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12605862-DS-9 | 24,552,257 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with a low potassium level
which improved with potassium supplementation. Your potassium
level was monitored and was stable.
You had a procedure called an EUS to better evaluate the mass in
your pancreas. Biopsies from this procedure are pending. You
also had a CAT scan to look at your pancreas. The final report
of this test is also pending. You were started on new
medications to help your itching including ursodiol, hydroxyzine
and Benadryl. Your dose of metoprolol was reduced as your blood
pressure was well controlled.
You have a follow up appointment on ___ in the
Multidisciplinary Pancreas clinic. It is important that you go
to this appointment to discuss next steps in your treatment. | ___ yo female with h/o newly diagnosed pancreatic mass concerning
for pancreatic adenocarcinoma who presents with hypokalemia.
# Pancreatic mass:
# Biliary obstruction:
The patient presented with ongoing itching and jaundice. Her
LFTs were checked and were improved from her hospitalization at
___. She underwent EUS with biopsy. Biopsy is
pending on discharge. She also underwent CTA pancreas protocol.
Final read is pending on discharge. The patient has follow up
scheduled in ___ pancreas clinic.
# Nausea with vomiting
The patient had one episode of nausea with vomiting. She will be
discharged with PRN Zofran.
# Hypokalemia:
Remained stable after initial repletion | 133 | 95 |
13830152-DS-10 | 24,858,610 | Ms. ___--
It was a pleasure taking care of you at ___
___. You were admitted after you lost consciousness
at home. You were found to have a low blood pressure which is
possibly due to your known spinal cord injury. You were given
IV fluids and your home medications and your blood pressure
improved. Physical therapy specialists cleared you for home and
recommended outpatient physical therapy.
Please continue taking your current medications. | # Syncope, secondary to orthostasis: Patient had a syncope while
getting up from couch. Pt was found to be hypotensive by EMS
with SBP in the ___. The most likely etiology is orthostatic
hypotension ___ autonomic dysfunction d/t spinal cord injury.
The patient does not take any medications that would be likely
to cause syncope. Alcohol abuse remains part of differential
given pt's blood ethanol level of 78, but less likely given that
the patient is likely tolerant of these levels given long
history of alcohol abuse. We monitored the patient on telemetery
for any arrhythmias, used compression stockings, ___ consult was
ordered who cleared the patient for d/c w/ outpatient ___.
# Hypotension: Patient has known spinal cord injury and
autonomic dysfunction which is being managed with midodrine. We
followed up w/ Pt's PMR doctor, restarted midodrine and
monitored orthostatic vitals | 74 | 141 |
13832372-DS-6 | 22,388,298 | Embolization
Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure (___)
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Brain Tumor
Surgery
You underwent surgery to remove a brain lesion from your
brain. A sample of this lesion was sent to Pathology for
testing.
Please keep your incision dry until your sutures/staples
are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is
ok to cover it when outside.
Call your surgeon if there are any signs of infection
like redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known | #Left parietal brain lesion; brain compression; cerebral edema
Patient admitted to ___ Neurosurgery on ___ as a transfer
from OSH for findings of a large left parietal brain lesion on
NCHCT. She was admitted to the ___ for close monitoring and
q2hr neuro checks and a MRI brain w/ and w/o was ordered that
demonstrated a highly vascularized left parietal lesion. She was
started on Keppra 1000mg BID and Dexamethasone 4mg Q6. A CTA
head/neck was also obtained and the decision was made to proceed
with embolization of the lesion on ___ followed by surgical
resection on ___. She was made floor status in the interim
period. Patient tolerated the embolization on ___ without
complications. Please see separately dictated OP note in OMR for
further details of the procedure. Patient recovered initially in
the PACU then further transferred back to the ___ for close
neurological monitoring. Patient was on bedrest until 1700 on
___ to allow for her groin to heal. Patient's neurological
status was monitored Q2hrs and patient remained stable
throughout the night. Patient underwent an MRI WAND study early
morning of ___ and further proceeded to the OR for tumor
resection. Please see OMR for separately dictated OP Note for
further details. She was extubated and transferred back to ___.
Subgaleal JP drain was placed intraoperatively and removed on
POD#2. Foley/Aline were removed on POD#1. She was started on
slow decadron taper to off. MRI showed post-operative changes
and no evidence of residual lesion. She was made floor status on
POD#1. She remained neurologically stable following her
procedure up until discharge.
#Diabetes
Metformin was held for CTA/Angio and she was put on insulin
sliding scale. Metformin was resumed for ___.
#Disposition
She was evaluated by ___ who cleared her for home. She was
determined to have no acute ___ or OT needs. | 797 | 302 |
19033798-DS-16 | 23,758,230 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were in the hospital because you developed a blood clot in
your lungs, which caused your chest pain and made it difficult
to breath.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were started on a blood thinner to prevent the clot in
your lungs from worsening.
- You had an ultrasound image study of your legs. This did not
show a clot in your legs.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed.
- Please follow up with all the appointments scheduled with your
doctor.
- Please weigh yourself every morning. Your weight on discharge
was 151.23 lbs. It is important that you call your doctor if
your weight goes up by more than three pounds (154lb) in
24-hours.
- You were started on a new medication called apixaban or
Eliquis. It is important that you take this medication twice
daily as directed. If you miss ___ dose of this medication, you
may develop a dangerous new blood clot.
Thank you for allowing us to be involved in your care. We wish
you all the best!
Your ___ Healthcare Team | SUMMARY STATEMENT
=================
Ms. ___ is a ___ year old with history of HIV (on
Biktarvy), craniopharyngioma s/p resection complicated by IPH,
vision loss, adrenal insufficiency and diabetes insipidus, HTN,
and chronic DM, recently progressive HFrEF of unclear etiology
with EF 26% with recent admission for HFrEF exacerbation who
presented with pleuritic chest pain and found to have new PE. | 225 | 58 |
19126821-DS-3 | 29,672,796 | You were admitted with a severe infection of your biliary tree
caused by obstruction. This is all related to your underlying
cancer. You underwent ERCP with stenting, and have been on
strong antibiotics for infection to your blood stream. You have
worked with physical therapy and have been deemed able to return
home.
Please complete your antibiotics at home and follow up with your
primary care physician and oncologist for ongoing care. | This is a ___ with history of gallbladder ca s/p cholecystectomy
(not currently being treated), s/p sphincterotomy & metal stent
placement x ___ for biliary stricture, who presented with
fevers (102 at home) and hypotension secondary to septic shock.
# Cholangitis/Hepatic Abscess: Pt presented with septic shock
from cholangitis. Pt found to have pseudomonal bacteremia on
admission. He was initially admitted to the ICU and resceived IV
fluid resussication and quickly weaned off pressor support. He
underwent ERCP on ___ and had a plastic stent placed in the L
hepatic duct. He has had a slow decrease in his bilirubin since
then. Antibiotics further adjusted to ceftolozane-tazobacteam
for a 2 week course to complete on ___. Despite clinical
improvement, his LFTs continued to rise and for that reason he
had follow up MRCP which showed a small hepatic abscess with
focal area of ductal dilatation. This finding was reviewed with
both GI and ID, and due to his clinical improvement the decision
was made to continue the antibiotics above and not pursue any
aggressive intervention. Plan is to complete antibiotics and
not pursue drainage.
# Gallbladder cancer/presumed cholangioCA: This is the likely
underlying cause of his infection above. He has deferred
treatment of this and continued to do so here. His CT findings
and nodules were reviewed with him, and he expressed
understanding of his likely progressing metastatic malignancy.
Further treatment can be pursued based on his goals of care.
# ___: Creatinine 1.9 on admission, up from baseline of
approximately 1.0. Thought to be pre-renal secondary to sepsis.
Improved with BP support as above.
# Chronic diastolic CHF: pt with fluid overload due to
aggressive resuscitation on presentation. He was diuresed with
good effect. Pt had no oxygen requirement at the time of
discharge.
# Goals of Care: Pt frustrated at the end of his hosptial stay
given recurrent setbacks. He also tearfully expressed that he
was ready to die and felt that this loss of independence was not
consistent with his goals of care. Palliative care was
consulted on ___ to evaluate his true goals of care. After
discussion with him and his son, the decision was initially made
to transition to hospice care and not pursue aggressive
intervention. However, by the time of his discharge he was not
interested in pursuing hospice at this time.
# Anemia: iron studies were consistent with anemia of chronic
disease. He had no evidence of hemolysis or DIC given elevated
fibrinogen and haptoglobin, direct hyperbilirubinemia, and
normal PTT.
# Oral thrush: continued nystatin swish and swallow
# Gallbladder CA: will need outpatient follow up
# Hypothyroidism: continued home levothyroxine.
# BPH: continued home finasteride
# Hyperlipidemia:
Pt off aspirin post-procedure.
-Will resume statin at discharge when LFT's improve.
# Coagulopathy: INR 1.8 on admission, likely nutritional due to
poor PO intake. Improved post vitamin K challenge. | 74 | 478 |
14944080-DS-3 | 20,883,944 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted from ___ for a rash on your
arms and legs, as well as a fever.
WHAT HAPPENED IN THE HOSPITAL?
- Your rash was monitored and you were given medicine/lotion to
help with the itching.
- Many tests were done to check for serious causes of your rash.
These have all been negative so far. Some results are still
pending. These results will be communicated to you by phone when
they are back.
WHAT SHOULD YOU DO AT HOME?
- You should take the antihistamine medicines (anti-itch) as
needed for your rash.
- You should resume your normal daily activities.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | PATIENT SUMMARY
================
___ year old female with no significant PMH, transferred from
___ for pruritic acral targetoid rash and fever.
Work up was negative for parasitic, bacterial, or autoimmune
etiology. Likely due to an unknown viral etiology, such as
erythema multiforme, or allergy.
ACUTE ISSUES:
============
#Rash / Fever:
Progressive rash without identifiable cause, in an otherwise
healthy young woman. Labs notable only for eosinophilia (14%).
Negative ANCA, ___, RPR, HIV. Normal cortisol level. Most likely
erythema multiforme vs urticarial reaction to unknown allergen.
Dermatology was consulted, but a biopsy was not felt to be
indicated. Anti-histamines were prescribed for symptomatic
relief on discharge. HIV negative. Strongyloides ab negative.
# Eosinophilia:
CBC with differential showed eosinophilia at 13.9%. Patient with
no history malignancy, no asthma or known allergies, cortisol
normal, initial blood smear negative for parasites, collagen
vascular disease unlikely given negative ANCA and ___. | 130 | 142 |
18652969-DS-19 | 24,220,578 | Dear Ms. ___,
It was a pleasure taking care of you here at ___. You were
admitted after a mechanical fall which resulted in left-sided
rib fractures and small left pneumothorax. You were admitted to
the Acute Care Surgery service for observation. Your pain was
controlled and you were breathing well. We obtained a repeat
chest x-ray that demonstrated your lung had improved. You are
now ready for discharge home. Please follow the below
instructions for a safe and speedy recovery.
Rib Fractures:
* Your injury caused left 2,4,5th rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | ___ h/o osteoporosis and several prior falls, admitted to ___
for observation after mechanical fall without headstrike or
loss-of-consciousness. Only injuries noted are left-sided 2, 4,
5th rib fractures, as well as a very small left-sided
pneumothorax. Patient's pain was well-controlled with tylenol
and tramadol, patient worked on incentive spirometry and
ambulated. She was breathing comfortably on room air. Her repeat
CXR demonstrated decrease in size of pneumothorax. She worked
with Physical Therapy and Occupational therapy which cleared her
for home with outpatient ___. She tolerated a regular diet. Her
tertiary trauma exam identified no new injuries. She is ready
for discharge home with pain medications and follow-up in
clinic. | 325 | 111 |
10578633-DS-10 | 26,557,514 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD any
aspirin until you see your urologist in follow-up
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated | Ms. ___ is a ___ year old obese female with multiple medical
problems and poor tolerance of renal colic presenting to the ED
for the fourth time in a week
reporting flank pain, nausea and vomiting secondary to a left
ureteral stone.
She is POD4 status post laser lithotripsy and ureteral stent
placement but she inadvertent self-removed the stent yesterday.
She was afebrile with
stable vitals but presented to ED with pain. Her labs were
negative for significant leukocytosis or elevated creatinine.
Imaging negative for obstruction. Urinalysis
consistent with recent urologic instrumentation. Cultures
contaminated. Given poor
tolerance of pain and multiple readmissions to the ED, she was
admitted to urology for pain control and observation. She was
continued on tylenol, narcotics for pain control as necessary
but NSAIDs were avoided due to history of gastric banding. She
was given a regular diet and continued all of her home
medications. On Hospital day two her symptoms had markedly
improved so she was discharged home. On discharge she was
tolerating a regular diet and on all of her home medications.
She was voiding independently and tolerating oral analgesics
without nausea. She was discharged home and will follow up as
directed. | 227 | 198 |
18901084-DS-11 | 21,298,094 | You were admitted to the hospital with difficulty breathing. You
were found to have pneumonia. You were treated with intravenous
antibiotics. Your breathing improved and you no longer required
oxygen at the time of discharge. You will need to continue on
antibiotics until ___. | Brief Course:
___ YM with Hx CAD s/p stents, emphysema, HTN and hyperlipidemia,
stage 4 squamous cell lung cancer with bone and adrenal mets
presented to the emergency room with dyspnea and hypoxia and
found to have right-sided pneumonia. | 44 | 40 |
19563715-DS-17 | 29,011,013 | You were admitted to the hospital because of a blockage in your
bile duct that caused jaundice, or yellowing of the skin. You
had an ERCP which is a procedure that was able to open the area.
You had additional tests to try and understand what caused the
blockage, since a mass is one of the possibilities. You will be
seen in follow-up with specialty docty | SUMMARY/ASSESSMENT: Ms. ___ is a ___ woman who
presents
with painless jaundice and Courvoisier's sign, and a CT that
shows biliary obstruction with gallbladder fullness, most
consistent with malignancy -- pancreatic CA versus
cholangiocarcinoma. The ERCP team was consulted and did the ERCP
on ___. They found that she has a 2cm mid-CBD stricture, and
CBD dilation to 1.5cm above the stricture. Sphincterotomy was
preformed, brushings obtained, and a ___ 8cm plastic stent was
deployed across the stricture. She tolerated the procedure
well, had IVF overnight, and tolerated a regular diet the next
day without any pain or nausea. Her bilirubin should decrease
over the next week, but jaundice will persist in the interim.
ERCP team recommended that she have CA ___ and pancreatic
protocol CT which were done, but results of this were pending at
the time of discharge. She will follow-up with the result of
these as well as the brushings in multidisciplinary pancreas
clinic upon discharge.
For her INR that was 1.5 and increased to 1.7 after the
procedure, this was likely from nutritional deficiency as well
as possible hepatic insufficiency. She has no bleeding noted.
She received Vitamin K 10mg PO x1 and can have INR rechecked as
an outpatient. Her ASA was initially held on admission, but
restated upon discharge from the hospital.
I spent > 30 min in discharge planning and coordination of care. | 69 | 237 |
15112739-DS-11 | 22,697,322 | Dear Mr. ___,
It was a pleasure to care for you during your recent admission
to ___. You came for further evaluation of multiple symptoms.
You were seen by Rheumatology and the gastroenterology teams.
During your workup you elected to leave AMA and thus a final
diagnosis has not yet been established. You understood the risks
to leaving the hospital against medical advice and you
acknowledged that you will return to the hospital if your
symptoms worsen.
Please follow up with your primary care physician as soon as you
are able. | ___ y/o M with longstanding atypical constellation of symptoms
(primarily intermittent joint pain/swelling and
nausea/vomiting), without a clear unifying diagnosis despite
extensive multidisciplinary workup. He was admitted to the
inpatient service for ongoing nausea and vomiting, and inability
to tolerate PO. He was also intermittently having difficulty
ambulating at home due to transient bilateral knee joint
swelling.
During this admission, the patient was evaluated by
Rheumatology, who felt that his clincal presentation was most
consistent with a diagnosis of fibromyalgia and functional
dyspepsia. There was a plan to aspirate the knee joint once
swelling occurred in the hospital, although there were no
episodes during this admission that were amenable to
arthrocentesis. Added to the workup were a heavy metal screen
and a porphyria screen, which were both pending at the time of
discharge. Rheumatology has considered the possibility of
starting therapy with plaquenil to prevent further development
of immunologic disease in the setting of a positive
antiphopholipid antibody, but there was low suspicion that the
current symptom constellation was related to the lab
abnormality, so it was not thought to be likely to be acutely
helpful. It was recommended that the risks/benefits of
plaquenil be discussed more fully on an outpatient basis.
Furthermore, rheumatology recommended referral to ___
___'s
Stress Management and Resiliency Program. This was discussed
with the patient, but since he left AMA in the middle of the
night, specific contact information was not provided at the time
of discharge. There was also a plan in place for home physical
therapy, which was not arranged due to the AMA departure.
Outpatient physical therapy had been recommended in the past,
but the patient was often unable to attend for fear of becoming
nauseated
and vomiting in transit. Of note, the patient did report that
his livedo reticularis symptoms did appear to improve after
doses of prophylactic subcutaneous heparin.
He was also evaluated by Gastroenterology for persistent nausea
and vomiting. He often declined to take medications that were
part of his bowel regimen, with concern that they would cause
large amounts of loose stool, leading to discomfort. He
complained of moderate-to-severe intermittent abdominal pain,
without a clear etiology identified. KUB was without ileus or
obstruction, but did show a significant amount of stool in the
bowels. GI recommended that he avoid opiate medications, and
that he be compliant with the prescribed bowel regimen, with
suppositories or enemas if unable to tolerate PO. The patient
was reluctantly agreeable to dry to a suppostitory, although it
is unclear whether he left AMA before that was actually
administered. He did not wish to try an enema. For symptomatic
relief of nausea, he was treated with dicyclomine,
trimethobenzamide (non-formularly home med), meclizine, and
zofran. It did appear that a large part of his symptoms were
exacerbated by anxiety in a cyclical nature; whether or not
anxiety itself is the primary cause of his symptoms.
On the day of discharge, the patient became irritated with the
pace of hsopital care, and was upset that prn medications were
not arriving as quickly as he wished them to. He met with
covering overnight physician, reviewed the risks of leaving AMA,
and decided to leave. His girlfriend was present at the bedside
throughout much of the hospitalization. | 92 | 561 |
16180527-DS-12 | 25,735,279 | Dear Ms. ___,
It was a pleasure to take care of you during this
hospitalizations. You were transferred from ___ to
___ for chest pain. Your heart was evaluated using
electrocardiogram, laboratory tests, and echocardiogram, which
showed that there was no new damage to your heart muscle. You
underwent a stress test to evaluate your heart, which showed no
new damage and stable decreased pumping of the tip of your
heart. You are now safe to go home, and have scheduled
follow-up with your primary care physician and ___. We
strongly encourage to stop smoking.
Your medications and follow-up appointments are summarized
below. | ATYPICAL CHEST PAIN: Of note, the patient underwent
catheterization on ___ with drug-eluting stent placed to ___
diagonal of LAD. This admission, she complained of chest pain
prior ischemic pain. On admission, EKG was reassuring, cardiac
enzymes were negative, and exam was begatuve for no new murmurs
or rubs. Upon presenting to ___ ED, she was seen by cardiology
and admitted monitor vitals and control pain. Throughout this
hospitalization, she remained stable without evidence of acute
coronary syndrome. Her pain as not responsive to nitroglycerin,
but responsive to dilaudid. She recieved a dose of dilaudid on
admission, and then her pain management was switched to
oxycodone. The Cardiology attendings who took care of her on
her recent admission recommended nuclear stress test, which was
condcuted on ___ and showed fixed defects in distal apex
consistent with known Takosubo cardiomyopathy and EF 41%. Repeat
echocardiogram showed worsening global left ventricular systolic
function, thought due to evolution of her known infarct in the
setting of non-reversible defects. Given the lack of
interventionable lesion, the patient was discharged with
Cardiology follow-up and medical management of coronary artery
disease as below.
CORONARY ARTERY DISEASE STATUS POST NON-ST ELEVATION MYOCARDIAL
INFARCTION COMPLICATED BY TAKOTSUBO CARDIOMYOPATHY: See chest
pain management as above. She was continued on prior discharge
medications of aspirin, clopidogrel, atorvastatin,
meoprololtable without starting any new interventions. She was
also continued on her home dose of coumadin for Takotsubo
cardiomyopathy, with monitoring of INR, which was therapeutic
___ on ___ and ___. On discharge, INR was 1.7 to be
managed as outpatient anticoagulation follow-up.
ANEMIA: The patient's hemoglobin on admission was down to 10.9
from 12.0 from prior discharge, which was concerning in the
setting of new anticoagulation. She was monitored and had no
evidence of acute bleeding beyond baseline occasional blood in
stool from known hemorrhoids. An active type and screen was
maintained, but patient did not require blood products. On the
day of discharge, hemoglobin was 13.5.
HYPERTENSION: During her last admission, the patient was
hypotensive. We continued her home lisinopril and metoprolol,
and monitored her blood pressure, which remained with systolics
of 100-110s this admission.
CROHN'S DISEASE: Monitored during this admission, remained well
controlled.
HYPOTHYROIDISM: Continued home levothyroxine
DEPRESSION/ANXIETY: Continued home wellbutrin, cymbalta,
trileptal
HYPERLIPIDEMIA: continued home atorvastatin
FIBROMYALGIA: continued home gabapentin and PRN oxycodone | 105 | 398 |
17182000-DS-19 | 20,173,866 | Dear Mr. ___,
You were admitted to the hospital after experiencing symptoms of
headache and lightheadedness. An MRI and CT scan of your brain
showed the changes related to your recent hemorrhage. We are
concerned that the medications recently started by your primary
care doctor may have lowered your blood pressure and caused you
to feel lightheaded given you had a low blood pressure at home.
We have discontinued these medications (chlorthalidone and
doxazosin). We also decreased your Lisinopril from 40mg daily to
20mg daily. We have started you on a new medication for your
benign prostatic hypertrophy. You should check your blood
pressure daily at home and follow up with your PCP about this
within one week.
We wish you all the best! | Mr. ___ is a ___ year old man with a past medical history of
hypertension, hyperlipidemia, and recent left parietal
intracranial hemorrhage (___) who was transferred to ___
from an OSH after presenting with an episode of headache and
orthostatic hypotension with NCHCT showing possible re-bleeding
of pt's known intraparenchymal hemorrhage. Neurosurgery was
consulted in the ED and deferred to medical management. Pt was
admitted to the stroke neurology service for further management.
In the hospital, pt underwent an MRI/A which suggested that the
pt had not development a new hemorrhage and that the blood
products were from the prior hemorrhage. The MRI also showed
restricted diffusion in the area of the hemorrhage with concern
for underlying infarction, indicationg the initial hemorrhage
may have been secondary to primary ischemic insult. Pt was
continued on a statin for stroke prevention with plans to start
aspirin as an outpatient. Pt will follow-up closely with Dr.
___ as an outpatient. Pt will also have a repeat MRI in 2
months.
Otherwise, pt's blood pressure was controlled to SBP < 140 with
lisinopril and amlodipine. Given pt had orthostatic hypotension
at home (see HPI), recent medications started by PCP including
chlorthalidone and doxazosin were discontinued. Additionally,
home lisinopril dosing was decreased to 20 mg daily (prior 40 mg
daily) given excellent blood pressure control (SBP ___ in
the hospital.
For history of BPH, pt was started on finasteride at time of
discharge as doxazosin was discontinued.
On day of discharge, pt was feeling well and eager to be
discharged home.
=============================
TRANSITIONS OF CARE
=============================
- Decreased lisinopril to 20mg daily (from 40mg daily), and
stopped the new chlorthalidone and doxazosin and chlorthalidone
at discharge as these medications were suspected to have caused
patient's presenting symptoms and since BPs were persistently
___ in the hospital. Please continue to monitor patient's
blood pressure closely as an outpatient.
- Please check repeat MRI in 2 months to assess for any
abnormalities underlying your hemorrhage.
- Started on finasteride for BPH. | 122 | 324 |
15337872-DS-36 | 23,358,422 | You were admitted with a severe headache. You had an MRI which
was normal. You also had a lumbar puncture which was normal
other than slightly elevated protein. A CT scan of your chest
showed no evidence of any return of your lymphoma. Ultimately,
this headache is consistent with a headache from your
nicotinamide -- please stop this medication; it should take
roughly a week to go away. In the meantime, I will send you home
with some pain medication. | Mr. ___ is a ___ male with a past medical history of
Crohn's disease on Humira and DLBCL currently in remission who
presented with progressive headache, and flush skin, after 2
months of niacinamide usage, most consistent with niacinamide
toxicity.
# Headache: He describes his headache as ___ and globally in
his head originating centrally; non-throbbing. Given the
patient's history seems most consistent with niacinamide
toxicity. He had a reassuring MRI of the head. LP also negative
for any evidence of viral or aspetic meningitis and time course
would be atypical. He has no B symptoms suggestive of lymphoma
and CT chest was negative for any evidence of active disease. We
discontinued his niacinamide and transitioned him from IV
dilaudid to PO oxycodone for a short post-discharge course.
# Epigastric pain: mild epigastric tenderness on palpation.
Otherwise no pain at rest, weight loss, bleeding, vomiting, or
other concerning symptoms. He should follow up with an
outpatient regarding his symptoms. Will hold off adding
medications at this time.
# DLBCL: currently in remission. Previous treatment complicated
by bowel toxicity requiring resection
- continued home cholestyramide-aspartame (patient has his own
meds)
# Crohn's: on Humira
- continued loperamide prn
Transitional Issues
1) Follow up CSF cytology
2) Follow up abdominal symptoms in 1 week | 80 | 207 |
11891514-DS-21 | 22,393,156 | Dear ___,
It was a pleasure taking care of ___ at ___.
___ were hospitalized due to symptoms of right arm weakness and
clumsiness, as well as slurred speech, resulting from an acute
ischemic stroke, a condition in which a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. High blood pressure
2. High cholesterol
3. Diabetes
4. Coronary artery disease/atherosclerosis
5. History of cancer
We are changing your medications as follows:
1. Increasing your aspirin dose from 81mg to 325mg daily
2. Putting ___ back on atorvastatin 80mg daily
3. Increasing your insulin regimen, from 40 units of Lantus
twice a day, to 45 units twice a day.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below. Please also ___ with an endocrinologist
to discuss your high blood sugar and changes in your insulin
regimen and diabetes medications.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around ___
- 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 ___ with care during this
hospitalization. | HOSPITAL COURSE: Ms. ___ is a ___ Farsi-speaking female
with a history of hypertension, hyperlipidemia,
insulin-dependent diabetes mellitus, obstructive sleep apea,
coronary artery disease (with an LAD stent in ___ who
developed acute right upper extremity weakness and
lightheadedness on ___ at 3pm with speech hesistancy and
slurred words when she reached the ___ ED at 3:45pm. Her
initial presentation was concerning for a stroke. She had a ___
stroke scale of 2, and therefore did not receive tPA. An MRI
showed a left branching MCA infarct, consistent with her
clinical presentation.
Given that there was no flow-limiting stenosis seen on CTA and
her history of CAD and possible rheumatic valve disease, her
infarct was likely cardioembolic in origin. To evaluate this she
had an trans-thoracic echocardiogram with a bubble study to look
for a PFO, which showed rheumatic mitral stenosis, but no
cardiac source of emboli. Pt will ___ with her
cardiologist.
For stroke risk factor modification, her home aspirin was
increased to 325mg. LDL was 67 (calculated, may be falsely low
due to elevated TGs of 153), and home atorvastatin 80 was
continued. We treated her blood pressure with a half dose of her
home Metoprolol, but resumed her home dose at discharge. Pt has
IDDM2, HbA1c 9.5%. Was put on diabetic diet w/ home insulin and
ISS; held metformin and exenatide while inpatient. Blood sugars
were high periodically during admission (>300), so ___ was
consulted and her Lantus dose was increased to 45 BID. Pt was
discharged on increased lantus dose and prior home oral meds, w/
instructions to ___ with ___ Diabetes as an outpatient.
She is now able to return home with ___ for home ___, and plan
for outpatient ___ care with neurology, cardiology, speech
therapy, and endocrinology at ___ Diabetes.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by Speech and Language Pathology] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
67) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - () No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A | 337 | 548 |
13746435-DS-15 | 21,596,934 | Dear ___,
___ were admitted to ___ because your
thyroid levels were very high.
This is probably because ___ had inflammation of your thyroid
gland (thyroiditis) or because of an autoimmune disease. We are
still awaiting some tests, which ___ will discuss with your
endocrinologist when ___ follow up.
___ were treated with anti-thyroid medications and a
beta-blocker (propranolol). ___ should continue taking
methimazole and propranolol, and ___ are being discharged with
prescriptions for both of these. ___ are also being discharged
with a prescription for vitamin D because ___ have previously
had low vitamin D levels.
If ___ develop any light-headedness or dizziness, ___ should
skip a dose of propranolol. Also, ___ should not perform intense
exercise until ___ follow up with your primary care doctor.
Please go to ___ in ___ (___r.) to have labs drawn. ___ will discuss them when ___ see Dr.
___ as an outpatient.
It was a pleasure to help care for ___ during this
hospitalization.
Sincerely,
Your ___ Team | #Hyperthyroidism/thyrotoxicosis: At ___, initial labs were
notable for TSH <0.01; T3 240, FT4 4.0. Patient was initially
treated with PTU, potassium iodide and hydrocortisone, but was
changed to methimazole shortly after admission. She had several
subjective fevers treated with ibuprofen and acetaminophen. She
was maintained on propranolol 80mg PO Q6H, which was
downtitrated to 60mg Q8H at discharge. Patient was educated to
look for symptoms of dizziness and fatigue. She was discharged
with a plan to f/u with her PCP and endocrinologist.
#Anemia: Per OSH records, last H/H was 10.9/31.6 in ___.
H/H was 10.3/30.5 on discharge and iron studies were
unremarkable.
#Vitamin D deficiency: Of note, patient's At___ records showed
a history of vitamin D deficiency, and patient was started on
vitamin D 1000U PO QDay. | 159 | 125 |
10779244-DS-21 | 22,516,615 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You were admitted to the ICU at ___ because you
developed a condition cause Diabetic Ketoacidosis. This occurs
when your blood sugar is high. You also had shortness of breath
that is likely from a pneumonia.
What happened while I was in the hospital?
When you arrived at the hospital your blood sugar and
triglyceride levels were very high. You were given insulin to
bring these both down. You were also given fenofibrate, another
medication to control your triglyceride levels. You had
shortness of breath and were given oxygen as well as antibiotics
for potential pneumonia. Scans of your stomach showed some
gallstones, which may have contributed to your pain. You were
continued on your home medications for anxiety and depression
What should I do once I leave the hospital?
