosyn on ___ for a 7 day course of
HAP (ending ___. MRSA swab was negative. Flu swab was
negative. She subsequently improved with speech and swallow
evaluation and diet was upgraded to soft/thin at discharge,
repeat CXR also demonstrated interval improvement of left
perihilar opacities.
# Metabolic encephalopathy:
# Schizoaffective disorder
During the hospitalization patient was intermittently lethargic.
This was thought likely in s/o clozapine and multiple medical
problems including pulmonary emboli, strokes, lung cancer.
Likely with overlying component of hypoactive delirium, as well
as worsening pneumonia. She was followed by psychiatry and her
clozapine doses were adjusted (clozapine dose at discharge was:
clozapine 25 mg qAM + 175 mg qPM); her clonazepam was weaned off
due to concern for sedation. She did not have any evidence of
hallucinations after clozapine dose decrease. She was moved to a
window room and delirium precautions were applied. She did have
cvEEG during stay without evidence of seizure. For the last 4
days prior to discharge, she was awake, oriented to self,
hospital, ___, and year, significantly improved after
psychiatric medication adjustment and treatment of underlying
pneumonia. Psychiatry team was in contact with patient's
outpatient psychiatrist Dr. ___ she was in agreement with
current dosing. We have attempted to set up outpatient follow up
but reached voicemail.
# Severe protein calorie malnutrition: Based on bed weights, 10%
weight loss since admission in setting of medical illness and
modified diet. Seen by nutrition with recommendation for
increased nutritional shakes. At this time attempting to
increase PO intake after diet upgraded, but this requires
ongoing reassessment.
# Anemia: Stable at around ___ since admission, 9.6 on
discharge, no evidence of bleed throughout stay.
# Leukopenia: Fluctuating, could be in setting of BM suppression
from infection/antibiotics, but note patient also on clozapine
(no evidence agranulocytosis). Resolved by day of discharge at
5.4 | 205 | 929 |
14654454-DS-19 | 21,434,017 | ================================================
PATIENT DISCHARGE INSTRUCTIONS
================================================
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
- You were admitted because you had a fainting spell and were
found to have low blood counts again.
WHAT HAPPENED IN THE HOSPITAL?
- You underwent a repeat endoscopy and capsule study, which
unfortunately did not show the source of your bleeding.
- Given your recent evaluation, we did not think there was much
utility in repeating these studies.
- Reassuringly, your blood counts improved markedly throughout
hospitalization.
- You should have a blood test early the week of ___ to
re-check your Hemoglobin, and these results will be faxed to
your PCP to monitor your Hemoglobin level. For reference, your
discharge Hemoglobin is 8.7 and through your recent stay your
Hemoglobin has ranged from 6.7 to 8.8.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Be sure to take your medications as prescribed and attend the
appointments listed below.
- You should have repeat blood counts obtained early next week.
- You should have your iron levels rechecked in the next 4
weeks.
CONTINGENCY PLANS FOR CONCERN OF BLEEDING
- "Bleeding but STABLE": If you notice darkening and sticky
stools, or if you are noticing your Hemoglobin counts are
dropping on blood tests, then you can present to the ___
Emergency Room, where we will plan for a STAT unprepped video
capsule endoscopy study.
- "Bleeding but UNSTABLE": If you notice darkening and sticky
stools, or if you are noticing your Hemoglobin counts are
dropping on blood tests, AND/OR if you feel faint, dizzy, or see
frank red blood in your stool, then you can present to your
local emergency room for urgent therapy; show them your
discharge paperwork and request for a CT Angiography of the
Abdomen/Pelvis.
Thank you for allowing us to be involved in your care, we wish
you all the best! | ================================================
TRANSITIONAL ISSUES
================================================
[] The source of patient's bleeding is unclear. It is suspected
to be a transient gastrointestinal AVM or Dieulafoy's lesion
that could not be found with imaging. Should he notice melena
again and is otherwise stable, he was instructed to present to
___ for un-prepped video capsule study (recommended by GI). If
he is symptomatic (i.e. has syncope), he should present to his
nearest urgent care for further evaluation with stat CTA of
abdomen and pelvis with goal of localizing source of bleed.
[] Discharge Hemoglobin: 8.7 (admission range 6.7 to 8.8)
[] Patient should have a repeat CBC in the next week for further
monitoring of his blood counts.
[] Patient should have repeat iron studies in ___ weeks to
further evaluate need for iron supplementation.
================================================
BRIEF HOSPITAL COURSE
================================================
___ without significant PMH, presenting now for recurrent
syncopal episode, again found to be anemic with some melena.
Repeat EGD on ___ was unremarkable, as was capsule study on
___. Given there was no further intervention warranted, the
decision was made to discharge.
ACTIVE ISSUES
# Acute Blood Loss Anemia
# Melena
On review of partners records, ___ 15 in ___, which
in combination with his normocytic anemia, is all suggestive of
an acute process. Admitted ___ with EGD, Video capsule,
Colonoscopy largely unrevealing for source of acute bleed.
Re-presented on ___ to ___ with Hgb of 6.3 at
___, given a transfusion, and transferred to ___ for
further evaluation. Here, his blood counts did not rise
appropriately following transfusion, raising concern for
continued bleeding, and thus he received a second transfusion.
GI did a repeat EGD on ___, which was unremarkable and did not
elicit the cause of bleeding. He also underwent CT abdomen and
pelvis w/ contrast, which also did not show AVMs or other
sources of bleeding. His blood counts continued to fluctuate,
raising concern for reoccurring bleed, and thus a repeat capsule
study was obtained on ___, which also unfortunately did not
reveal the etiology of his symptoms. Given no clear etiology of
his bleeding, further monitoring of patient's blood counts did
not seem warranted given he remained asymptomatic. Return
instructions were explicitly discussed with the patient.
# Syncope
Syncopal episode likely in the setting of acute blood loss and
hypovolemia. No historical features suggestive of arrhythmia,
seizure or medication effect.
CHRONIC ISSUES
# Hyperlipidemia
Continue home simvastatin
CORE MEAUSURES
==============
# CODE: Full Code, confirmed
# CONTACT: ___ ___
___ ___ | 322 | 396 |
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