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14355608-DS-12 | 23,301,143 | Dear ___,
It was a great pleasure taking care of you as your doctor. As
you know you were admitted to ___ for fever. We did echo for
your heart which did not reveal abnormal valves or infectious
masses. Your urine analysis and chest xray did not show
infection. Your blood cultures are drawn. We think this might
have been secondary to chemotherapy.
You are scheduled to received your chemotherapy tomorrow.
We did not make any changes in your medication list. You were
given allopurinol ___ mg once during your stay and you will be
taking it daily until you are told otherwise.
Please follow with the appointments as illustrated below. | ___ year old pleasant woman with follicular lymphoma C2D2 of
bendamustine/rituxan comes with fever following her
chemotherapy.
.
# Fever: She had fever following her 1st dose of chemotherapy
which is the most likely cause of her fever. She does not report
any localizing symptoms of a possible infection. Given new
murmur, infective endocarditis was considered. Another possible
source of infection considered was the port. She received 1 dose
of vancomycin and gentamycin in the ED. She was afebrile during
her stay on the floor. Blood cultures are drawn and pending.
Urine is collected for culture and pending. CXR did not show
pneumonia. UA not suggestive of UTI and does not report urinary
symptoms. No GI symptoms. Not neutropenic. ESR 9 with CRP of
9.5. Echo did not reveal valvular abnormality to explain the
murmur, nor found a vegetation. She is discharged afebrile in
stable condition. Chemotherapy was given during this admission.
She will receive it tomorrow morning.
.
# Follicular lymphoma: Today C2D2, will hold on chemotherapy for
now given fever and Will receive tomorrow. Allopurinol ___ mg
one dose was given during her 1 day stay in the hospital. She is
instructed to take it daily unless told otherwise.
.
# GERD: we continued PPI daily.
.
# Depression/anxiety: We continued paroxetine 40 mg daily and
lorazepam 1mg q8 hr as needed.
# Psoriasis: We continued clindamycin lotion as needed.
.
.
====================================
The patient was seen, evaluated and discussed with Dr ___. | 109 | 235 |
14115302-DS-12 | 22,172,706 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were transferred from ___ for pneumonia.
You were found to have bacteria growing in your blood as well as
very low blood counts. We started you on antibiotics for your
infections and gave you blood products to help support your low
counts. You will need to finish antibiotics for your infections,
continue to follow up with ___ for your low blood
counts.
New medications:
vancomycin, ceftazadime and azithromycin to treat infection
Neupogen to increase your blood counts | Mr. ___ is an ___ with myelodysplasia s/p fall with head
strike and confusion undergoing a CT/head at the OSH, at the
time found to be pancytopenic and transferred to ___ for
further management also found to have a pneumonia.
ACTIVE ISSUES
===============
#PNEUMONIA:
Patient not reportedly symptomatic. CXR revealing for
retrocardiac opacity. Patient does have a leukopenia/neutropenia
and tachypnea, therefore does meet SIRS criteria. Blood and
urine cultures remained negative at ___ at the time of
discharge. However, culture at ___ showed pansensitive
ecoli in the blood. He was started on vancomycin, ceftazadime
and azithromycin on ___ to cover for community acquired
pneumonia as well as Ecoli bacteremia.
#BACTEREMIA:
Patient with blood cultures positive for Ecoli at AJ; all
cultures have remained negative at ___ to date. He is being
treated as above with ceftrazadime. Given concern for biliary
source (ascending cholangitis), RUQ U/S was performed and was
negative for biliary dilitation. Source possibly GU
translocation vs. PNA (sputum unable to be collected)
#HYPOXIA:
Patient with multiple episodes of hypoxia at ___ on the
medical floor (once on ___ and again on ___.
Baseline has been on 5L while at ___ (at home on 4L) and
during episodes always improves on facemask. Unclear if these
episodes are ___ volume overload from transfusions as below vs.
contributions from known PNA vs. sleep apmea. He was diuresed
aggressively with 20mg IV lasix at each transfusion and
Azithromycin was added back for atypical coverage (had initially
been stopped after 5 day course).
#PANCYTOPENIA:
High grade MDS, RAEB1 on ___. His bone marrow biopsy
revealed 10% blasts in the setting of trilineage dyspoiesis.
FISH showed isolated 5q deleition. S/p 3 cycle treatment of
decitabine, last dose on ___. Differential here was
re-assuring for patient not having a blast crisis. Heme/onc was
consulted and recommended transfusing platelets to >10 and
Hematocrit >21 unless actively bleeding. Platelets did not
increase appropriately despite transfusion so HLA antibodies
were sent and were pending at discharge. Most likely platelets
were degraded due to antibiotics and upon discontinuation
platelets should be more responsive to transfusion. He was given
neupogen daily. CBC with diff should be checked daily and
neupogen should be continued until ANC is >1000 x2 days.
Revlimid is being held due to pancytopenia and it will be
important to communicate with outpatient providers. Patient
received 2 units of pRBCs on ___, 2 units again on ___
and 2 units again on ___ for Hct<21. He received 20mg IV
lasix with each unit of pRBCs given concerns for flash pulm
edema.
#FALL WITH HEADSTRIKE:
Unclear etiology. Fall sounds from ED and EMS as if this was
mechanical. Patient could have syncopized from blood loss
attributed to anemia. CT head reassuring. Neurological exam
remained stable.
#pAFiB:
He has been in normal sinus rhythm since admission. Due to his
anemia, his coumadin was stopped during his admission to ___ on
___. He is rate controlled with Coreg 3.125 mg b.i.d. His
CHADS2 score is 3 for cardiomyopathy, hypertension and age. He
was continued on carvediolol 3.125mg BID.
#CHF:
From records from ___ per OMR in ___, his ejection fraction
was 20%. He has an ICD Biotronik that was placed in ___ in ___. Last BNP was 2000s in ___. Patient's ___
has been held (unclear why discontinued). He was continued on
his home lasix with extra doses of IV lasix with blood products,
and lisinopril 5 mg daily was started prior to transfer.
#CAD/troponemia:
Status post RCA stents in ___. Not on aspirin. Unclear if
patient had GI bleed in the past. Also not on a statin but hx
states hypercholesteremia. On admission, troponin elevated,
like demand related with no new EKG ischemic changes, but need
to trend given extensive cardiology hx. Troponins were trended
and EKG was without ischemic changes. Therefore, his troponemia
was thought to be secondary to demand in the setting of
infection.
# Nonsustained VT:
He has had ___ beats a few times on morning of admission, but of
note, he has an ICD - Biotronik. CXR shows leads to be in
correct position.
# Bladder cancer:
Reported surgical partial removal of tumor at ___ in
___. Not an issue during this hospitalization. | 91 | 710 |
16622773-DS-14 | 20,195,118 | Dear Ms. ___,
You presented to the ___ on
___ with abdominal pain and secondary shock to your liver
and kidneys. You were admitted to the Acute Care Surgery team
and underwent emergent surgery.
Since being admitted, you have been taken to the Operating Room
and have underwent an exploratory laparotomy to identify
intra-abdominal issues, bowel resections, repair of your bowel,
colostomy formation and removal of your appendix.
You are now tolerating a regular diet and moving your bowels.
Your pain is better controlled. You are now medically cleared
to be discharged to home with Visiting Nurse ___ to
continue your recovery.
Please note the following discharge instructions: | ___ year old female with past medical history for congenital
neuropathy on opioids who presented to ___ with acute abdomen
now s/p exploratory laparotomy. Per report, patient presented
from OSH with complaints of progressive abdominal pain for 4
days with nausea and NBNB emesis. Patient denies any
fever/chills/GI bleeding. Patient was found to be hypotensive in
the ED despite 8L LR, patient was also found to have an acute
transaminitis ( AST 1819, ALT350), and renal failure ( Creat
6.3).
Patient was taken emergently to the operating room for ex-lap,
and was found to have bowel necrosis in the SMA distribution as
well as sigmoid colon. Patient underwent SBR as well as
sigmoidectomy and was left in discontinuity. Patient was closely
monitored in the ICU from ___. Patient required further
abdominal washouts and abdomen was closed on POD# 8. Please see
operative notes for further details. Her ICU course was
uneventful and the patient progress adequately. She was
extubated on POD#3, required temporary CVVH given her ___ and
supportive nutrition though nasogastric feeding tube. She was
transferred out of the ICU on POD#8.
Since being transferred to the step-down surgical floor, the
patient has remained stable. Her hospital course is summarized
by systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medication awaiting return of bowel function and then
transitioned to oral pain medication on ___ (POD 5 after
closure) once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___ (POD
3 after final closure) , the NGT was removed after return of
bowel function was confirmed through increased ostomy output,
therefore, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored.
The patient did require renal replacement therapy while in
the ICU and came to he inpatient floor with a temporary
hemodialysis line in place. She was managed with CVVH renal
replacement therapy in the intensive care unit, and required 2
dialysis sessions while on the inpatient floor, with the final
dialysis session taking place on ___. Pt urine output was
noted to be improving during the postoperative period, and after
consultation with nephrology, her dialysis access line was
removed on ___. The patient's foley catheter was removed on
___ after which she had difficulty voiding and she was
straight cathed. She was able to void independently after this
and did not require a foley catheter.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. She was noted to have C.
Albicans growing in blood cultures that were drawn while she was
in the ICU, and was transferred to the surgical floor on
micafungin. The infectious disease service was consulted, and
recommended a 14 day course of fluconazole beginning after all
central access and dialysis lines were removed from the patient.
She was started on this therapy while in the hospital, and it
was continued at discharge. The patient had 4 more days of
fluconazole to complete at the time of discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding. On ___, (POD 2 after final closure), pt HCT
was noted to be decreased to 21.6. She was given 2 units of
PRBCs and a stat CT angiogram of the abdomen and pelvis revealed
no active bleeding. Her HCT increase appropriately. She remained
hemodynamically stable throughout this episode, and subsequent
laboratory monitoring revealed no acute hematocrit drops.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan | 110 | 714 |
18174227-DS-9 | 29,195,190 | Dear Ms ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
-You came to the hospital because of change in mental status and
confusion.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
-We did not find a cause for your change in mental status. Our
neurology and ophthalmology doctors saw ___. Your vision in the
left eye is good but you do have glaucoma. You may have been
experiencing hallucinations because of poor vision.
-Our physical therapy team thinks that you would benefit from
rehab
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Continue to take your medications as prescribed
-We have not made any changes to your medicines.
-Please make an appointment with your PCP within one week of
discharge. We recommend physical therapy at a rehab center. It
may be possible that your PCP can facilitate rehab or outpatient
___.
Best,
Your ___ Team | Ms ___ is a ___ year old woman with a history of hypertension &
left frontoparietal stroke (___) with abulia, who presents
with encephalopathy.
# Encephalopathy:
# Dementia:
In reviewing notes, pt has hx of dementia. Was recently admitted
to ___ (___) for acute change in mental status.