- Take your medications as prescribed and follow up with your
doctor appointments as listed below.
We wish you the best!
Your ___ Care Team | Summary:
___ h/o depression, anxiety, psoriasis, HTN, HLD, and T2DM on
metformin p/w 2 days of abdominal pain, nausea and vomiting as
well as resp failure. Workup revealed leukocytosis,
hyperglycemia, metabolic acidosis with ketonuria and an anion
gap and cxr showed opacities concerning for CAP. Started on
insulin drip and IVF. Anion gap resolved. Treated for CAP.
Developed mild pulm edema and dyspnea after fluids which
improved.
ISSUES
===============
# T2DM
# AG metabolic acidosis
# Diabetic ketoacidosis
Patient initially with hyperglycemia, metabolic acidosis with
ketonuria and an anion gap. Initially thought to be from
cholecystitis, but abd pain resolved, HIDA neg, ACS signed
off. Received IVF, insulin drip and anion gap closed, elevated
BOH resolved wnl.
# Hypoxic respiratory failure
# Multifocal PNA vs pneumonitis
While in ED, patient noted to be increasingly tachypneic and
hypoxic requiring 4L NC. CTA chest notable for multifocal
bilateral ground-glass and nodular opacities with associated
bronchial wall thickening c/f possible pneumonia. Patient was
vomiting so may have had aspiration. No underlying lung
disease.
Patient with increased O2 requirement overnight ___, cardiac
workup with EKG and trops neg. Repeat CXR showed pulm edema,
likely ___ large fluid bolus tx for dka. No fever, sputum, CAP
less likely than pulm edema due to fluid overload with possible
mild diastolic dysfunction. Treated for CAP with abx x5days (CTX
and Axithro). IVF d/c'd. TTE to workup pulm edema/possible
diastolic dysfunction. Referred to sleep clinic as patient has
signs/sx of OSA.
# Abdominal pain
Patient presented with RUQ pain in setting of dieting, initially
concerning for cholecystitis.
RUQ u/s shows echogenic liver c/w steatosis and cholelithasis
w/o
sonographic evidence of suggest cholecystitis. In ED, surgery
evaluated patient, can not rule out acute cholecystitis but DKA
complicates clinical assessment as abdominal pain and nausea
could be secondary to this. HIDA was negative. Abd pain
resolved. ACS signed off. Rec outpatient f/u with Dr. ___
___
possible elective chole.
# Anxiety/Depression- Continued celexa and Wellbutrin. EKG for
Qtc monitoring (esp if she continues getting Zofran. Ativan prn
nausea and anxiety while in ICU.
CHRONIC ISSUES
===============
# HTN
# HLD
- Holding Lisinopril for now
- Holding metoprolol for now
- Holding simavastatin, fishoil, fenofibrate for now | 184 | 362 |
10012688-DS-17 | 23,145,708 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
You came to the hospital because you developed dizziness, ear
fullness, and unsteadiness when walking at home. These symptoms
were concerning for a stroke. We performed blood tests and
imaging of your brain and determined that you did not have a
stroke. We also performed examinations of your ears and found no
abnormalities. We believe your symptoms are related to a problem
in your inner ears, which is an area of your body that controls
balance. It is safe for you to return home. ENT also evaluated
you and recommended you follow up in their clinic on ___
at ___:30 AM for a hearing test.
While in the hospital, we found that your cholesterol levels
were high and we started you on a medication to lower your
cholesterol ("atorvastatin"). You will also have ___
rehab" sessions which will help you regain and improve your
balance.
Please continue to take your medications as prescribed and to
___ with your doctors as ___.
We wish you all the best,
Your ___ care team | Ms. ___ is a ___ year old woman with history of chronic left
ear pulsatile tinnitus of unclear etiology and GERD who
presented with 1 day history of dizziness and gait unsteadiness.
She was ruled out for acute stroke.
#Vestibulopathy of unclear etiology:
Initially presented with intermittent dizziness, described as a
combination of dysequilibrium, gait unsteadiness and room
spinning over one day. Her dizziness was positional and worse
with standing, she was unable to ambulate independently which is
a change from her baseline. She also developed new left ear
"fullness". Initial exam notable for unremarkable HINTS exam,
however did have truncal ataxia. Interval repeat examination was
notable for persistent gait unsteadiness (veered to left), and
right beating nystagmus on right gaze. Tympanic membranes had no
evidence of infection or effusion. Head CT and MRI with no
evidence of stroke. Etiology of her symptoms is unclear, has
mixed features. Peripheral vestibulopathy possible, lower
suspicion for vestibular neuritis (no preceding viral symptoms,
nausea, or vomiting), BPPV (negative ___, Menieres
(late age of onset). Stroke risk factors were checked: LDL 134,
A1C 5.9. Initiated atorvastatin 40 mg daily. At the time of
discharge, patient felt subjectively better although still
required some assistance with walking. ___ recommended discharge
home with ___ rehab. | 181 | 206 |
11988172-DS-25 | 27,573,183 | Dear Mr. ___,
It was a pleasure to participate in your care at ___. You came
here because you had the flu and were noted to be weak and
confused. You were treated with Tamiflu and had to be
transferred to the unit for increased oxygen requirements. You
had to be intubated while in the intensive care unit. Imaging of
your lungs showed a pneumonia, for which you were treated. Once
you were extubated and noted to have improved, you were
transferred back to the floor.
You were noted to have gout, which was treated with steroids,
colchicine and indomethacin. As you improved, we tapered down
the steroids, which you'll continue to do after you leave the
hospital. We'll also taper off the other medications for gout
flares.
We wish you a speedy recovery!
Your ___ team | Mr. ___ is a ___ with metastatic prostate cancer with bone
mets at T11 (recently progressed on Lupron/Xtandi), chronic
urinary incontinence s/p radical prostatectomy, HTN, DM, CAD s/p
stents in ___ who presented on ___ from home with weakness
and altered mental status, found to be flu positive, now
transferred to the FICU for increased oxygen requirement, then
extubated and transferred to the floor on ___.
# Hypoxemic respiratory failure: Patient with hypoxemic
respiratory failure, influenza +, found to have persistently
increased oxygen requirement. On ___, he persistently
desaturated requiring a nonrebreather. CT scan showed possible
pneumonia in lower lobes concerning for aspiration for which he
was placed on broad spectrum antibiotics. Patient was
transferred to the ICU on ___ and intubated.
He completed a five day course of ostelamavir (Day 1 ___,
stop date ___. He continued to spike high fevers, so
there was concern he was developing ventilator associated
pneumonia. He was restarted on vanc/cefepime on ___, which was
discontinued on ___ when sputum cx grew commensal respiratory
flora. His CXR was consistent with pulmonary edema, so he was
diuresed to optimize extubation. He was extubated on ___
without complication and transferred to the floor the next day.
On the floor, his oxygen requirement decreased steadily and he
was off oxygen for his last several days in the hospital.
# Altered mental status: Likely multifactorial. Per wife's
report, the patient frequently becomes altered and delerious in
the setting of acute illness. His mental status likely toxic
metabolic given influenza and recurrent fevers. Head CT without
e/o intracranial pathology. Upon extubation, the patient stated
he was confused, but was otherwise following commands and
answering questions appropriately. His mental status continued
to improve and he was at baseline per wife on discharge.
# Influenza A: Flu positive, signs and symptoms consistent with
influenza. Pt did receive flu and pneumonia vaccines this
season.He completed a five day course of ostelamavir (Day 1
___, stop date ___. Per infection control, he
remained on flu precautions for 14 days, ending ___.
# Gout: The patient has a history of gout and had not been
taking allopurinol during this hospitalization. While he was
intubated, it was noted that he had continued right foot pain. A
right foot xray showed no acute fracture. The right big toe
ultimately was warm to touch and erythematous. He was started on
prednisone on ___. With the intiation of prednisone, he
subsequently deferevesced. He remained quite symptomatic for
which he was continued on steroids. He remains on prednisone 20
mg daily on discharge with plan for a slow taper. Indomethicin
and colchicine were started for acute gout flare. Indomethacin
was stopped the day prior to discharge, with the plan to stop
colchicine in 3 days thereafter.
# Metastatic prostate ca: Treatment per primary oncology team.
He previously received leupron injections, his last one which
was missed during this hospitalization. He was also receiving
treatment with enzalutamide which was held in the setting of his
recent illness. Enzalutamide was restarted on ___.
#DM2: Initially, he was continued on his home lantus and insulin
sliding scale. He continued to be hyperglycemic, which was
exacerbated by his prednisone so his insulin was uptitrated
appropriately.
# CAD s/p stenting in ___: Continued ASA, atorvastatin.
Metoprolol was held in the setting of acute illness.
# Hypertension: BPs have been stable despite deteriorating
mental status. Cr is stable. Held lisinopril and HCTZ in the
setting of sepsis.
# Bipolar disorder: Continued depakoted. It is unclear if this
patient is on wellbutrin and his prescribing psychiatrist is on
vacation. | 136 | 588 |
17531962-DS-17 | 22,432,490 | Dear Ms. ___,
You were admitted to the postpartum service for care of an
infection in your uterus due to retained parts of the pregnancy.
You underwent a procedure to remove the retained parts of
conception, and were started on IV antibiotics in order to treat
the uterine infection, did not ahve any more fevers.
Your blood pressures were monitored for your diagnosis of
gestational hypertension and you were found to have slightly
elevated liver enzymes, these remained stable. Your blood
pressures were stable during your admission and we did not start
any medications.
You were found to have bacteria in your urine, please take the
antibiotic prescribed to treat. If you continue to have burning
with urination, increased frequency, or urge please call your
doctor's office, you may need a different antibiotic. | Pt was admitted and had an ultrasound which showed retained
products of conception. She was started on antibiotics and then
was taken to the OR for an ultrasound guided D&C on ___. She
had cultures sent. Her WBCs were 15. She was found to have a
UTI, for which she was started on a 5-day course of Keflex. She
remained afebrile and was discharged home.
She did have transaminitis which will need follow up as an
outpatient. | 132 | 78 |
12945480-DS-17 | 22,706,042 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital because you
had severe pancreatitis. You were stated on tubefeeds to bypass
your pancreas and underwent treatment with antibiotics. You were
found to have partial SMV thrombosis and were started on SC
Lovenox. You are now safe to return home to complete your
recovery with the following instructions:
.
Please ___ Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
What to watch out for when you have a Dobhoff Feeding Tube:
1. Blocked tube: If the tube won't flush, try using 15 mL
carbonated cola or warm water. If it still will not flush, ___
your nurse or doctor. Always be sure to flush the tube with at
least 60 mL water after giving medicine or feedings.
2.Vomiting:
___ doctor if vomiting persists. Vomiting causes the loss of
body fluids, salts and nutrients.
*Give the feeding in an upright position.
*Try smaller, more frequent feedings. Be sure the total amount
for the day is the same though.
*Infection may cause vomiting. Clean and rinse equipment well
between feedings.
*Do not let formula in the feeding bag hang longer than 6 hours
unrefrigerated. After the formula can is opened, it should be
stored in refrigerator until used.
3. Diarrhea:
*This is frequent loose, watery stools.
*Can be caused by: giving too much feeding at once or running it
too quickly, decreased fiber in diet, impacted stool or
infection. Some medicines also cause diarrhea.
*Avoid hanging formula for longer than 6 hours.
*Give more water after each feeding to replace water lost in
diarrhea.
___ doctor if diarrhea does not stop after ___ days.
4. Dehydration:
*Due to diarrhea, vomiting, fever, sweating. (Loss of water and
fluids)
*Signs include: decreased or concentrated (dark) urine, crying
with no tears, dry skin, fatigue, irritability, dizziness, dry
mouth, weight loss, or headache.
*Give more water after each feeding to replace the water lost.
___ your doctor.
5. Constipation:
___ be caused by too little fiber in diet, not enough water or
side effects of some medicines.
*Take extra fruit juice or water between feedings.
*If constipation becomes chronic, ___ the doctor.
6. Gas, bloating or cramping: Be sure there is no air in the
tubing before attaching the feeding tube.
7.Tube is out of place: If the tube is no longer in your
stomach, tape it down and ___ your doctor or home health nurse.
Do not use the tube. You will need to have a new tube placed.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions. | ___ male with history of BPH and pancreatitis ___
presenting with acute onset of epigastric and periumbilical
abdominal pain and CT with acute necrotizing pancreatitis.
ACTIVE ISSUES
==============
___ PMHx significant for BPH and prior episode of pancreatitis
in ___ who represents with necrotizing pancreatitis.
#. Acute necrotizing pancreatitis: The etiology of the patient's
pancreatitis as unclear as patient has no history of EtOH, and
admission RUQ US showed no evidence of obstructing stones.
Triglycerides were normal. BISAP score 1 at admission. His
prior episode of pancreatitis was attributed to herbal
supplements and patient did start taking new supplements over 1
month prior to this current episode. Patient also had an
elevated Igg4 on last pancreatitis admission in ___. The
patient was initially admitted to the medicine floor on ___
however, his lactate acute rose and GI/Surgery recommended
transfer to the ICU for closer monitoring and aggressive
hydration. The patient returned to the medical floor once his
lactate normalized. He later developed a hyperbilirubinemia;
RUQ US on ___ showed no gallstones but biliary sludge.
Because of his continued uptrending bilirubinemia, the patient
underwent ERCP for stent dilatation of his CBD (compressed by
pancreatic inflammation). He tolerated ERCP w/o issue. LFTs and
T.bili downtrended after stent placement. Abdominal CT on
___ showed progression of his pancreatitis to 75% necrosis
and the patient was started on broad spectrum antibiotics
(vancomycin/cefepime/flagyl) for concern of his risk for
infected necrotizing pancreatitis. The patient was subsequently
transferred to the ___ Surgery service for further
management given his progressive pancreatitis.
# Leukocytosis. Patient's impressive leukocytosis is most
likely ___ severe pancreatitis. C. diff was negative, UA
negtive, and CXR was negative. The patient has had no abdominal
tenderness or fever to suggestion infection, and CT abdomen did
not note any gas in his pancreatic fluid collections suggestive
of infection.
- D/c broad spectrum antibiotics per GI
- Continue to monitor CBC
- Continue to monitor VS for fever, hypotension, tachycardia
# SMV thrombus. New finding noted on abdominal CT. Unlikely
related to his thrombocytopenia as his HIT PF4 antibody was
negative.
This does not seem to be a significant thrombus, but he is now
on therapeutic dosing of fondaparinux.
- Consult Vascular Surgery re: f/u studies, any surgical
intervention
- Hem/Onc re: anticoagulation course and bridging to Coumadin
# Diarrhea. Developed after taking contrast for CT abdomen o/n.
C. diff was negative.
- Imodium prn diarrhea
- 500 cc NS bolus + MIVF
#Hypoxic respiratory failure: Resolved. Previously thought to
be ___ aggressive IVF resuscitation as his O2 sats improved with
diuresis with Lasix. He has no underlying infectious process or
ARDS. He does have new moderate pleural effusions on CXR on
___ without any pulmonary edema. The patient is also very
distended on abdominal exam so he may have some compressive
component with increased intraabdominal pressure contributing to
his hypoxia due to hypoventilation. Patient triggered on ___
and CXR and KUB showed pulmonary edema as well as ileus.
Patient's respiratory status improved with additional Lasix
diuresis and well as NGT placement and has been weaned to room
air.
-trend o2 sats
-Lasix prn
-Encourage incentive spirometry
-Simethicone prn
# Urinary symptoms. Reports dysuria, but UA is negative. Will
f/u urine cultures. Pt appears to have had decreased UOP, most
likely due to his BPH.
- Bladder scan
- Place Foley is significant urine or continued decreased UOP
- Start Flomax qhs
***TRANSITIONAL ISSUES***
- Patient will need follow-up with GI regarding interval
cholecystectomy.
The patient was transferred to HPB Surgery service on ___.
Patient had Dobhoff NJ tube placed on ___ and tube feed was
started. Tube feed was advanced to goal and patient tolerated TF
well. The patient was started on IV Cefepime, Vanc and Flagyl
secondary to rising WBC. Blood and urine cultures were sent for
microbiology and were negative. Per Vascular surgery patient was
started on IV fondaparinux with plan to transit patient on PO
Coumadin when he tolerated PO. Patient was working with ___ and
was screened by Rehab. Vancomycin was discontinued on ___ as now
gram positive growth was discovered. On ___ patient was noticed
to have small bright red emesis and abdominal CT scan was
obtained. CT demonstrated enlarged peripancreatic fluid
collection, slight prominence of the distal most aspect of the
visualized left gastric artery, however no evidence of
extravasation of contrast or other abnormality seen on delayed
phase imaging. GI was called for consult. Tube feed were held,
PICC line was placed and TPN was started. On ___ patient was
transferred in ICU for upper GI bleeding. Angio revealed
gastroduodenal artery bleeding and branch was embolized with
Gel-Foam. Patient received 3 units of FFPs for elevated INR and
2 units of pRBC for HCT 23.7. On ___ patient received one unit
of pRBC for HCT 24.3, his HCT improved appropriately to 28. On
___ tubefeeds were restarted and patient was transferred back
to the floor. Tube feed was advanced to goal and TPN was weaned
off. The patient was noticed to have slight hypernatremia on
___ and he received a bolus with D5W. After bolus patient
developed SOB, tachypnea and was required supplemental O2 to
maintain his O2 sat > 90%. Patient's chest radiograph was
negative for pulmonary edema. He was started on daily Lasix and
his respiratory status improved prior discharge. | 593 | 888 |
14144857-DS-8 | 25,033,403 | Mrs. ___,
As you know you were recently admitted to the ___ for
decreased oxygen saturation and shortness of breath. While you
were here, you received supplemental oxygen, antibiotics, and
inhalers to improve your breathing. No changes to your home
medications were made.
Please continue taking your levaquin and doxycycline pills until
___.
It was a pleasure taking part in your care!
-Your ___ Care Team | This is a ___ year old female with past medical history of COPD,
CAD, prior M. ___ pulm infection recent admission ___
for COPD exacerbation and bacterial pneumonia, admitted
___ with dyspnea and left upper lobe
consolidations concerning for acute bacterial pneumonia with
concurrent acute COPD exacerbation treated with antibiotics and
steroids with clinical improvement, discharged home on
prednisone and antibiotics course, recommended for close
pulmonary follow-up and outpatient pulmonary rehab.
ACTIVE ISSUES
# Hypoxemia / Acute COPD Exacerbation / Acute Bacterial
Pnuemonia - Patient with baseline O2 in mid ___ on room air, but
was found to be 88% on room air with significant dyspnea and
wheezing; CT chest showed LUL consolidation. Patient was
treated with prednisone, doxycycline (to avoid use of
levofloaxin or azithromycin in case she had recurrence of her M.
___) and augmentin per pulmonary service recommendations,
with subsequent improvement in her pulmonary status to baseline.
Continued home home inhaler regimen, discharged on prednisone,
doxycycline and augmentin to be completed on ___.
INACTIVE ISSUES
#CAD
-Continued Aspirin 162 mg PO DAILY
-Continued Atorvastatin 40 mg PO QPM
-Continued Metoprolol Succinate XL 25 mg PO DAILY
#Anxiety
-Continued Lorazepam 0.5 mg PO BID:PRN anxiety
#GERD
-Continued Ranitidine 150 mg PO BID | 63 | 207 |
15512381-DS-6 | 28,519,404 | Dear Ms. ___,
You were admitted to ___ for evaluation of high fevers. Blood
cultures, urine cultures, chest x-ray, and basic lab work, did
not show any obvious source of infection. Your symptoms and
fevers are likely caused by a viral infection. You developed a
rash that was likely caused by the antibiotic, cefepime. You did
not require any furthur antibiotics. Your fevers resolved and
you continued to feel well. It is very important that you call
your oncologist, Dr. ___ you have any fevers greater than
100.5 - 101 as this could be a sign of serious infection.
Please keep your follow up with Dr. ___ on ___, however if
anything comes up in the mean time please feel free to give a
call. | Ms. ___ is a ___ year old woman with a history of stage IIA
breast cancer, currently cycle 2 day 2 of TC chemotherapy, who
presented with high fevers suspicious for viral infection.
# Fevers:
Infectious work-up with blood Cx, urine Cx, and CXR was
unrevealing. Received one dose of cefepime in the ED but
antibiotics were discontinued on arrival to the floor given low
suspicion for bacterial infection. Her high fevers, antibiotic
drug rash, and LUQ tenderness raised the suspicion for EBV
infection, but monos-spot was negative and no splenic
abnormalitiy on abdominal ultrasound. Had recent unprotected
intercourse with a new partner, HIV was sent and pending at
discharge. Respiratory viral screen negative, but final viral
culture pending at discharge. The patient was observed off
antibiotics with improvement in fever curve.
# Breast Cancer:
Currently receiving adjuvant TC. Patient recieved Neupogen 300mg
SC daily on ___ and ___. Patient was resistant to doing
injections at home and therefore was discharged off Neupogen.
# Leukocytosis:
WBC to 21K on day of discharge. Thought to be secondary to
neupogen recieved on ___.
# Morbilliform Drug Rash:
Developed a drug rash to one dose of cefipime. Had no mucous
membrane involvement. Was mildly symptomatic, but did recieve
Benadryl x 1 with good relief. Cefepime was added to allergy
list. | 123 | 215 |
17239480-DS-3 | 20,651,649 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
___ was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abdominal fullness and vomiting
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on chemotherapy for your ovarian cancer
- You had a tube placed in your stomach to help remove pressure
from the stomach
- You were given medications to help with your nausea and
constipation
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Call Dr. ___ office at ___ to confirm a time for
your next chemotherapy infusion that works for you.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with advanced ovarian
cancer s/p laparoscopic evaluation on ___ with omental biopsy
and ascites drainage who presents with abdominal distension and
nausea/vomiting, admitted for expediated start to chemotherapy.
Hospital course was hospital course c/b ongoing discomfort from
distension not
amenable to paracenteses, ultimately requiring G-tube placement
for venting. | 137 | 49 |
17280392-DS-15 | 24,857,348 | Dear Ms. ___,
Why you were admitted to the hospital:
- You presented to the hospital with cough, fever, and shortness
of breath, you were found to have pneumonia (infection in your
lungs)
What we did while you were here:
- You were started on oxygen to help you breath. You were also
given antibiotics for seven days to treat your infection. After
several days of antibiotics, you breathing started to improve
and we tried to take off the oxygen but you had to be discharged
on oxygen.
- During your hospitalization, your heart went into atrial
fibrillation (an abnormal heart rhythm). You were started on a
medication (metoprolol) to help control your heart rate
- You also had difficulties swallowing and there was concern
that you could aspirate (swallow food into your lungs). Thus, we
placed an NG tube and started tube feeds for a couple days
before your strength returned and you were able to swallow
effectively again.
- A CT of your chest showed a 1.7 cm indeterminate breast
nodule. It will be important to follow-up with your primary care
provider about this.
What you need to do once you leave:
- Please follow-up with your primary care doctor about the
breast nodule found on CT chest
- Please consider seeing a gastroenterologist who can further
evaluate your swallowing.
- Please continue taking metoprolol to control your heart rate
- Please use caution when eating, taking small bites and eating
ground/soft foods to ensure you do not aspirate
It was a pleasure taking care of you.
Sincerely,
You ___ Medicine Team | Ms. ___ is a ___ y/o female with a hx of schizoaffective
disorder, HTN, GERD, and dysphagia who presented from ___ with cough x 2weeks and fever, found to have pneumonia and
acute hypoxic respiratory failure require MICU admission, now
with atrial fibrillation, dysphagia and deconditioning. | 253 | 44 |
17725086-DS-11 | 23,529,655 | Lower Extremity Bypass Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite
will return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Lower Extremity Angiogram
MEDICATION:
Take Aspirin 81mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Ms ___ is a ___ with right lower extremity
critical limb ischemia with threatened graft and toe ulcer. who
was admitted to the ___ on
___. The patient was taken to the endovascular suite and
underwent a right lower extremity angiogram on ___. For
details of the procedure, please see the surgeon's operative
note. The patient tolerated the procedure well without
complications and was brought to the post-anesthesia care unit
in stable condition. She subsequently underwent a right leg
bypass from the common femoral to the anterior tibial using 6 mm
PTFE ringed, tunneled laterally subcutaneously on ___. For
details of the procedure, please see the surgeon's operative
note. The patient tolerated the procedure well without
complications and was brought to the post-anesthesia care unit
in stable condition. After a brief stay, the patient was
transferred to the vascular surgery floor where she remained
through the rest of the hospitalization.
Post-operatively, she did well without any groin swelling. She
presented with chronic right lower extremity edema which was
stable postoperatively and her right DP remained palpable and
graft dopplerable. She was closely followed while inpatient by
the diabetes service. Podiatry was consulted for degloving of
her right fourth toe on ___, for which they recommended
betadine and outpatient follow-up. She was noted to have
developed superficial thromboplebitis of the right wrist IV
access site, for which warm compresses were advised. She was
increased on her Xarelto on the day of discharge in addition to
aspirin for graft patency.
By discharge, she was able to tolerate a regular diet, get out
of bed and ambulate without assistance, void without issues, and
pain was controlled on oral medications alone. She was deemed
ready for discharge with a visiting nurse to take down her groin
prevena, and was given the appropriate discharge and follow-up
instructions. | 795 | 303 |
13316122-DS-23 | 29,138,058 | Dear Ms. ___,
You came to the hospital with headache, nausea, and vomiting.
You were given antibiotics and nausea medication and your
symptoms improved.
You will see Dr. ___ in follow-up in 2 weeks (during the week
of ___ to get another lumbar puncture, and to decide
whether you need any more treatment.
It was a pleasure participating in your care.
Sincerely,
Your ___ Oncology Team | ___ is a ___ woman with hx of Ependymoma s/p
suboccipital craniotomy with VP shunt placement in ___
presented with worsening nausea and vomiting along with
headaches. LP on admission (performed ~12 hours after antibiotic
initiation) showed elevated opening pressure, glucose < 40% of
serum glucose, elevated protein, and TNC ~650 with 83% PMNs
consistent with bacterial meningitis. ___ blood cultures from
admission grew coagulase-negative staph, LP cultures remained
negative. She was treated with vanc/cefepime, then narrowed to
vanc monotherapy per ID recs. Repeat LP showed improvement in
TNC to 40, with only 29% PMNs. Neurosurgery was consulted
regarding the possibility of removing the VP shunt. Given the
anticipated difficulty with replacing the shunt, the decision
was made to leave the shunt in place and have the patient
follow-up in ~2 weeks for a repeat LP. Depending on the results
of that LP, the decision will be made to leave in or take out
the VP shunt. At discharge, her headaches had resolved, and
nausea had returned to baseline.
ACUTE:
1. Bacterial meningitis: Likely CONS, given ___ blood cultures
positive and VP shunt recently placed. Symptoms and CSF studies
dramatically improved with antibiotics. Ultimately, decision was
made to leave VP shunt in place, with plan for repeat LP in 2
weeks to decide whether to remove the shunt. She was started on
1mg dexamethasone, famotidine, standing reglan with prn zofran,
and acetazolamide (to decrease CSF pressure).
2. History of Ependymoma: s/p sub-occipital craniotomy with
placement on VP shunt in ___. Neurosurgery consulted re:
possibility of removing VP shunt in the setting of likely
bacterial meningitis. Decision made to leave in pending repeat
LP in 2 weeks. | 61 | 277 |
18786508-DS-43 | 28,716,717 | Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to fevers and abdominal pain, and
were found to have acute pancreatitis. You were treated with
bowel rest and intravenous fluids. Your blood cultures grew
bacteria and you were initially treated with antibiotics.
However after the specific species of the bacteria was detected,
it was determined that the bacteria was likely to be a
contaminant and your antibiotics were stopped. We have also
stopped your MMF.
You were noted to have rising creatinine (marker of kidney
function). This subsequently stabilized, and you were seen by
the renal team and a renal ultrasound was obtained. You will
need to have blood tests on ___ and ___ to ensure that your
kidney function remains stable. Please make sure to have this
lab draw prior to taking your rapamycin (sirolimus).
Please also be sure to keep your follow-up appointments (below). | Mr. ___ is a ___ y/o M with h/o cryptogenic cirrhosis s/p DDLT
___ on cellcept and rapamune with h/o pancreatic cyst, recent
h/o cholangitis and pancreatitis, who presents with fever and
epigastric pain.
# Pancreatitis: Patient with history of biliary strictures,
cholangitis, and recent pancreatitis, presents with fevers,
elevated lipase and epigastric pain. BISAP score is 3,
associated with > 15% mortality. APACHE II score is 15. Evidence
of pancreatitis on CT. He was treated with IV fluids and bowel
rest, and his symptoms subsequently improved. He was tolerating
regular diet well prior to discharge.
# Acute on chronic kidney disease: Patient had creatinine
elevation from 1.2 on ___ to 2.3 ___, subsequently stable.
Differential includes pre-renal ___ in setting of pancreatitis
and third spacing of fluid with intravascular volume depletion
vs ATN in setting of vancomycin with elevated trough at 27
(drawn late). Urine sediment was remarkable only for few
granular casts. Unlikely to be HRS given no evidence of
hyponatremia or decompensated liver disease. Patient making good
urine so less likely to be obstruction. FENA 1.8%. Renal
ultrasound with no hydronephrosis or obstruction. Stopped
vancomycin given elevated trough and likely contaminant
bacteria, resuscitated with IV fluids to improve renal
perfusion. He will need repeat labs after discharge with
outpatient renal follow-up if creatinine continues to worsen.
# Coag neg staph bacteremia: His initial blood cultures were
notable for gram positive cocci. He was initially treated with
vancomycin. Speciation subsequently revealed coagulase negative
Staph and Staph epidermidis of multiple morphologies, and in
consultation with the infectious disease service this was felt
to most likely represent contaminant. Vancomycin was
subsequently stopped.
# Anemia: Thought to be likely secondary to chronic inflammation
and viral suppression. Inappropriately low reticulocyte count.
Guaiac neg, no evidence of active bleed. Hemolysis unlikely
given TBili normal at ~0.2.
CHRONIC / STABLE ISSUES
# Cryptogenic cirrhosis s/p Liver transplant ___
- Continued MMF, sirolimus, ursodiol
# GERD:
- Continued home lansoprazole
# Nutrition:
- Continued fish oil, multivitamins | 155 | 343 |
11155160-DS-6 | 28,520,719 | Mr. ___,
You were admitted due to worsening cough and shortness of
breath. You were found to have parainfluenza infection and COPD
exacerbation. This improved with antibiotics, steroids, and
time. Your symptoms improved and you will be discharged home.
You will follow up in clinic as stated below. Please do not
hesitate to call in the meantime with any questions or concerns.
It was a pleasure taking care of you. | Mr. ___ is a ___ year-old gentleman with a
history of COPD, AF on apixaban and most recently follicular
lymphoma now s/p 1C of Bendamustine who presents with a fever,
productive cough and dyspnea, found to have parainfluenza, being
treated for CAP.
#Community Acquired Pneumonia
#COPD Exacerbation
#Fever
Per clinical presentation with fever, productive cough and
dyspnea. O2 requirement in absence of correlating opacity on
CXR,
bronchorrhea and wheezing make COPD exacerbation likely and
warrant steroid course. However, need to cover for superimposed
PNA given compromised immunity. There is also a possibility that
this ___ represent an adverse effect of his benadmustine
infusion
which he received last on ___. off O2 as of ___ with
significant improvement in sx
-completed ceftriaxone x7d course(d1: ___
-completed azithromycin (d1: ___
-received x1 methylpred 60mg on ___, given worsening dyspnea in
the evening on ___, administered 40mg of methylpred in AM
and
20mg in ___ then transitioned to PO prednisone 20mg BID starting
___ continue x4 d (___) then 10mg daily x 2d
(___) will continue x1 day at home then off
-off O2 as of ___
-Duonebs q6h prn and albuterol neb prn
-guaifenesin/tessarlon pearles/mucinex prn
-Continue fluticasone-salmeterol BID
-rapid flu negative but + paraflu as above
#Diarrhea: resolved. Possible side effect of benadmustine as can
occur in 9%-37% of patients; however, given fever spikes and
concern for infection, sent specimen for stool cultures which
was
negative for norovirus and cdiff. Remaining stools cultures neg.
In addition, noted to have positive guaiac stools without clear
evidence blood loss or frank blood. H/H is WNL and hapto
slightly
elevated. Continue with hydration support and monitoring of
stool
output
#Electrolyte Imbalances: most notably hypomag and hypophos, now
new hyperkalemia likely secondary to losartan, held in setting
of hypotension as well--see below, improvement in K prior to
discharge. will monitor. repleting per sliding scale, monitor
closely
#Follicular Lymphoma: On C1D15 of R-Bendamustine on admission.
Was scheduled to get rituximab on ___ but holding iso active
infection
-f/u scheduled in clinic on ___ receive Rituxan then as long
as no sx/sx infection
#Atrial fibrillation: Rate controlled and anticoagulated.
-Continue apixaban 5mg q12h
-Continue metoprolol succinate 100mg daily (switched to
short-acting while in-house)
-continue digoxin 0.25mg daily, level 1.5 on ___
#Hypertension
#LVH
-held losartan and HCTZ for now in setting of hyperkalemia and
hypotension on ___ will continue to hold upon discharge and
will then have managed by outpatient team
#Coronary artery disease:
-Continue metoprolol as above
-Continue atorvastatin
#GERD: Continue omeprazole 20mg daily
#BPH: Continue tamsulosin qhs
#FEN: IVF/Encourage PO, Replete Electrolytes PRN, Regular heart
healthy
#PPX:
-DVT: apixaban 5mg q12h
-BOWEL: holding given diarrhea
-PAIN: none
#CODE: Full Code, presumed.
#COMMUNICATION: Patient
#EMERGENCY CONTACT/HCP: Health care proxy chosen: No
Info. offered to patient?: Yes
Offered on date: ___
Comments: Information offered
Verified on date: ___ | 70 | 410 |
12042817-DS-17 | 23,651,233 | Dear Ms. ___ ,
You were admitted to the gynecology service for anemia from a
heavy period. Your heavy bleeding was likely from a fibroid,
benign growth in the uterus. You were no longer bleeding while
here and you received 2 units of blood for your anemia. You have
recovered well and the team believes you are ready to be
discharged home. Please call the office with any questions or
concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Can take provera which has been prescribed for you if you have
heavy bleeding again
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* lightheadedness, fainting
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the gynecology service for
syncopal episode due to heavy menstrual bleeding with a Hct of
16.
Upon arrival, patient's bleeding had decreased. She was
transfused 2 units of pRBCs. Upon transfusing the first unit,
patient developed a temperature of 100.3, but was otherwise
asymptomatic. Transfusion was stopped and a Direct Coombs test
was ordered and negative. Her temperature was likely due to a
febrile non-hemolytic transfusion reaction. Transfusion was
restarted with 2 new units without difficulty with an
appropriate rise in hct to 24.6.
By hospital day #2, bleeding was minimal and patient was
hemodynamically stable. She was voiding, ambulating and
tolerating a regular diet. Upon discharge, patient was
prescribed Provera and iron supplementation for further
management of bleeding and appropriate outpatient follow-up was
scheduled. | 154 | 131 |
11700816-DS-11 | 28,155,691 | Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted after taking GHB and needed a tube placed down your
throat to help you breathe. The tube was removed when safe, and
you are now breathing appropriately on your own. It is extremely
important that you avoid taking these substances in the future
to prevent dangerous consequences to your health, including
death. In addition, you were found to have a fracture of your
right ankle. As noted below, please followup with the
orthopedics clinic this week.
Please continue to followup with your outside providers for
assistance with your substance dependence. | ___ M with history of depression and polysubstance abuse
including previous hospitalization for GHB intoxication found
unresponsive by EMS with bottle of jungle juice.
Altered mental status and respiratory failure: Presumed
secondary to intoxication. Pt presented with urine positive for
amphetamines and has a history of admissions for GHB toxicity,
though this could not be assessed through our toxicology screen.
He was managed supportively with mechanical ventilation, and
his mental status gradually returned to baseline by the morning
following admission. He was successfully extubated that morning
as well.
Bloody OG tube drainage: Patient OG suction demonstrated some
coffee-ground-like fluid on admission. He was managed with IV
protonix. His hematocrit was WNL and he remained
hemodynamically stable during his stay, and no blood products
were required.
Polysubstance abuse: Patient has a known history of
polysubstance abuse with prior admissions for drug toxicity. He
has been living in sober house prior to this admission and
attending AA/NA meetings. He reports he just "fell off the
wagon." He was seen by social work during this admission and
they discussed the importance of continuing to seek support and
participate in rehabilitation when he returns to ___.
Depression: History of depression with prior suicide attempts.
Current psychiatric care unknown. He denied suicidal ideation.
He discussed his depression therapy with social work and plans
to find a therapist in addition to his current psychiatric
treatment.
Malleolar fracture: The patient was noted to have a R lateral
malleolar fracture on admission. He insisted on leaving the
hospital as soon as possible for personal reasons, and could not
be seen by orthopedics as an inpatient. Recommendations for
follow-up with orthopedics and contact information were given to
the patient and are listed again below. | 112 | 294 |
12518771-DS-18 | 26,800,317 | Dear Mr. ___,
You were admitted to ___ because you were experiencing
worsening shortness of breath and leg swelling. We started you
on a Lasix drip to remove excess fluid and you responded well.
You were transitioned to a new diuretic medication (torsemide).
Please start taking this medication tomorrow. You should
continue this medication as prescribed until your follow-up
appointment with cardiology.
You were also found to have very high blood pressure requiring a
nitroglycerin drip. We transitioned you to several oral
antihypertensives with good control of your blood pressure. Your
cardiologist or PCP ___ continue to adjust your medications as
needed.
At discharge, you weighed 132.2kg. It is very important that you
weigh yourself every morning before getting dressed and after
going to the bathroom. Call your doctors if your ___ goes up
by more than 3 lbs in 1 day or more than 5 lbs in 3 days.
We wish you the best,
Your ___ Cardiology Team | ___ y/o M with diastolic heart failure diagnosed in ___ with
recent HF course notable for two hospital admissions in the
preceding two months, cardiac catheterization without need for
PCI & s/p thoracentesis for persistent transudative pleural
effusion at ___, who presented with
worsening dyspnea, bilateral ___ edema, and orthopnea due to
acute on chronic diastolic heart failure exacerbation.
Exacerbation was thought to be from recent decrease in his
outpatient regimen from bumex 4mg to 1mg daily due to elevated
creatinine. He was successfully diuresed with Lasix gtt ___
and transitioned to torsemide with good urine output.
There was initial concern for PE given elevated D-dimer at OSH.
___ showed no e/o DVT and V/Q scan showed no e/o PE. He was
briefly on heparin gtt but this was discontinued due to low
concern for PE.
Patient was also hypertensive to the 180s on admission requiring
nitro gtt briefly. He was transitioned to oral hydralazine,
Imdur, and labetalol to maintain SBP between 120s-150s. Blood
pressure control was limited as ___ hospital course was
complicated by ___, preventing use of ACEi, ___ or
spironolactone (though he does not have an indication for
spironolactone given preserved EF). ___ was thought to be
secondary to active diuresis. | 155 | 204 |
13531354-DS-5 | 26,586,877 | Dear Ms. ___,
Thank you for choosing to receive your care at ___. You were
admitted with chest pain and underwent a stress test to
determine whether it was caused by poor blood flow to your
heart. This stress test was negative; however, during the test
you demonstrated an abnormal heart rhythm called a ventricular
tachycardia. You underwent an echocardiogram to evaluate your
heart for any structural abnormalities; none were present. You
were started on a new medication, Metoprolol, which will help
control your heart rate moving forward and prevent further
episodes of ventricular tachycardia. You will also be using a
___ of hearts" monitor at home to track your heart rhythm and
ensure there are no repeat episodes.
You will have to make a follow up appointment with the holter
monitor lab to get set up for ___ of hearts monitor. Please
call them at ___ on ___ to schedule a time to come
in, receive your monitor, and have it set up (you can also ask
whether they might be able to mail it to you and you can call in
to have it set up). You should also call to schedule a follow-up
appointment with your cardiologist, Dr. ___, at
___ please try to coordinate this appointment to fall
sometime just after the end of your two-week monitoring period
so that you can return the monitor at the same time.
Moving forward, you should continue to take the medications
listed below. You should also schedule a follow-up appointment
with your PCP in the next ___ weeks.
We wish you the best with your ongoing recovery.
Sincerely,
Your ___ care team | ___ with HTN, HLP, obesity, asthma, GERD, NASH, OSA, bipolar
disorder, endometrial cancer presents with chest pain with
normal exercise stress test except for ectopy and runs of up to
11-beat NSVT.
# CHEST PAIN: Troponins negative x2, EKG without ischemia.
Exercise stress with modified ___ lasted 7 min, ___ METS, fair
functional capacity, stopped for fatigue. No ischemic changes
but lots of ectopy with PACs, PVCs, and up to 11-beats NSVT. No
recurrence of chest pain during admission. Managed on ASA 81 mg
daily, Metoprolol succinate 50 daily.
#Ventricular ectopy: patient with considerable ventricular
ectopy in the setting of her stress test. No recurrent episodes
subsequently. On the floor, patient able to walk 2 flights of
stairs and elevate HR to 120s without ventricular ectopy. TTE
with no abnormalities suggesting structural cause of ectopy.
Started on metop succinate 50 daily; will return as outpatient
to have ___ monitor for further evaluation as an
outpatient.
CHRONIC ISSUES
===============
# Chronic venous stasis. Cont Lasix.
# HTN. Cont Lasix, lisinopril
# HLP. Cont simvastatin.
# Asthma. Cont Advair BID.
# Bipolar disorder. Cont pramipexole.
# OA. Cont tramadol PRN.
# Endometrial cancer. Residual loose bowel movements per patient
which are chronic. Cont loperamide.
# OSA. Cont CPAP. | 273 | 215 |
17741115-DS-22 | 28,451,948 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- you were admitted to the hospital because you missed a
dialysis session and you were having chest pain and left leg
pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received dialysis
- You received many tests to determine the cause of your leg
pain and chest pain
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | Patient Summary:
=================
___ male PMH ESRD on HD TTS, HFpEF, DM, PVD s/p R BKA, L
AKA (___) c/b SSTI s/p 2 debridements on ___, L EIA
PTA/stent, AKA washout and closure ___ who presented from rehab
with AMS. In addition to this, the patient was reporting left
stump pain and chest pain. We discussed with the rehab facility
what their specific concerns regarding the patient's mental
status were. They were concerned that he was "saying things that
do not make sense." Of note he was completely oriented to self,
time, and place while inpatient. While he would often use
metaphors/idioms, upon further questioning/clarification ("what
you mean by that") he consistently provided a meaningful and
sensible answer. He had no altered mental status while he was
admitted. Regarding the patient's left stump pain; upon further
questioning it appears patient largely has discomfort when
attempting to move his LLE (consistent with phantom limb pain)
and occasionally has pain to palpation of the fluid collection
surrounding the stump. He did not have any fevers, chills, night
sweats. He denied any skin changes around his left leg. We
obtained ___ sampling of the known fluid collection around his
left stump. We consulted ID who recommended continued daptomycin
therapy with ID follow-up to review cultures and decide on
outpatient antibiotic plan. Regarding the patient's chest pain;
the pain was reproducible on palpation. Had no clear correlation
with activity. His troponins were lower than baseline. He had no
EKG changes. Given that he is high risk for cardiovascular
disease, reasonable to pursue outpatient stress test to further
evaluate the symptoms. | 133 | 262 |
17111670-DS-14 | 23,281,486 | Dear ___ was a pleasure taking care of you. You were admitted to the
hospital with abdominal pain and abnormal liver tests. We found
that your plastic biliary stent had migrated out of the
appropriate location, causing a blockage. You had an ERCP
performed in which a metal stent was placed, with excellent
result. You will need to continue 6 more days of ciprofloxacin
(12 doses) after leaving the hospital.
Sincerely,
Your ___ Team | ___ with hx of stage IV cholangiocarcinoma s/p
gemcitabine/cisplatin, s/p ERCP ___ for sphincterotomy and
plastic stent placement who presented with epigastric pain and
progressive biliary obstruction by labs, found to have migrated
stent now s/p replacement with metal stent.
# Migrated biliary stent / epigastric pain:
In setting of known cholangiocarcinoma with hx of biliary
obstruction, s/p stent placement, and rising LFTs, there was
concern for recurrent obstruction. She underwent ERCP that
showed migrated plastic stent, which was replaced with a metal
stent. Patient tolerated the procedure well. Her LFTs improved,
she was pain-free, and was tolerating a diet on the day of
discharge. She will complete a 7 day course of ciprofloxacin.
# Stage IV cholangiocarcinoma:
Followed by Dr. ___. Has T4N1 stage ___
cholangiocarcinoma that developed in the setting of HCV treated
with gemcitabine/cisplatin administered per ABC-2 regimen, dose
reduced for neutropenia and thrombocytopenia, as well as
Cyberknife stereotactic radiotherapy which completed ___.
Eight cycles of chemotherapy completed as of ___, and Ms.
___ then entered a treatment break. Was hospitalized in
___ for biliary obstruction and underwent plastic stent, now
with metal stent replacement as above. Still has completely
blocked left system. She will complete 7 days of PO
Ciprofloxacin per ERCP team.
# Myelosuppression / chronic thrombocytopenia:
Leukopenic and thrombocytopenic, with mild stable anemia. Stable
compared to prior checks. No chemo since ___. Per pt, she has
been told that this may be related to HCV, and has hepatology
appt scheduled. A haptoglobin was 55, and iron studies were
ordered. I spoke with Dr. ___ who is aware and will follow
up her iron studies. She denied any melena, hematochezia,
hematemesis - did not stool here in house. Has normal low BP
(SBP 100-115) per her report and she was stable on her feet
without orthostasis.
# Coagulopathy:
PTT rose to mid-50s while on TID SC heparin. This was
discontinued on day of discharge, and should resolve off
heparin, as was likely a drug side effect.
# Chronic HCV:
Has outpatient f/u with Liver clinic. | 72 | 342 |
11818101-DS-82 | 24,308,010 | Dear. Mr. ___,
You were admitted to the ___
for shortness of breath and chest pressure.
On admission, it appeared that you had too much fluid in your
lungs so were given a medication to enable you to urinate extra
fluid. You were also treated with nebulizers and medications to
improve the wheezing in your lungs.
We provided you with a nebulizer for use at home. We are also
starting you on a new medication, Lasix 20 mg, which you will
take every day. It is important that you weigh yourself every
morning, and call your doctor if your weight goes up more than 3
lbs.
Please follow up with your PCP on ___, as listed
below.
It was a pleasure taking care of you. We wish you the very best!
Sincerely,
Your ___ Care Team | ___ M with pmh of paroxysmal Afib s/p PPM, with AV node
ablation in ___ on Xarelto and amiodarone, hypertrophic
nonobstructive cardiomyopathy with EF >55%, chronic atypical
chest pain,OSA, HTN, HLD who presents with acute worsening of
SOB and wheezing concerning for asthma/COPD exacerbation versus
CHF exacerbation.
#Dypsnea: Diffuse wheezing consistent with asthma exacerbation
but overall clinical picture may be due to new CHF exacerbation
on top of resolving asthma exacerbation. He also has a newly
midly elevated proBNP at 1737 which is consistent with a CHF
exacerbation. CXR ___ appears to be more congested than prior
CXR in ___. Repeat CXR on ___ showed clearer lungs. Crackles
on exam resolved but he had persistent wheezing. Albuterol prn
was increased to Q2H. His lung exam improved and his work of
breathing improved. He never had an oxygen requirement. He was
also treated with prednisone 40 mg which is being tapered.
#Chest pressure: He presented with chest pressure. Initial EKG
showed a ventricular paced rhythm. Initial trops were 0.02 but
repeat was 0.01. He had a few episodes of palpitations which
self-resolved.
#Abdominal distension: He reported abdominal distension and had
RUQ tenderness on palpation. LFTs were only remarkable for
mildly elevated ALT. These should be rechecked. It is possible
that this is due CHF exacerbation. A RUQ US should be considered
if this doesn't resolve. He reports subjective improvement in
distension over the course of the admission.
He was continued on home medications for HTN, HLD, and Afib.
TRANSITIONAL ISSUES
===================
- Discharged on Lasix 20 mg daily
- Discharged on prednisone taper
*** 40 mg for 5 days (will finish on ___
*** 30 mg for 3 days
*** 20 mg for 3 days
*** 10 mg for 3 days
- Discharged on albuterol nebs PRN SOB. Has nebulizer machine.
- PFT's scheduled for ___
- BRBPR in hospital. H/H stable. Likely hemorrhoidal, but will
need outpatient workup with colonoscopy.
- Elevated FSBG in hospital. Likely in the setting of steroids.
Consider HbA1C as outpatient.
- Anxious in hospital. Likely acute on chronic in the setting of
steroid burst, but would follow-up as outpatient.
- Follow-up with PCP at ___ scheduled | 132 | 347 |
16828456-DS-20 | 23,225,621 | Dear Ms ___,
You were admitted for bleeding from your intestine. You had
multiple procedures to identify the site of bleeding in an
attempt to control it. Unfortunately this proved challenging. We
are concerned that even if a site of bleeding is identified,
that you may continue to have intermittent bleeding from
abnormal blood vessels called arteriovenous malformations, in
part because of your blood thinners. At this point we have
decided that the best plan will be for you to get frequent lab
checks and potentially have blood transfusions as needed as an
outpatient, and if you have a noticable increase in your
bleeding then you can go to the hospital to obtain more urgent
treatment. You may also benefit from iron transfusions so that
your oral iron pills due not make it difficult to determine
whether or not you are bleeding.
You had a capsule study and a small bowel study and we feel that
you have intermittent bleeding from your small intestine that
can be difficult to localize at the time of bleeding.
You are going to have your blood counts checked twice weekly for
the next several weeks. If your blood counts gradually decline,
you can talk with your primary care physician (Dr. ___,
about having an outpatient blood transfusion.
If, on the other hand, you pass large amounts of blood in your
stool or have recurrent black-tarry stools, please seek
immediate medical attention.
For your heart failure treatment:
-You will continue your home medications of torsemide daily,
spironolactone daily, and metolazone every ___ and every
___.
-Please weigh yourself each morning. If your weight is
increasing from your current weight, you should contact your
PCP/Cardiologist (Dr. ___ to ask about taking an extra dose
of either Torsemide or Metolazone.
-Please continue the fluid restriction of 1500 mL per day.
-Please monitor your sodium intake (look at the food labels) and
try to keep the amount of sodium you consume from all sources to
less than ___ mg per day.
For your Coumadin management:
-You are being discharged on 3 mg daily (1 mg tab x3 tabs per
day)
-Please check your INR daily
-If your INR is not within the target range, please call your
primary care physician, ___ guidance in adjusting
your Coumadin dosing.
Regarding your discomfort with urination and cloudy urine:
-Your urinalysis was suggestive of inflammation, and you may
ultimately need antibiotic treatment for a urinary tract
infection if the urine culture is positive.
-The urine culture is pending, we will notify you if the results
indicate you need treatment with an antibiotic.
-If you start having fevers or chills in the next 2 days, please
call the floor you were on (12 ___ at ___ between
7AM and 7PM and ask to speak with Dr. ___.
It was a pleasure caring for you while you were in the hospital,
and we wish you the best.
Sincerely,
The ___ Medicine | ___ female COPD on ___ at home, CAD, HTN, CHF, frequent
GIB, MVR/AVR anticoagulated on Coumadin (INR goal 2.5-3.5)
transferred from ___ for evaluation of GI
bleed. Now with persistent bleeding despite clipping of duodenal
lesion.
#Acute GIB/Acute blood loss anemia.
This is a recurrent problem for this patient. During the
admission she underwent multiple upper endoscopy studies and a
capsule study. A lesion in the duodenum was clipped, but it was
felt that bleeding is likely starting and stopping at multipe
locations and that she may have very intermittently bleeding
AVMs that are difficult to localize. Goal was to stabilize and
manage as outpatient with frequent lab monitoring and outpatient
transfusion, although her rate of bleeding and hgb decline led
to multiple blood transfusions during the admission. The
bleeding appeared to stop for ___ days at a time and was never
rapid to the point of causing BRBPR, but at times she required
up to ___ transfusions over ___ days, which was a rate not
conducive to outpatient management. She underwent her final
EGD/SBE on ___, which was limited in duration by hypotension &
hypoxia but was able to evaluate the first ~50 cm of small
intestine and revealed only 1 AVM, which was not bleeding and
was APC'd. Coumadin was continued throughout her hospital
course for target INR 2.5-3.5. Her Hgb was stable from
___, so she was discharged home with close INR and Hgb
monitoring.
# Mechanical AVR/MVR:
INR somewhat erratic, but stabilized in ___ range (slightly
below goal) with 3 mg coumadin (home dose is 2.5mg most days
with ___ days of 5mg). Continued to titrate with goal of low end
of therapeutic range (2.5-3.5). INR on day of discharge was 3.4.
Plan to take coumadin 3 mg PO QPM, with frequent (daily) INR
checks until regimen is firmly stabilized.
#Acute on Chronic Diastolic CHF:
Restarted torsemide at 40 mg dose ___. Volume status
management challenging in setting of bleeding, transfusions,
multiple causes of dyspnea (COPD, CHF, anemia), diarrhea, and
limited exam. Increased torsemide to 60 mg on ___. (Home dose
is torsemide 100 mg, also on spironolactone and metolazone,
which were held). She developed evidence of worsening volume
overload, so given additional torsemide and resumed her home
dose of torsemide 100 mg daily. Home spironolactone and
metolazone were resumed on discharge. She was advised to
maintain a fluid restriction of 1500 mL per day as tolerated, a
sodium restriction of ___ mg per day, and to weigh herself each
day. She was advised to contact her PCP/Cardiologist, Dr.
___ her weight is increasing despite her home diuretic
regimen.
#UTI: on the day prior to discharge she reported dysuria and
changes in the odor & appearance of her urine. UA was positive
and UCx was sent and was pending at the time of discharge. UCx
subsequently grew > 100K GNRs, which speciated to a
pan-sensitive Klebsiella pneumoniae. I called the patient to
notify her of the microbiologic confirmation of her urinary
tract infection and called-in an Rx to her preferred pharmacy
for Macrobid ___ mg BID x7 days). Macrobid was chosen to
minimize impact on her coumadin dosing (alternative oral agents
such as cipro, TMP-SMX, and augmentin would be expected to have
more interaction with her coumadin). She was advised to continue
to closely monitor her INR and notify her PCP if any major
changes arise as a result of starting/discontinuing macrobid for
the UTI.
#Hyponatremia: mild, in 130-135 range, and fluctuating during
her initial hospital course. likely related to volume
status/CHF. Resolved prior to discharge.
#COPD/Chronic hypoxic respiratory failure on ___ at home:
No evidence of COPD exacerbation. Continued home oxygen.
Patient's inhaler Tudorza, (not on formulary). Continued duoneb
PRN. Was stable on 3L at rest during the last several days of
her hospitalization. Requires higher rate with exertion.
#Acute renal failure: Resolved.
#CAD - patient not on ASA (presumably due to recurrent GI
bleeding). Restarted on lower dose metoprolol tartrate during
admission after initially being held.
#GE junction erythema - noted on EGD - GI recommends repeat
outpatient EGD for further evaluation.
===================== | 477 | 675 |
16113020-DS-18 | 25,883,423 | You were admitted with septic shock without any definitive
source for fevers, however, felt to be possibly due
thrombophlebitis vs urine retention vs aspiration. Sepsis
resolved with IVF and IV antibiotics, plus short course of
pressor.
However, you were found to have massive left lower extremity
DVT. In consultation with Hematology and Vasc Surgery, a
determination was made to start Lovenox with close monitoring.
You were also noted to have urine retention, leading to an
episode of fevers, however, no UTI. Therefore Foley catheter
was placed, but was subsequently removed and you were able to
void without difficulty after that.
For your dysphagia and achalasia, we are recommending sticking
to a full liquid diet only, until you follow-up with your
outpatient gastroenterologist in ___. | Ms. ___ is an ___ woman with h/o essential
thrombocytosis, recurrent DVT's previously on Coumadin (recently
discontinued with GIB during recent hospitalization), achalasia,
recent R. periprosthetic femur fx s/p surgical repair ___ who
p/w confusion, noted hypotension and fevers, admitted to ICU and
treated for shock presumed to be sepsis, course c/b
encephalopathy and leukocytosis.
# Fevers
Patient initially admitted to the MICU with fevers, leukocytosis
and hypotension, presumed to be septic shock. Infectious workup
including CT abd/pelvis did not reveal any infectious source.
Patient treated empirically with vanc/cefepime and IVF and was
transferred out of the MICU. Further workup revealed urine
culture growing pseudomonas and + CMV viremia. ID was consulted
and felt fever was due to significant clot burden found in the
LLE (see below). She was treated with cefepime for 5 days for
pseudomonas in the urine per ID recommendations. Fever recurred
and felt to be secondary to urinary retention, which resolved
after Foley placement.
# Leukocytosis: pt's initial leukocytosis resolved with IV
antibiotic treatment (described above); however, on ___ she was
noted to have a progressive leukocytosis from 8.7 to a peak of
15.8 on ___. She had no fevers, tachycardia or other source of
infection. Interestingly, her leukocytosis correlated with
changing her diet from full liquid to a pureed diet. We noted
that her cough worsened as well, and suspect she ___ be
aspirating on a pureed diet d/t her underlying achalasia. We
switched her back to a strict full liquid diet only on ___, and
her leukocytosis subsequently resolved and her cough improved.
We suggest she remain on a full liquid diet until she follows up
with her gastroenterologist at ___ in ___.
# acute toxic metabolic encephalopathy
# hyper-somnolence with Seroquel
# hallucinations likely ___ delirium
Patient p/w confusion, likely caused by acute illness as above.
She had continued encephalopathy that waxed and waned during
hospital course, though overall improved. She was initially
treated with seroquel and was unable to tolerate it as it caused
significant somnolence. This was discontinued and she improved.
She also developed hallucinations during hospitalization which
were thought to be due to delirium.
# ___
Creatinine on admission noted to be 2.3, which resolved with
IVF. Thus, likely pre-renal in etiology given possible infection
as above.
# recurrent large LLE DVT
# essential thrombocytosis
Patient recent after taken off anticoagulation after
hospitalization for GIB. Ultrasound revealed large LLE blood
clot from distal tibial veins to approx. 1.5cm from IVC filter.
No clots above IVC filter were seen on CT torso. Patient had h/o
remote large LLE DVT in ___ felt to be due to uncontrolled ET
and L. common iliac vein stricture 2* ___ Syn.
Hematology consulted and recommended Lovenox, which patient
tolerated well. Home hydroxyurea was continued. Vascular surgery
also consulted and recommended bilateral TEDs, which were
placed.
# achalasia
# chronic dysphagia
Patient has known history of achalasia and previously required
Botox injection for improvement. Her case was discussed with Dr.
___ recommended full liquid diet and advancement as
tolerated to Pureed diet and to not advance past a soft solid
diet. As noted above, she will be kept on a full liquid diet d/t
her leukocytosis.
# urine retention, chronic.
Patient has known chronic urinary retention and has failed
multiple voiding trials in the past. She failed 1 voiding trial
early in her hospital course and had Foley placed for 1 week.
Additional voiding trial was successful after the foley was
removed on ___. Flomax was unable to be resumed as it cannot be
crushed.
# anemia
# h/o recent LGIB with sigmoid colitis and ulcerations, in
setting of supratx INR
Patient's anemia remained stable during hospitalization without
any indication of bleeding while on Lovenox.
# right thyroid 2.3 x 2.4 x 2.3 cm well-circumscribed
heterogeneous mixed solid cystic nodule
-will need elective FNA when improved, d/w son and daughter/HCP,
however given risk & benefit, will defer for now. | 125 | 644 |
19693912-DS-38 | 24,849,661 | Patient was admitted with hypoactive encephalopathy and
catatonia, likely related to her underlying psychiatric
condition. Medical and metabolic derangments were treated and
excluded. She will now be discharged to the psychiatry service
for ongoing care | ___ yo F with MMP presenting with depression, now admitted for
hypoactive encephalopathy attributed to her psychiatric disorder
# Acute encephalopathy/Delerium/schizoaffective d/o: No clear
medical etiology to explain her symptoms. Infectious w/u
negative and head CT reassuring. No known hx of drug use or
evidence of withdrawal. TSH, chem 10 WNL other than calcium
which is mildly, chronically elevated. No LFTs negative. CT
head reassuringly normal. EKG nl. Given hx of seizures, would
consider EEG if no improvement, however no e/o seizure activity
here. Given relatively acute decompensation while in the ED
without clear organic etiology as well as hallucinations,
concern for acute psychiatric decompensation. Polypharmacy also
suspected. Her oxycodone, gabapentin, and lunesta were held.