Was evaluated by neurology and MRI revealed amyloid angiopathy.
Etiology of decline was thought to be related to progressive
dementia vs. TIA vs. delirium. Also with prior left
frontoparietal stroke in ___, with "abulia" (defined as a loss
of the impulse, will, or motivation to think, speak, and act)
noted at ___ Neurology follow up.
On ___, patient presented with several days of confusion and
hallucinations as well as visual changes. No obvious signs of
infection by history or exam; chest XR and urine normal. No
leukocytosis. Unable to obtain LP (failed) to rule out CNS
infection in ED. CT head without acute bleed. Given time course,
low likelihood of meningitis or HSV encephalitis. No new
medications (and no anticholinergics or opiates). Toxicology
screen negative. EEG previously w/o sz.
Neurology evaluated and believe that patient is at her baseline
mental status and is suffering from ___ syndrome"
causing her hallucinations. Despite her diagnosis of CAA,
because she has suffered from ischemic strokes in the past,
neurology recommended continuing aspirin. Ophthalmology
evaluated and noted R eye blindness (which is chronic) and
macular degeneration in the left eye with concern for
neovascular changes given a small macular hemorrhage. L eye with
good visual acuity (___).
Patient's mental status improved. Physical therapy evaluated and
recommended rehab.
Unfortunately on ___, patient and daughter (___) left
against medical advice due to financial burden associated with
hospital stay. We discussed that we would recommend rehab and
not home. A safe discharge plan was discussed: we recommended
close PCP follow up and coordination for physical therapy (rehab
or outpatient).
*TRANSITIONAL ISSUES*
-No changes to medications made during hospitalization
-F/u with PCP
-___ with ophthalmology
-Would benefit from physical therapy
**INPATIENT team recommended rehab with physical therapy.
Patient left against medical advice on ___ | 134 | 332 |
16462507-DS-21 | 29,610,848 | Dear Mr. ___,
You were admitted to ___ for
evaluation of abdominal pain on ___. Imaging done here showed
that you had perforated sigmoid diverticulitis with an abscess.
This means that your large intestine was inflamed and there was
a tear seen with a fluid collection, which was infected. Thus,
you were placed on bowel rest, given IV fluids, kept nothing by
mouth, and administered IV antibiotics. We closely monitored
your blood lab values and your vital signs this admission. You
have been advanced to a regular diet and your pain has been
controlled on oral pain medications. However, on ___ you
were insistent on leaving the hospital and going home. The
surgical team explained the risks of leaving the hospital to
you. The team also emphasized with you that because of the
fevers you were having and the fact that your abscess was not
able to be drained (no source control) if you have any warning
signs after discharge you were strongly encouraged to come back
to the hospital. Please follow the instructions below to
continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid driving or
operating heavy machinery while taking pain medications. | ___ w/COPD p/w sigmoid diverticulitis and pericolonic abscess.
Patient reports he has had progressively worsening LLQ pain
starting 4 days ago with loss of appetite. He presented to ___ ED in ___ on ___, underwent a CT scan
which showed sigmoid diverticulitis and an associated abscess.
Patient was evaluated by surgery who offered admission for
nonoperative management however patient left AMA with a px for
Levofloxacin and Flagyl. He reports that his pain did not
resolve
and after seeing his PCP earlier today, presented to ___ ED.
Upon presentation he was afebrile and hemodynamically stable. He
underwent CT a/p which showed sigmoid diverticulitis with an
adjacent abscess (2.3 x 2.0 x 1.2 cm). He reports his last
c-scope was last year at ___ which was inconclusive due to poor
prep and was told to repeat in ___ years. C-scope prior to that
was ___ years ago which showed diverticulosis and several polyps
that were biopsied as benign. Patient currently reports pain in
lower abdomen minimally improved from before. He notes no
exacerbating or alleviating factors. He denies any chest pain,
SOB, vomiting, diarrhea, melena or BRBPR.
He was treated conservatively with IV antibiotics, IVF, and
bowel rest. After improving and remaining afebrile, his clinical
exam improved. His repeat CT of the abdomen and pelvis did not
demonstrate worsening pelvic fluid collection. His diet was
advanced, which he tolerated well. Antibiotics were converted to
oral equivalents and he was discharged. Of note, he was very
insistent to go home, and after an at length discussion with
___ the risks and benefits of leaving, they were able
to reach a concession -- no fever, tolerating diet, home
antibiotics, and follow-up in two weeks, with a close eye for
warning signs, with the patient understanding that discharge was
a risk for potential rehospitalization at that time. | 383 | 287 |
10456837-DS-10 | 28,030,839 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital due to
concerns that your gangrenous foot was worsening due your new
graft failing. We found that there was no immediate concern our
your disease acutely worsening. However you will likely need
further surgical intervention to manage your right lower
extremity gangrene. Please follow up with Dr. ___ to
discuss the results of your arterial studies and what further
interventions are needed.
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 | The patient was admitted to ___ on ___ due to referral from
PCP for increased ___ from right ___ toe and concerns for
increasing gangrene and necrosis and concerns for peroneal graft
occlusion. Noninvasive arterial studies were performed on
___, which demonstrated complete occlusion of the peroneal
graft. We discussed options and need for BKA in the future. He
understands the plan and would like time to think through plan
alongside family. He was discharged with 1 week of antibiotics
and close follow up.
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. He will reach out with
questions and if worsening of toe wounds. | 273 | 145 |
10791772-DS-5 | 26,096,086 | Surgery
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your staples are removed
on POD 10.
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.
* You will need to follow up with Orthopedic surgery in 2
weeks for your shoulder dislocation. Continue to wear your sling
for comfort until this appointment.
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 reason
Please follow-up with your PCP/ Oncologist:
-Repeat CT Chest in 6-months (from ___ to monitor Right
lung nodules and mildly enlarged hilar lymph nodes & prominent
mediastinal lymph nodes.
-Dedicated Thyroid ultrasound for further evaluation of 3.3 x
2.6 cm left thyroid lobe lesion. | #Intracranial lesions
The patient was admitted to the ___ on ___ for further
work-up of the left frontal IPH. She underwent a MRI which
showed a left frontal underlying lesion and a right temporal
lesion. She underwent a CT of the abdomen and pelvis which
showed a 3.1cm soft tissue density. CT of the torso showed right
lung nodules, a left thyroid nodule and mildly enlarged lymph
nodes. On ___, the patient remained neurologically stable on
examination. She underwent pre-operative work-up in anticipation
for undergoing surgery the following day. On ___, the patient
was taken to the operating room and underwent a left frontal
craniotomy or resection of tumor. A subgaleal drain was left in
place. Post-operatively, she recovered in the PACU and was later
transferred to the ___. Post op MRI revealed expected post op
changes. She was started on a dexamethasone taper.
Neuro-Oncology, Radiation Oncology and Hematology Oncology were
all consulted and patient was scheduled for follow up. On ___,
the subgaleal JP drain was removed without any issues. She
remained stable and continued to recover post-operatively.
#Tachycardia- Post-operatively the patient was tachycardic. She
received PRN hydral and Lopressor in PACU with good effect. When
she transferred to the ___ her HR remained WNL.
#Hypotension: She had an episode of hypotension (SBP 60's) in
the restroom, repeat SBP was 150. She was noted to have a
negative fluid balace and was given an IV fluid bolus and her
Lasix was held. EKG was stable. Cardiac enzymes were flat. Her
potassium was repleted. Hypotension was resolved.
#Leukocytosis: On ___ her WBC were elevated at 21. She
continues on decadron however infectious work-up was remarkable
for positive UA. She was started on Ceftriaxone for UTI. Urine
cultures was negative on final and her Ceftriaxone was
discontinued on ___. Blood cultures from ___ were negative and
cultures from ___ are still pending. WBC uptrended to 22, she
remained afebrile and clinically stable. CXR negative for
pneumonia. Her WBC began trending down ___ to 20.2.
#Right shoulder dislocation
___ overnight patient had more difficulty moving right arm, RN
heard a pop when patient was ambulating to the bathroom. Xray
confirms R shoulder dislocation. Ortho was consulted. Right
shoulder reduced at beside, Xrays inconclusive, CT showed no
fracture. Ortho recommended a sling prn for comfort and f/u in
two weeks.
#Dispo
She was evaluated by ___ and OT who recommended acute rehab.
Follow-up appointments and treatment plans for obtained from
neuro onc, radiation onc, and heme onc to prepare patient for
discharge to rehab. | 541 | 420 |
15921538-DS-17 | 24,086,752 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
- You were brought to the hospital because of a clot in your
right leg veins.
WHAT HAPPENED WHILE YOU WERE HERE?
- The clot in your right leg veins was removed and you were
started on a blood thinner.
- An imaging scan showed a mass in your right pelvis, and a
biopsy of the mass showed lymphoma.
- You were started on chemotherapy for your lymphoma and
monitored for side effects.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue to take all of your medications as directed,
and follow up with all of your doctors.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with a past medical history
of hypertension, right total knee replacement, history of
subarachnoid hemorrhage after a fall and family history of
Factor V Leiden mutation who presented as a transfer from
outside hospital with extensive RLE DVT for Vascular Surgery
consult.
======================== | 126 | 49 |
16571669-DS-10 | 20,504,698 | Thank you for allowing us to take part in your care. You were
admitted to ___ after you
called an ambulance because of vomiting dark and bright red
blood. We consulted with the gastroenterology service (GI) and
they performed a test called an EGD. This allowed them to
examine the inside of your esophagus. The results of the test
showed that you had torn the inside of your esophagus, most
likely as a result of the repeated episodes of vomiting you had
been having for the past few days. You likely had a viral
infection which caused the vomiting. During the EGD procedure
they also injected some medicine and placed a clip on the torn
tissue to stop the bleeding.
The test also showed some inflammation and damage to your
esophagus caused by your reflux disease. It is important that
you go to a follow-up appointment and have a repeat of the EGD
procedure because the damage done to your esophagus, if it does
not heal properly, can increase the risk of esophageal cancer.
We also discussed the increased risk of cancer that smoking
causes. We encourage you to continue to avoid smoking as you
have for the past eight days.
When you go home, make the following changes to your
medications:
START taking Ranitidine 150mg every night
START taking Ondansetron, 1 tablet as needed for nausea
Continue to take Omeprazole 40mg daily
You should also follow the acid reflux diet recommendations
given to you. This includes avoiding chocolate, peppermint,
alcohol, caffeine, onions, ibuprofen (NSAID's) and aspirin.
Elevate the head of your bed three inches and avoid eating two
hours before going to bed. | Mr. ___ is a ___ man with history of gastroesophageal
reflux disease (GERD) and chronic hepatitis B, with no known
history of cirrhosis or varices, who presented after three days
of nausea, vomiting, and diarrhea which culminated in two
episodes of hematemesis on ___ with epigastric pain.