She was placed on 1:1 with ___. There was no evidence of
infection. Her clozapine and Cymbalta were continued. Low dose
Ativan was trialed which seemed to help. She was transferred to
inpatient psychiatry for ongoing care
# Depression: Followed by psychiatry, kept on 1:1 with ___. Continued medications as above
# Anemia: mild, chronic, stable.
# Hypothyroidism: ___ WNL
-continued levothyroxine
# overactive bladder
-held toviaz given non-formulary, can resume on discharge
# GERD: continued omeprazole, ranitidine
# Asthma: continued fluticasone/salmeterol, albuterol
# Shoulder pain: continued Tylenol, will held oxycodone and
gabapentin given somnolence. Can consider resuming with caution
# HLD: continued statin
# Hypercalcemic hyperparathyroidism: Ca stable, awaiting
surgical eval
# Hypercalcemia/MM: outpt monitoring. Chronically elevated.
Hydrated with short term improvement in the hospital.
Name of health care proxy: ___
Relationship: Lawyer
Phone number: ___ | 37 | 257 |
18523470-DS-17 | 22,961,757 | It was a pleasure taking care of you during your recent
hospitalization. You were admitted with severe pain and we
increased your pain medications. You were sent home on hospice.
Please call your doctor with any medication questions. | ___ w/ BRAF-wildtype metastatic melanoma s/p C1 dacarbazine on
___ and cyberknife on ___ p/w several days of lethargy,
chills/rigors, and anorexia, found to have subsegmental PEs and
worsening intrathoracic metastatic disease burden.
#Pain - Mainly in back with walking and sitting. Likely ___
intra-abdominal metastatic disease and osseous mets, he does
also have apparently new compression deformity of the T11
vertebral body which could be contributing. No hematuria or
hydronephrosis to suggest urinary/renal etiology. No Pleuritic
component to suggest pulmonary cause. Home MS ___ increased
from 60 q8h to 90mg q8h. He was discharged on hydromorphone 4mg
___ tabs q2h PRN for pain, standing acetaminophen, and lidocaine
patches. He was discharged home on home HOSPICE.
#Lethargy, anorexia, chills/rigors: No e/o infection on exam or
imaging. Symptoms likely cancer-related with anorexia,
diaphoresis, weakness figuring heavily into his overall
subjective malaise. Metastatic disease burden seems to be
worsening in spite of initiation of dacarbazine. Received
vanc/levoflox in ED, but antibiotics were discontinued on the
floor given no source. He did not have ongoing fevers on the
floor, but remained diaphoretic.
#PE: New diagnosis. Multiple subsegmental PEs, no hypoxemia, no
dyspnea or e/o RH strain. Anti-coagulation was not started given
his hemorrhagic metastatic melanoma lesion in brain (seen on
prior MRI, and corroborated by head CT on this admission) and
patient's wish to discharge home on hospice.
#Widely metastatic melanoma: Worsening intrathoracic metastatic
disease burden, esp in left lung base. Patient chose to become
DNR/DNI and focus on comfort at home and to avoid ongoing
medical interventions.
#Tremor/Increased tone: Patient had ___ reflexes, increased
muscular tone, and postural tremor in all 4 extremities.
Strength was ___ throughout. This was concerning for upper motor
neuron disease, though this would not be accounted for by
unilateral brain lesion. Because of this MRI spine was ordered
to rule out cervical involvement by myeloma, however, this was
cancelled when the patient decided to go home on hospice.
#COPD: cont prn advair, montelukast, albuterol
#home meds: cont pravastatin, prn fexofenadine | 38 | 328 |
13971660-DS-13 | 22,202,277 | You were admitted because of abdominal pain and were found to
have mild inflammation in your pancreas. Your pain gradually
improved and you were able to tolerate food well.
.
You are discharged for follow-up with your PCP and ___
gastroenterology specialist. Inflammation of the pancreas can be
caused and worsened by cigarettes and alcohol so you should
avoid smoking and drinking alcohol. | ___ past medical history includes HTN, diabetes, depression,
reflux, ETOH and smoking who presented with acute on subacute
abdominal pain and elevated lipase. Also reported chronic mild
diarrhea over the past month and significant weight-loss. Bed
side US in ED did not show evidence of bile/gallbladder issues.
CT contrast of his abdomen showed minimal haziness between the
head of the pancreas and the duodenum which may be consistent
with subtle early groove pancreatitis. In discussion on day of
discharge with the radiology attending ___. ___ the
findings are not concerning for malignancy and no further
imaging is indicated.
Mr. ___ did very well clinically throughout his admission.
Abdominal pain resolved without any specific intervnetion. Did
not require analgesia. Diet was advanced and tolerated well.
problem summary:
- Acute on Subacute RUQ pain: likely ___ mild acute ___,
___ have a mild chronic pancreatitis in the backround. Also has
history of EGRD which may explain some of his more chronic
abdominal pain and discomfort.
- Diarrhea 1 month: etiology is unclear, most of his pancreatic
tissue appears normal on imaging so exocrine failure seems
unlikely.
- significant weight loss: as reported by patient. this will
require further work-up in the out-patient setting.
- elevated lipase - likely ___ to mild acute pancreatitis.
- normocytic anemia - further work-up including iron profile and
B12 should be pursued following discharge.
- h/o of alcohol and tobbaco consumptions.
- HTN, DM - oral diabetic meds were held and restarted on
discharge. Other meds were continued.
Transitional Issues:
- follow-up with PCP and GI for health maintnance and further
work-up of diarrhea, chronic abdominal dyscomfort and
weightloss.
- please also check Triglyceride levels to r/o
hypertriglyceridemia as a cause of pancreatitis.
- normocytic anemia - further work-up including iron profile and
B12 should be pursued following discharge. | 61 | 306 |
17633426-DS-16 | 24,288,194 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain and had a
CT scan that was consistent with a small bowel obstruction. You
had a nasogastic tube placed to help decompress your intestines
and were given oral contrast. You had a follow up xray of your
abdomen that showed the contrast was able to pass though and you
were able to have a bowel movement. Therefore your diet was
gradually advanced which you tolerated well.
You are now doing better and ready to be discharged home to
continue your recovery.
Please follow the discharge instructions below:
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. | Mr. ___ is an ___ year old man with a history of HTN, open
cholecystectomy (___) presenting from OSH with abdominal pain,
n/v, WBC 12.6, and CT abd/pelvis concerning for high grade bowel
obstruction. He initially presented to an OSH where he had a WBC
12.___bd/pelvis concerning for high grade SBO. He was
transferred to the ___ ED for further evaluation.
At ___ ED he was found to have WBC 13.5, lactate 1.4, Cr 2.0
(last Cr at ___ ___ 1.5-1.6). An NGT tube was placed in the
ED that put out 500cc feculent appearing output. He was admitted
to the Acute Care Surgery service for serial abdominal exams and
IVF resuscitation. He was decompressed with NGT and had a
gastroview KUB which showed persistent dilatation and distension
of proximal through mid small bowel. On HD3, the patient self
removed his NGT. The NGT was replaced, however it fell out.
The patient passed flatus and had a bowel movement. Diet was
advanced to clears which he tolerated well. On HD5, diet was
advanced to regular which he tolerated well. He continued to
pass flatus and have bowel movements.
The patient was alert and oriented throughout hospitalization.
He remained stable from a cardiopulmonary standpoint; vital
signs were routinely monitored. Good pulmonary toilet and early
ambulation were encouraged throughout hospitalization. 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. | 291 | 338 |
16079206-DS-10 | 24,662,712 | Dear ___ were admitted to the ___ because of confusion, fever, and
found to have a blockage and infection in your bile ducts in
your liver. ___ were given antibiotics to treat your infection
and ___ had a drain placed because of the blockage. ___ improved
after this.
___ were discharged with a plan to complete a 10 day course of
Augmentin antibiotics. Please also followup with all outpatient
appointments that have been arranged on your behalf (please see
followup instructions below).
It was a pleasure taking care of ___ at the ___. We wish ___
all the best.
Your ___ team. | Ms. ___ is a ___ yo female with a new diagnosis of metastatic
pancreatic cancer who was admitted for weakness and found to
have fevers likely secondary
to cholangitis evident by elevation in ___.
# Cholangitis: Patient has known pancreatic cancer and presented
with fever and elevation of ___ and ALP suggestive of an
acute picture of cholangitis. On admission her AlkPhos was
elevated to 440, TBili elevated to 1.___ 0.9. Her
fevers and increase in TBili was concerning for cholangitis. On
admission to the floor, she was hemodynamically stable. Pt was
covered with IV Zosyn 4.5 g IV Q8H and plan was made for ERCP.
Patient failed ERCP on ___, and plan was made for ___ PTBD on
___. ___ was able to place L sided PTBD, however no
dilatation on the R was noted as liver parenchyma had been
replaced fully by tumor and thus ___ could not cannulate w/o
going through tumor without risk of hemorrhage. Single PTBD was
deemed to be sufficient, and pt returned to the floor s/p ___
PTBD for trending of LFTs, monitoring VS, and fever curve. Pt
did well s/p PTBD, and pt was narrowed to Augmentin 875 Q12H and
then transitioned to Augmentin 500 Q8H oral suspension for ease
of taking liquid meds vs pills. Pt tolerated Abx therapy and
PTBD well, with drainage of approx 410cc from the PTBD before
being capped. T ___ overall downtrended to discharge Tbili of
1.8 (1.9->2.7->2.6->2.9->2.4->1.8->2.0->1.8), with AlkPhos has
been labile, overall downtrending to AlkPhos of 307
(440->213->307). ___ was consulted regarding pts fluctuating
LFTs, and noted improvement in TBili and overall downtrending of
AlkPhos in setting of stable clinical status, and plan was made
for pt to be d/c'ed to rehab and return in the future for
internalization of drain.
# Pancreatic Cancer: The patient has known new diagnosis of
cancer of
the pancreatic tail with invasion of the splenic hilum and the
right adrenal gland with multiple hepatic nodules as well as
multiple bilateral pulmonary nodules. Plans were held to place a
port for chemotherapy while concern remained for infection, with
port deferred as an outpatient for at least 1 week after
discharge to start weekly palliative gemcitabine.
#Hyponatremia During this admission had mild hyponatremia,
likely due to poor PO intake and mainly consuming water. Pt was
encourage to increase po intake with improvement of Na to 131 at
the time of admission. Pts Na will needed to be trended as an
outpatient.
# Atrial Fibrillation: pt's Afib medications including her
Atenelol, Amlodipine and HCTZ were held due to cholangitis and
concern for sepsis. Pt was rate controlled to HR<110 during this
admission with Metoprolol 12.5 TID and transitioned to
Metoprolol succinate 50 QD at the time of discharge, which she
tolerated well. Pt was restarted on home dose of Warfarin, with
INR supratherapeutic with INR 3.3, most likely due to effect of
concurrent antibiotic treatment with Warfarin. Pts warfarin dose
was reduced to 1.5mg daily, with plan for close followup with
the ___ clinic to monitor for INR to be at goal of
___.
# Hypertension: Patient not hypertension during hospital stay.
Medications were stopped in setting of infection and she
remained normotensive. | 101 | 529 |
14161008-DS-14 | 20,525,202 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
had a stroke. You were given tPA (clot dissolving medication)
and was monitored in the ICU. You were restarted on coumadin
during this hospitalization because the atrial fibrillation is
the most likely cause of your stroke.
Because of your confusion and somnolence, EEG was done and did
not show seizures. You were started on medication called
amantadine to help make you more awake.
You were also started on Bactrim for urinary tract infection. | TRANSITIONAL ISSUES:
[] Ongoing swallow evaluation
[] ?evaluation of the multinodular goiter as outpatient
[] INR monitoring
[] had urinary retention in house, possibly related to new UTI.
please monitor.
[] Patient has fluctuating level of arousal, with question of
frontotemporal dementia given history and imaging, but unable to
diagnose at this time.
==================================
___ with PMH of AF previously on coumadin, CAD s/p MI in ___
with BMS stent placed, HTN and HLD who present with acute onset
severe right MCA syndrome from rehab. Patient had been just
discharged from ___ where she was hospitalized for an MI
requiring cardiac catheterization and BMS stent placement to
RCA. The hospital course at ___ was complicated by groin
hematoma from cardiac cath requiring intubation and transfusion.
She was taken off coumadin during this hospitalization given her
active bleeding. Her hospital course was further complicated by
decreased level of arousal, prompting neurological evaluation
with head CT, MRI and EEG. CT and MRI did not show acute
strokes, and EEG showed some GPEDs which were not treated.
Patient eventually woke up and the episode was attributed to
sedating medications (with intubation, and also received some
antipsychotics for agitation).
Here, found to have large R MCA infarct, received tPA in the ED
and intubated for decreased level of arousal and need for airway
protection. She was monitored in the ICU and transferred to the
floor. The hospital course here was also complicated by
decreased level of arousal, and EEG here showed bilateral spikes
but no electrographic seizures. She was started on amantadine to
help with awakefulness.
#NEURO: Per PCP, patient may have some paranoia at baseline but
has never had formal diagnosis of frontotemporal dementia or
other behavioral variant of dementia. However, given the history
of fluctuating level of alertness during these hospitalizations
and given her imaging with significant brain atrophy, it is
possible that she has some underlying dementia that become
exacerbated with these stressors. After her prolonged
hospitalization at ___ as above (for MI c/b hematoma), she was
discharged to ___. She had been there for 1 day when
she developed new left hemiplegia with garbled speech and gaze
deviation to the right, and brought into ___ ED. She was found
to have a large area of signs of early ischemia on the non
contrast head CT. After contrast, the area of hypodensity became
more pronounced and involved the entire right MCA territory.
Given the finding on her imaging and as she presented within
three hours of last normal, it was decided to give her IV tPA.
She was felt to be not protecting her airway by ED and was
intubated just after NIHSS performed. Post intubation she had
significant hypotension and was rapidly put on pressor support
with neosynephrine.
She was given tPA, still within 3 hours after last known normal,
but about 65 minutes after presenting to the ED, the delay was
due to her almost coding in the CT scanner. 24 hours after TPA
she became able to move all her limbs. F/u MRI MRA were positive
for right MCA territory ischemic infarct.
She was evaluated by speech/swallow, physical therapy and
occupational therapy. She did pass s/s evaluation in the ICU
with modified diet of pureed solids and nectar thick liquid,
however, her hospital stay was complicated by decreased and
fluctuating level of arousal which made feeding difficult. She
had an NG tube placed for tube feeding given the poor caloric
intake. EEG was done to rule out seizures as a cause of her
mental status, and though it showed bilateral spikes, there was
no electrographic seizures noted. She was started on amantadine
to help with her level of arousal with some improvement.
# CV: patient with known atrial fibrillation, monitored on
telemetry which showed atrial fibrillation but rate controlled.
Some of her antihypertensives were held in the setting of acute
stroke, but they were restarted with goal normotension. If her
blood pressure becomes more elevated, lisinopril can be
increased to 20 mg daily (which was her home dose). She was
initially anticoagulated with coumadin with aspirin bridge, but
coumadin was held and she was started on lovenox bridge as there
was thought of PEG tube. However, as she is tolerating PO intake
better, will restart coumadin with lovenox bridge.
# PULM: Intubated in the ED, extubated successfully in the ICU.
No respiratory issues afterwards.
# ID: completed course of ceftriaxone for UTI (coag negative
staph). No further leukocytosis or fevers. Also had history of c
diff treated with oral vancomycin, which was completed during
this hospitalization. Repeat c diff toxin was negative. On
___, found to have difficulty urinating, and UA showed
leukesterase, WBC and bacteria, started on 3 day course of
Bactrim.
# HEME: In the ICU, she also developed drop in H/H, so Coumadin
and Plavix was held and CT of abd/pelvis was performed to rule
out retroperitoneal hematoma. Fecal occult blood result came
back positive. She received 1 unit of PRBCs and her hematocrit
remained stable afterwards.
# Renal: Had ___ with Cr of 1.5 on admission, but creatinine
improved throughout the hospitalization.
# FEN: passed speech/swallow evaluation on ___, on pureed
solid and nectar thick liquid. PO intake improved with improved
alertness.
# PPx:
- systemic anticoagulation for atrial fibrillation, at the time
of discharge, patient is on lovenox bridge to coumadin
- continue famotidine
- bowel regimen with docusate/senna
# Code Status:
- DNR/DNI per conversation with HCP.
- Contact: HCP ___, ___ (cell) | 95 | 906 |
16995602-DS-5 | 21,061,341 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted because you were having
increased confusion and difficulty getting around your home. We
found that you have a urinary tract infection that was
exacerbating your hepatic encephalopathy. We gave you
antibiotics for the infection, which you will need to take for 7
days. WWe also gave you a few extra doses of lactulose to
improve the encephalopathy and gave you an extra supply of
rifaximin. You need to make sure to call Dr. ___
tomorrow to set up an appointment within the next week. He can
also help you start to set up services to help you with your
medications. Please note the following changes to your
medications:
START Ciprofloxacin 250mg by mouth twice daily for 6 more days.
No other changes were made to your medications. We wish you a
speedy recovery. | PRINCIPLE REASON FOR ADMISSON:
___ yo F with h/o cirrhosis ___ fatty infiltration c/b hepatic
encephalopathy, DM, and genetic lipodystrophy p/w worsening
confusion.
. | 147 | 28 |
11103897-DS-16 | 22,424,650 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
WHY DID I COME TO THE HOSPITAL?
- You had diabetic ketoacidosis (DKA)
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given an insulin infusion until your sugars and labs
normalized.
- You were given antibiotics for your tooth infection
WHAT SHOULD I DO WHEN I GET HOME?
- Please continue to take all of your medications and follow up
with all of your doctors.
We wish you the best!
Your ___ Care Team | Ms. ___ is a ___ yo woman with late onset type 1 DM on tresiba
and Humalog with recent tooth infection s/p extraction and
implant, admitted to the ICU with DKA secondary to insulin
omission and active tooth infection.
#DKA
#T1DM
Patient presented with nausea, vomiting, weakness, found to be
in DKA with pH 7.29, AG 23, FSBG 433 on admission. Likely
precipitant was dental infection and nonadherence to basal
insulin regimen. She was on an insulin gtt in the ICU, gap
closed, gap reopened and was back on insulin gtt. After her gap
closed again she was switched back to subQ insulin. She has
improved significantly and is now on a subQ insulin regimen,
feeling well with well-controlled sugars, no acidosis, and a
closed gap. Her diabetes is poorly controlled (A1c 10.1) with 1
episode prior DKA. ___ was consulted and provided
recommendations. Her insulin regimen will be as follows:
- 16 units lantus BID
- Meal Humalog per ICHO (1 units for every 10g of carbs)
- ISS: for BG >150: 2+2 for every 50mg/dL. Bedtime HISS for
BG>200: 2+2 for every 50mg/dL
We will give her the information to establish care at ___
___ as she requested this.
#Subperiostal dental abscess
Patient developed R canine infection (#30), started on
azithromycin outpt, now transitioned to clindamycin, s/p
extraction and implant ___. OMFS was consulted on admission and
did not recommend any procedural intervention at this time. She
is currently improving, with no abnormalities or oropharyngeal
exam. Still has some pain, however is now "burning"/likely nerve
related pain from the dental procedure. No leukocytosis/fever.
We used ibuprofen/acetaminophen for pain control. Treated
infection with clindamycin and will treat for a total of 10 days
(end date ___.
#Diarrhea
Likely secondary to clindamycin and disruption of normal gut
flora. Given no leukocytosis and improvement, suspicion for c.
diff is minimal. This decreased by the time of discharge - we
recommended her taking a probiotic and or eating yogurt while on
the abx.
# Hypocalcemia
# Hypophosphatemia:
# Hyper PTH (appropriate)
Normal axis is intact - evident by low Ca, High PTH, leading to
low phos. Unclear etiology or her original low Ca -
possibilities include Vitamin D deficiency (was measured and is
low), sepsis/severe illness with her DKA (although was brief).
PTH was 68 (upper limit normal) on discharge and her Ca had
normalized. We recommend this be followed up outpatient. We are
starting her on Vitamin D supplementation.
# Low BUN:
Likely dilution in the setting of fluid resuscitation, no
evidence of malnourishment on exam. Patient reports recent poor
PO intake, but it is not a chronic issue for her.
# ___ (resolved):
Presented with elevated Cr to ___ Cr 1.4, baseline
around 0.7. Her ___ resolved with fluid. It was likely due to
dehydration in the setting of hyperglycemia, polyuria, and poor
PO intake. | 83 | 472 |
16430633-DS-12 | 28,458,496 | Dear Mr. ___,
It was a pleasure to care for you here at ___. You were
admitted here as a transfer from ___ after
you fell.
You had several laboratory abnormalities, which were initially
dangerous and serious. We think this was a combination of your
alcohol drinking and also the metformin medication. YOU SHOULD
NOT TAKE METFORMIN AGAIN, and also we strongly encourage you to
stop drinking alcohol.
Your right arm is broken, and you will need to wear a sling to
allow healing. You will need to follow-up with an Orthopedic
(bone) doctor.
We strongly encourage you to establish with a Primary Care
Doctor. ___ have provided you information to do this below.
We wish you the best,
- Your ___ Team | Summary
___ y/o male with a past medical history of diabetes, alcohol use
who presented initially to ___ s/p fall.
He was found to have a right humeral fracture, as well as
alcohol intoxication and lactic metabolic acidosis. His initial
labs were concerning for a pH of 7.1 and lactic acid level of
14. He was thus transferred to ___ MICU for further
evaluation. Clinically he looked well, with no alteration in
mental status, stable vital signs. He was seen by toxicology,
who thought this was likely a combination of EtOH intoxication
and metformin toxicity. He improved with supportive IVFs and
time. He was placed on a phenobarbital taper for possible EtOH
withdrawal. He was transferred to the medicine floor. He has
ongoing issues with pain control and will need Orthopedic
follow-up in ___ weeks.
Acute issues
# Lactic acidosis
# Etoh intoxication
His initial labs were concerning for a pH of 7.1 and lactic acid
level of 14. He was thus transferred to ___ MICU for further
evaluation. Clinically he looked well, with no alteration in
mental status, stable vital signs. He was seen by toxicology,
who thought this was likely a combination of EtOH intoxication
and metformin toxicity. He improved with supportive IVFs and
time and his lactate was downtrending. He was placed on a
phenobarbital taper for possible EtOH withdrawal. He was
transferred to the medicine floor and labs remained stable. He
was discharged home in good condition.
# Right humeral fracture: Seen by Ortho at ___ who recommend
non operative care at this time as this fracture is actually
extra-articular and amenable to nonoperative care with a
___ brace and a cuff and collar. He will need Ortho
follow-up in ___ weeks.
# Thrombocytopenia
Likely secondary to chronic alcohol use. However cannot rule out
alternative explanation in acute setting. Did not have signs of
hemolysis or active bleeding.
# Transaminitis: ___ alcohol intoxication. No signs of
coagulopathy or encephalopathy. TB normal. Was improving at time
of discharge, however could consider obtaining hepatitis
serologies or obtaining additional liver imaging in the
outpatient setting.
Chronic issues
# Alcohol abuse: patient denies having had a history of DTs or
seizures in the past. He stated that he was clean over the past
7 months up until this most recent drinking episode. There was
still concern that he could potentially withdraw and he was
started on phenobarbital protocol. He did well without concern
for acute withdrawal symptoms. He was started on a MV, thiamine
and folate.
# DM: His metformin was held as above and he received insulin
sliding scale while in house. He should follow with a PCP and
consider starting alternative diabetes regimen.
# L knee pain, Gout
Patient complaining of L knee pain consistent with previous gout
flairs. Restarted on home allopurinol. Previous wrist joint
aspiration at ___ was without crystals. No fracture on knee
xray or on L femur xray, however there was evidence of chornic
changes. Could consider MRI to further evaluate.
# Normocytic anemia
Exacerbated by aggressive fluid resuscitation. Possibly
secondary to alcoholism and chronic disease. Iron panel and B12
were wnl. | 117 | 509 |
17949145-DS-11 | 25,075,712 | It was a pleasure taking care of you during your recent
hospitalization. You came in with chest pain. We did some
bloodwork which showed this was not a heart attack. This was
confirmed by a nuclear stress test. Please follow-up with your
primary care doctor in regards to your chest pain.
You were also withdrawing from alcohol so we gave you
medications to help with the symptoms of withdrawal. You were
not withdrawing at the time of your discharge.
You were assessed daily and on the day of discharge you did not
need any more medication to help with alcohol withdrawal.
MEDICATIONS TO CONTINUE:
Atenolol 50mg daily
Clonidine 0.3 mg TID
Duloxetine 60mg BID
Fentanyl Patch every 72 hours
Oxycodone 5mg every 6 hours as needed for pain
MEDICATIONS CHANGED THIS ADMISSION:
START folic acid 1 tablet daily
START multivitamin 1 tablet daily
START thiamine 100 mg daily | REASON FOR HOSPITAL ADMISSION:
___ yo male with recent IVDA heroin and alcohol binge presenting
with substernal chest pain.
. | 142 | 20 |
18732942-DS-6 | 23,374,850 | You were admitted with profound anemia, with suspicion it is due
to a slow GI blood loss. You were transfused 3U blood and your
count remained stable. You had an upper endoscopy and
colonoscopy without identification of source. You will need a
capsule endoscopy study to be set up by your PCP (I informed
your PCP ___. You tolerated food after the scope procedure.
You should have twice/week blood test, and I have referred you
to ___. Finally, I recommend you discuss with your PCP ___
referral to a nephrologist in light of your chronic kidney
disease
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Patient arrived to floor, vital signs stable, s/p 2 units pRBC
with appropriate crit bump. Etiology of bleed thought to be
occult bleed via GI tract. Hemolysis labs negative. Iron labs
grossly normal. Transfused another unit pRBC on the morning of
___ for slow downtrend. EKG abnormalities improved with
transfusion and troponin remained flat with no symptoms.
Abdominal pain resolved with straight cath x 1 for urinary
retention with normal urination since. Home lasix held for ___
which improved somewhat with volume resuscitation but may be at
new baseline based on recent values.
Called out to floor for further work-up with plan for repeat
___. | 114 | 104 |
11592968-DS-13 | 23,410,963 | Dear Mr. ___,
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 brought into the hospital after your caretakers at home
noticed that you had a fever and were short of breath. When you
arrived, we also found that the level of sodium in your blood
was very high, which is concerning for dehydration.
WHAT HAPPENED IN THE HOSPITAL?
We evaluated you for infections, and found by chest x-ray that
you had pneumonia. We treated you for this with IV antibiotics.
We also evaluated you for blood clots, as we were concerned that
you may have a blood clot in your lungs. We did find a blood
clot in your leg, which we treated with blood thinners.
Fortunately, we did a chest CT and found no evidence of clot in
your lungs. To treat your high sodium level, we gave you more
water by IV and through your NG tube. Your sodium level improved
over two days.
WHAT SHOULD I DO WHEN I GO HOME?
Please follow up with your primary care provider as below. In
addition, please see the changes in your medications as below.
You will continue on antibiotics for a total of 7 days. You will
also be receiving blood thinners by injections in your abdomen
and by pills in your NG tube to continue to treat your blood
clot and to prevent future clots.
We wish you the best,
Your care team at ___ | Mr. ___ is a ___ year old man with T2DM, prior CVA c/b right
hemiparesis and aphasia, dysphagia s/p G-J tube placement,
history of aspiration pneumonia, and admission ___ with
pseudomonas sepsis d/t UTI, who presents with fevers and
hypoxemic respiratory failure concerning for pneumonia, and
hypernatremia. Now breathing comfortably on room air;
hypernatremia resolved after correction with D5W and more
regular free water flushes.
ACTIVE ISSUES:
============================
#COMMUNITY-ACQUIRED PNEUMONIA:
Patient presented with new hypoxemia, reported as low as 80% on
room air at his facility, up to 100% on 4L after admission,
tapered to room air satting 98% on ___. Frequent cough
productive of thick, clear secretions, diminished over
admission. Chest x-ray with potential left base opacity. CTA
ruled out PE on ___ after positive LENIs. Volume overload
remained of low suspicion throughout admission given clinical
exam. Legionella antigen negative, sputum culture contaminated
and not processed. Urine culture without growth. Started on
empiric vancomycin/cefepime on admission for HAP coverage,
vancomycin discontinued ___ after negative MRSA swab. Cefepime
discontinued ___ to finish 5-day course on Augmentin
(amoxicillin-clavulinic acid).
#DVT:
Found to have a DVT in the left lower extremity by ultrasound on
___. Most likely provoked by stasis secondary to hemiplegia,
bed-bound at home. No concern for PE given negative CT ___.
Started heparin gtt overnight ___, d/ced ___. Lovenox bridge
and warfarin started ___ pm, to continue until warfarin is
therapeutic.
#HYPERGLYCEMIA:
Sugars elevated to the ___ on admission, most likely in the
setting of acute stress response to potential infection or PE.
On admission, restarted home insulin dosing and uptitrated.
Restarted home metformin ___. Sugars ___ on discharge.
#ANEMIA:
Anemic at baseline. Most likely slow GI oozing, as noted in
documentation from prior admissions. H/H slowly trending down
since admission, from 10.7/36.9 (___) to 8.8/30.7 (___).
Partially dilutional, though platelets steady from ___ to ___.
We maintained an active type and screen and continued home
lansoprazole and iron. | 249 | 320 |
19504537-DS-10 | 21,876,632 | Dear Mr. ___:
You were admitted because you had pain in your hip and your
abdomen, as well as chest pain and generally feeling unwell. You
had blood cultures that have not grown any bacteria. You had an
ultrasound of your abdomen that did not show any reason for your
abdominal pain.
We recommended that you have physical therapy evaluate you for
your hip pain, which is probably from a disk bulge in your lower
back, but you wanted to leave before seeing physical therapy.
We recommend that you stop using cocaine and heroin.
It was a pleasure to care for you!
Your ___ team | ASSESSMENT AND PLAN: ___ yo M with h/o IVDU who presented with
several days of malaise, myalgias, chest pain; upon admission
his primary complaints were RUQ pain and R hip pain.
#R hip pain: Exam notable for pain with palpation of the
buttocks, +SLR. No pain over joint itself, no pain with log roll
pointing against intraarticular process. Plain films revealed
chronic degenerative changes. Most likely was due to radicular
pain vs sacroiliac pathology vs OA. Able to weight bear without
dificulty. Continued outpatient pain regimen. On discharge was
ambulating with normal gait.
#Malaise, myalgias: These complaints had resolved by admission.
Blood cultures from ED had no growth to date after >48 hours at
time of discharge, and he remained afebrile and w/o
leukocytosis. HIV Ab negative, VL pending at time of dc.
#RUQ pain: RUQ U/S without any pathology and with less CBD
dilation than previously (recent extensive w/u for dilated CBD
was unrevealing). LFTs were normal. This complaint resolved
during admission.
# Chest pain: Complained of chest pain in ED which resolved on
its own. Ruled out for ACS in ED with two negative trops.
CHRONIC ISSUES
# Hepatitis C: HCV VIRAL LOAD (Final ___ 73,700,000 IU/mL.
Has not been treated. LFTs normal, no stigmata of cirrhosis.
# Opioid use disorder:
Chronic and complicated by polysubstance abuse with cocaine as
well, maintained on Methadone. Admitted to recent heroin use as
well as cocaine. Continued home methadone 125 mg daily
(confirmed with Addiction Treatment ___
___. Placed on ___ scale, no e/o withdrawal while
inpatient. Of note patient was found to be hiding an unknown
pill in his hand during his stay, prompting a room search. Room
search found several bottles of perscription meds labeled with
patients name, though several pill bottles had a variety of
other medications in the prescription bottle which were
unidentified at this time. He was also found to have an empty
Seroquel bottle in bedside table drawer, the pill in his hand
was also identified to be Seroquel. He was further found to have
a used syringe hidden in his bag. | 101 | 347 |
18853762-DS-38 | 29,237,564 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___! You came in after fainting and with a recent
history of vomiting and diarrhea. We believe your symptoms were
due to dehydration secondary to gastroenteritis (viral
infection). Your symptoms improved with hydration and have now
resolved.
Some of your blood pressure medications have been changed.
Please have your doctors ___ from 50 back to
200mg daily if you become hypertensive. If you continue to be
hypertensive after increasing metoprolol, please restart
chlorthaidone. | ___ with history of CAD, DM2, HTN, COPD on ___, RA,
prosthetic joint infection who present after syncopal event.
# Syncope:Patient was at outpatient appointment and syncopized
on route to bathroom. Fall was witnessed and she did not strike
her head. Likely related to hypovolemia and/or vasovagal from
nausea/vomiting and recent diarrhea. Less likely to cardiogenic
or neurogenic. Troponins were slightly elevated but remained at
baseline x3 and ECG was at baseline. Neurologic exam was
reassuring with no focal deficits. She was given IV fluids on
admission and had no further episodes of syncope,
lightheadedness, or dizziness. Orthostatics were normal. She
was monitored on telemetry with no events. Urine culture showed
no growth.
# Gastroenteritis: Ms. ___ presented with several day
history of nasuea with vomiting and diarrhea thought to be
secondary to viral infection. Given lack of fevers or blood in
bowel movements invasive enterocolitis. Her symptoms resolved
during admission and she is having no vomiting or diarrhea prior
to discharge. She tolerated a regular diet.
# Leukocytosis: Ms. ___ had an elevated WBC on admission
which normalized after admission. Likely inflammatory from
underlying gastroenteritis.
# Acute on chronic KI: On admission, her creatinine was
elevated to 2.0 from New baseline of 1.8 in setting of AIN from
vancomycin. Exacerbated by dehydration. It improved with IVF and
is 1.4 on discharge. Her valsartan and chlorthalidone were held
and will be restarted at time of discharge.
# Chronic osteomyelitis of right knee: She has antibiotic spacer
in place. There was no change on xray and on orthopedic exam in
emergency department. She wore knee immobilizer at all times and
complete a 6 week course of daptomycin on ___. her PICC
was pulled prior to discharge. Will need to follow up with ortho
in 3 weeks.
# Hyponatremia: Pt was found to be hyponatremic on admission to
130. She has a history of hyponatremia and baseline in low
130's. It was thought her slight decrease from baseline was
secondary to hypovolemia. Her sodium returned to baseline with
normal saline boluses. | 86 | 341 |
13404558-DS-8 | 25,933,643 | Dear Ms. ___,
You were admitted to the hospital for acute onset of left sided
weakness and were found to have had a right sided hemorrhage,
likely caused by high blood pressure. While here, your blood
pressure was elevated, and it was controlled with both oral and
intravenous medications. During your hospitalization, you
vocalized some suicidal ideations and were initially placed on a
___, but this was removed when psychiatry felt you were
no longer a danger to yourself. Unfortunately, on ___, you
insisted on leaving the hospital against medical advice (AMA),
despite us informing you of the risks of stroke, seizure or
death that accompanied you leaving. We spent an hour
counselling you on the reasons you should stay, and despite
this, you decided to leave anyways. You were sent home with a 3
day prescription of the following medications:
1) amlodipine 10mg QD
2) lisinopril-HCTZ ___ QD
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room. | ___ is a ___ RHF w/ h/o HTN presenting w/ L sided
weakness found to have R posterior putamen/internal capsule
hemorrhage, with hospital course c/b likely withdrawal sx as
well as active suicidal ideations and one suicide attempt.
.
# NEURO: patient's blood pressure was controlled after her
hemorrhage to prevent vasospasm, extension of the bleed or
further stroke. She was agitated and appeared to be withdrawing
from some substance while here. On interview, pt admitted to
taking methadone from the street, although her UTox was positive
for opiates, but negative for methadone. We treated her
symptomatically with ativan for agitation and clonidine for
withdrawal symptoms and methocarbamol as needed for muscle
spasms or anxiety. She then became suicidal (see below). On
the evening of ___, she insisted on leaving AMA with her
family to go home. She had been taken off of her ___,
and expressed understanding of the risks of stroke, seizure and
death that could occurr if she left. She also expressed
understanding of the risk that her insurance may not pay for the
full length of her hospital stay if she left AMA, and wanted to
leave anyways. She was sent home with a 3 day supply of her
blood pressure medications as she reported she had a PCP
appointment set up already for the day after discharge.
.
# CARDS: While here, we used hydralazine as needed to keep her
blood pressure less than 160. We initially put her on
amlodipine 5mg and lisinopril 10mg, but after discussion with
her PCP, it was determined that the doses she was supposed to be
on were amlodipine 10mg and lisinopril 20mg as well as HCTZ
12.5mg, and she was put on the increased doses. When pt insisted
on leaving AMA, we encouraged her to check her BP at home every
hour and to call her PCP or go to the ED if the SBP went above
160 and remained above 160 if rechecked 5 mins later. She
expressed understanding of this.
.
# PSYCH: On the evening of ___, pt was screaming "I want to
kill myself" repeatedly, and attempted to ___ herself with
the nasal cannula tubing. She was seen emergently by psychiatry
who placed her on a 1:1 sitter and a ___. However, the
next morning, the pt insisted that she did this to get the
nurses attention, and psychiatry felt she was no longer a danger
to herself, and removed the ___. Pt decided to leave
AMA, and as psychiatry had already determined she was not
suicidal, we had no choice but to let her leave.
.
# ENDO: while here, we put pt on an ISS. As an outpatient she
may benefit from
further endocrine for possible secondary causes of HTN.
.
# CODE: Full Code | 172 | 470 |
11871434-DS-12 | 23,923,171 | Dear Mr. ___,
You were admitted for evaluation of shortness of breath and
increased sputum production and treated for pneumonia.
You were also found to have evidence of aspiration so, after
discussions with you and your wife, a feeding tube was placed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your "dry weight" should be around 168 lbs.
Sincerely,
Your ___ Team | ___ man with a past medical history of MSA, COPD,
chronic respiratory failure s/p tracheostomy, Afib (on Eliquis),
CAD, HFpEF, bilateral RAS s/p stenting, s/p suprapubic catheter,
who presents with cough, dyspnea and increased sputum
production, found to have significant aspiration.
# PNA
# Aspiration
# Chronic Respiratory Failure
The patient had significant cough and dyspnea. Initial CXR
without clear PNA but this was difficult to exclude. Although no
overt fever, he has had sweats and increased secretions. Tm in
ED 99.4 and leukocytosis present. Overall picture was concerning
for PNA. Flu negative in ED. Legionella neg. Sputum cx initially
contaminated; repeat cx with yeast. CT chest with pulm edema,
consolidation concerning for aspiration. Video swallow with
aspiration and strict NPO recommended. The patient was placed on
vanc/CTZ/azithro for CAP. However, vanc was ultimately d/c'ed
given low suspicion for PNA. Given high aspiration risk, G-tube
was placed by ___.
Pt was treated with CTX and Azithro and is discharged on 2 more
days of Cefpodoxime. Blood cx negative x5 days. Cont home neb
therapy, including duonebs and acetylcystiene. G-tube placed on
___ (indication = high aspiration risk). Tube feeds started.
The patient will likely need tube feeding via G tube at least
for 3 months, SLP may re-evaluate and determine If he may resume
swallowing again. He will remain NPo till then.
# Afib:
The patient has a history of AF. CHADVASC score is 5. Patient
was previously on anticoagulation, held due to concern for GIB.
However, his PCP has since resumed a low-dose apixaban. Although
he does not technically meet criteria for reduced dose apixaban,
given borderline age and renal function (EGFR significantly
reduced by cystatin c), as well as concern for bleeding, will
maintain low dose apixban going forward. He was bridged with
heparin gtt while NPO. Apixaban was resumed after G tube placed.
# Acute on Chronic HfpEF:
On admission, appeared euvolemic though cxray concerning for
some
vascular congestion. He was briefly off of PO diuretic ___ NPO
status. Following trigger on ___ for tachypnea, it was noted
that
he was net fluid positive, pro BNP was elevated and increased
form before, CXR showed vascular congestion. He was aggressively
diuresed and responded well. His weight was around 168 lbs at
the time of discharge
# H/o Anemia and GIB:
Per rehab record, Apixaban was previously held in ___ due to
+guaiac stools and drop in HCT. Last colonoscopy in ___ with
adenomatous polyp and poor prep. Patient was re-scheduled for
repeat CS but was felt to be a poor candidate for colonoscopy
given multiple comorbidities, per rehab notes. Iron studies c/w
ACD. Stools have been guaiac negative here. H/H stable.
# s/p suprapubic Foley: Urology came and changed on ___.
# CAD:
Severe 3VD. Currently asymptomatic. ASA switched to apixaban by
PCP. Statin also recently discontinued. Given hx of HLD and
severe 3VD, would favor resuming statin. TnT slightly elevated
in setting of demand and CKD. | 64 | 478 |
13739802-DS-4 | 21,469,546 | Dear Mr. ___,
It was a pleasure caring for you during your recent admission to
the ___. You were admitted to the hospital for a massive
bleed from your stomach. You lost almost ___ of your blood
volume and we transfused you with blood. Our
gastroenterologists performed an endoscopy and found that you
had a bleeding ulcer in your stomach which was closed. We also
treated you with medications to prevent bleeding. We stopped
the medication you were on to thin your blood (pradaxa). Our
gastroenterologists were in agreement that you should not take
blood thinning medications for 7 days after your bleed. We
prescribed you a new medication to thin your blood which is
apixiban. You should start this medication on ___ and you
should follow up with your gastroenterologist and your
cardiologist at the appointments listed below. | Mr. ___ is a ___ year old male with a history of hypertension,
CHF, COPD, Afib on pradaxa who presents s/p fall with resultant
rib fractures and treatment for ?COPD exacerbation, now with
melenic stools and anemia concerning for upper GI bleed. | 148 | 42 |
18125318-DS-20 | 29,324,526 | You were admitted to ___ with abdominal pain and were found to
have acute cholecystitis. You had an MRCP to evaluate for any
common bile duct stones, for which there were none. You were
then taken to the operating room and underwent a laparoscopic
converted to open cholecystectomy. You tolerated this procedure
well. You are now eating a regular diet and your pain is well
controlled. You are medically cleared for discharge home to
continue your recovery. Please note the following:
Please follow up in the Acute Care Surgery clinic. You will need
to call to schedule an appointment.
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. | Mr. ___ is a ___ male with Crohn's disease who
presents after acute epigastric abdominal pain episode and is
found to have cholecystitis with elevated LFTs, concerning for
choledocholithiasis. He was evaluated by the ERCP team and they
felt that there was no role for ERCP during this admission given
no evidence of CBD stone visualized on MRCP, so he was
transferred to the ACS service for cholecystectomy. The patient
underwent laparoscopic converted to open cholecystectomy, which
went well without complication (reader referred to the Operative
Note for details). After a brief, uneventful stay in the PACU,
the patient arrived on the floor tolerating sips, on IV fluids,
and IV analgesia for pain control. The patient was
hemodynamically stable.
.
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 home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 724 | 235 |
18367623-DS-33 | 22,117,800 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY DID YOU COME TO THE HOSPITAL?
You had blood in your stool
WHAT HAPPENED WHILE YOU WERE HERE?
The bleeding initially got better, but returned
We held your lovenox
CT Scan showed the lymphoma was blocking your intestines
You received radiation to shrink the lymphoma
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- You should follow up with Drs. ___ next week
as you prepare to transfer to ___ for CAR-T therapy.
- You will have additional sessions of radiation
- Please continue to take all of your medications as outlined in
your discharge paperwork
Sincerely,
Your ___ Care Team
New Medications:
[] Metronidazole (Flagyl) 500mg PO every 8 hours | Summary:
----------
Mr. ___ is a ___ year-old man with a background history of
mechanical AVR on Lovenox, remote Type A aortic dissection s/p
Dacron graft repair, and hypertension, with oncologic history of
stage IV DLBCL with persistent disease despite 6 cycles of
DA-EPOCH-R and 2 cycles of salvage R-ICE, who was admitted to
___ for management of lower GI bleeding. | 113 | 60 |
13458840-DS-16 | 26,863,382 | Dear Ms. ___,
You were admitted to ___ with fever and chills due to a skin
infection. During this admission, you were started on
antibiotics to treat the infection and underwent incision and
drainage of an abscess on your thigh. It is now an open wound
and will require daily packing and dressing changes. You are now
being discharged with antibiotics and will be set up with home
nursing to help you manage the dressing changes. Please continue
your home medications as previously prescribed and use the
prescribed pain medications for dressing changes. Please call
the office if you experience any prulent drainage from the
wound, worsening pain, redness or induration as these may
indicate an infection.
ACTIVITY
1. Activity as tolerated.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep ___ fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change ___ your symptoms, or any new symptoms that
concern you.
It has been a pleasure taking care of you.
Sincerely,
Your ___ care team | Mrs. ___ is a ___ year old female with left lateral thigh
melanoma s/p wide local exision and left groin lymphadenectomy
who now presents from home with cellulitis of left
inguinal/femoral lymphadenectomy site now s/p bedside I&D. She
was admitted from the ED after presenting with fevers, night
sweats, chills and left leg cellulitis. She was started on
empiric vancomycin/zosyn, with daily to twice daily dressing
changes which were well tolerated. On ___ patient underwent
bedside incision and drainage after left thigh demonstrated a
small collection. Zosyn was discontinued following positive
wound culture for MRSA and diptheroids. Patient improved after
incision and drainage, and was transitioned to PO Bactrim. She
will complete abx course as an outpatient. She tolerated a
regular diet and her pain was controlled on oral pain
medications during this admission. At the time of
discharge, she was set up with ___ at home for twice daily
dressing changes and will see Dr. ___ ___ clinic on ___
___. | 270 | 162 |
10722545-DS-16 | 20,202,359 | Dear Mr. ___,
You came into ___ because you
were having chest pain. At the hospital, you were found to be
having a heart attack. This occurs when one or more of the
vessels providing blood to your heart muscle is clogged. You
underwent a cardiac catheterization (a procedure where they look
at the heart vessels with dye). During the catheterization, they
placed two stents to prop open the vessel that was clogged. We
also added several new medications to your regimen. It will be
important to take these medications EVERY DAY. Do NOT miss ___
dose of the Ticagrelor or the Aspirin as the stents could clot
up again! We also stopped your blood pressure medications
because your blood pressure was low while in the hospital. You
should discuss whether you should restart these medications with
your cardiologist. You can find a full list of your medications
below. Please go over this list carefully and bring a copy with
you to your next doctor's appointment.
It was a pleasure caring for you at ___.
We are glad that you are feeling better!
Take Care,
Your ___ Cardiology Team | ___ male with a history of HTN, HLD and ___ Disease who
presented with a year of exertional chest pain and ___ days of
intermittent nonexertional chest pain, found to have a STEMI.
# STEMI
Exertional chest pain x ___ year with intermittent non-exertional
chest pain x ___. Increased stress over last ___ years, worse
since wife's passing ___ year ago. EKG with new STE in III (1mm)
and aVF (<1mm); troponin elevation to 0.81 on admit. Received
full dose aspirin and loaded with ticagrelor in ED, and put on
heparin drip continued overnight. He underwent cardiac
catheterization on ___ via the right radial artery which
showed a 100% occlusion of the RCA and 50% occlusion of the LAD.
Two ___ were placed to the RCA. Afterward, the patient
continued to be chest pain free. He was discharged on ticagrelor
(for at least one year), aspirin and high dose atorvastatin.
# LEUKOCYTOSIS: WBC 20 on admit with 84% PMNs. Lactate 2.3.
Chronic cough evaluated by CXR, but this was without focal
opacity or lesion. On history and exam, he had no other focal
signs/symptoms, so this was felt to be likely a stress reaction.
This was trended and decreased over time. Blood cultures were no
growth to date, but not finalized at discharge.
# HTN: He was initially continued on his home atenolol 50 daily
and nifedipine CR 30 daily; however, his BPs went down to the
high ___ with ambulation on ___. He was asymptomatic
with the low BPs, and heart rate did not change; we suspect that
this was possibly secondary to autonomic dysregulation from his
___ Disease. Patient was monitored and had improved BPs
later in the day, which did not decrease upon walking or
re-evaluation by Physical Therapy. Therefore, we stopped his
antihypertensives and told him to follow-up with his primary
care physician ___ cardiologists about the preferred blood
pressure regimen for him. We would suggest ___
metoprolol rather than previous regimen in order to optimize
cardiac function. He will also be seen by a visiting nurse who
will measure his blood pressure at home.
# HLD: patient had previously declined statin outpatient in
favor of lifestyle modifications. Started atorvastatin 80mg PO
daily while inpatient.
# PARKSINON'S DISEASE: continued home meds: sinemet,
trihexyphenidyl and pramipexole.
# ANXIETY: continue home Clonazepam 0.5mg PO BID. | 186 | 383 |
15586921-DS-12 | 26,992,175 | Dear Mr. ___,
It was a pleasure to take care of your during this
hospitalization. You were admitted to ___
___ after you were found to be confused. This
improved with better control of your pain.
We gathered your family including ___ (your health care
proxy and granddaughter), your other grandchildren, your
daughter, and your girlfriend to talk about your goals of care.
Together with them, you decided that you would not want to
aggressive resuscitation if your heart were to stop or if you
were to have difficulty breathing (your code status was made "Do
Not Resuscitate/Do not Intubate"). You also decided that you
would like to continue eating by mouth, understanding the risk
for secretions and food to go into your lungs. You decided to
focus you medical care on "comfort," so the hospice and case
management teams saw you and you are now leaving for hospice
care.
We started you on intravenous and oral medications to better
treat you pain. We placed you on nebulizers to help your
shortness of breath. | ___ with past medical history of COPD, pulmonary fibrosis, and
asbestosis and recent admission for shortness of breath who
presents with further shortness of breath and requesting hospice
care.
# Goals of Care: Patient has end-stage pulmonary disease and
significant functional decline over the several months prior to
admission characterized by worsening dyspnea, physical decline
to a bedbound state, and more recently confusion. Since the
patient's most recently ___ admission, the patient has
remained Full Code. At the time of this admission, the
patient's granddaughter and health care proxy desired to
re-discuss goals of care. A family meeting was held on ___
with the patient, ___ (patient's granddaughter and
HCP), and additional family members. Medical staff provided
information about patient's pulmonary disease, risk of
aspiration, and available medical options. Patient and family
unanimously agreed to change patient's code status changed to
DNR/DNI, to allow patient to eat despite acknowledged risk of
aspiration, and to transition patient to comfort-focused/hospice
care.
# Shortness of Breath: Patient has COPD, pulmonary fibrosis,
asbestosis, and chronic aspiration. During prior ___
admission, extensive infectious work-up was conducted and
negative. At the time of admission, patient reported
progressive worsening of chronic dyspnea but no acute worsening
of symptoms or lab abnormalities to suggest recurrent infection.
In the setting of goals of care discussion (see above), patient
was treated symptomatically with home inhalers, nebulizers, and
morphine (initially IV transitioned to PO prior to discharge).
# Rheumatoid arthritis: Patient was continued on home
Methotrexate 7.5mg PO weekly. His pain was treated with
morphine, Tylenol, ibuprofen, and lidocaine patch.
# Peptic ulcer disease: Continued on home omeprazole.
# Spinal stenosis: Pain controlled with morphine, Tylenol,
ibuprofen, and lidocaine patch.
# Iron deficiency Anemia: CBC remained within baseline without
active signs of bleeding.
# Depression: Continued on home sertraline 100 mg daily. | 176 | 304 |
13093925-DS-4 | 29,252,636 | Dear Ms. ___,
You were admitted to the hospital with breast pain and fevers,
concerning for an infection of the breasts (mastitis). You were
treated with antibiotics, with improvement in your symptoms. You
are being discharged on clindamycin, which you should take every
6 hours through ___.
It will be important that you establish care with a primary care
doctor and with a breast specialist to determine the cause for
your recurrent infections.
With best wishes for a speedy recovery,
___ Medicine | ___ with hx of depression/anxiety and recent L-sided mastitis
(s/p courses of amoxicillin and doxycycline) presenting with
L-sided breast pain that progressed to bilateral involvement,
fevers, and leukocytosis, concerning for bilateral mastitis, now
improving.
# Fever:
# Leukocytosis:
# Bilateral non-lactational mastitis:
Patient has a recent hx of L-sided mastitis (___) for
which
she was treated with amoxicillin and then doxycycline through
urgent care centers in ___. She reported that the
L-sided pain/erythema was improving until the day of admission,
when she developed L-sided breast pain/erythema with associated
fevers while at work. She was febrile to 102.7 on presentation
with a leukocytosis to 19, with breast exam notable for L>R
erythema and tenderness. On ___, she reported extension of pain
to the R breast, with exam notable for b/l erythema without
induration, masses, or fluctuance to suggest abscess. She has no
hx of breast surgeries and has not breastfed in years.
Gynecology
was consulted, and presentation was thought most consistent with
non-lactational mastitis, likely periductal, although
bilaterality is atypical. Swab of nipple discharge was growing
rare staph aureus, grp B beta strep, and mixed bacterial flora
at
discharge. HIV was tested and negative. DDx for non-lactational
mastitis includes idiopathic granulomatous mastitis, although no
solid masses were seen on b/l breast U/S done ___. U/S also
showed no evidence of fluid collections or abscesses. She
received doxycycline on admission but was broadened to
vancomycin
on ___ in setting of spreading erythema. Pain was initial
controlled with tylenol and tramadol. Given clinical
improvement,
she was transitioned to clindamycin on ___ (given c/f MRSA,
recent doxycycline, and allergy to Bactrim), with no recurrence
of fevers and improvement in her leukocytosis, pain, and
erythema. WBC had normalized to 7.4 at discharge. CRP, however,
which was 87 on admission, had risen to 116 on discharge, likely
a delayed inflammatory marker response to clinical improvement.
Of note, patient's initial complaint of chest pain worse with
inspiration was concerning for PE, but negative D-dimer in the
ED
essential ruled out this diagnosis. ACS was thought equally
unlikely given negative troponin and non-ischemic EKG. CXR was
negative for PNA. Ms. ___ will continue clindamycin 300mg q6h
for a 10d course, through ___. Given that she does not
currently
have a PCP, she was assigned a new provider at ___, whom she
will see on ___. In addition, she was referred to the ___, where she will be seen on ___ for further w/u of
recurrent mastitis.
# Depression/anxiety:
Continued home Wellbutrin.
# Cocaine use:
# Tobacco use:
Utox positive on admission for cocaine, which patient endorses
using intermittently (never IV). Also endorses ___ cig/week.
Tobacco and cocaine cessation were encouraged.
** TRANSITIONAL **
[ ] clindamycin 300mg q6h through ___ (10d course)
[ ] f/u BCx, NGTD at discharge
[ ] f/u final nipple discharge culture
[ ] f/u with PCP (___)
[ ] f/u with ___ further w/u of recurrent
mastitis (___)
# Contacts/HCP/Surrogate and Communication: ___ (mother)
___
# Code Status/ACP: FULL (presumed) | 78 | 440 |
12707289-DS-19 | 27,091,347 | Dear Mr. ___,
It's been a pleasure to take care of you at ___
___. You were admitted because of low
sodium (hyponatremia). We asked you to drink less fluid and
take salt tablets. Your studies also showed secondary adrenal
insufficiency.
You will need to followup with your regular endocrine doctor for
continued care.
NEW MEDICATIONS: these NEW medications are necesary for you to
take as you have low levels of some hormones such as thyroid
hormones and steroids
- HYDROCROTISONE: please take 20mg in the morning and 10mg in
the evening for your adrenal function.
- SYNTHROID (Levothyroxine Sodium): please take 25mg daily for
your thyroid function | 1. Hyponatremia due to Secondary Adrenal Insufficiency:
Patient presented after his sodium was incidetally discovered to
be 122 on a ___ clinic lab visit. He was given a further 2L of
NS in the ED which dropped his Na to 120. Urine lytes
demonstrated urinary sodium of 117, serum osms of 249 and urine
osms of 389 indicating inappropriate loss of sodium consistent
with SIADH. The pt does not have a hx of polydypsia, pulmonary
or psychiatric disease. We started him on a fluid restriction
and salt tabs but his sodium drifted down to 118. Renal and
Endocrine consults were called. At this point we decided to
perform a ___ test and his cortisol went from 1.6 at
baseline to 12.9 and 17.6 at 30 and 60 minutes respectively. He
was started on hydrocortisone 20mg Qam/10mg Qpm) and
levothyroxine for his low free t4. His sodium improved
appropriately and he was dc/ed w/ an Na of 132.
Patient is s/p Pituitary Macroadenoma, undergoing cyberknife
about 9 months ago. Pt is already known to have testosterone
deficiency. However, not being treated due to old age and DM.
Likely cause of current presentation as late hormonal imbalances
can occur in patients after cyberknife typically around 9
months, which would explain this event.
2. Benign Hypertension.
Pt remained within normal limits. we continued Norvasc,
Lisinopril.
3. Type 2 Diabetes Controlled without Complications.
We continued Metformin, ___. His most recent HbA1c was 6.8.
4. Hyperlipdiemia:
Stable. We continued Atorvastatin 20
TRANSITIONAL ISSUES: Pt has a followup appt in 2 days with
endocrine and later this week with his PCP. | 108 | 264 |
16547279-DS-15 | 24,885,021 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
weight bearing as tolerated. range of motion ___ degrees with
left leg in ___ brace.
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take aspirin for DVT prophylaxis for 4 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with ___ in 14 days
post-operation for evaluation and suture/staple removal. Call
___ to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
WBAT LLE in bledose with ROM ___ degrees
Treatments Frequency:
Home ___ | The patient was admitted to the Orthopaedic Trauma Service for
left knee pain. The patient was taken to the OR and underwent
an uncomplicated left quadriceps tendon debridement. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: WBAT LLE in ___ ROM ___.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively with aspirin. All
questions were answered prior to discharge and the patient
expressed readiness for discharge. | 231 | 175 |
15469636-DS-20 | 26,110,211 | Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
Exercise should be limited to walking; no lifting >10lbs,
straining, or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; you will not require blood work
monitoring.
Do not drive until your follow up appointment.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Mr. ___ was evaluated by the Neurosurgical team in the ___ for
his subarachnoid hemorrhage on ___. CTA showed an 6 x 5 x 3
mm aneurysm of the proximal superior division of the left middle
cerebral artery. While in the ___, he began having severe nausea
and emesis and had worsening mental status for which he was
intubated. An EVD was emergently placed by Dr. ___ in the ___.
He was taken for a repeat head CT which showed worsening of the
SAH, and then to the Interventional Neuroradiology Suite for
coiling of his left MCA aneurysm. After angiography he was taken
to the Neuro ICU. He was placed on nimodipine and q1h neuro
checks for vasospasm watch. He was placed on a heparin drip at
700 units/hour overnight. His blood pressure was maintained with
an SBP goal of <140 mm Hg.
On ___, a repeat head CT was performed on POD1 and showed
endovascular embolization of the left MCA aneurysm, now with a
new parenchymal hemorrhage in the left external capsule. His
heparin drip was stopped in the AM and he was started on SCH for
DVT prophylaxis. He was weaned off sedation and extubated in the
afternoon. An echo was performed and was normal. In the
afternoon he began to have high urine output with 250-300 cc/hr
over several hours. He was bolused as needed to keep his fluid
status even to prevent vasospasm and urine electrolytes were
sent which showed urine osm of 391 and serum osm of 298.
On ___ TCDs were done which showed no spasm and his IVF
continued at 150cc/hr. His EVD stopped working around 6pm and it
was troubleshot and drain began working again properly. IT
stopped again and tPA was given at ___ and CT was obtained.
On ___ he was noted to have increasing lethargy in the early
morning so another CT head was obtained which showed a slightly
enlarged bleed along the catheter tract and at the septum. Neuro
was having difficluty with his TCds due to poor windows and the
EVD was working well until approximately 1600. tPA was again
instilled with good effect. At ___ he acutely was noted to not
be moving the right side. A STAT CTA was obtained whcih shwoed L
MCA spasm mild/mod, as well as increasing edema around the known
left sided sylvian fissure clot. His exam returned to baseline
later on without intervention. He continued with expressive
aphasia.
On ___ EVD stopped draining. STAT head CT scan showed decreased
size of ventricles. The patient was more lethargic on exam. He
was taken to the OR by Dr. ___ emergent left
decompressive crani. Post operatives the patient underwent
angiogram that showed vasospasm in left MCA. Angioplasty was
performed and verapmil was injected. Post op non contrast head
CT scan showed expected post operative changes, no new
hemorrhage. The patient was taken to SICU for close monitoring.
On ___ TCDs showed no vasospasm. He was febrile to 101.5F,
cultures were obtained. Angio sheath was pulled. EVD remained in
place however did not drain.
On ___ EVD continued to not drain, it was removed. Angiogram
showed mild to moderate spasm, both MCA received Verapamil.
Systolic blood pressure was kept about 140. He was started on
Cefepime for H. flu.