.
#. GI bleed: Given history of hematemesis and dark guiac
positive stool, we suspected upper gastrointestinal bleed. We
gave antiemetics, PPI, and H2 blocker, monitored serial Hcts and
consulted with Gastroenterology, who performed an
esophagogastroduodenoscopy which was significant for a
___ tear, hiatal hernia, and evidence of esophagitis
secondary to reflux. Mr. ___ was initially NPO for the
procedure but his diet was advanced until he was discharged
tolerating a regular soft diet. We gave him materials about the
importance of following a special diet (acid-free) for reflux
disease and set up follow-up appointments with GI. He should
continue a PPI and H2 blocker until seen by GI.
#. Epigastric pain: Mr. ___ had complained of burning chest
pain on admission. CXR ruled out aortic dissection or pulmonary
process, and cardiac enzymes were negative x 2. Pancreatitis
was less likely given normal lipase. Biliary pathology unliking
given normal Tbili/AlkPhos. The chest pain improved after PPI
and H2 blocker medications as well as Maalox as needed. Upon
discharge he had been pain-free for 24 hours.
#. Chronic hepatitis B: ALT/AST elevated, though have been
similarly elevated on prior testing. HBV viral load was
undetectable in ___. Patient has had abdominal ultrasound in
___ showing a diffusely echogenic liver, compatible with fatty
infiltration, but he does not have any documented history of
cirrhosis. No varices noted on EGD ___. We followed his LFTs
which trended down throughout his hospitalization. They should
be repeated on outpatient followup. | 276 | 303 |
19803635-DS-12 | 29,863,370 | Dear ___ was a pleasure to take care of you at ___
___. You were admitted with symptoms of weakness and
clumsiness in your right hand, a facial droop, and difficulty
pronouncing words. Based on this history and your neurological
exam, we obtained an MRI of your brain, which confirmed that you
had a stroke.
We obtained an echo (ultrasound) of your heart to look for a
possible cause of a stroke. This showed a mass in your heart.
This is likely a blood clot but it is possible that it is a
tumor in your heart. Because of this, we started you on a blood
thinner medication called warfarin (Coumadin). You will need to
take this medication every day, and have blood levels checked on
a number called INR. We have arranged follow-up in the
___ clinic for you.
You will need to have another echo in one month to assess what
has happened to the blood clot.
Over the course of this hospitalization your weakness and other
difficulties improved. We expect your deficits from your stroke
to continue to improve over the next months.
The echo of your heart also showed that you have a condition
called HOCM (hypertrophic obstructive cardiomyopathy). This
means that there is an obstruction to the blood flow out of the
heart. I believe your cardiologist was already aware of this.
Because the outflow tract gradient was high, and because your
blood pressure was high during this hospitalization, we made
some changes to your blood pressure medications, and we will
discharge you on metoprolol 100 mg every evening and amlodipine
5 mg daily. This plan was discussed with your cardiologist, Dr.
___. Please monitor your blood pressure at home and call
your primary care physician if it is higher than 160. Your
visiting nurse ___ also check your blood pressure.
These CHANGES were made to your medications:
NEW MEDICATIONS:
- pravastatin 40 mg daily for high cholesterol
- metoprolol succinate 100 mg every evening for high blood
pressure
- amlodipine 5 mg daily for high blood pressure
- warfarin (coumadin) 5 mg daily as a "blood thinner". It is
important that you get your blood checked by visiting nurses and
to adjust this medication depending on your INR level.
CHANGES in MEDICATIONS:
- verapamil was STOPPED
- STOP taking verapamil as needed. If your blood pressure is
high at home, please call your primary care physician or your
cardiologist, Dr. ___. | ASSESSMENT:
___ yo. WF w/ poorly controlled HTN and untreated dyslipidemia,
with complaints of new right hand deficits, facial droop, mild
dysarthria.
MRI demonstrates the clinically suspected stroke in the left-mid
precentral gyrus.
Her deficits on exam were lower facial weakness (UMN), mild
dysarthria, and mild clumsiness and slowing of FFM as well as
orbiting deficit, and these have improved and are barely
noticeable now.
TTE demonstrated HOCM, MAC, a small mobile mass (differential
thrombus vs tumor), and new pulmonary hypertension.
In light of these TTE findings, have started warfarin, and pt
will be discharged on 5 mg daily. She has been set up for outpt
ATC f/u.
Ms. ___ was maintained on continuous cardiac telemetery.
During this admission she had one episode 20-beat of
asymptomatic monomorphic VTach and other shorter runs. Pt has
HOCM and is thus predisposed to cardiac arrhythmias. This was
discussed with cardiology, no further recs.
Ms. ___ blood pressure was difficult to control during this
admission. She had a predictable am spike in SBP to approx. 200
with good control afterwards on a regimen of metoprolol 12.5 mg
q6h and amlodipine 5 mg daily. Per cardiology recommendations,
pt will be discharged on metoprolol succinate 100 mg qhs and
amlodipine 5 mg daily.
She was also started on atorvastatin 40 mg daily in light of LDL
134 (previously untreated dyslipidemia) | 397 | 219 |
14230590-DS-21 | 27,619,809 | 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 continue to take home coumadin daily with target INR
___.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE, anterior precautions | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for L hip hemiarthroplasty, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with services and 24h family
care was appropriate. The patient will be contacted by ___
clinic ___ for INR check and coumadin dosing as an
outpatient. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE w/anterior
precautions, and will be discharged on coumadin for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 144 | 261 |
14061330-DS-20 | 23,651,215 | Mr. ___,
You were admitted with weakness, shortness of breath, and
swelling in the legs. We think this is from your kidney disease
resulting in extra fluid build up in the body. You were not on
an adequate dose of diuretics at home. We treated you with IV
medication (furosemide) to remove the fluid, and helped set up
outpatient follow up with your nephrology specialists. We gave
you a new prescription to replace furosemide called torsemide.
We also transfused you with blood for anemia.
Best wishes!
Your ___ Medicine Team | Mr. ___ is a ___ with a history of dementia, DM2, dCHF, CKD
who presents with weakness, shortness of breath and ___ swelling.
He was treated with IV diuretics (100 IV lasix twice daily),
with improvement in volume overload secondary to his renal
failure. Renal dialysis evaluated him in the hospital and
recommended outpatient follow up for consideration of HD
initiation.
ACTIVE ISSUES
# Volume overload and ___ edema: likely in setting of his
underlying CKD and chronic dCHF. Pt appears to have been
undergoing eval for fistula placement, had UE US vein mapping on
___. He had been unable to keep outpatient appointments due to
logistical issues with transportation. Renal dialysis evaluated
him in the hospital and recommended outpatient follow up for
consideration of HD initiation. He was treated with agressive
diuresis with 100 mg IV lasix twice daily, and discharged on
torsemide, with plans for outpatient follow up for consideration
of HD initiation.
# Anemia: Normocytic and stable. There was no evidence of active
blood loss. He was treated with 2 units pRBCs, with appropriate
response, and iron supplementation. It was noted that
erythropoeitin was already prescribed on an outpatient basis.
#Dementia/delirium: Metabolic encephalopathy, progressive
dementia, and delirium in the hospital have contributed to his
disorientation. He was treated with dose reduction of
venlafaxine, attempts at reorientation, minimizing tethers
(d'c'___). He was oriented to self at the time of
discharge.
CHRONIC ISSUES:
# IDDM: Last HbA1c 5.9% on ___. He was treated with ISS and
lantus 16U in AM
# HLD: continued home statin
# Hypertension: continued labetolol; lasix per above
# Hypothyroidism: continued home synthroid
# Gout: continued allopurinol, dosed for renal function.
# Depression: Decreased dose of venlafaxine as above | 88 | 288 |
15431209-DS-4 | 24,742,362 | Dear Ms. ___,
You were admitted to the ___ service at ___
___ due to abdominal pain and a small bowel
obstruction. You are now ready to head home.
Please follow this discharge instructions to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Please continue your bowel regimen daily in order to prevent
constipation.
Your ACS Team | Ms. ___ is a ___ woman with history notable for
cystic
fibrosis, IDDM ___ cystic fibrosis, and ex-lap/SBR/appendectomy
at 8 days of age (___ due to SBO, who
now
presents to the hospital with a chief complaint of epigastric
abdominal pain. She was admitted to ___ for monitoring of
obstruction. A NGT was placed for decompression and draining
fecal content. Patient received gastrograffin through her NGT,
which after 6 hours was only seen initially reaching the small
bowel. Patient reported on ___ that her pain was improving, she
reported her abdomen felt less distended. Patient overnight was
given gastrograffin and reported having ___ bowel movements. AM
KUB 0n ___ showed contrast passing all the way to the colon
and patient persisted having multiple bowel movements. GI was
consulted for help with management of the obstruction, they
suggested continuing Creon, schedule an appointment with Dr.
___ awaiting return of bowel function. Due to patient
passing gas and having bowel movements on ___ her diet was
advanced. Initially to clears and later in the afternoon to
regular diet. Patient tolerated diet very well and felt ready to
go home. She was discharge with an scheduled bowel regimen of
Miralax 3 times a day. Patient was instructed on warning signs
and will follow up with us in clinic in 10 days. Her appointment
with Dr. ___ was also scheduled. | 245 | 223 |
13926282-DS-21 | 22,670,695 | Ms ___,
You were admitted to the hospital with worsening chest and
abdominal pain and a recent CT scan showing pulmonary nodules.
You were evaluated by the GI team and underwent an endoscopy to
evaluate your esophagus, stomach, and duodenum, which revealed
some mild inflammation. You also underwent a cardiac stress test
which was essentially normal and demonstrated no evidence of
ischemic heart disease. You also underwent esophageal
manometry, the results of which will not be ready until next
week. Dr. ___ will review the results of the manometry testing
with you when you see him in clinic.
The GI physicians, working in coordination with Dr. ___,
___ that you continue to take omeprazole twice daily,
that you start rifaximin 550 mg by mouth twice daily (to be
taken for 14 days) for possible treatment-refractory SIBO, that
you start nifedipine 10 mg taken up to three times per day as
needed for substernal pain for possible esophageal spasm, that
you start an over-the counter probiotic called "Align," and that
you continue to follow-up in GI clinic with Dr. ___.
Regarding your lung nodules, the Interventional Pulmonology team
was consulted and reviewed your imaging. They will work to
schedule a procedure called a bronchoscopy with ultrasound and
possible biopsy to be done within the next several weeks.
Because you had persistently low heart rates, the medication you
take for anxiety, Propranolol, was discontinued. Now that you
may be taking the nifedipine, you should NOT resume taking
propranolol until discussing with both your primary care
physician and your psychiatrist.
It was a pleasure caring for you while you were in the hospital,
and we wish you a full and speedy recovery.