On ___ CTA was obtained that showed bilateral MCA vasospasm
(L>R; narrow M1 and distal MCA). In the evening around 10 pm the
patient had a change in exam. He underwent an emergent
angiogram. Angiogram was performed in the early morning hours on
___ that showed vasospasm in bilateral MCA. Angioplasty was
performed and verapamil was injected.
On ___ the patient was more alert on exam. Spontaneously opening
his eyes, wiggling his toes to command.
On ___ head CT was stable. He underwent an agiogram that showed
vasospasm, he underwent angioplasty and received Verapamil. Post
angio he was started on a heparin drip at 700 units per hour.
Systolic blood pressure was kept between 160-180. Post angio non
contrast head CT showed slight increased edema in left parietal
lobe.
___ Reapeat head CT stble compared to yesterdays head CT.
Heparin d/c yesterday, sheath d/c today, sm hematoma at groin
site about half the size of a golf ball with bounding pulse.
Tcds ordered for tomorrow. MAE on exam and follows simple
commands. Trach/peg was plan for today but not done yet. The
patient was extubated and doing well on room air. The order for
the trach was discontinued. Nimodipine was discontinued.
___ Partial staples were discontinued.
___: The remaineder of the patient's staples were removed. He
was weaned off pressors and maintained a stable blood pressure.
___: Mr. ___ was discontineed.
___: He was transferred to the step down unit as he no longer
had icu needs. Speech and swallow evaluated him and felt he was
not yet appropriate for PO intake as he was pocketing food. They
recommended re-evalauting him on ___ or ___. Later in
the day, he pulled out his dobhoff.
___: He remaiend stable, his dobhoff was replaced
___: He was in the stepdown unit. Patient was re-evaluated by
speech and swallow and passed for thin liquids and pureed
solids. He was started on Ceftriaxone IV for pneumonia X 14
days.
___: He was eating well at breakfast and lunch and it was noted
that he had pulled out his Dobhoff tube almsot the whole way
out. The dobhoff was then removed fully as he was taking good
PO's and tube feeds discontinued. His exam remained stable. On
___, patient was stable on exam. He was evaluated by ___ and his
foley was removed. A condon catheter was placed. He was able to
void on ___ on his own. He continued to have adequate PO
intake. On ___ he was stable while awaiting placement.
On ___, he remained stable on exam. Speech and swallow advised
to increase diet to ground solids and thin liquids. He continues
to await placement.
On ___ Mr. ___ was dishcharged to rehab in stable condition. | 181 | 994 |
10628370-DS-26 | 24,069,801 | Dear, Mr. ___,
You were admitted to the hospital because you were confused.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given medications to help reduce your confusion.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[] Hepatic encephalopathy: likely I/s/o not having BMs.
Uptitrated lactulose to 60 ml QID and added miralax prn. Ensure
compliance and that patient is responding, i.e. clear mental
status with this medication change
[] Gastric varices s/p banding on ___: needs repeat EGD 1
month after this procedure
- Post-Discharge Follow-up Labs Needed: CBC, CHEM10, LFTs within
7 days
- Discharge: Cr 2.0, BUN 38, T bili: 5.2, WBC 2.7, Plt 15, Hgb
8.9
- Incidental Findings: n/a
- Discharge weight: 67.36 kg
# CODE: FCp
# CONTACT: ___ ___
BRIEF HOSPITAL SUMMARY
=======================
___ male with history of cryptogenic cirrhosis s/p transplant in
___ ___/b decompensated cirrhosis MELD 18, ___
C presumed d/t
allograft failure (on pred/tacro) with ascites and HE, acute
cellular rejection ___ in setting of reducing
immunosuppression for
skin cancers), s/p shunt embolization and TIPS ___ and
revision ___, currently listed for re-transplantation; CKD,
skin cancers, presenting with confusion and asterixis concerning
for hepatic encephalopathy. Patient was given increased doses of
lactulose with return of his mental status to baseline. He was
discharged on more rigorous bowel regimen to help avert
constipation episodes at home which likely precipitated his
encephalopathy. Infectious work-up negative. He was discharged
home without services.
ACTIVE ISSUES
=============
#Hepatic encephalopathy
Likely HE given confusion, asterixis in setting of cirrhosis c/w
prior presentations, though with unclear trigger. Other than dry
cough after EGD and loose smelly stools in the setting of
lactulose, no
symptoms of infection. No increase in abdominal distention, ___
edema, and no dark stool, BRBPR, hematemesis, to suggest bleed.
Likely due to constipation as patient reports only having 2
bowel movements daily, which in the past has not been sufficient
to prevent hepatic encephalopathy for him. In ED CT head
unremarkable, trace ascites on RUQUS, unable to tap. CXR, U/A,
blood cultures unrevealing. Started on lactulose q2h with
increasing dosage intervals as mental status improved. Diuretics
and beta blockers held due to initial concern for
bleed/infection, but resumed. His lactulose was titrated to 60
ml QID with miralax prn for ___ BM/day with maintenance
clearance of his hepatic encephalopathy.
#Cryptogenic cirrhosis s/p OLT ___ c/b graft failure. MELD-Na
18, ___ C. Listed for transplant. Previous transplant at
___ ___ c/b post-transplant cirrhosis and acute cellular
rejection. Continued home prednisone 5 mg daily and tacrolimus
0.5 mg every other day. S/p TIPS on ___ w/ revision in
___ for HE. TIPS revision w/ portosystemic gradient of
12mmHg. EGD ___ demonstrated medium-sized varices x4 in the
distal esophagus, nonbleeding. Status post banding x2. Findings
consistent with portal hypertensive gastropathy. No gastric
varices. Hgb remained at baseline. Continued home PPI,
sucralfate, simethicone. Trace ascites noted on RUQUS, unable to
tap in ED.
CHRONIC ISSUES
==============
#Type 2 diabetes | 138 | 432 |
17361720-DS-25 | 27,521,377 | Dear ___,
You were admitted to the hospital for weakness and shortness of
breath. We gave you mediation to take fluid off your body and
you improved. We also found that your blood counts were lower
than usual and we gave you blood. Your stool found found to be
positive for blood but you did not have any symptoms. You need
to follow-up with a hematologist outpatient to better manage and
treat your anemia.
Your heart rate was at times very fast due to atrial
fibrillation/atrial flutter and we adjusted your medications to
better control your heart rate. Your heart rate becomes elevated
with any exercise, but you do not feel any symptoms.
You were started on new medications including an increased dose
of metoprolol and starting a new medication called diltiazem.
Your Lasix dose wasa halfed from 40 mg PO daily to 20 mg PO
daily. Also Aspirin, Amlodipine and Clonidine were discontinued.
It is very important that you continue to take these. All of
your medications are detailed in your discharge medication list.
You should review this carefully and take it with you to any
follow up appointments.
Please call your primary care provider or go to ED if you are
having chest pain, shortness of breath, or palpitations.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ PMH of CHF, AFib, HTN, CKD who presented with progressive
exertional fatigue and shortness of breath found to have
uncontrolled atrial flutter secondary to anemia and diastolic
heart failure exacerbation.
#Atrial fibrillation with RVR/Atrial flutter.
Patient with recent diagnosis of atrial fibrillation per
hospitalization in ___. On admission patient had
atrial fibrillation with RVR requiring IV metoprolol pushes and
PO metoprolol. Additional PO diltiazem was added to patient's
regimen. Ultimately patient was felt to have atrial flutter
after persistent monitoring on telemetry and repeat ECG's this
hospitalization. The underlying cause of her worsening rates was
felt to be secondary to anemia (see below.) She was discharged
on Metoprolol succinate 300 mg daily and Diltiazem 120 mg Daily.
Consideration of atrial flutter ablation at follow up can be
discussed if patient has ongoing symptoms from atrial flutter
though they were improved with medical management this
hospitalization. The patient was continued on warfarin with INR
at goal prior to discharge. Additionally given her anemia
aspirin 81 mg was stopped.
#Anemia secondary to thalassemia minor
She was also noted to have anemia this hospitalization felt to
be contributing to her atrial flutter trigger. For this she
required 1 unit PRBC. Iron studies showed findings consistent
with thalassemia minor and iron deficiency. B12 was normal. he
patient was evaluated by hematology/oncology that did not
recommend further follow up for the patient unless there was a
clinical change. SPEP/UPEP and hemoglobin electrophoresis were
pending at time of discharge. Guaiac of stools were positive
this hospitalization as they had been in the past but patient
was hesitant of further invasive procedures such as colonoscopy.
Also aspirin was stopped in setting of guaic positive stools. In
the past patient has not been interested in colonoscopy for work
up of this.
#Acute on chronic diastolic heart failure
Patient presented with dyspnea on exertion and fatigue. She was
admitted for heart failure exacerbation and improved with a few
doses of IV lasix and was transitioned to PO lasix prior to
discharge. Dose was decreased to 20 mg daily.
#Wedge shaped opacity in lungs
Patient noted to have wedge shape opacity on CXR on admission.
She did not have symptoms consistent with pneumonia. Repeat
imaging on ___ also showed a slightly improved wedge shaped
opacity that may have been secondary to pleural effusion.
#Hypertension
During this admission amlodipine and clonidine were stopped.
Lisinopril was continued and metoprolol uptitrated with addition
of diltiazam as above. The patient had normal orhtostatic vital
signs and was without orthostatic symptoms with ambulation prior
to discharge. | 230 | 420 |
13791839-DS-2 | 26,140,927 | Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with back pain. You
were ultimately found to have metastatic malignant melanoma.
You were also found to have spinal stenosis, which could explain
your back pain. You will need to meet with oncologists going
forward to discuss the next plan in treatment. You are now
being discharged.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck! | This is a ___ year old male with past medical history of CAD s/p
CABG, BPH, presenting with several weeks of fatigue, 1 day of
acute back pain, incidentally found to have signs of significant
metastatic disease, undergoing expedited workup
# Suspected Secondary malignancy of spleen, liver
# Lymphadenopathy
# Malignant Ascites
Patient incidentally found to have findings consistent with
extensive hepatic, splenic and oseous metastasis, as well as
notable lymphadenopathy. Labs notable for LDH 3000 with
remainder of tumor lysis labs negative. Patient was seen by
oncology consult service, and underwent excisional axillary
lymph node biopsy by the general surgery service. Given high
risk for tumor lysis syndrome he was started on allopurinol and
IV fluids. Biopsy results returned showing malignant melanoma.
Oncology met with the patient and explained the diagnosis.
Follow-up with Dr. ___ was set for ___ for further planning.
He was kept on allopurinol, though there is overall low risk for
tumor lysis. It should be decided whether this should be
continued going forward.
# Generalized edema:
Patient developed generalized edema (most noted in lower
extremities and scrotum) related to getting IVFs to prevent
tumor lysis. He received three days of IV diuresis, and will be
discharged on furosemide 40 mg PO on discharge. He will need to
get a Chem10 on ___ to make sure his creatinine and
electrolytes remain stable. It will need to be decided how long
he needs furosemide for his edema.
# Transaminitis: likely from metastatic infiltration of his
liver. LFTs should be rechecked intermittently, first time on
___.
# Lower back pain
Patient presented with worsening lower back pain. CT scan
incidentally revealed the above. An MRI showed severe spinal
canal narrowing at L4-5 from disc disease, with resulting nerve
root compression. He was seen by orthospine service--patient
had no related neurologic deficits and his symptoms were
controlled with prn tylenol. They recommended non-operative
management. Patient was seen by ___ and they recommended home
with physical therapy.
# CAD
Continued home ASA, statin. Home metoprolol was held, as blood
pressure was on low side, and it will need to be decided whether
he should continue this medication on discharge.
# Depression:
Continued home citalopram
# BPH
Continued Tamsulosin
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with his PCP. Follow-up
with Dr. ___ in Oncology was set for ___ for further planning
for the patient's malignant melanoma. He was kept on
allopurinol, though there is overall low risk for tumor lysis.
It should be decided whether this should be continued going
forward. He will need to get a Chem10 on ___ to make sure his
creatinine and electrolytes remain stable. It will need to be
decided how long he needs furosemide for his edema. Home
metoprolol was held, as blood pressure was on low side, and it
will need to be decided whether he should continue this
medication on discharge. LFTs should be rechecked
intermittently, first time on ___.
# Contact - Son ___ until ___ - ___, then daughter
___
# Code Status - presumed Full | 90 | 521 |
14585953-DS-6 | 22,953,279 | Dear Mr. ___,
You were hospitalized after you experienced weakness and falls.
Your home ___ medications were adjusted to decreased
your rigidity and improve your working. You will go to a rehab
facility to further work on these skills. You were also started
on two new medications, Aricept and Sertraline, to prevent
___ disease related mood disturbances. Please stop
taking your home Oxybutynin as this can interact with Aricept.
We wish you all the best! | Mr. ___ is an ___ year old man with a past medical history
of ___ Disease who presented to the ___ ED ___ with
generalized weakness and recurrent falls.
He was initially admitted to the medicine service, who he was
treated with lasix for a presumed congestive hepatopathy (pt
presented with elevated bilirubin and AST, slight crackles on
pulmonary exam, and mild peripheral edema). These results then
normalized. Infectious workup including UA, urine culture, CXR
and blood culture were unremarkable.
He was transferred to the general neurology service as he still
continued to demonstrated an inability to ambulate with notable
rigidity and bradykinesa. He underwent a lumbar spine MRI as he
had had a recent fall and reported back pain; this showed mild
spinal stenosis at L2-3 and L3-4 levels and no evidence of
high-grade thecal sac compression or acute compression fracture.
His Sinemet was then adjusted as his symptoms were attributed to
progression of his ___ disease. He developed
hallucinations when the dosing amount of Sinemet was increased.
He then tolerated an increase in the frequency of his Sinemet to
QID (prior dosing of TID at home). He was also started on
Aricept to limit hallucinations. Home oxybutynin was also
discontinued due to its anticholingeric effects. He was also
started on sertraline to treat ___ disease related
depression.
Otherwise, he was continued on a bowel regimen and
fludrocortisone to prevent constipation and othostatic
hypotension related to ___ disease. He did have
intermittent hypertension during hospitalization; he was
continued on his home captopril and received hydralazine PRN. He
was also continued on finasteride and tamsulosin for history of
benign prostatic hypertrophy.
Physical therapy worked with patient during hospital stay. He
was discharged to a rehab facility in stable condition.
=====================
TRANSITIONAL ISSUES
=====================
-His Sinemet was increased in frequency; please continue to
monitor and adjust as needed.
-He was started on Aricept for hallucinations related to
Sinemet; this led to an improvement of symptoms.
-He was started on Sertraline for concern for depression in day
prior to discharge. | 74 | 329 |
18760823-DS-7 | 25,006,985 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were sent in for low blood pressure
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given a unit of blood
- You were monitored for low blood pressure, which did not
happen
- You were found to have a leaky aortic valve surgery. Vascular
Surgery was consulted who recommend starting a medication to
control your blood pressure.
- You were weaned down to your baseline 1L oxygen.
- You were found to have a small hole in your heart that you
should see Cardiology for as an outpatient.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
=========
Ms. ___ is a ___ female with history of ascending aortic
aneurysm (since ___ and aortic regurgitation s/p
mAVR/Bentall/CABG on warfarin c/b ___ requiring brief HD, GI
bleed, respiratory failure (requiring tracheostomy) now
reversed, and complete heart block (requiring PPM) in ___
with recent admission for Type B aortic dissection s/p thoracic
EVAR, referred from ___ for hypotension, found
on CTA chest to have endovascular leak within the aneurysm. | 152 | 70 |
14983953-DS-21 | 25,351,804 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Wear your hard collar at all times. | Patient was admitted to Neurosurgery on ___ for his
cervical fracture and further syncope work up.
A Cervical MRI was obtained which showed that the fracture was
old. Thus, he remained in a cervical collar. Syncope work-up
was obtained. Echo revealed only mild aortic stenosis, ECG was
WNL, cardiac enzymes were negative, EEG **** , but carotid u/s
were unable to be performed secondary to the cervical collar.
___ and OT were consulted for assistance with discharge planning
and they recommended acute rehab.
Medicine was consulted and they recommended that his
hyponatremia was secondary to fluid hypovolemia. Patient was
given fluid boluses.
Upon rehab bed availability he was cleared for discharge. | 78 | 114 |
16882534-DS-17 | 25,252,205 | Surgery
Please keep your sutures along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ year old female with bilateral acute on chronic subdural
hematoma who presented after one week of progressively worsening
headaches. She was admitted for further evaluation.
#Bilateral Acute on Chronic Subdural Hematoma
Head CT was stable compared to outpatient head CT from
___. She was started on Keppra for seizure prophylaxis.
Treatment options were discussed with the patient/family, who
initially wanted to continue to wait and see if would improve
without neurosurgical intervention, however after several days
of observation they decided on surgical intervention.
She was taken to the OR on ___ and underwent right
craniotomy for evacuation of subdural hematoma with Dr. ___.
The procedure was uncomplicated, please see operative report for
further details. A subdural drain was left in place. She was
extubated and transported to the PACU for recovery. Postop head
CT was without acute complication. She was transferred to the
___. Drain was lowered to promote drainage. Drain was removed
on ___. She was transferred to the floor. Patient
complaining of uncontrolled headache prior to planned discharge
on ___. Aside from the headache, the patient was otherwise
neurologically intact. Head CT was ordered given the patient's
uncontrolled headache and recent subdural drain removal the
previous day. Head CT revealed stability of the bilateral
subdural hematomas. There was a new 0.9cm hyperdense focus in
the right frontoparietal subdural hematoma, possible
post-procedural. Patient was closely monitored over the weekend
& she remained neurologically intact and with improvement in her
headaches. She was evaluated by ___, who recommended discharge
to rehab. She was discharged on ___ in stable condition.
Keppra should be continued 7 days postop (to ___, then
discontinued. | 431 | 271 |
11937566-DS-20 | 24,383,764 | Dear Mr. ___,
You were admitted with influenza. This has improved and you are
feeling well. We gave you extra doses of steroids and antiviral
medication. Please followup with your primary care doctor. Your
oxygen level was noted to drop at night and you will benefit
from having a sleep study to test for sleep apnea.
Sincerely,
Your ___ Team | ___ h/o hypopit who presented with weakness, lethargy, possible
syncope, and cough, with a new O2 requirement and found to be
flu positive.
#Influenza pneumonia: Pt was flu positive. CXR showed no
definite acute cardiopulmonary process, likely viral bronchitis
with extensive secretions. Improved with supportive care,
including IVF, IS, flutter valves, chest ___, bronchodilators,
and tamiflu. Ambulating on RA at d/c.
#Panhypopituitarism: Pt with malaise and high fevers and
required stress dose steroids - 30 mg BID x4 until d/c, then
switched back to home doses. Continued levothyroxine, DDAVP,
testosterone
# ___: Baseline CR 1.2, peaked at 1.6, likely pre-renal despite
Una>20. Improved with IVF.
# Syncope: Most likely hypovolemic/orthostatic vs. pituitary
apoplexy given stable BPs during admission. Lower c/f cardiac
process. Also lower c/f PE given absence of risk factors, s/o
DVT, persistent hypoxia, tachycardia, or chest pain. No events
on tele, TTE only showed borderline pulmonary hypertension but
no significant valvular disease.
# Nocturnal hypoxia (mild): Noted on tele. Suspect undiagnosied
OSA. Echo (TTE showed mild pulmonary HTN). We recommended he
pursue outpt sleep study via his PCP.
# Home meds: Restarted nonformulary creams, antihistamine eye
drops at d/c. Continued home MVI, statin, ASA.
# HTN: Held home meds while receiving IVF and recovering from
viral sepsis. Restarted amlodipine/benazipril at d/c. | 57 | 214 |
15380379-DS-11 | 24,319,781 | You were admitted with cholangitis from gallstones that are
dropping down into your bile duct from your gallbladder. You
were very sick and required the intensive care unit. You
improved with supportive care, antibiotics, IV fluids and then
diuretics, and an ERCP procedure.
You had atrial fibrillation here (an abnormal heart rhythm that
increases the risk for stroke). We started you on a blood
thinner, to lower this risk, which will be managed at rehab.
You will need to come back to the hospital for more work on your
bile ducts and likely cholecystectomy (gallbladder removal
surgery). | ___ y/o female with a hx of HTN, HLD, TIA, severe AS, PUD, and
admission in ___ for choledocholithiasis/cholangitis who
presents as a transfer from ___ with nausea and
vomiting, diagnosed with cholangitis with severe sepsis. She was
admitted to the medical ICU, started on pressors and
antibiotics, and diagnosed with cholangitis and bacteremia.
Active Issues
=============
#Severe Sepsis
#Leukocytosis
#Transaminitis/Hyperbilirubinemia
Presented with ___ SIRS criteria with lactic acidosis c/w severe
sepsis. WBC 26.3 with a neutrophil predominance. OSH CT scan
showed choledocholithiasis with dilated intra and extrahepatic
biliary ducts and RUQ US confirmed 1.___ile
duct secondary to obstructing 1.8 cm distal CBD stone. ERCP
showed copious pus confirming the diagnosis of cholangitis. She
was treated with vancomycin/zosyn and norepinephrine initially
due to persistent hypotension despite fluid resuscitation. Blood
cultures returned positive for pansentisive klebsiella and strep
anginosas, at which time her antibiotics were narrowed to
ceftriaxone with plan to complete a two week course. ID was
consulted, and recommended Upon discharge, would transition to
PO levofloxacin 750mg q24h and metronidazole for 14d course
(___).
#Hypoxic Respiratory Failure
Developed a new oxygen requirement prior to transfer to ___.
Initial exam was notable for fluid overload, BNP was elevated,
and CXR showed pulmonary congestion and atelectasis, all
consistent with a component of pulmonary edema i/s/o fluid
resuscitation. She was intubated for ERCP and was extubated
after ~48 hours. She was diuresed briefly with IV Lasix with
rapid improvement in her O2.
--PO furosemide 10 mg daily started, along with standing K
repletion.
--Discharge weight: 40 kg
--Continue to wean down oxygen
# Coagulopathy
Anticoagulation started for AF, with heparin gtt. Warfarin
started on ___, given 2 doses of 2.5 mg. Switched from heparin
gtt via PICC to enoxaparin on ___. PTT & INR elevated this
morning, to 100 & 5.4 respectively. Repeat INR 7.2. Repeated
again, via phlebotomy and elevated to 9.5. No signs of bleeding
on examination. Suspect due to interaction with Flagyl. Given
2.5 mg PO vitamin K x1, with improvement in INR. O discharge,
INR 5. 4.
--Trend INR daily
--Will need to start warfarin (perhaps with enoxaparin bridging,
depending on INR [goal ___ depending on INR
# Paroxysmal atrial fibrillation: New onset AF on ___ following
ERCP. Likely due to the procedure, sepsis and pressors.
Converted back to NSR within ___ hours. CHADSVASc 6 with
history of CVA/TIA. Given high risk of stroke, and risk for post
procedure bleeding, have started heparin gtt for bridging/easy
off. Transitioned to enoxaparin/warfarin bridging.
--Anticoagulation as above
#NSTEMI type II
#Elevated BNP
Mild troponin elevation initially. She denied having any chest
pain and vomiting not felt to be an angina equivalent. EKG with
poor R-wave progression, though overall unchanged from prior and
serial EKGs stable. Felt to be a type II NSTEMI ___ sepsis and
severe AS.
#Anion Gap Metabolic Acidosis
#Lactic acidosis
Lactate 2.5, AG 17 on admission, likely ___ sepsis and poor
perfusion. Improved with intravenous fluids.
=================
CHRONIC ISSUES
=================
# Hypertension
# Likely CAD
# Severe Aortic Stenosis
# Type 2 NSTEMI / Demand Ischemia: TTE in ___ showed severe
AS (valve area 0.5, peak velocity 4.4, peak gradient 79).
Cardiology was consulted and planned for outpatient
follow-up/consideration of TAVR. Unclear if this evaluation ever
occurred. Troponin elevation, peaked at 0.2. She denies having
any chest pain. EKG
with poor R-wave progression, though overall unchanged from
prior. Serial EKGs stable. Likely type II ___ sepsis and severe
AS. Continued atorvastatin, Toprol XL.
--Home amlodipine at ___ dose. Follow up hemodynamic response to
diuretics and consider increasing to home dose.
--Consider outpatient cardiology following for TAVR
consideration.
# Metabolic encephalopathy: Fairly severe initially by report.
Now improving though still waxes and wanes. Some memory
impairment has been apparent (i.e. forgetting family visiting).
#Hypertension
Her home metoprolol and amlodipine were held initially given
severe sepsis. Following improvement in her BP, her metoprolol
was restarted. | 96 | 629 |
11826927-DS-31 | 27,632,356 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for painful toes. You were seen by
vascular surgery and had studies to look at the blood vessels in
your legs which showed that these vessels are narrower than they
are supposed to be. We are treating your foot pain with
hydromorphone, tramadol, amitriptyline and dronabinol. In order
to increase blood flow to your feet, we stopped your midodrine,
unless you are having dialysis. We are also stopping your
warfarin as we think that might be contributing to the vessel
narrowing. We started aspirin and atorvastatin in order to treat
your vessel disease. | Ms ___ is a ___ y/o female with HIV/AIDS (CD4 108 in ___,
ESRD on HD, and neuropathy who presents with worsening toe pain
and black discoloration. | 112 | 27 |
10976798-DS-2 | 24,826,558 | Dear Mr. ___,
It was a pleasure taking care of your on your hospital stay at
___.
Why was I hospitalized?
- You were admitted to the hospital for a clot in your lung
called a pulmonary embolism
- you were treated with IV heparin an anticoagulant
- You were taken off of warfarin and started on a new blood
thinning medication called lovenox
- You had an ultrasound of your heart which showed a clot which
was consistent with your lung clot
What you need to do once you leave the Hospital
- You need to continue taking your new medication - Lovenox
twice daily
- You will need to see your regular doctor and ___ cardiologist
when you are discharge from the rehab facility
- You should avoid high risk activities not that you are using a
blood thinner; activities such as using power tools, walking
without assistance.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ care team | Summary:
Mr. ___ is an ___ year old gentleman with a history of HLD,
HTN, myeloprolipherative disorder, A fib on warfarin, and
pulmonary HTN with chronically dilated right atrium who
presented for ___ with acute onset pleuritic chest pain
and acute hypoxia respiratory failure found to have an occlusive
left PE on CTA started on heparin gtt. and transferred to ___
for further management. He was admitted to the CCU where he was
continued on heparin gtt and respiratory support with a
non-rebreather on 100%Fi02. He improved with home diuresis and
was on heparin and eventually transitioned to lovenox per
hematology recommendations.
# Acute Occlusive Left PE: New occlusive left PE, with hypoxia
and pleuritic chest pain. Patient started on heparin gtt at
outside hospital. Patient risk factors include hx of
malignancy/myeloproliferative disorder, and PAH. Patient also
has A fib but on warfarin with most recent INR therapeutic 2.6.
We continued him on a herparin gtt and then consulted Heme/onc
and per their recs we transitioned him to lovenox. We also got a
formal TTE which demonstrated right atrial thrombus of 2.4X2.2CM
in size. He was treated with lovenox on his stay and followed
clinically. On day of discharge he was on ___ 02. He had APAS
labs done which were negative.
#Hypoxic respiratory Failure: Baseline 4L at day 2L at night.
Now with increased oxygen requirement, most likely secondary to
acute occlusive PE seen on outside CTA. Patient requiring
non-rebreather and desats to the ___ when off of mask, however
he does use 4L at home. His PFTs do not demonstrate an
obstructive pattern FEV1 >70, but do show decreased diffusion
capacity. He was back close his baseline 02 by discharge. He was
diuresed with Lasix 40mg PO his home dose and given extra 20mg
IV doses for extra respiratory support.
#Chronic Pulmonary HTN: Per outside records he is thought to
have class 1 PAH, however his hx of myeloproliferative disorder
may be a possible etiology and would make him class 5
(miscellaneous). Prior Right heart cath with PA pressure mean of
37 with wedge of 13. On sildenafil 20mg TID and home oxygen, his
sildenafil was increased to 40mg TID for SOB.
# Right Atrial Thrombus: Patient seen to have 24mmx10mm right
atrial thrombus on CTA at ___ in setting of chronically
dilated right atrium. New thrombus on therapeutic warfarin is
concerning for need to transition to other anticoagulant.
Patient denies missing any doses and his INR was therapeutic. He
was treated with heparin gtt and then transitioned to Lovenox.
He will need to be on lovenox outpatient BID for life.
#Diastolic Heart Failure: Patient has a history of diastolic HF
per outside records on Lasix 40 PO and beta blocker. On his exam
he appears to have some mild JVD elevation which is consistent
with is Right atrial enlargement and increased pressures from
both chronic PAH and new PE. No lower extremity edema, but there
are some lung crackles which may be contributing to his new DOE
and hypoxia. He was diuresed with his home 40mg Lasix dosing,
with extra 20mg IV dosing intermittently for extra respiratory
support.
# CAD: Prior cath history with Lcx disease of 40% occlusion ___. We continued his home atorvastatin.
#Atrial Fibrillation: Anticoagulated with warfarin last INR 2.6,
beta-blocked with atenolol 12.5 BID. He was anticoagulated with
heparin gtt and transitioned to lovenox.
Chronic Stable Issues:
#Chronic Kidney Disease: Patient has elevated cr. from ___
of 1.34. On this admission his Cr. is 1.2.
#HTN: we held home lisinopril and atenolol
#HLD: continued home Atorvastatin 20mg daily
^^^^^^^^^^^^^^^^^^^^The patient was discharged to ___ of
___ | 159 | 603 |
11958553-DS-8 | 25,694,510 | *** You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener. | On ___, the patient was trasnferred to ___ from ___ for
work up of a left cerebellar lesion. The patient was admitted
to the ___ for further observation and work up. A brain MRI
was ordered which showed a left cerebellar lesion. He was stable
overnight in the ICU. On ___, a wand study was performed for
the OR and he was taken to the OR with no intraoperative
complications. He was extubated post operatively and transferred
to the ICU for close monitoring. Post operative CT showed post
surgical changes with no acute hemorrhage.
On ___, patient was neurologically intact on exam. MRI head was
performed and showed improvement in effacement and mass effect.
His subgaleal drain was removed at the bedside and he was
transferred to the floor. His foley was removed and he was OOB
to chair.
On ___ Patient was neurologically stable. He became
hypertensive to 170s sustained when ___ attempted to evaluate
him. He was ordered for PRN hydralizine will attempt to
re-evaluate tomorrow.