Sincerely,
The ___ Medicine Team | Ms. ___ is a ___ yo CF with PMH significant
PTSD/Anxiety/Insomnia/depression, osteopenia presents with 1.5
months of nonspecific chest and abdominal pain, report of poor
PO intake and weight loss, and CT scan demonstrating multiple
pulmonary nodules.
.
# Epigastric/LUQ pain - LFTs ok, lipase not done in ED. No
nausea but diffuse pain across upper abd & chest. Denied any
inciting factors. Denied any aggravating or consistently
alleviating factors.
--GI consulted for EGD per Dr. ___
--EGD on ___ demonstrated gastritis, no evidence of gastric
outlet obstruction, no clear explanation of patient's symptoms
--GI team recommended omeprazole BID, rifaximin 550 mg PO TID
x14 days for possible therapy-refractory SIBO, and continued
outpatient follow-up with Dr. ___
--Dr. ___ esophageal manometry: testing completed
on ___, results won't be available till next week per GI
fellow
--Dr. ___ is also recommending a trial of a calcium-channel
blocker for possible empiric therapy of esophageal spasm: she
was started on nifedipine 10 mg q8h
--Pain was initially treated in the ED with IV narcotics. She
was treated with PRN oxycodone while on the floor, and she was
not interested in trying other PRN medications for possible pain
relief (e.g. simethicone, dicyclomine were offered).
--She is, and has been, tolerating PO without severe pain or any
evidence of obstruction, and with an entirely benign abdominal
exam throughout her hospicalization. Discharged home with
ongoing GI follow-up with Dr. ___ call to arrange
an appointment), who will review the results of the esophageal
manometry when he sees her in clinic.
--Advised patient keep food & pain diary to help identify if any
foods are potential causes or contributors to her pain
.
# Constipation: likely multifactorial, including poor PO intake
combined with narcotics given while inpatient
- senna on discharge
- advised using miralax PRN no BM x 24 hours
- continued f/u in GI clinic
.
# Chest pain - Described an atypical chest pain that was not
always located in the same place. Felt like a
tightness/squeezing that was sometimes associated with SOB and
was sometimes substernal. Other times the pain was located in
the left lateral or right lateral chest. She thought it was
"gas bubbles that need to break." Pain specifically not brought
on by exertion or by stress, and not relieved by resting. The
patient did note that she had essentially stopped all physical
activity (used to go to the gym) over the past several weeks and
was now living with her parents, as opposed to independently, as
a result of the pain. Initial EKG on ___ demonstrated sinus
bradycardia w/ TWIs in inferior and anterior leads. Repeat EKG
showing sinus bradycardia with TWIs in III, aVF, TW flattening
in II as well as in V3-V6, without ST elevations or depressions.
CK-MB was normal. The patient denied history of additional
cardiac work-up in the past. Due to concern for ischemic heart
disease given her age, hx of smoking, and the squeezing
substernal (intermittently) pain, exercise cardiac stress
testing was performed and was normal. Of note, she exhibited
good exercise capacity. Although fairly atypical, symptoms may
have been a manifestation of symptomatic bradycardia induced by
propranolol (prescribed and taken for anxiety); her HRs on
admission were high ___ to ___. Her symptoms seemed to have
improved significantly over the course of her hospitalization,
though it is not possible to say whether improvement due to
holding propranolol (with corresponding improvement in HRs),
starting rifaximin, or receiving narcotic pain meds. Because
she is being discharged on nifedipine for possible esophageal
spasm, and because she had bradycardia of unclear clinical
significance while on propranolol, we have advised her NOT to
resume propranolol upon discharge. Of note, on the day of
discharge, the primary pain complained of was in the upper left
lateral chest and the pain was completely reproducible with
palpation. Furthermore, after palpation of the region with
reproduction of the pain, she subsequently described development
of substernal squeezing pain that was similar in character to
prior episodes. This pain eventually resolved spontaneously.
.
# Bradycardia - sinus - likely due to propranolol use. HR
improved off propranolol (___). As above, given that she is
going home on nifedipine, we have advised her NOT to resume
propranolol and she will communicate this medication change to
her primary psychiatrist, Dr. ___.
.
# Pulmonary Nodules - multiple with large 5-8mm along pleural
and peribronchial. Denies night sweats. Endorses 15 pound wt
loss ("semi-intentional"). h/o light tobacco use. No recent
infection symptoms. No spiculated nodules. Read as likely
reactive LAD. DDX: infectious vs malignancy vs lymphoma vs
autoimmune. Pt is UTD on colonoscopy and mammogram. Consulted
IP: imaging could be consistent with sarcoidosis, they evaluated
the patient and ultiamtely advised outpatient EBUS w/ FNA. She
will be contacted by the ___ clinic to arrange the procedure.
.
# Anxiety/PTSD - severe, per pt PCP wants to try to get off ___
medications but pt cannot tolerate SSRIs. We spoke with her
primary Psychiatrist, Dr. ___, by phone on ___ and he
informed me that the patient's anxiety is extremely severe and
has not been responsive to many of the medications they have
tried. Continued Xanax 2 mg qhs, vistaril 150 mg (verified with
patient) po qhs. Continued Ativan 2 mg q4hr prn. Held home
propranolol as above and did not resume upon discharge.
Notably, her anxiety seemed to gradually improve over the course
of her hospital stay. Patient will follow-up with Dr. ___
___ ongoing outpatient psychiatric care. | 282 | 918 |
17185799-DS-10 | 28,262,413 | Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk for ___
minutes as part of your recovery. You can walk as much as you
can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have some
constipation related to pain medication. You have been given
medication to help with this issue.
You should resume taking your normal home medications.
You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Physical Therapy:
WBAT with Walker
Treatments Frequency:
No dressings. Frequent turns to prevent pressure ulcers.
Physical therapy. | Patient was admitted to the ___ Spine Surgery Service on
___ with sacral insuffeciency fractures. A complete neuro
exam was performed and deemed normal. Her pain was initially
controlled with IV pain medication then transitioned to PO pain
medications. ___ was consulted to work on mobilization.
TEDs/pnemoboots and lovenox were used for postoperative DVT
prophylaxis. Diet was advanced as tolerated. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet. | 199 | 92 |
17014176-DS-16 | 29,117,503 | Dear ___
___ were admitted to the hospital for lethargy and were found to
have atrial fibrillation. ___ required an ICU admission to help
manage your heart rate which improved with higher dose of
metoprolol and a new medication called digoxin. Please see the
new cardiologist for follow up. They will need to check your
digoxin blood level and consider taking ___ off it if possible.
___ were started on a long acting version of oxycodone - watch
out for constipation!
Regards,
Your ___ team | ___ w/ stage IV multifocal HCC w/ mets to porta hepatis,
portacaval space, and retroperitoneum lymph nodes, as well as
mets to bone, currently on sorafenib, p/w weakness and fatigue,
fevers, poor PO intake, and palpitations, found to have afib w/
rvr. He was admitted ___ and transferred to the ICU for Afib w/
RVR on ___ and back to the oncology service on ___.
#AFib w/ RVR
#Palpitations
#History of Rheumatic Heart Disease
AFib diagnosed on this hospitalization. This was likely provoked
by poor PO intake from uncontrolled cancer related pain. He had
a CTA which did not identify PE. TTE revealed trivial MR, mild
aortic stenosis, mod pulmonary hypertension, mildly dilated
right atrium, and LVEF 60%. He was transferred to ___ for
difficult to control rates despite IV diltiazem, and was
eventually controlled on digoxin/metoprolol w/ HR ranging in the
___. While in the ICU, he completed his loading dose of digoxin
IV and was transitioned to PO digoxin of 0.25 mg daily. He
maintained high rates of 110-120, so his metoprolol was
increased to 100 mg four times daily. He converted to NSR on
___ and has maintained SR. He was not started on
anticoagulation in the setting of bleeding risk from
chemotherapy and HCC. He did have one low- range temperature of
100.8, but suspicion for infection was low and suspected to be
___ to underlying malignancy. He did have some pedal edema upon
arrival to the FICU, which seemed ___ to the fluid received when
initiated admitted for dehydration.
-- home metoprolol tartrate of 100 bid increased to 200 mg BID
-- cont Digoxin 0.125 mg daily, consider discontinuing
-- pt to see new cardiologist as outpatient in context of h/o
Rheumatic Heart
-- CHADS 2 given HTN/Diabetes
-- anticoagulation to be discussed w/ his outpatient oncology
and cardiology team
-- of note h/o severe nasal bleeding which required packing
while on anticoagulation in past
#Fever
For fever on presentation, patient initially had CT torso with
no definitive source of infection, but possible suggestion of
pyelonephritis, though UA with only 9 WBC, neg nitrite, tr
leuks, and culture was negative. Blood cultures have remained no
growth to date. Lower extremity duplex bilaterally were
negative. It was felt that this was most likely from his
malignancy.
#Stage IV Multifocal HCC (currently on sorafenib)
-- Continue home sorafenib
-- f/u scheduled w/ Dr ___
-- ___ morphine/oxycodone for pain
-- started oxycontin for longer acting relief
#HTN
-- Continue metoprolol as above
-- home amlodipine and lisinopril stopped to allow for higher
beta-blocker
#T2DM
-- cont home metformin
BILLING: >30 min spent coordinating care for discharge
DISPO: home w/ ___
CODE: Confirmed FC
EMERGENCY CONTACT HCP: Wife ___ ___
______________
___, D.O.
Heme/___ Hospitalist
___ | 83 | 435 |
11618876-DS-14 | 22,818,167 | Dear Mr. ___,
You were admitted to ___ for diverticulitis. The surgeons
evaluated you in the Emergency Department, and did not feel that
you required surgery. We gave you antibiotics and bowel rest,
and you improved. You also had migraines, which we treated with
improvement. You were discharged when your pain improved and
were able to eat again. Please follow up with your primary care
doctor and get an outpatient colonoscopy. | Assessment and Plan:
___ with PMH ruptured appy, obesity who presents to the ___ ED
with LLQ pain of 1.5 days duration with CT abd concerning for
sigmoid diverticulitis vs. focal colitis.
# Abd pain: CT abdomen showed stranding in ___ to mid sigmoid,
likely diverticulitis vs. focal colitis. Patient was given
antibiotics (cipro/flagyl) and kept NPO until pain resolved.
Diet was advanced while in the hospital, which he tolerated, so
he was discharged on 7d course of antibiotics.
# Abnl ED EKG: Pt had normal stress test in ___. But ED
EKG was abnormal with likely J point showing early
repolarization. Repeat EKG on the floor was reassuring.
# Chronic headaches: Pt c/o of h/a for several hours on arrival
to the floor, without vision changes. Patients reported getting
similar headaches weekly, but has not taken meds yet. He
typically takes nortriptyline. Patient was given sumatriptan and
nortryptiline during hospitalization with resolution of
symptoms. | 70 | 154 |
17337033-DS-21 | 28,768,128 | Mr. ___,
You were admitted due to significant cough and difficulty
breathing. You had a CT scan of your chest that showed
Bronchitis that could be bacterial or viral. You were given
medicine through the IV and fluid through the IV.
Please take the new medications (Antibiotics) prescribed.
Please do not use marijuana for next month until you see a lung
doctor.
BEST WISHES,
Your ___ Team | ___ man with IDDM, Renal Tx (on AZA/Pred 5) who presents from
home with severe cough leading to dyspnea who was admitted to
the ICU for tachycardia (up to 160s in the ED) and elevated
lactate (up to 3) now transferred to floor with resolution of
both lactate and tachycardia. | 62 | 50 |
13557457-DS-13 | 20,276,065 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because you were feeling
weak.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You received imaging of your head, which did not show any acute
findings.
You were assessed by the neurology team, and it was determined
that you did not have new neurological weakness or signs of
stroke.
Your weakness and confusion was thought to be due from your
underlying dementia
-Your infectious work-up was negative
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications as prescribed
and follow-up with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ male with a history of bladder
cancer status post surgical removal, coronary artery disease
status post CABG, bradycardia status post permanent pacemaker,
type 2 diabetes, hypertension, followed by neurology and
outpatient setting with chronic neurocognitive decline thought
to be secondary to Alzheimer's versus possible frontotemporal
dementia, who presented with measured fever at home of 101 and
worsening weakness, admitted for altered mental status workup.
Remainder of infectious work-up returned negative and
antibiotics were deferred. Had CT Head on admission which showed
stable ventriculomegaly however without other acute process. His
weakness improved during hospitalization with ___, weakness was
thought ultimately to be secondary to his underlying
neurocognitive disease with possible worsening. Was evaluated by
neurology here, plan for discharge to rehab with n eurology
follow-up.
--Plan for discharge to rehab for < 30 days-- | 129 | 138 |
13011235-DS-10 | 28,135,872 | Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted for left arm swelling. We
diagnosed you with a deep vein thrombosis. We treated you with
Lovenox (a blood thinner), which you will continue to take as
directed by your oncologist. If you have any further questions
about your hospitalization feel free to contact your ___
providers.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STARTED Lovenox for DVT | ___ year old ___ female with recently diagnosed
pancreatic ___ (s/p C1 of Gemzar, last infusion
___ presented with left upper
extremity redness, swelling and pain.
# LEFT UPPER EXTREMITY DVT: Left upper extremity ultrasound
demonstrated near occlusive clot in the basilic and cephalic
veins and patent deeper venous structures. She was started on
Lovenox in the emergency department. She was admitted for
Lovenox teaching and close observation. Predisposition to DVT
include pancreatic cancer and recent chemotherapy infusions. She
had no evidence of additional DVTs on exam or history. Her vital
signs were stable throughout her hospitalization with oxygen
saturations in the high ___. She is to continue on Lovenox 80mg
Sub-Q Q12 at discharge; therapy length to be determined by her
primary oncologist.
# PANCREATIC ___: Discovered during evaluation for abdominal
pain and reflux symptoms. Tissue diagnosis obtained via EUS
(___): pancreatic adenocarcinoma with signet cell features.
Widely locally invasive cancer encasing the celiac axis, splenic
artery, as well as encasing the portal confluence. Non-operable.
Patient to undergo radiotherapy and chemotherapy. No complaints
of pain this admission. PRN ativan and prochlorperazine for
nausea.
# HYPERTENSION: Blood pressure well controlled on admission.
HCTZ and lisinopril continued during her admission.
# HYPERLIPIDEMIA: Home dose of simvastatin continued.
# ASTHMA: Mild, intermittent based on history. The patient takes
albuterol rarely and Flovent during allergy season. PRN
albuterol continued during her hospitalization.
# GERD: Protonix continued.
TRANSITIONAL ISSUES
*******************
-patient to make follow up appointment with her Atrius PCP and
oncologist | 86 | 248 |
10577647-DS-81 | 22,561,517 | Dear Ms. ___,
You came in because you were having back pain. Fortunately we
did not find any evidence of a urinary tract infection. Your CT
scan also did not show any signs of infection or kidney stones.
Your pain was probably a muscle pain.
It was a pleasure taking care of you, and we are happy that
you're feeling better! | Ms. ___ is a ___ female with diabetes, chronic
abdominal pain and a UTI treated with Cefpodoxime starting 4
days ago presenting with acute right flank pain. Pt was given IV
Meropenem and admitted to medicine given long list of allergies
to abx and failed outpatient treatment on cefpodoxime. | 59 | 48 |
13952663-DS-16 | 20,091,699 | You were admitted to the neurosurgery service for work-up of
your severe headache, blurred vision, and nausea. You underwent
a CT head which showed thrombosed left MCA aneurysm and was
negative for hemorrhage. LP results showed supernatant clear and
was negative for subarachnoid hemorrhage. You were discharged
from the hospital with recommendations for follow-up MRA head in
___ year.
Medications
Resume your all your normal medications with the following
exceptions:
* Do not resume taking valsartan
* Do not resume taking furosemide (Lasix)
You were cleared by the neurosurgeon to resume your aspirin.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Soreness in your arms from the intravenous lines.
When to Call Your Doctor at ___ for:
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
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
Other Instructions
Remember to eat food that is low in fat and cholesterol. This
lowers the risk of narrowing in your arteries.
If you smoke and have not stopped smoking yet, please consider
doing so. We can help you find a program that can help you make
this very important change. | # Left MCA Aneurysm
The patient was admitted on ___ for headache, nausea, and vision
changes. On ___, she underwent a lumbar puncture in ___ to
confirm absence of xanthrochromia to confirm lack of
subarachnoid hemorrhage. She was cleared for discharge to home
however stayed inpatient for work-up of a failed bedside swallow
and symptomatic hypotension.
#Dysphagia
Patient was coughing on thin liquids while taking her
medications. Speech therapy evaluated the patient and cleared
her for a regular thin diet and outpatient video swallow study.
#Hypotension
Patient is on 4 antihypertensive medications at home. Just prior
to discharge she became hypotensive with associated blurred
vision and lightheadedness while sitting in the chair. Medicine
was consulted for assistance in management. They recommended
discontinuation of her home Lasix and valsartan, which
significantly improved her blood pressure by day of discharge.
She was advised to hold these two medications at home, and
discuss her BP regimen with her PCP.
#Diabetes
Patient's oral diabetes medications were held for possible
planning for OR and due to receiving contrast. She was ordered a
regular insulin sliding scale in the meantime. Her standing
lantus and Glucophage were restarted and her sugars were
monitored. Her blood sugar was elevated and ___ was consulted
for advice on management. They recommended restarting her home
medications as soon as possible, and restarting her home Januvia
(nonformulary medication) upon discharge, with close follow up
with her primary care provider.
#Dispo
On ___ she was neurologically stable, ambulated at baseline with
her walker, her blood sugars were not unreasonably elevated. She
was discharged home with appropriate instructions to restart her
home meds (holding her Lasix/valsartan), and to follow up with
her PCP ___ ___ weeks regarding her hypotension on her
anti-hypertensive meds, and her diabetes. She was also advised
to seek follow up with neurology and podiatry for her diabetic
neuropathy and foot/nail care. She also had expressed some
concern over her asthma medications (however did not have any
respiratory issues this admission), and was given a referral to
___ pulmonology | 250 | 331 |
14938988-DS-14 | 26,796,033 | Dear Mr. ___,
You came to the hospital with pain in your thigh and were found
to have a fluid collection in your thigh that was infected as
well as an infection of your pelvic bone. We treated you with
antibiotics and you improved. You will continue these
antibiotics when you leave the hospital to complete a full 6
week course. Please call your urologist and follow up with him
in ___ weeks of leaving the hospital.
It was a pleasure being involved in your care.
Your ___ Team | Mr. ___ is a ___ ___ man s/p TURP for
lower urinary tract obstruction admitted with ___
abscess and osteomyelitis s/p drainage CT guided aspiration of
the left perineum and left thigh treated with antibiotics.
# Periprostatic abscess, Left adductor abscess, and Pubic
Symphysis Osteomyelitis:
Patient presented with left thigh pain and was found to have
periprosthetic abscess and osteomyelitis of pubic symphysis on
CT scan. Infection was thought to be post TURP complication with
abscess and localized spread causing pubic symphysis
osteomyelitis per MRI (___). Patient underwent retrograde
urethrogram showing no fistula. Patient underwent CT-guided ___
aspiration (___) for culture though with no growth on specimen
including fungal and AFB studies. Blood cultures obtained also
showed not growth to date. Patient treated with IV zosyn 4.5 mg
IV q8h for total ___ourse to continue until ___. PICC line placed for continuation of intravenous
antibiotics and should be removed upon completion of antibiotic
course. Weekly safety labs to be drawn per ID
recommendationsincluding CBC with differential, BUN, Cr,
ESR/CRP. Please fax labs to ATTN: ___ CLINIC - FAX:
___. ID will call patient with outpatient follow up
appointment time. All questions regarding outpatient parenteral
antibiotics after discharge should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
Patient to follow up with Urology in ___ weeks post discharge.
INACTIVE PROBLEMS:
# HTN: Continued home Losartan
# HLD: Continued home Simvastatin
# HEPATITIS B: Continued home Entecavir 0.5 mg PO DAILY | 86 | 256 |
16477848-DS-29 | 23,294,459 | Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
You were admitted to the hospital because you vomited dark
material.
WHAT HAPPENED TO ME IN THE HOSPITAL?
Your blood counts were monitored. You did not obviously
appear like you were bleeding.
When we felt that it was safe to restart your Coumadin and so
we gave you a lower dose than you were taking before.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
You should take your Coumadin at your new dose of 0.5mg daily.
You should follow up with your primary care provider as
scheduled.
Weigh yourself every morning, call your primary doctor if
weight goes up more than 3 lbs.
We wish you the best! | ___ year old F PMHx asthma, HTN, CAD/PCI ___ and recent STEMI
managed medically (discharged ___ on Plavix/warfarin, cerebral
calcifications from cystercercosis, who presented to the ED on
___ with abdominal pain, nausea, and vomiting of thick
black/brown material, with subsequent resolution of symptoms.
ACUTE MEDICAL ISSUES
# Nausea/Vomiting
Shortly after prior discharge for STEMI on ___, at which time
plavix and warfarin were started for medical management,
patient had one episode of emesis without frank red blood.
Emesis was "coffee brown" with a thick consistency. She had one
further episode of emesis while hospitalized described as dark
by RN but no obvious evidence of blood or coffee grounds and
occurred after having meatballs with sauce for dinner the night
before. Hemoglobin remained stable, so low suspicion for
significant bleeding. Patient tolerating PO on discharge.
# Supra-therapeutic INR
Coumadin was held for two days (___) while supratherapeutic
INR was trended. The patient had no more emesis, no bloody
stools, no black tarry stools. She denied any chest pain or
shortness of breath. IRN at discharge 1.6. Coumadin dose at
discharge 0.5mg daily down from 2.5mg before admission. Will
need continued close titration.