On ___ Increased home dose of lisinopril for consistent
hypertension with good resolution of hypertension. Patient was
cleared for discharge home by ___. He was discharged home in good
condition with instructions for follow up. | 319 | 206 |
17442082-DS-13 | 26,181,051 | Dear Ms. ___,
you were seen in the hospital because you had an episode of
visuo-spatial confusion where you felt like you couldn't figure
out where you were or how to get out of the place. We had wanted
to evaluate your brain with an MRI but it was deferred due to
your claustrophobia.
We did do an EEG (brain wave testing) which did not show
seizures. You also had a CTA (CT angiogram) which showed no
narrowing that would limit blood flow.
We are not sure of the final diagnosis at this time, but the
dangerous things to rule out would be stroke or transient
ischemic attack, seizures or confusional/complex migraines.
Without an MRI, it is hard to definitely rule out a stroke. To
this end, we will increase your aspirin, and have checked your
other risk factors. Your hemoglobin A1C (which checks for
diabetes) is still pending at this time, but please follow up
with your primary care physician.
If you have other episodes of confusion, please return for
re-evaluation. | Patient was admitted to stroke service for an episode of
visuo-spatial disorientation/confusion. Limited work up was done
as patient refused MRI due to her claustrophobia. She did have
prolonged EEG which did not show seizures on prelim read.
Aspirin was increased given possibility of TIA.
On routine labs in the hospital, she was found to have mild
leukopenia and thrombocytopenia, which had been intermittently
present before. This should be followed up as outpatient. | 171 | 74 |
16135826-DS-5 | 21,747,638 | You were admitted for evaluation of urinary retention and
constipation. Your urinary retention is likely related to a few
of your medications and constipation. Fortunately, you had a CT
scan that did now show any blockages, but did show constipation.
Your ___ was removed and you were able to urinate on your own
without any difficulties. Your constipation resolved and you had
some diarrhea. You had a fall and had some L.arm pain after
this, your xrays did not show any broken bones.
Please be sure to continue to discuss the medications you are
taking and the need for them long term as many can lead to
urinary and bowel side effects like you are experiencing.
You are on multiple sedating medications including hydrocodone,
baclofen, lorazepam, trazodone fioricet. None of these
medications should be taken at the same time or within a few
hours of each other as this can cause confusion, difficulty
breathing, failure of breathing and death. As above, please
continue to discuss the ongoing need for these medications with
your primary care doctor. You were started on some medication to
help prevent constipation. | Ms. ___ is a ___ female with a PMH notable for CKD
stage 3, fibromyalgia, migraines, chronic constipation and
urinary incontinence who presents with urinary
retention and LLQ abdominal pain with constipation. Now
resolved.
But pt now s/p mechanical fall this am and having L.arm pain. | 186 | 43 |
15299366-DS-15 | 27,625,447 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I admitted?
- You were admitted because of GI bleeding and your INR was very
high.
What happened while I was at the hospital?
- Your Coumadin level was reversed with medications.
- You were initially monitored in the intensive care unit. Your
blood counts were watched very closely.
- Your blood counts did drop a bit from the blood that you lost,
but they have mostly stabilized.
- To be very safe, we recommended that you stay in the hospital
for one more stay to make sure you did not have any more GI
bleeding. However, you did not want to stay in the hospital any
longer, therefore we are discharging you home. This is
technically against medical advice, but we respect your
decision.
What should I do after I leave?
- You should have your blood counts checked tomorrow. We are
giving you an order for this and also putting it into the
computer. We will email your primary care physician to let him
know.
- We will also let Dr. ___ of your decision to
discontinue Coumadin. You can discuss with her whether or not
there are other medications you should take to prevent strokes
from atrial fibrillation.
We wish you the best!
- Your ___ Team | ___ year old gentleman with history of ESRD (hypertensive
nephropathy) on peritoneal dialysis, history of C. difficile
infection, atrial fibrillation on anti-coagulation, who was
referred to the ___ ED after experiencing bright red blood per
rectum and having an elevated INR of 11. | 212 | 44 |
15666511-DS-22 | 25,768,999 | Dear ___ it was a pleasure caring for you during your stay
at ___. You were admitted with abdominal pain and jaundice
and found to have another blockage where your new stent was
placed. You underwent ERCP on ___, the previous stent was
removed and a new stent was placed.
You went to the ICU after having the fiducial seeds placed for
radiation because transiently some bacteria got into the blood
stream around the time of the procedure but we are treating you
with antibiotics for that to go through ___.
We think the tumor is bleeding slowly so radiation ___ should
help with that but you will see your doctor in clinic this week
to see if you need any more transfusions. If you notice any
blood in your stool call your doctor. Please take 0.5-1 mg of
ATivan and 8 mg of Zofran 30 minutes prior to your Radiation
Oncology appointment to help with the anxiety and nausea. Bring
your bottle of ativan with you to the radiation oncology visit. | Ms. ___ is a pleasant ___ w/ fibrolamellar HCC, currently on
C4 FOLFOX, s/p L hepatic lobectomy ___ and TACE ___
complicated by anastomotic stricture with biliary
obstruction/biloma and sensitive Enterococcus bacteremia
(___) who presents w/ abdominal pain/transamnitis. She was
inintialy treated for presumptive cholangitis s/p ERCP w/ stent
placement ___, later developed sepsis and bacteremia in setting
of ___ guided fiducial placement, subsequently s/p FICU stay for
MDR E.coli bacteremia with sepsis physiology resolved and on
carbapenem therapy.
# Malignant Biliary Obstruction/Cholangitis
# Persistently elevated bilirubin -
Pt presented with abdominal discomfort and elevated LFTS
(specifically elevated Tbili compared to prior). Has complicated
history including internal stents and has required multiple
prior external PTBDs but none in at present. She initially
underwent ERCP on ___ w/ removal of old stent, cholangioscopy
showing tumor infiltration of R hepatic duct, new plastic stent
placed in R anterior hepatic duct. Slow bleeding was also
visualized inside ducts from tumor. Per ERCP, nothing further
they can do endoscopically at this point based on what they saw,
but her bilirubin remained elevated after the procedure. She was
initially given a 7 day course of cipro for cholangitis in that
setting. Given worsening tumor progression and the bleeding that
was seen (see anemia below) it was decided RT should be pursued
as the next option. Prior to her discharge, Tbili remained
elevated, though was slowly downtrending. ___ did attempt to
place a PTBD on ___ to see if any component amenable to
external drainage, but on cholangiogram everything seemed to be
patent including the internal stent, so no PTBD drained placed
at this time as it was felt that there would be no benefit of
doing this. Hemolysis labs were not suggestive of such to
explain the elevated bilirubin and ultimately this was felt due
to tumor progression with hopes that radiation would improve
this marker as well. Imaging of CT and RUQ u/s done during this
admission also demonstrated no worsening collections or biliary
dilation amenable to intervention at this time.
# Septic Shock
# MDR E.coli bacteremia
Pt went for ___ guided fiducial placement on ___ which was
followed that same day by the development of fever and septic
shock and FICU transfer requiring pressors for a brief period of
time to maintain MAPs. In that setting she was started on
vanc/cefepime/flagyl empirically, and blood cultures from ___
grew MDR E.Coli bacteremia, R to cefepime, so she was changed to
meropenem on ___ was the only day of positive blood
cultures and with antibiotic therapy she improved rapidly and
was transferred out of the FICU after short stay. Hemodynamics
remained stable throughout and no further fevers. It was felt
that given the timing of the episode immediately after/at the
time of ___ guided fiducial placement this represented transient
bacteremia in setting of procedure/instrumentation. CT a/p ___
done at the time of FICU transfer did not show any other process
suggestive of infection. RUQ done ___ did show that the right
kidney had an abnormality which was either artifactual or could
suggest pyelo, but she never had flank pain or abnormal UA/Urine
culture, nor dysuria or vomiting, so this was ultimately felt to
be artifactual. She was continued on meropenem with 2 week
course planned ___, and she was transitioned to
ertapenem which was started just prior to discharged. No other
sources of infection were identified.
# Complicated infectious history - to summarize briefly for
future reference:
She has a complicated infectious history in setting of recurrent
biliary obstruction; hepatic collection isolated MDR E coli in
___ and pt is s/p prior TACE which resulted in superinfection
of bilomas. She has had enterococcus bacteremia in ___
(sensitive) and complex collection aspiration grew
enterococcus and also C. albicans. She was transitioned to dapto
and fluc ___ from ___ vs pip tazo, felt zosyn more
likely). Readmitted ___ after ERCP with frank pus
drained, stenting not possible, got 2 week course tigecycline,
readmitted with fever in ___ puss again, cultures
negative and she again got IV tigecline empirically. Readmit for
cholangitis as above s/p course of cipro and ERCP stenting, w/
subsequent ESBL E.Coli bacteremia ___ ___,
treating w/ carbapenem as above. Note that per last ID outpt
note, it was felt that chronic suppression therapy would not be
advisable, in order to preserve antibiotic sensitivity for the
future given her complicated history).
___ - Creatinine went up during this admission felt due to
ATN in setting of hypotension and sepsis but downtrended
ultimately back to normal. There may have been component of
elevated vanc trough and toradol administration earlier in the
hospitalization contributing to ATN/AIN. Urine output remained
good throughout.
# Anemia: stable/slow downtrend overall. Her hgb declined from
baseline mid 9s to now 7 range, (10 on admission but likely
hemoconcentrated) also suppression from chemo and possible
chronic bleeding from bile ducts as ERCP w/ mild oozing.
Possible contributor chemotherapy. CT during FICU stay (torso)
without e/o acute bleed otherwise. No melena or brbpr. Hemolysis
labs not suggestive of such (hapto 140, fibrinogen not low, LDH
not elevated, retics low at 3.0). It was felt unlikely to be
hemolysis and more likely due to slow tumor bleed that had been
visualized on ERCP. She was given 1 U PRBCs on ___,
___, and ___, trying to keep hgb > 7. She will follow up with
outpt oncology this week for counts check. Prior iron studies
c/w inflammatory block. B12 and folate were wnl.
# ABD/RUQ pain - ___ underlying disease as has large mass in
liver, exacerbated by biliary obstruction. Pain overall improved
compared to admission, she was ultimately discharged on MS
contin 15mg q8 with prn po dilaudid. Palliative care follows her
closely due to pain requirements and history of narcotic use.
Ritalin was used to hellp with sedation (20mg in AM and 5mg in
___. Social work and psychiatry following.
# Right neck pain - improved w/ bengay use. neck U/S reassuring.
likely muscle tension/cramping only. exam reassuring, neuro
exam WNL. Cyclobenzaprine used once daily to help with this with
good effect.
# Fibrolamellar HCC: was due for C5D1 FOLFOX on ___, on hold
given acute issues
above. ___ to start cyberknife on ___, plan for 3 treatments. Had
been hoping to get her into trial at ___ but needs bilirubin
lower to qualify.
BILLING: >30 min spent coordinating care for discharge | 172 | 1,050 |
18966240-DS-29 | 29,823,110 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had an acute pain episode caused
by sickle cell disease
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We gave you pain medications to treat your acute pain episode.
- We evaluated you to ensure that you did not have a worsening
infection.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Take all of your medications as prescribed.
- It is very important for you to see a nephrologist for your
nephrotic syndrome as this disease can be very serious and have
long term impacts on your health.
- It is very important that you follow-up with your
hematologist, and schedule appointment with your primary care
provider, so they can coordinate your medications.
- Be sure to take all your medications and attend all of your
appointments listed below.
We wish you all the best,
Your ___ health care team. | SUMMARY:
Mr. ___ is a ___ history of sickle cell disease, ___
c/b CVA x4 w/ residual L-sided weakness, asthma, depression,
nephrotic range proteinuria, who presents with back and
bilateral hip pain and worsening lower extremity swelling,
admitted for acute pain episode, requiring IV pain medication
initially. Infectious work-up, given reported fever to 105, was
negative. He was transitioned onto his chronic dose of
oxycodone, but was not discharged with a new prescription, given
multiple flags on ___ and previously filled prescriptions. | 175 | 81 |
18011662-DS-17 | 22,416,671 | Dear Mr. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You had an infected ulcer on your foot which led to a bone
infection
WHAT HAPPENED TO ME IN THE HOSPITAL?
-The ulcer was debrided by podiatry and a culture was taken of
the bone
-An additional antibiotic was added to your regimen which we are
able to discontinue on discharge, after seeing results from the
culture
-Vascular surgery examined your leg blood vessels and determined
that no further intervention was needed at this time
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Make sure you follow-up with the infectious diseases clinic at
___
We wish you the best.
Sincerely,
Your ___ Team | SUMMARY OF HOSPITALIZATION
============================
Mr. ___ is a ___ year old man w/ CAD s/p CABG in ___ with
recent PCI to vein grafts in ___, ESRD on ___ HD, type II
DM, peripheral neuropathy, and recent ___ toe amputation
complicated by osteomyelitis who presents for debridement of
ulcer and osteomyelitis; antibiotics managed with assistance
from ID, bone culture collected and pending, angiography
performed and not significantly changed from prior, with no
indication for intervention. He is discharged with
recommendation not to bear weight on the affected foot until
follow-up with podiatry, and to continue with vancomycin and
ceftazidime dosed with HD.
ACUTE ISSUES ADDRESSED
========================
# Osteomyelitis of R foot
# Necrotic ulcer
Previous cultures grew enterococcus, MSSA, and pseduomonas.
Subsequently developed foot ulcer, found to have ongoing
osteomyelitis on imaging. Underwent debridement and
metatarsalectomy of R foot w podiatry on ___. Treated with
vancomycin/ceftaz with HD and flagyl daily per ID; flagyl is
discontinued at discharge as anaerobic culture is negative.
Non-invasive vascular studies completed with increase in
calcification ___. Underwent angiogram with vascular on ___,
not significantly changed, no indication for surgery. Non
weight-bearing, using surgical boot, waffle boot at night. He
will follow-up with ID at ___, appointment scheduling
pending, ___ ID will reach out to patient.
# ESRD on ___ HD
Continued with HD, sevelamer, furosemide, nephrocaps. Continued
home lorazepam and Percocet before HD session. Renal diet
# Deconditioning
Patient endorsed significant deconditioning since his initial
surgery and is very frustrated by this, as he previously was a
very active person. ___ was consulted and recommended rehab.
# Coping
Patient was frustrated with recurrent hospitalizations and of
note, his daughter was undergoing BMT for AML in the coming week
with his wife being her bone marrow donor. Social work was
consulted.
# Pain management
# Anxiety
Patient with chronic low back pain attributed to a slipped disk
and has a lot of pain with dialysis. He also has some anxiety at
night and with HD. Continued with home lorazepam and clonazepam;
would suggest trying to consolidate to one agent as outpatient.
Continued home tramadol and oxycodone-acetaminophen.
CHRONIC ISSUES ADDRESSED
========================
# HTN
Continued home amlodipine, lisinopril, nadolol
# CAD s/p CABG in ___ with PCI to vein grafts in ___
Continue aspirin and Plavix, simvastatin; consider changing to
atorvastatin given interaction with amlodipine. Continued fish
oil.
# B12 deficiency
Continued home B12
# GERD
Continued omeprazole
# IDDM
Continued home glargine 24 units daily with SSI qac
TRANSITIONAL ISSUES
===================
[] Would consider consolidation of lorazepam and clonazepam
[] Consider atorvastatin over simvastatin given interaction with
amlodipine
[] Given family hx of cancer, please ensure patient up to date
on all cancer screenings
>30 minutes spent on discharge activity | 136 | 424 |
15496609-DS-25 | 29,821,330 | You were treated in the Medical Intensive Care Unit because of
your alcohol intoxication. You recovered. There was a small
pneumonia on chest X-ray please continue to take the last day of
your antibiotic. Please follow up with your primary care doctor
over the next ___ days to make sure you are improving. Return to
the Hospital if you have any concerns. | Mr. ___ is a ___ year old man with history of multiple
admission for EtOH use, history of seizures (possibly in setting
of withdrawal but not certainly), who presents after being found
down and unresponsive with EtOH level of 587. Found to have
respiratory failure with period of apnea requiring intubation,
with subsequent development of hypotension and CXR with evidence
of pneumonia.
# Altered mental status/obtundation
# EtOH intoxication
# Alcohol use disorder
Patient has had innumerable ED visits for alcohol intoxication,
nearly on daily basis. He was found down by EMS with EtOH level
fo 587 on arrival. He was somnolent and unresponsive with
periods of apnea and was intubated for inability to protect
airway. He admitted to the MICU where he was given phenobarb
load and taper to prevent alcohol withdrawal (pt with history of
withdrawal per chart). He had a negative serum osmolar gap when
corrected for ethanol. He was supported with multivitamins,
thiamine repletion, folate repletion. Following uneventful
extubation, patient was alert, oriented, and medically stable.
He was offered social work consult. On ___ was discharged in
pursuit of section 35 for ongoing management of substance use
issues. Police escort to court appearance, with plan for patient
to go subsequently rehab for alcohol use disorder.
# Pneumonia:
# Acute respiratory failure
As above, the patient was intubated for apnea and inadequate RR
in setting of obtundation. Retrocardiac opacity suggestive of
PNA, pt at risk of aspiration given alcohol and hx of seizures
so patient was initially covered broadly with vancomycin and
zosyn. He was subsequently narrowed to levaquin prior to
discharge for 5 day CAP course given clinical improvement and
uneventful extubation.
# Hypotension: Patient became hypotensive after intubation,
possibly related to sedation/positive pressure ventilation with
likely contribution from concurrent infection. With time off
sedative medications and improvement of infections, blood
pressures returned to normal.
#Lice: after discharge lice were noted in his clothing. The
___ rehab will be contacted regarding this. | 62 | 322 |
12936451-DS-21 | 26,162,982 | ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion.
1.When you are discharged from the hospital and settled at
home/rehab, if you do not have an appointment, please call to
schedule two appointments:
1.a wound check visit for 8 -14 days after surgery
2.a post-operative visit with your surgeon for ___ weeks after
surgery.
1.You can reach the office at ___ and ask to speak
with staff to schedule or confirm your appointments.
Wound Care
If not already done in the hospital, remove the incision
dressing on day 2 after surgery. Keep the incision dry for the
first two days after surgery.
There will often be small white strips of tape over the
incision (steri-strips). These should be left alone and may get
wet in the shower on day 3.
Starting on the third day, you should be washing your incision
DAILY. While holding the head and neck still, gently clean the
incision and surrounding area with mild soap and water, rinse
and then pat dry.
Do not put any lotion, ointments, alcohol, or peroxide on the
incision.
If you have a multi-level fusion and require a hard cervical
collar, this may be removed for showering, and often sleeping
and eating. The collar will typically be removed at the week 4
visit.
You may remove the compression stockings when you leave the
hospital
Have someone look at the incision daily for 2 weeks. Call the
surgeons office if you notice any of the following:
___ redness along the length of the incision
___ swelling of the area around your incision
___ from the incision
___ of your extremities greater than before surgery
___ of bowel or bladder control
___ of severe headache
___ swelling or calf tenderness
___ above 101.5
At your wound check visit, the Nurse Practitioner or ___
___, will check your wound and remove any sutures or
staples or steri-strips.
Do not soak or immerse your incision in water for 1 month. For
example, no tub baths, swimming pools or jacuzzi.
Medications
You will be given prescriptions for pain medications and stool
softeners upon discharge from the hospital.
Pain medications should be taken as prescribed by your surgeon
or nurse practitioner/ physician ___. You are allowed to
gradually reduce the number of pills you take when the pain
begins to subside.
If you are taking more than the recommended dose, please
contact the office to discuss this with a practitioner ___
medication may need to be increased or changed).
Constipation: Pain medications (narcotics) may cause
constipation (difficulty having a bowel movement). It is
important to be aware of your bowel habits so you ___ develop
severe constipation. Call the office if this occurs for more
than 3 days or if you have stomach pain.
Most prescription pain medications cannot be called into the
pharmacy for renewal.
The following are 2 options you may explore to obtain a
renewal of your narcotic medications:
1.Call the office ___ days before your prescription runs out and
speak with our office staff about mailing a prescription to your
home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS)
2.Call the office 24 hours in advance and speak with office
staff about coming into the office to pick up a prescription.
If you continue to require medications, you may be referred to
a pain management specialist or your medical doctor for ongoing
management of your pain medications.
Avoid NSAIDS for 12 weeks post-operative. These medications
include, but are not limited to the following:
Non-Steroidal Anti-Inflammatory Agents: Advil, Aleve, Cataflam,
Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin,
Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen,
Tolectin, Toradol, Trilisate, Voltarin
Activity Guidelines
If you have a multi-level cervical fusion, you will be asked to
wear a hard cervical collar. This is typically removed at week
4 after surgery. You may not drive while wearing the collar.
You may remove your cervical collar for eating, sleeping, and
when showering.
Avoid strenuous activity, bending, pushing, or reaching
overhead. For example, you should not vacuum, do large loads of
laundry, walk the dog, wash the car, etc. until your follow-up
visit with your surgeon.
Avoid heavy lifting. Do not lift anything over ___ pounds for
the first few weeks that you are home from the hospital.
Increase your activities a little each day. Walking is a form
of exercise. Exercise should not cause pain. Limit yourself to
things that you can do comfortably and plan rest periods
throughout the day.
You are not unless you are not taking narcotic medication and
are not required to wear a collar. You may ride in a car for
short distances and avoid sitting in one position for too long.
You may resume sexual activity ___ weeks after surgery,
avoiding stress on the neck and shoulders.
Physical Therapy
Outpatient Physical Therapy (if appropriate) will not begin
until after your post-operative visit with your surgeon. A
prescription is needed for formal outpatient therapy.
You may be given simple stretching exercises or a prescription
for formal outpatient physical therapy, based on what your needs
are after surgery.
Blood Clots in the Leg
1.It is not uncommon for patients who recently had surgery to
develop blood clots in leg veins.
Symptoms include low-grade fever, and/or redness, swelling,
tenderness, and/or an aching/cramping pain in your calf.
You should call your doctor immediately if you have these
symptoms.
To prevent blood clots in legs, try walking and/or pumping
ankles several times during the day.
If the blood clot breaks free from the leg vein, it can travel
to the lungs and cause severe breathing difficulty and/or chest
pain. If you experience this, call ___ immediately.
Questions
Any questions may be directed to your surgeon or nurse
practitioner/ physician ___.
1.During normal business hours (8:30am- 5:00pm), you can call
our office directly at ___. If no one picks up,
please leave a message and someone will get back to you.
If you are calling with an urgent medical issue, please go to
nearest emergency room (i.e. pain unrelieved with medications,
wound breakdown/infection, or new neurological symptoms).
Rigid Collar Instructions
How to put collar on:
___ collar is labeled front and back with arrows
indicating top and bottom.
___ the back section on your neck first. Apply the
front section placing your chin in the chin rest.
___ securing the Velcro, make sure the front overlaps
the back section. This allows more Velcro to be exposed giving
the collar a more secure fit.
___ the collar as tight as you can while remaining
comfortable. The tighter it is worn, the more immobilization of
your spine is obtained and the less likely you will move your
neck.
Care for/during use:
___ alert to pressures under your chin. Some pressure
is necessary but do not allow a blister or pressure sore to
develop.
___ provide comfort, you should wear the collar liners
provided between the brace and your chin to absorb perspiration
and lessen irritation. We recommend that these liners be hand
washed.
___ collar can be washed with mild soap and water, then
dried with a towel and/or hair dryer on the lowest setting.
Hand washing is recommended. | Patient was admitted to Orthopedic Spine Service on ___ and
underwent the above stated procedure. Please review dictated
operative report for details. Patient was extubated without
incident and was transferred to PACU then floor in stable
condition.
During the patient's course ___ were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with oral and IV pain medication. Diet was
advanced as tolerated. Hospital course was otherwise
unremarkable. Her drain was removed in routine fashion. OT saw
patient and cleared for home
Now, Day of Discharge, patient is afebrile, VSS, and neuro
intact with improvement of radiculopathy. Patient tolerated a
good oral diet and pain was controlled on oral pain medications.
Patient ambulated independently. Patient's wound is clean, dry
and intact. Patient noted improvement in radicular pain. Patient
is set for discharge to home in stable condition. | 1,407 | 152 |
14283409-DS-21 | 24,661,575 | It was a pleasure taking care of you during your recent
hospitalization. You were admitted with confusion which was
because you had stopped taking your lactulose. When we restarted
the lactulose your confusion cleared.
We made NO changes to your medications during this
hospitalization. | ___ with NASH cirrhosis and portal hypertension, CAD s/p stent,
carotid stenosis s/p R CEA, HTN who presents with 2 week h/o
worsening mental status, especially this AM when pt was confused
and disoriented for 3 hours. | 44 | 39 |
16318056-DS-18 | 24,871,723 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch-down weight-bearing right lower extremity, range of
motion as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
touch-down weight-bearing right lower extremity, range of motion
as tolerated right knee
Treatments Frequency:
Dry sterile dressing to incision as needed | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right distal femur periprosthetic fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for revision ORIF right
distal femur periprosthetic fracture with ___ plate 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
touch-down weight-bearing activity 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. | 207 | 264 |
19676805-DS-31 | 23,628,778 | Dear Mr. ___,
It was a pleasure being involved in your care while you were
admitted at ___!
What happened while you were at the hospital?
-You were initially admitted to the intensive care unit for low
blood pressure.
-We gave you steroids to help keep your blood pressure in a safe
range.
-We noted that many of your body's vitamins and minerals were
low/deficient. We started TPN, which is nutrition through your
IV, to assist with you nutrition.
-We performed many tests to evaluate your low blood counts. The
most likely cause for your low blood counts was thought to be
nutritional, however we will have you follow up with a
hematologist to further explore this.
What should you do when you leave the hospital?
-Continue taking all of your medications as prescribed
-Keep your appointment with your gastroenterologist Dr. ___.
-Keep your appointment with endocrinology to further evaluate
the cause of your adrenal insufficiency.
-Keep your appointment with hematology to further investigate
your low blood counts.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Regarding your adrenal insufficiency, it is important for you to
remember these guidelines:
-Sick Day Rules - patient should take double steroid dose for
two days if they feel sick or have a cold. Furthermore should
triple dose for three days if very ill.
-Use the intramuscular injection of solu-cortef if you feel
extremely ill likely with symptoms of nausea and vomiting.
-Continue wearing your medical bracelet indicating that you have
adrenal insufficiency;
Sincerely,
Your ___ team | Mr. ___ is a ___ male with history of hyperlipidemia,
gastric cancer
s/p Roux-en Y esophagojejunostomy and appendiceal carcinoma s/p
right hemocolectomy ___, CKD (1.2-1.7), Heart Failure with
Reduced Ejection fraction ___, PPM, concern for adrenal
insufficiency (prior equivocal ___ stim tests, previously
managed on prednisone 3mg daily), DVT on Eliquis, and chronic
abdominal pain who
presented with 1 month of general weakness and dizziness with
ongoing shock of unclear etiology, suspected to be secondary to
nutritional deficits.
ACUTE ISSUES
===============
# Shock, undifferentiated:
# Adrenal insufficiency:
Patient presented with shock requiring pressor support although
the etiology was unclear. The etiology is likely multifactorial
and it is possible that he has some underlying autonomic
dysfunction (consider increased vagal tone in the setting of his
prior roux-en-y surgery), so he was started on midodrine and
uptitrated to 15mg TID. There was low suspicion for hemorrhagic
given no overt bleeding and not clinically consistent with
bleeding into an extremity although he had steadily dropping
Hgb. Endocrinology was following as there was suspicion for
adrenal insufficiency. He has had multiple stim test in the past
with inadequate response (none of the stim tests ever reached a
level of 18). He has also had an aldosterone stimulation test
as noted in the labs and it responded well indicating possible
secondary adrenal insufficiency. An MRI of the pituitary was
performed without evidence of adenoma. There was low suspicion
for sepsis (no sources identified). His pressor requirement
norepinephrine was discontinued on ___ with good MAP. Suspect
that his poor nutritional status may have been contributing to
his hypotension and orthostasis, given improvement with TPN
administration.
#Malnutrition:
Patient was quite malnourished with hypoalbuminemia and several
low vitamin/mineral deficiencies including low vitamin D,
vitamin A, zinc, copper, selenium. Niacin was low/normal and
Vitamin E was normal. This was likely secondary to altered GI
anatomy with esophagojejunostomy. A1AT was borderline, but not
felt to be consistent with a protein-losing enteropathy. He was
started on rifaximin for a 2-week course for presumed small
bowel intestinal overgrowth. He was started on TPN via ___ and
began repletion of his nutritional deficiencies.
#Urinary tract infection, catheter-related
Developed UTI following urinary catheter insertion for urinary
retention with symptoms of dysuria and + UA. He was started on
empiric ceftriaxone and then transitioned to augmentin when
urine culture returned as enterococcus (vancomycin resistant).
He should continue for a ___nd date ___.
#Macrocytic anemia
Baseline hemoglobin appears close to 10, stools remaining
reassuring and H/H was trended. B12 was normal. Fibrinogen has
been chronically low. No formal heme onc work up thus far.
Hematology was consulted in the ICU but given Plasmic score 3,
low likelihood of TTP, 4T score of 3, and would also consider
myelodysplasia although also clinically inconsistent with the
acute presentation of his worsening anemia. He is to follow up
with hematology as an outpatient for further evaluation of his
anemia. He received 3 u pRBCs throughout his admission.
Discharge Hgb: 8.5.
___ on CKD: Baseline 1.2-1.7, elevated to 2.6 on presentation,
slowly downtrending back to baseline. Likely pre-renal given
hypotension with some contribution from low blood pressures and
possible ATN. Discharge Cr: 1.1.
#Chronic Systolic CHF:
EF ___ with moderate AI, unchanged on repeat TTE this
admission. ICD in place for ppx. Pt with anasarca which was
thought to be primarily ___ hypoalbuminemia. He was started on
his home dose of diuretic 2 days prior to discharge but was held
on ___ I/s/o dysuria with his UTI. Please weight patient daily
and give furosemide if weight gain > 2 lbs. He was unable to
tolerate daily dosing of furosemide due to urinary irritation
and frequency. Consider restarting daily dosing when UTI
resolves.
#Thrombocytopenia
Platelet count consistently downtrended. DDx included
nutritional (copper/zinc deficiency) v a primary bone marrow
malfunction such as MDS. ___ evaluated pt throughout
hospitalization ruled out TTP/DIC. HIT score was low at 3. Final
assessment was most likely secondary to antibiotic exposure to
pip/tazo on presentation vs less likely nutritional given acute
decline in the hospital. He will follow up with hematology with
consideration of bone marrow biopsy. Discharge platelet count:
79.