CHRONIC ISSUES
# HTN
Pts Imdur was initially held for one day in the setting of
questionable upper GI bleed. It was subsequently restarted. Her
metoprolol, lisinopril and plavix were all continued at their
pre-hospitalization doses.
# Insomnia
Continued Mirtazapine 15 mg po qhs
# PVD with peripheral neuropathy
Continued Gabapentin 300mg po qhs
# COPD/Asthma
Continued home medications
# Thrombocytopenia
Stable, no change from recent discharge. Plts at discharge 155.
TRANSITIONAL ISSUES:
====================
- Please continue warfarin and Plavix on discharge.
- Anticoagulation plan: Continue Warfarin 0.5mg for now with
frequent checks and titration; next check INR on ___ by home
___ to be faxed to primary care Dr. ___ ___
- Consider repeating TTE in 3 months for evaluation of left
ventricular thrombus and transitioning to dual anti-platelet
therapy with aspirin and Plavix only if echo is without
akinetic apex.
- Weight on discharge: 117 lbs | 120 | 332 |
13233464-DS-4 | 28,193,313 | Dear Ms. ___,
It was a pleasure taking part in your care during your admission
to ___.
Why you were admitted:
========================================
- You were admitted to the hospital after you had a fall at home
- You were found to have an irregular heart rhythm at ___
___, and transferred to ___ for further
evaluation of your abnormal heart rhythm
What was done during your admission:
========================================
- You were seen by the electrophysiology team who discussed the
possibility of placing a pacemaker, but decided, with your
family, that this would not be within your goals of care given
the nature of the procedure, and the postoperative requirements
of it
- You were observed, and your heart rhythm returned to the
normal heart rhythm, and your blood pressures were stable.
- You were noted to have a low blood pressure when standing up.
Please see below for further recommendations about this.
What you should do when you go home:
========================================
- Please follow up with your regular doctor as noted below, in
the next ___ days
- Please have your blood pressure measured by a visiting nurse
while sitting and standing to monitor your blood pressures with
standing
- Please DO NOT get up within 1 hour of eating, as you may be
more likely to be lightheaded with standing after a meal
- Please continue to take your home medications
- Please wear compression stockings
- Please stay hydrated by drinking 6 glasses of water a day
- When getting up from bed, please get up slowly, first sitting
for a few minutes, then standing and waiting for a minute so as
not to be lightheaded.
We wish you the best!
-Your ___ care team | Ms. ___ is a ___ year old woman with history of dementia who
presented after unwitnessed fall and found to have brief episode
of
junctional bradycardia and possible complete heart block at ___
___. She was transferred to ___ for EP evaluation. EP
discussed potential PPM with family, and decided was not within
goals of care. Patient was noted to be orthostatic with resting
SBPs in the 100s-160s, but falling to as low as ___ upon
standing, thought to be secondary to autonomic instability, as
it continued after IVF.
# FALLS
History of multiple falls with unclear etiology and unclear
history/preceding symptoms given dementia. Lives in assisted
living facility. Falls could be syncope ___ junctional
bradycardia discussed below.
Could also be mechanical, medication-related (on gabapentin,
lorazepam, and duloxetine). Less likely infection, though
patient had leukocytosis but with negative infectious work up
and with improvement to near normal without abx. EP consulted,
and after discussion with daughter,
determined not within GOC for PPM placement. Patient was
orthostatic, thought to likely be chronic, with
normotension/hypertension at baseline and not tachycardic.
Behavioral modifications were recommended to mitigate these
effects. TSH, B12 were WNL.
# JUNCTIONAL BRADYCARDIA AND COMPLETE HEART BLOCK
EKG from ___ with sinus node dysfunction with junctional
escape versus complete heart block. EKG and changed to normal
sinus rhythm. Unclear if this is the etiology of her falls vs
orthostatic hypotension vs. gait instability from
ventriculomegaly (see below). After discussion with family, not
within ___ to get PPM. Monitored on telemetry and remained in
sinus.
# LEUKOCYTOSIS
WBC 20.5 with 91.4% PMNs on admission. No localizing signs of
infection. Afebrile. UA negative and CXR clear. No abx and
decreased to 11 by time of discharge. No fevers. Likely stress
response. No report of
seizure-like activity or loss of consciousness (but lack of
history).
# DEMENTIA
# AGITATION AND ANXIETY
Patient has end stage dementia and has history of agitation and
anxiety. Currently on lorazepam standing, gabapentin standing
and
prn for agitation, and duloxetine. Would recommend follow up
with psychiatry and decreasing meds as possible.
# ORTHOSTATIC HYPOTENSION
Noted during admission, and could be contributor to falls.
Patient has been hypertensive so unlikely dehydrated, may have
autonomic instability given age and comorbitidies. Please see
below for recommendations on managing this as an outpatient.
# DIFFUSE VENTRICULOMEGALY
Seen on CT scan at ___ during prior admission for fall.
Patient could have NPH causing her falls. Concern for NPH on
that
admission was discussed with neurology and family and decision
made to decline evaluation with MRI given that LP and VP shunt
placement would not be within goals of care.
# HLD - continued home colestipol
# Vit D deficiency - continued home vit D
# GOALS OF CARE
After long discussion with HCP ___, learned that patient is
DNR/DNI. She is also not okay with electric shocks or
transcutaneous pacing. She is unsure about ICU transfer. Per
family would not want PPM after discussion with cards fellow
yesterday. | 266 | 458 |
17475607-DS-25 | 20,065,521 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted because
the culture from the spinal tap grew a bacteria. You were
started on IV antibiotics but these were discontinued after we
discovered that the bacteria was a contaminant (not a true
infection). You should follow up with your primary care
physician and in the neurology and neurosurgery clinics as
scheduled.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ gentleman with a history of COPD (on
2L NC at home), CAD s/p PCI in ___, CKD (baseline Cr 1.3),
HTN, and recent SAH, who was discharged on ___ from the
Neurosurgery service for recurrent SAH and who was asked to
return to the hospital due to a CSF culture positive for GPCs.
He was started on vancomycin and ceftriaxone but culture
speciated to coagulase negative Staph aureus, thought to be a
contaminant. He had no clinical evidence of a bacterial
meningitis. Two separate blood culture also grew coagulase
negative Staph aureus (with different sensitivities), and ID
also believed these to be a contaminant. He remained afebrile
and antibiotics were discontinued. Patient reported right
shoulder pain, most likely due to rotator cuff tendinitis vs.
cervical radiculopathy. Exam was not consistent with septic
arthritis. Patient was discharged home with home ___ and PCP
___. | 74 | 149 |
11775739-DS-14 | 28,439,757 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L intertroch hip fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for L proximal femur replacement, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE extremity, and
will be discharged on lovenox 40mg x2wks for DVT prophylaxis.
The patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. | 139 | 239 |
12666083-DS-7 | 29,747,616 | You were admitted with swelling of the right eye. There was some
concern that you might have a skin infection "cellulitis" around
the eye, or that this might be progression of the tumor aroung
the eye. It is impossible to know for sure, so you are being
discharged on oral antibiotics that you will take for a week. | ___ year old male with tonsillar cancer with skull base/orbit
involvement with tumor progression following re-irradiation in
___ who presents with progressive right eye swelling
and one day of drainage.
#EYE SWELLING, TONSILLAR CANCER: The progressive swelling over
the past two months seemed most consistent with disease
progression although other etiologies were considered.
Infection, including the possibliity of cellulitis, was
considered and was difficult to exclude on exam given the
extensive orbital edema. He had no sytemic signs of infection
with a normal white blood cell count. Ophthalmology was
consulted and recommended MRI/MRV of head. MRI revealed likely
progression of malignancy, but was unable to exclude
superimposed infection. The patient was seen by neuro-oncology
(Dr. ___ and the case was discussed with radiation oncology.
He was discharged on decadron, bactrim and keflex. He will
follow up with oculo-plastics as scheduled and his family will
call his medical oncologist at ___ on ___ to discuss
salvage chemotherapy options.
#HYPOTHYROIDISM:
-continued levothyroxine
#HYPERTENSION:
-continued atenolol
-continued amlodipine
#DIABETES:
-continued glipizide and metformin
# FEN: regular
# PPX: heparin SQ
# CODE: full (confirmed)
# CONTACT: son - ___ | 58 | 190 |
11224698-DS-16 | 27,935,092 | Dear Mr. ___,
It was a pleasure taking care of you here at ___. You were
admitted for worsening shortness of breath and cough. You were
found to have worsening your pulmonary fibrosis that is likely
causing your symptoms. We started you steroids which improved
your breathing. You also now require increased oxygen. We also
started you on a medication called atovaquone to prevent you
from getting an infection called PCP ___. At this time,
were also treated you with two antibiotics to pneumonia as well:
azithromycin (last dose ___ and cefpodoxime (last dose: ___
). You had a long discussion with both our team your
pulmonologist Dr. ___ at which time you decided that you would
like to go home with hospice where you can enjoy time with your
family and try to avoid rehospitalization if possible. We wish
you all the best.
Sincerely,
Your ___ team | ___ year old male with a h/o lung CA of the LLL s/p ___,
pulmonary fibrosis, c/o 2 days of shortness of breath and cough,
found to have CT imaging with dramatic progression of pulmonary
fibrosis but smaller left lung mass consistent diagnosis of IPF
flare.
ACTIVE ISSUES
# Interstitial pulmonary fibrosis flare: Patient was started on
solumedrol 125mg IV BID X 48 hours (day 1: ___ with remarkable
improvement. He was then transitioned to po prednisone on day of
discharge. He was maintained on more aggressive insulin sliding
scale during this time. Steroids should be continued for ___
weeks until he follows up with outpatient pulmonologist who will
determine further course of care. He was also started on PCP
prophylaxis with atovaquone (bactrim allergy). He was also
treated symptomatically with PRN and standing nebs. He was
saturating 83% on 3L NC on day of admit but high ___ on 6L NC.
Ambulating O2 saturation was 88% on 6L NC. Patient knows to try
morphine for relief of severe dyspneic symptoms though he did
not require this during stay.
# Community acquired pneumonia/ Dyspnea: In addition to
progressive pulmonary fibrosis, dyspnea was also thought to
possibly be duet to CAP and/or mild volume overload (the latter
- much less likely). There was also concern for CAP in the
setting of productive cough and subjective fevers/chills. He was
started on azithromycin and ceftriaxone, and transitioned to
cefpodoxime on discharge. Though patient's last TTE in ___
had EF 50% and clinical exam had little evidence of volume
overload, there was a small concern that pulmonary edema may be
contributing to symptoms. Patient was gently diuresed during
hospital stay. Patient was also noted to have extensive coughing
and choking when eating and drinking suggesting that aspiration
may be contributing to symptoms as well, but patient was cleared
by speech & swallow to have regular solids and thin liquids.
Progression of metastatic disease was though to be less likely a
cause of dyspenea given findings of decrease in size of left
infrahilar mass lesion on repeat imaging though there is a new
8mm nodule in LUL (unclear if malignancy vs
fibrosis/inflammation).
# Goals of care: In discussion with the palliative care team and
his outpatient pulmonologist, patient and family decided that
going home with hospice would be within goals of care. He would
like to minimize hospitalization as much as possible and he
remains DNR/DNI.
CHRONIC ISSUES
# Squamous cell lung carcinoma: s/p ___ ___ treatments
___. Malignancy was not thought to be primary cause of
dyspnea and imaging did not show progression of disease.
# CAD s/p CABG and with 3 vessel disease: No chest pain. Recent
TTE ___ stable. He was continued on betablocker, statin, and
aspirin during hospital stay. Statin was discontinued given
limited utility in the near future.
# DMII: held orals and byetta during hospitalization and patient
was maintained on ISS which was titrated up while on prednisone.
Diabetes medications should be titrated up as indicated while
patient remains on prednisone for the next ___ weeks.
# HTN: stable. continued carvedilol
# HLD: continued statin
# BPH: tamsulosin was held during hospitalization, but on
discharge it was _____
TRANSITIONAL ISSUES
# Patient is to complete a 5 day course of azithromycin (day 1:
___, last dose ___
# Patient is to complete a 10 day course of cefpodoxime (day 1:
___, last dose: ___
# He should continue atovaquone for PCP prophylaxis while he
remains on high dose prednisone for the next 4 weeks -- he will
be reevaluated by Dr. ___ within 4 weeks to
determine course at that time
# f/u urine histoplasma antigen, aspergillus galactomannan,
sputum fungal culture, respiratory viral culture, and blood
culture
# ***Uptitrate diabetes medications as needed while patient
remains on prednisone for the next ___ weeks***
# Consider f/u of 8mm nodule in LUL (unclear if malignancy vs
fibrosis/inflammation) | 145 | 633 |
12612603-DS-30 | 23,440,628 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a bloodstream infection.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received antibiotics to treat your infection.
- You received IV diuretics to remove fluid from your body
- You underwent surgery (partial gastrectomy) which showed clear
margins and no other evidence of cancer.
- You had a connection between the surgical site and your
stomach with a fluid collection at the surgical site, and a
drain was placed in the surgical site which will stay there
until this connection closes.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Please call your cardiologist or the HeartLine at ___
if your weight increases by more than 3 pounds in 1 week
- You will continue with IV antibiotics until it is confirmed
that your fistula has closed
- You will also continue tubefeeds until the fistula heals. As
discussed in the hospital, you can have clear liquids, but any
intake of solid food will increase the chances of your fistula
not healing properly and risking further infections.
- You will take a new regimen of insulin: 32 units of glargine
before bed time daily, and a sliding scale as documented below.
- Take 14 mg of warfarin on ___, and on ___ you will have
your INR checked and someone from Dr. ___ will
tell you what dose of warfarin to take. Until your INR is
therapeutic, you will take lovenox injections twice daily.
- You will have follow-up appointments with PCP, ___,
surgery, and interventional radiology
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | TRANSITIONAL ISSUES:
=====================
#HFrEF s/p ___ III LVAD:
[] Will take 14 mg warfarin on ___ at 4 pm. He will call the
clinic on ___ to discuss further dosing based on INR that day.
Target INR is ___. Until therapeutic, continue lovenox 1 mg/kg
BID.
[] Continue ASA 162 per heart failure attending
[] Needs 2nd dose of shingrix vaccine; first dose given
___
[] Needs to see ___ (oncology) for follow-up, as her
input is needed regarding re-listing patient for heart
transplant.
#Gastric NETs s/p partial gastrectomy, gastric fistula, fluid
collection s/p ___ drainage:
[] Has 1 week follow-up with surgery being scheduled on
discharge; if not confirmed at follow up please call
___ to schedule follow up with Dr. ___
[] Per ___, pt should follow up with surgery regarding JP drain.
[] Continue Zosyn and tubefeeds until confirmed fistula closure.
[] Following goals of care discussion, it was decided ___ can
take in clear liquids but should continue to anything beyond
that to maximize changes of proper fistula healing
[] Will need repeat CT in approximately 2 weeks to monitor fluid
collection and drain and likely repeat EGD around 4 weeks to
confirm fistula closure.
#Incidental Findings:
[] Follow-up echogenic liver found on abdominal ultrasound
(___) concerning for hepatic steatosis. Consider further
evaluation by FibroScan or MR ___, and hepatology
consultation, to r/o liver fibrosis.
[] Pt found to have splenomegaly on abdominal imaging. Monitor
splenomegaly on repeat CT (see above), and consider heme-onc
workup.
Other:
[] Did not need significant sevelamer while inpatient. Can be
restarted as an outpatient if necessary.
#CODE: Full Code
#CONTACT/HCP: ___ (wife) ___ | 310 | 263 |
10212492-DS-18 | 28,756,051 | ******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*******
Non Weight Bearing in long arm splint
******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******
- No systemic anticoagulation needed. Please keep active. Walk
as tolerated. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left both bone forearm fracture. The patient was
taken to the OR and underwent an uncomplicated repair. 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: Non Weight Bearing in long arm splint.
The patient received ___ antibiotics. 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.
All questions were answered prior to discharge and the patient
expressed readiness for discharge. | 184 | 158 |
16522510-DS-17 | 22,707,765 | You have undergone the following operation: Minimally Invasive
Microdiscectomy
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery.
Brace: You do not need a brace.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___ 2. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Hospital course was otherwise unremarkable.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet. | 575 | 122 |
18797174-DS-32 | 28,975,988 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for cellulitis of your right leg. You were
first given IV antibiotics (vancomycin) and were changed to oral
antibiotics (bactrim and keflex). You remained without fevers
and your cellulitis slowly improved. You will go home with your
prior home health services and on antibiotics. You will take the
antibiotics for 4 more days and will finish on ___. These
antibiotics may affect your warfarin dosing. We have told the
nurses that monitor your warfarin dose about this and they will
let you konw if you need to change your dose. | Ms. ___ is a ___ yo F with a PMHx significant for atrial
fibrillation on warfarin, DM2, and chronic lymphedema who
presented with right lower extremity cellulitis progressing
despite outpatient augmentin-clavulanate. She received
vancomycin and was transitioned to bactrim and keflex, her
cellulitis improved on exam and she remained afebrile throughout
hospitalization.
# Right lower extremity cellulitis
Likely streptococcal species versus strep. She was covered for
MRSA given recent hospitalization and DM2. She never had fevers
or leukocytosis. She was given a dose of vancomycin upon
admission and changed to bactrim and keflex, both of which she
will continue upon discharge for a ___hronic lower extremity lymphedema
Ace wraps of left lower extremity were used and legs were
elevated throughout hospitalization while in bed.
# Atrial fibrillation
Remained anticoagulated on warfarin with goal INR ___ and
rate-controlled with metoprolol, diltiazem, and digoxin. The ___
___ clinic was notified of her hospitalization as
well as the need for short-term antibiotics.
# Hypothyroidism
Continued on home dose levothyroxine.
# Hypertension
Stable on home diltiazem and metoprolol.
# Obstructive sleep apnea
Continued on home BiPap
# DM2
Sliding scale humalog used during hospitalization, sugars in the
100's throughout. Transitioned to home glipizide upon discharge. | 109 | 190 |
11126593-DS-15 | 23,189,915 | Dear Mr. ___,
You were admitted to ___ because you were having palpitations
due to an episode of atrial fibrillation. You were started on
an IV medication to control your heart rate and your symptoms
improved. We started you on a new medication called digoxin.
Since your heart rate is now controlled and you are no longer
having symptoms we feel it is safe for you to return home and
follow up with your primary care physician.
We made the following changes to your medications:
-START digoxin - take one dose tonight, then take one dose every
morning starting tomorrow
We made no other changes to your medications.
Please have your coumadin level checked again on ___ and the ___ clinic.
Please see below for your currently scheduled appointments.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery. | Primary Reason for Hospitalization:
___ with h/o paroxysmal afib on coumadin c/b CVA ___ who
presents with palpitations and found to be in afib with RVR. | 143 | 25 |
19978630-DS-9 | 21,940,751 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight-bearing as tolerated left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Subcutaneous heparin three times daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
-weight-bearing as tolerated left lower extremity
Treatments Frequency:
-staples to remain in place until follow up visit | The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for left
retrograde femoral nail, 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.
In discussion of dispo planning, multiple conversations
involving the family, medicine, palliative care, and case
management teams were had. Ultimately given the family's goals
of care regarding the patient, it was decided that comfort
measures only would be in the patient's best interest. Given the
frequent demands and needs for care of the patient, it was
thought that nursing home with hospice would be the best setting
for the patient. However, the family wanted the patient to be
brought home with hospice services despite the demands including
wound care, dressing changes, assistance with transfers and
ambulation, and administration for subcutaneous heparin on a
daily basis.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight-bearing as tolerated in the left lower extremity, and
will be discharged on Subcutaneous Heparin twice daily for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 204 | 341 |
14877326-DS-23 | 24,156,761 | Dear ___ was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
rectal bleeding. Your INR (measure of how thin your blood is)
was elevated to 14, so you were given blood products and
medications to bring it down to normal level.
During the hospitalization, you had episodes of coughing up
blood, so bronchoscopy (looking with a camera into your lungs)
and flexible sigmoidoscopy (looking with a camera into your
rectum/lower colon) were done. They did not show any areas that
were actively bleeding. You were also given blood transfusions
for your anemia.
Your creatinine (measure of your kidney function) was increased,
and it was thought to be due to contrast dye you received with
your CT scans.
These CHANGES were made to your medications:
STOP taking Aleve
STOP taking compazine
START tylenol ___ mg tablet: ___ tablets every 6 hours as needed
for pain
START oxycodone 5 mg tablet: ___ tablet as needed for pain
START lorazepam 0.5 mg tablet: 1 tablet every 8 hours as needed
for anxiety or insomnia
START ondansetron (zofran) ___ mg by mouth as needed for nausea | Brief Hospital Course: ___ with recurrent ovarian cancer
initially Dx ___, s/p TAH-BSP, s/p bowel perforation ___
with right hemicolectomy and ileostomy, s/p ___,
Doxil, Arimidex, currently C6 D5 of gemcitabine who presents
with lower GI bleeding in the setting of supratherapreutic INR.