# RLE DVT:
# Coagulopathy:
INR 1.7 on presentation likely in the setting of nutritional
deficiency and apixaban use. He was maintained on heparin drip,
and bridged to warfarin per hematology recs due to concern for
malabsorption and inability to determine if therapeutic. He was
continued on warfarin with goal
# History of VT: Noted during ___ admission, started on Sotalol
80mg daily. This was initially continued but then subsequently
held given his ___. As his kidney function improved. He
frequently has bursts of NSVT for which his pacer was required
to appropriately implement ATP. Ectopy improved but was not
eliminated after restarting metop and sotalol daily. Given his
fluctuating renal function, cardiology recommended stopping
sotalol and starting amiodarone 400 BID x 7 days then
transitioning to 200 mg daily. He will follow up with cardiology
as an outpatient.
CHRONIC ISSUES
===============
# Pancreatic Insufficiency:
# Protein Losing Enteropathy, Chronic Pancreatitis
# Chronic Abdominal Pain:
Follows with Dr. ___ ___ GI. Continued on Creon
24,000 units with meals 12,000 lipase with snacks. He was
continued on MVI daily and home hydromorphone. He was initiated
on TPN per above.
# GERD: Continued PPI as above
# HLD: Continued statin
# Hypothyroidism: Continued home levothyroxine | 252 | 892 |
17833222-DS-23 | 22,955,452 | Dear Mr ___,
You were seen at the hospital because you were having fever and
cough. Becuase of your history of having a weakened immune
system you were admitted to the hospital. You were evaluated ___
blood tests and scans of your chest. It was determined that you
likely had a viral infection of your lungs and windpipe. You
were treated with antibitiotics and anti-virals. As you
clinically improved, you will be sent home with intent to follow
up with your primary care doctor.
Please take all medications as prescribed and keep all scheduled
appointments.
It was a pleasure taking care of you!
Your ___ Care Team | Mr. ___ is a ___ yo man PMH AML s/p allo no evidence disease
re-occurence, COP presenting with fever and cough as well as
myalgias. Most consistent with viral illness.
#Fever: The constellation of fever, myalgia, and cough with
normal CXR was concerning for community acquired pneumonia vs.
viral illness. The normal CXR makes bacterial illness less
likely. The patient refused nasopharyngeal swab to rule out
viral illness. On day of admission concern for meningitis
because of light sensitivity, and he was started on ceftriaxone.
ID was consulted and thought meningitis highly unlikely so
ceftriaxone was discontinued. Infectious work-up was
inconclusive.
- Patient completed course of levaquin and ostelamavir.
#Chest Pain: Worse than patient's baseline. No pain with
exertion, does not seem anginal. EKG without acute changes.
- Pain control with acetaminophen and tramadol
- IV benedryl at night
Chronic Issues:
#COP
- Continues prednisone 1 mg
- Vitamin D for bone protection
#GVHD: Lung, joints, liver- chronic.
- Dexamethasone elixir for oral GVHD
- prednisone 1mg daily for liver GVHD | 105 | 180 |
10971495-DS-7 | 21,938,974 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ year old male s/p redo-sternotomy, mechanical AVR on ___
(# 23 mm ___ Aortic Valve Replacement) with
___. Please refer to discharge summary on ___ for
further hospital course details. He was taking coumadin and
lasix. During his follow up visit in clinic this am, he was
noted to be orthostatic and symptomatic. He did not respond to
oral hydration. ___ was sent to ER for IV hydration. His
BP improved and Pt felt a little better.
-Case discussed with Dr. ___ the decision was made to
admit the Patient for observation to ___ 6. With continued
hydration, negative TTE done in ED, and lower dose of lopressor,
his symptoms resolved. ___ the lopressor dose was increased
to the previous dose for optimal heart rate and blood pressure
control. ___ was cleared by ___ discharge from
observation to home today. | 119 | 141 |
10037928-DS-13 | 22,490,490 | You were admitted due to dangerously high blood sugars. You
required a continuous infusion of insulin when your first
arrived. This was changed back to your usual insulin and the
dose was adjusted with the help of the ___ Diabetes
specialists.
You should continue to follow a diabetic diet. You need to check
your sugars in the morning when you wake up and before every
meal.
This is very important to regulate your sugars so you do not
need to go to the ICU again. You will also need to take insulin
twice daily.
Stop taking Glipizide, Determir
Start Linagliptin 5mg daily for diabetes
Start Lantus (Glargine) 38 units in the morning and ___ 30
units in the evening
Start Ciprofloxacin 500mg twice daily- last dose is ___ | Ms. ___ is a ___ with type 2 diabetes mellitus who presents in
a hyperosmolar, hyperglycemic state in the setting of poor
medication compliance.
# Type II diabetes, uncontrolled with hyperosmolarity/HHS -
diagnosed by Serum Glucose > 600(996), HCO3 > 15(24), no
ketonuria,no ketonemia . This is most likely from med non
compliance as daughter has worries about this and patient notes
there are times she forgets to take her insulin. No signs of
infection though she does have a labial ulcer but it is not
erythematous or painful. She was intially on an insulin drip and
was weaned off, given long acting insulin and her BG levels
returned to the 100s. Her MS was at baseline by the time she
reached the MICU. ___ was consulted for recommendations on
control of her BG levels. Her K was repleted. She received 4 L
of NS in ER and ICU. At discharge glucose remained labile but
was in the range of 150-300 the day prior to discharge. Insulin
regimen was limited by the pateint's schedule (she often sleeps
until ___ and does not eat until noon) and the fact that her
family can only administer insulin early in the morning and in
the evening. Given these limitations, she was discharged on a
regimen of Lantus 38 units in the morning and ___ 30 units at
dinner. She was advised to continue to check her blood sugar 4
times daily. She has a follow up appointment scheduled in the
___ on ___.
# Elevated Lactate - 4.9 on arrival and went down to 1.9. Likely
related to hypovolemia, and/ or metformin in setting of poor
GFR. Lactate resolved
# Met Acidosis with AG: AG initially 19 (from lactate), improved
with HHS rx as above
# Microcytic Anemia with low MCV elev RDW. Differential includes
iron deficiency (guaiac pos brown stool, h.o ulcer in the past
per daughter though not ___ in records) vs thallasemia
(per pt she has been anemic all her life). Also on differential
is MM in setting of renal failure. SPEP and UPEP were checked
and were negative. Labs showed more of iron deficiency picture
though it is possible she also has thallasemia. In setting of
guaiac pos brown stool, history of angioectasisas seen on ___
and ___ ulcers pt should follow up with GI. H. pylori testing
was positive, and patient should discuss with PCP and GI in
follow up next week whether to treat for this.
# Acute on chronic kidney disease: Initial Cr 1.9, likely due to
hypovolemia in the setting of hyperglycemia. Improved to 1.3 on
discharge.
#Urinary tract infection:
Complaints of urinary frequency- UA was positive and culture was
positive for pan sensitive E. Coli. She was treated with oral
ciprofloxacin and will complete a 7 day course. Of note, she did
have a low grade fever the day prior to discharge. She had no
new symptoms of infection and WBC count was not elevated
therefore no further infectious work up was pursued.
# Gyn: pt with labia majora ulcer and vaginal atrophy possible
lichen sclerosis atrophicus. Could not insert foley because
entroitus was so narrowed. Started on topical steroids and
estrogen for atrophic vaginitis v. lichen. Will need gyn f/u.
CHRONIC ISSUES
#HTN:
continued hctz, losartan, propanolol
#Depression: continued buspirone and paroxitene | 124 | 542 |
11865416-DS-9 | 24,509,376 | Dear Ms ___,
It was a pleasure taking care of you at the ___
___.
Why were you here:
-You had significant pain in your abdomen, as well as vomiting
What was done:
-You were found to have an infection in your gallbladder.
-We gave you antibiotics and placed a drain in the gallbladder
-Your pain and nausea improved
What to do next:
-Continue taking these oral antibiotics as prescribed
-You will leave the drain in place for ___ weeks. You have a
"Tube study" on ___ to evaluate if you can have it removed
or not.
We wish you all the best,
Your ___ team | ___ female with recently diagnosed metastatic
adenocarcinoma, intestinal type (suspected ovarian primary), who
was admitted through the ED from clinic for severe epigastric
and RUQ pain with vomiting, found to have likely acalculous
cholecystitis, underwent perc chole on ___ with ___. Initially
treated with unasyn, then narrowed to cipro/flagyl. Patient
tolerated POs & pain free on discharge.
# Acalculous cholecystitis: Presented with severe RUQ pain and
vomiting. Remained afebrile throughout admission, with negative
blood cultures, no
evidence of sepsis physiology. Underwent percutaneous
cholecystostomy
with ___ on ___ with resolution of pain. She will need a tube
study in ___ weeks. She was discharged on cipro/flagyl to
complete a 10 day course of antibiotics (___)
# Metastatic adenocarcinoma
Presumed to be ovarian origin. She presented to her otpt onc
office for second cycle of FOLFOX. Held because of her abdominal
sx. Continued her home reglan, compzine and zofran for nausea
control, dronabinol for appetite.
# Misplaced PICC: Picc noted to no longer be located centrally.
Replaced on ___.
CODE: Full Code
EMERGENCY CONTACT HCP:
Name of health care proxy: ___
Relationship: aunt
Phone number: ___
Grandmother (___): ___
TRANSITIONAL ISSUES
--------------------
-Tube study for perc chol on ___
-Last day antibiotics on ___ (total 10 days after perc chole
placed)
-Urine GC/chlamydia pending given reported new vaginal discharge | 97 | 203 |
12451629-DS-21 | 29,057,646 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted after you passed out. We were initially concerned that
this may have been another pulmonary embolism, but your V/Q scan
(a test for a pulmonary embolism) was negative. We were also
able to rule out a heart attack or unstable rhythm.
We found you to be quite anemic while you were admitted. It
is important that you start taking the iron supplements as well
as the stool softeners in order to improve your blood counts and
prevent constipation.
The following changes were made to your medications
1. START Ferrous Sulfate for your anemia
2. START Colace to prevent constipation
3. STOP Factor Transfer 4 Plus, these supplements are not FDA
approved and can interact with your medications and make you
sick!
4. DECREASE your warfarin level to 7.5mg (3 2.5mg tablets daily
until you are seen by the ___ clinic). You should present
to the ___ clinic within 3 days. | Ms. ___ is a ___ yo with a past medical history of DVTs,
recent bilateral provoked pulmonary embolism in ___ with
concern for hypercoagulopathic state who presented with
pleuritic chest pain, syncope, and lightheadedness for 24 hours
in the setting of self described decreased PO intake and
palpitations.
# Syncope: Pt had a syncopal event on the night prior to
admission after her first day returning to work in over 1 month.
(Of note, she also reports that her last syncopal event occurred
in the setting of returning to work and exerting herself). She
also describes that her intake of fluids on the day of admission
was subnormal. CT head was unremarkable. Although Ms. ___
endorsed palpitations prior to syncopal episode, telemetry
demonstrated no events. ACS was ruled out with negative
troponins.
In light of Ms. ___ prior episode of syncope occurring
in the setting of a PE, and her continued pleuritic chest pain,
we were concerned for recurrent PE although she was therapeutic
on warfarin with an INR of 2.8. Initially, we deferred a CT scan
given her lack of evidence for right heart strain, hemodynamic
stability, and multiple prior CT scans. We decided, instead to
engage in a V/Q scan which was unremarkable.
Ms. ___ does complain of persistent orthostatic
dizziness, but her orthostatic vital signs were within normal
limits.
Ms. ___ was encouraged to increase her oral intake, and
was also encouraged to start ferrous sulfate (see anemia below)
in order to correct a fairly dramatic iron deficiency anemia.
# Trauma: Ms. ___ complained ___ back pain in the setting
of recent trauma. CT head negative, and Lumbar/hip films
negative for fracture. Pain was controlled initially with low
dose oxycodone (2.5mg) and tramadol in addition to tylenol.
# Facial numbness: Pt described ___ sided facial numbness after
her first syncopal episodes, concerning for trigeminal nerve
involvement. Other cranial nerves were intact on exam. Given her
history of multiple blood clots, there was concern that her
symptoms may have been secondary to cavernous sinus thrombosis.
Neurology was consulted previously and recommended MRI/MRV,
which were normal on prior admission. They did not feel that
there was a physiological explanation for symptoms. Currently
her facial numbness is minimal and corresponds to a 2cm radius
on the ___ border of her lip.
# Anemia: Ms. ___ has demonstrated anemia to a hematocrit of
30 with iron studies demonstrating a profound iron deficiency
(Ferritin of 3) and a low reticulocyte count. Ms. ___ will
need evaluation for ongoing GI blood losses. It is possible that
Ms. ___ iron deficiency stems from her prior
menometrorrhagia and vaginal cuff bleed, but this blood loss
occurred over 3 months ago, and evoking this as a cause would
require that her diet was quite deficient in iron. Ms. ___
was started on ferrous sulfate supplementation (along with
colace). Her iron deficiency will need to be re-evaluated as an
outpatient. | 169 | 493 |
17351979-DS-11 | 29,700,009 | Dear Mr. ___,
You were admitted to the hospital after an episode of left hand
numbness, slurred speech and facial droop. Your symptoms rapidly
resolved while you were still in the emergency room. You had an
MRI which showed several small strokes on the right side of your
brain. We checked labs to assess your stroke risk factors, and
found that you had very high LDL ("bad cholesterol") and
triglycerides, so we started you on a high-dose statin
medication for treatment. We also started you on high-dose
Aspirin for treatment and prevention of future strokes. An
echocardiogram of your heart showed that you had no cardiac
defects that would increase your stroke risk. We also sent out
lab work to look for uncommon causes of hypercoagulability
(increased blood clot risk); these are still pending and will be
followed up as an outpatient.
.
Please attend the appointment listed below with Neurologist Dr.
___ to follow up on your hospitalization and your
pending labwork.
.
We made the following changes to your medications:
1. STARTED aspirin 325mg by mouth daily
2. STARTED atorvastatin 80mg by mouth daily | # STROKE: Mr. ___ was admitted to the Stroke service for
further workup and treatment. He was initially started on ASA
325mg daily and atorvastatin 40mg daily for secondary stroke
prevention. On admission and throughout hospitalization his
neuro exam was completely normal except for subtle left
nasolabial fold flattening. His modifiable stroke risk factors
(A1C, full lipid panel) were checked and were notable for LDL
145, ___ 425. He was started on atorvastatin 80mg daily for this.
He was normotensive throughout hospitalization. On HD #2 he had
MRI which showed acute infarcts in right frontal and parietal
lobe and insula, smaller than predicted by CT Perfusion study.
Given that several strokes were present and presence of sharp
vessel cut-off with retrograde filling on CTA, etiology of
stroke was found to be most likely embolic. Patient thus
underwent TEE with bubble study which revealed no PFO, ASD,
aortic arch atheroma or aneurysm. He was monitored on telemetry
with no evidence of AFib/other arrythmia throughout
hospitalization. Given his relatively young age and unclear
etiology of embolic stroke (only risk factor was hyperlipidemia,
which would be unlikely to explain stroke in absence of
significant large vessel calcification), he also had
hypercoagulability workup sent (labs listed below) to rule out
other potential causes of embolic stroke; studies pending on
discharge. He will follow up as outpatient with Dr. ___
his own PCP in ___.
.
# HYPERLIPIDEMIA: Per above, pt started on atorvastatin 80mg
daily for HLD. He was counseled extensively about lifestyle
modification with weight loss, diet and exercise.
# SUBCLINICAL HYPOTHYROIDISM: Pt was incidentally found to have
subclinical hypothyroidism (high TSH, normal T4) during routine
AFib risk factor workup. He has no symptoms of hypothyroidism;
no intervention required. Should be monitored as outpatient.
.
===================
TRANSITION OF CARE:
-Labs pending on discharge = ___, lupus anticoagulant, protein C
antigen, protein S antigen, plasminogen activity, alpha 2
antiplasmin, beta 2 glycoprotein 1 antibodies (IgA,IgM,IgG),
anticardiolipin antibody (IgG, IgM) | 181 | 321 |
10507402-DS-6 | 25,127,527 | Dear Ms. ___,
It was a pleasure to participate in your care at ___. You were
admitted for cellulitis of the left hand and foot. You received
antibiotics and your symptoms improved. You were seen by
infectious disease and hand surgery doctors. ___ MRI of your hand
was done and showed: "Cortically based enhancing 4mm lesion at
the distal fourth metacarpal with intramedullary and
intramuscular extension on post contrast imaging. Findings are
nonspecific and may represent a juxtacortical chondroma. Follow
up xray is recommended in ___ months."
as well as "Cellulitis and tenosynovitis of the dorsum of the
hand. No evidence of osteomyelitis" and "Cystic likely
degenerative changes at the first CMC joint, enhancement of the
lesions could represent early erosions and correlation with labs
is recommended to exclude ___ inflammatory arthropathy
component." Thus we would recommend repeat imaging of the hand
and consideration of follow-up with a joint specialist (ie
Rheumatologist). If your symptoms worsen/recur please seek
prompt medical attention.
Best Regards,
Your ___ Medicine Team | ___ with PMHx of HTN, HBV, fibroid uterus, h/o ruptured
ectopic pregnancy, h/o fibroadenoma, h/o trichomonas and h/o
gonorrhea, who presented with L arm and leg swelling and
erythema.
# Edema/Erythema in LUE and LLE:
Pt presented with findings concerning for cellulitis in LUE and
LLE. Etiology was not clear and presentation is atypical. She
denied trauma and had no evidence of skin breakdown to suggest
clear
source of infection (though blister on LUE). Per ID, ddx
included GC/CT related disease (tenosynovitis noted on MRI
though per Hand surgery this was felt to be reactive to
cellulitis. GC/Chlamydia cervical swab was obtained. Pt
underwent L hand XR which was initially concerning for osteo.
MRI hand did not show evidence of cellulitis but did show
possible tenosynovitis as well as a lesion which would require
follow-up (see below). Pt received Vanc/Cefazoling in ED (___)
with minimal improvement (not thought to be treatment failure
but rather insufficient time, per ID, given findings most
suggestive of strep SSTI). Pt was treated with Vanc/Zosyn
(___) and transitioned to cefazolin ___ with continued
improvement in sx. On ___ pt was dischagred on keflex per ID
recommendations with plan to complete a 14d course of abx.
# HTN: Continued home HCTZ-triamterene, Lisinopril. Amlodipine
held to avoid possibility of confounding (though clinically,
cellulitis much more likely than drug-related edema) and was
restarted on discharge.
# Constipation: Mag citrate provided | 164 | 230 |
15193172-DS-10 | 23,689,446 | Dear Mr. ___,
It was a pleasure to care for you during your stay with us,
Why was I admitted to the hospital?
- You were feeling faint and found to have a bad heart rhythm
called "ventricular tachycardia" or "VT", which you've had
before and were taking mexiletene for.
What happened while I was admitted to the hospital?
- You were given shocks to fix the heart rhythm before you came
to the hospital, and once again while you were here
- You were given medications to prevent this rhythm from coming
back again.
- You were seen by our heart rhythm doctors
(___) who ___ follow up with you.
What should I do when I leave the hospital?
- Please continue taking your medications as listed below
- Please follow up with your appointments as listed below
We wish you all the best,
Your ___ Care Team | ___ with a PMH of COPD, esophageal dysmotility, HFpEF, SS,
aflutter, chronic AF not on anticoagulation and monomorphic VT
s/p ___ placement on amiodarone who presents with lightheadedness
found to have recurrent monomorphic VT in the setting of
discontinuing his mexilitene due to poor tolerance. He was
admitted, trialed on a lidocaine drip but with recurrence of VT,
then started on quinidine, with up titration of his metoprolol
and continuation of his amiodarone.
#CORONARIES: Unknown
#PUMP: 60%
#RHYTHM: AF, monomorphic VT
ACUTE ISSUES:
=============
# VT Storm/Recurrent VT: ___ placed ___. DDDR 70/120.
Recurrent VT likely due to recent discontinuation of mexiletine
due to adverse side effects. Possibly hypovolemic, no obvious
infection. He received electrical cardioversion x4 on ___ in
the ambulance/ED. Initially attempted lidocaine gtt, but
recurrent VT, required additional shock ___. Transitioned to
quinidine 324 mg BID, continued on amiodarone, and had his
metoprolol succinate uptitrated from 12.5 mg QD to 50 mg QD. He
had no recurrent VT for over 24 hrs prior to discharge. He will
f/u with Dr. ___ and Dr. ___ as listed.
# L hemidiaphragm elevation
Unknown etiology at this time, likely no intervention would be
within goals.
# Esophageal dysmotility/Schatzki's ring. Pt is able to swallow
pills crushed or with applesauce. Able to eat regular diet.
Needs to continue taking pills with apple sauce.
# GOC: Per discussion with HCP (daughter ___, patient and
family, pt is now DNR/DNI. Previously was okay for shocks if
pulse present, but now declining all shocks even when pulse is
present due to discomfort. MOLST form was signed during this
admission.
CHRONIC ISSUES:
===============
# HFpEF: Appears hypovolemic, with elevated lactate to 2.3 on
admission. Likely iso poor PO intake. stabilized w/ holding
diuretics and IVF. He had significant urine output to 60 PO
lasix (home dose 60 mg BID), so his regimen was decreased to
Lasix 40 mg QD.
# COPD: Continued his home inhalers
# Chronic Afib: Not on anticoagulation. Discharged on metoprolol
as above, amiodarone 200 mg QD, aspirin 81 mg QD. | 139 | 332 |
11748541-DS-11 | 22,553,502 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were having
progressively worsening abdominal pain, and your primary care
doctor felt ___ mass near your ovary when doing a pelvic exam.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You had a CT scan of your abdomen and pelvis which showed an
abnormal gallbladder, a mass in the liver, masses in the
ovaries, and enlarged lymph nodes. These findings are concerning
for cancer, likely of the gallbladder or ovaries. Further
testing, including the biopsy results, will help to determine
the source.
-You had a CT scan of your chest which showed enlarged lymph
nodes.
-You had an ___ biopsy of the mass in your liver. The
results of that test will be available after discharge. This
will help guide management.
-Your pain was controlled with pain medications.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all of your medications as prescribed.
-Please attend all follow up clinic appointments, especially
with your oncologist (cancer doctor).
We wish you all the best,
Your ___ Care Team | PATIENT SUMMARY:
================
___ year-old female with a history of right-sided mastectomy for
precancerous lesion, IDDM, CAD, fibroid uterus, history of
cesarean section, family history of ovarian cancer; presenting
with periumbilical abdominal pain, right adnexal mass, and
periumbilical nodules, found to have abnormal gallbladder, b/l
adnexal masses, liver lesions, diffuse LAD on CT A/P concerning
for metastatic malignancy, likely gallbladder primary. | 185 | 59 |
19372432-DS-17 | 28,608,068 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- Your leg was becoming painful and swollen. You were found to
have a skin infection.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with IV antibiotics for your infection. An
ultrasound was done on your leg which showed fluid collection.
You were seen by surgery who drained the fluid.
- You were also seen by renal transplant doctors who ___
your renal transplant medications.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY
========
Mr. ___ is a ___ year old man with ESRD s/p LURT ___, HTN,
and DM who presents with 4 days of left leg pain and swelling,
found to have cellulitis with abscess, s/p I&D and IV
clindamycin.
ACUTE ISSUES
======
Patient presented with 4 days of left leg pain and swelling in
the setting of immunosuppression for his renal transplant. He
was stable and non-toxic in the ED and initially treated with
ceftriaxone, broadened to cefipime, then transitioned to
clindamycin due to history of penicllin allergy. Ultrasound of
the lower extremity showed with likely 2cm abscess formation
versus fluid collection. Surgery was consulted and I& D was
preformed ___. He was transitioned to IV vancomycin for better
MRSA coverage, since abscess finding raised likelihood of MRSA.
Cefazolin was also added for additional coverage of MSSA and
Strep sp., following further history that patient has indeed
been able to tolerate first generation cephalosporins in the
past despite listed allergy to penicillins. He was transitioned
to oral antibiotics Keflex and doxycycline with plan for 14 day
course given immunosuppression. He will also be prescribed short
course of low dose oxycodone (2.5mg PRN) for pain after I&D. We
recommend he follow up with his PCP ___ 1 week, and has follow up
with renal transplant team in 2 weeks.
CHRONIC ISSUES
==============
# ESRD s/p LURT ___: Creatinine was 1.5 on admission near
recent baseline of 1.31-1.41. Tacrolimus trough was 2.8. He was
continued on his home mycophenolate ___ 360 mg PO BID, tacrolimus
0.5 mg PO BID, and atovaquone. Cr at discharge returned to
baseline (1.3).
# HTN: Intermittently hypertensive during admission,
asymptomatic. Continued home lisinopril
# HLD: continued home atorvastatin
# DM: Held home glipizide and Jardiance. Continue home glargine
22U QHS and Insulin sliding scale. Will resume
anti-hyperglycemics on discharge.
# Gout: Continued home allopurinol, dose reduced based on renal
function.
TRANSITIONAL ISSUES
==================
[] Continue Keflex and doxycycline with plan for 14 day course
given immunosuppression (___)
[] Prescribed short duration oxycodone post I&D procedure as
well as Tylenol
[] Prescribed PRN bowel regimen (Miralax, senna) while on
opiates
[] Follow up with PCP ___ 1 week of discharge
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge. | 131 | 364 |
14583397-DS-18 | 20,577,917 | You were admitted with a urinary tract infection in septic
shock, which was treated with powerful IV antibiotics. However,
the bacteria in our lab is actually sensitive to oral
antibiotics, so you will not need further IV medications. | ___ year old ___ speaking female with PMH of type 2 DM, HTN,
hyperlipidemia, and schizophrenia who presents from ___
for fever to 101.6, tachycardia to 110, and hypoxemia to 92% on
RA found to have septic shock from a bacterial UTI with proteus.
# Severe Septic shock due to Bacterial UTI:
Pt meets SIRS criteria with lactate elevation to 6.8, likely
urinary tract tract as source of infection. Likely pylonephritis
given flank pain. No clear biliary source on imaging and LFTs
WNL. Pt put on vancomycin/meropenem.
Blood cultures returned with proteus miribalis ___ bottles so
narrowed to meropenem along pending speciation and
sensitivities. U/S without evidence of perinephric abscess. Pt
volume resuscitated for sepsis and remained hemodynamically
stable in ICU. When sensitivities returned as above,
pan-sensitive, she was changed over to ciprofloxacin.
# Hypoxemia:
Pt with hypoxemia to 92% on admission, satting 98% on 5L on
admission to ICU. Unclear precipitant as CXR is clear with no
evidence of infectious process or pulmonary edema. Supplemental
O2 weaned.
# Acute Renal Failure:
Pt with Cr of 1.5 up from baseline of 0.9-1.0. Likely from
hypovolemia and pre-renal azotemia in setting of sepsis. Cr
normalized by discharge.
# Renal Cyst
Incedentally found septated renal cyst, which was relayed via
letter to the PCP over at ___ for follow up
>> Chronic issues:
# Type 2 DM Uncontrolled without complications:
Patient with history of diabetes mellitus, on metformin as
outpatient. SSI in house.
# Benign Hypertension:
antihypertensives held in setting of sepsis and resumed on floor
# Schizophrenia/Depression/Anxiety:
Patient continued on OP Topamax, ziprasidone. Clonazepam held
initially.
# Chronic Pain:
Pt with chronic pain in right arm shoulder and legs. Continued
tramadol
>> Transitional issues:
- Bilateral renal cysts. Right renal cysts contains a septation,
follow up is recommended within one year.
- EKG follow up daily for QTc monitoring | 38 | 297 |
11060501-DS-2 | 22,813,055 | Dear Ms. ___,
You were presented to ___ on ___ with abdominal pain.
You had an ultrasound and CT scan which was concerning for acute
acute cholecystitis, an inflammation of your gallbladder. You
were admitted to the Acute Care Surgery team for further medical
management.
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:
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. | ___ year-old female with a history of RNY bypass ___ and
panniculectomy ___, who presented to ___ on ___ with
RUQ and epigastric pain. She had a CT ABD&Pelvis and a
gallbladder ultrasound which were concerning for acute
cholecystitis. She was made NPO and admitted to the Acute Care
Surgery team.
On ___, she was taken to the operating room and underwent a
laparoscopic cholecystectomy. During the procedure, she was
noted to have a 2cmx1cm vaginal laceration for which the
Gynecology team was consulted and they placed a ___ Vicryl
suture. The patient was made aware of this post-operatively.
The patient tolerated the laparoscopic cholecystectomy well and,
after a brief, uneventful stay in the PACU, she was transferred
to the surgery floor for pain control, hydration and to await
return of bowel function.
The patient was hemodynamically stable. 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 home without services.
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. | 764 | 271 |
13470722-DS-10 | 23,797,720 | Dear ___,
___ was a pleasure meeting you and taking care of you. You were
admitted with a rash on your forehead caused by shingles. You
had swelling and redness of your eyes and face which was
concerning for a bacterial infection of your skin. You were seen
by our ophthamologists who felt that your vision and eyes were
were unaffected and that you should followup in 1 week with
them. You had a CT scan of your orbits which showed no evidence
of deep infection involving your eyes. You were started
medications which helped treat your infections. Your rash
improved during your hospitalization and you were transitioned
to oral medications which you can take at home.
It is important to followup with your PCP and ___.
We wish you the best,
Your ___ team | Patient is a ___ with a h/o COPD, HTN, anxiety who presents
with rash consistent with herpes zoster and overlying
pre-orbital cellulitis.
# Right V1 Zoster Rash: Patient presented with grouped vesicular
rash of right forehead that did not cross the midline were
consistent with herpes zoster. By time of discharge the vesicles
had completely crusted over. The rash was associated with
significant ___ swelling and drainage concerning for
ocular involvement. She had a CT orbit which showed evidence of
deeper soft-tissue infection or eye. She was seen by
___ who felt that she had no vision changes related to
infection. She was started on IV acyclovir and transitioned to
valacylocir
# Facial Cellulitis: patient's erythema and swelling is
concerning for secondary preseptal cellulitis. Given that
swelling is worsening with IV unasyn, will cover for community
acquired MRSA
- continue oral regimen with bactrim/keflex for 10 day total
course
TRANSITIONAL
- Continue valacyclovir (Day ___. Plan for 7d total
course.
- Continue bactrim and cephalexin for 10 day total antibiotic
course
- Patient will followup in 1 week with ___.
- Right MCA aneurysm at bifurcation seen incidentally on CT
orbit, consider following up in the future
- Patient with heart murmur consistent with mitral regurgitation
on exam. No cardiopulmonary complaints so workup was not pursued
during this hospitalization. | 133 | 212 |
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