Her hospital course was complicated by hypoxia due to volume
overload in setting of RBC transfusion and hemoptysis requiring
bronchoscopy. Bronchoscopy and flexible sigmoidoscopy did not
show active bleeding, and her BRBPR and hemoptysis were thought
to be all due to supratherapeutic INR. When she was stable, she
was restarted on coumadin with heparin bridge. She was also
found to have transaminitis/direct hyperbilirubinemia on labs,
concerning for obstruction. Imaging did not show any
obstruction, so it was thought to be due to medication effect
(gemcitabine vs. aleve) and improved on its own. She also had
acute on chronic kidney failure, thought to be due to contrast
nephropathy.
# Hemoptysis/BRBPR from coagulopathy: Patient presenting with
INR of 14.4, likely combination of coumadin and gemcitabine
interaction and poor PO intake increasing INR. Her INR was
corrected with IV vitamin K and FFP in the ED but patient had an
episode of hemoptysis and BRBPR early in the hospitalization
which were concerning. Bronchoscopy and flexible sigmoidoscopy
were done and did not show actively bleeding lesions. She was
monitored for few days and her bleeding did not recur, so she
was restarted on coumadin with heparin bridge.
# Transaminitis/direct hyperbilirubinemia: patient with
transaminitis with obstructive/cholestatic pattern, RUQ u/s and
MRCP without evidence of obstruction. ?medication effect most
likely ___ gemcitabine vs. aleve at home. Her LFTs were trended
and improved on its own. Hepatitis panel were checked and
negative. Her outpatient oncologist was notified of the LFT
abnormalities so it can be monitored with her next dose of
gemcitabine.
# Hypoxia: After transfusion with 2 units of RBCs for acute on
chronic anemia, patient developed shortness of breath and
hypoxia. Most likely secondary to volume overload significant
amounts of IV fluid. EF 55%. Ruled out for PE on CTA. She was
gently diuresed with lasix and was weaned off supplemental O2.
# Acute on chronic kidney injury (baseline stage III):
Creatinine at 1.5 on admission, stable around 2 at this time.
Likely due to contrast dye load from CTA. Chronic KI could be
related to chronic NSAIDs use. Her creatinine was monitored and
reached peak of 2.5 but remained stable.
# Nongap metabolic acidosis: likely from her acute kidney
failure and impaired bicarb reabsorption, stable. It resolved on
its own.
# Pancytopenia: Patient developed pancytopenia during this
hospitalization, thought to be due to her recent chemotherapy.
She received transfusion for her anemia and thrombocytopenia.
Her leukopenia and thrombocytopenia resolved on its own, and
anemia remained stable. Patient likely has chronic anemia from
chemotherapy/chronic inflammation.
# DVT/elevated INR: initially elevated INR, secondary to
continued coumadin in the setting of poor PO intake after her
last chemotherapy. Given patient's history of DVT in ___,
coumadin was restarted with heparin bridge when her GI bleed was
stable.
# Metastatic ovarian cancer: Metastatic disease, per CT with
progression in lymph nodes from prior imaging from ___.
Patient receives care with Dr. ___ in ___,
currently undergoing gemcitabine treatment. Her ___ cycle
started on ___ and she received her last dose of chemo on
___. Her CA 125 was found to be elevated to 800s during this
hospitalization. She will continue her chemotherapy in ___
with her primary oncologist.
# R leg pain: Patient suddenly developed right leg cramping
which interfered with her ambulation. ?neuropathic/sciatic pain
vs. musculoskeletal. Given concern for recurrent DVT, right
lower extremity doppler was checked and was negative for
thrombus. She was managed with tylenol/low dose oxycodone and
heat packs. NSAIDs were avoided given her chronic kidney
failure.
CHRONIC ISSUES
# Chronic back pain: Tylenol/Oxycodone for back pain
# Cyanosis of fingertips: Likely vasogenic, sats stable, no
signs of embolic disease or hypoxia, and warfarin necrosis less
likely. | 185 | 650 |
17123392-DS-30 | 23,006,213 | Thank you for allowing us to take part in your care. On ___ you came to the emergency department ___
___ because you had been having trouble
breathing, a cough, chills, and congestion. You also had pain in
your abdomen and in your right foot. A urine test in the ED was
positive for cocaine. A CT scan showed that you had pneumonia.
You received antibiotics to treat pneumonia. In the ICU you
became very confused and delirious. All medications which can
worsen delirium were stopped. Over the course of a few days,
your condition slowly improved and we transferred you back to a
regular medical floor. Your breathing improved until you were
back at your baseline condition. You continued to experience
some pain in your abdomen and in your right foot. An ultrasound
of your abdomen was normal. We treated your pain with
Gabapentin and with Tylenol. Physical therapy evaluated you and
after working with you for a few days they determined that you
were safe to go home and follow up with ___ rehab as an
outpatient.
When you go home, make the following changes to your
medications:
STOP taking Lyrica (Pregabalin)
STOP taking Trazodone
STOP any narcotics
START taking Gabapentin twice a day
START taking Quetiapine (Seroquel) at bedtime
We strongly advise avoiding all narcotics, alcohol, and illicit
drugs. These substances will worsen your breathing and thinking. | Ms. ___ is a ___ year old woman with COPD, severe pulmonary
hypertension, GBS, and polysubstance abuse who presented with
dyspnea and productive cough x3 days.
. | 233 | 27 |
19473726-DS-16 | 22,945,925 | You were admitted to ___ after sustaining injuries from
falling down stairs. You hit your head which caused intracranial
bleeding. You also fractured your left hip, pelvis, and ___
lumbar vertebrae. You were seen by the Neurosurgeons and your
neurological status was closely monitored. A repeat head cat
scan showed the bleeding had stabilized. You will need to
continue the Keppra to prevent seizures and will need to
follow-up in the ___ clinic as scheduled below for a
repeat head CT. You were seen by the Spine doctors, who
recommended you wear the TLSO brace when out of bed and
follow-up in their clinic. You were seen by the Orthopedic
surgeons, and were taken to the operating room for repair of
your pelvic and hip. You have worked with Physical Therapy, who
recommend rehab. You are now medically stable and ready to be
discharged to continue your recovery. Please note the following
discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | ___ yo female admitted to the trauma service on ___ s/p fall
down stairs with (+) head strike and reported LOC. Pt taken to
OSH where she had bilateral temporal and right frontal SAH,
right temporal parenchymal hemorrhage, left acetabular fracture
and L1 compression fracture, and a left forehead laceration
which was sutured in the ED. Patient transferred to ___ for
further care, hemodynamically stable and neurologically intact.
Patient seen by Ortho Spine who recommended TLSO and f/u in
clinic. Patient seen by neurosurgery, repeat head cat scan was
stable and they recommended keppra BID until follow-up in ___
weeks. Patient was seen by Orthopedics who took her to the
operating room on ___ for ORIF of left acetabular fracture.
The patient tolerated the procedure well and was returned to the
floor in hemodynamically stable condition. Per Neurosurgery it
was safe to start lovenox for DVT prophylaxis. The patient
worked with Physical and Occupational therapy, who recommended
rehab at the time of discharge, as the patient remained
nonweight bearing on the left lower extremity.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability. The patient voided without problem.
During this hospitalization, the patient ambulated with
assistance with ___, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received lovenox and venodyne boots were used
during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged to rehab. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 448 | 289 |
11829192-DS-16 | 21,672,011 | You were admitted for evaluation of shortness of breath and
cough. You had a CT scan and chest x-ray that revealed
progression of your lung metastasis, including a lesion causing
a blockage of one of your airways. Therefore, you were evaluated
by the interventional pulmonary team who offered to perform an
intervention on ___. However, you declined at this time
wishing to follow up on ___. The etiology of your
shortness of breath is likely from the progression of your
metastatic disease but work up is not complete and it is
possible that you could have a pulmonary embolism which would
require blood thinning medication and could be life-threatening.
.
You are less likely to have a pneumonia. However, you were given
a prescription for an antibiotic to take for 4 more days just in
case.
.
In addition, you were noted to have worsening kidney function
which is likely related to blockage "hydronephrosis" from your
cancer. You were offered a kidney ultrasound for further
evaluation as well as consideration of drainage by nephrostomy
drainage tubes but you declined at this time. With continued
blockage, your kidney function will likely continue to worsen.
As you mentioned, please be sure to follow up with your already
scheduled urology appointment next week. | Pt is a ___ y.o male with h.o metastatic rectal cancer not
currently on therapy who presents with SOB and continued rectal
pain, found to have ARF.
.
#Shortness of breath/cough=likley due to progression of
pulmonary metastatic process including invastion of the R.middle
bronchus. Pt did have dry cough, but no fever or leukocytosis
suggestive of pneumonia. Would like to further eval for PE given
h.o malignancy. No tachycardia and s1q3t3 is old, but contrast
was not used given ARF. The interventional pulmonary service was
consulted for possible intervention of the bronchial lesion. IP
was going to perform the procedure ___, but pt declined and
wanted to think about it more. No obvious signs of pneumonia,
however, given pt's strong desire for discharge, elected to
treat the patient with 5 days of levofloxacin. Pt desired to be
discharged, stating that he "knows he is terminal" and he was
concerned about his sons at home. Discussed with the patient
(see OMR note dated ___ for further details) that we
believed his SOB was due to progression of metastatic burden but
could not r/o PE given lack of contrast. Pt strongly desired to
be discharged home and to follow up with ___ clinic to have the
procedure on ___. Pt was not febrile or hypoxic
during admission. Discussed pt's desire for discharge with his
primary oncologist Dr. ___.
.
#acute renal failure-etiologies include prerenal vs. post-renal
which was more likely given FENA >2%, lack of improvement with
IVF and known h.o hydronephrosis. However, pt declined renal u/s
for further deliniation and also stated that he would not be
interested in nephrostomy tubes. HE stated he has an appt with
his urologist next week as an outpt and he would f/u then. Pt
aware that renal function likely to worsen.
.
#metastastic rectal cancer-Pt is not currently on therapy. He
seems to feel like he knows the "end is near" and that he is
"terminal". He reports that he will likely want to try
experimental therapy 1 more time for his sons. He is aware of
palliative care and feels that he knows his options at this
time. Is interested in further surgical procedures to attempt to
relief his rectal pain. Oncology and surgery were notfied of
admission. Pt was continued on his home regimen of oxycodone. Pt
initially appeared interested in procedures to offer symptom
relief. However, he declined IP procedure for now, likely will
f/u ___. He was offered palliative care and social work, but
he declined during admission
.
#non-gap acidosis-trend/monitor. Changed IVF to LR. Pt
requested discharge before this could be further investigated,
monitored.
.
#anemia, normocytic with thrombocytopenia-no clear signs of
acute bleeding. Tansfused 1 unit prbc for possible symptomatic
anemia with improvement in symptoms..
.
FEN: regular
.
DVT PPx: hep SC TID
CODE: DNR/DNI
. | 206 | 477 |
17419895-DS-14 | 27,807,873 | DISCHARGE INSTRUCTIONS:
MEDICATIONS:
Take Aspirin 81 mg once daily
Take Lovenox ___ subcutaneous injections twice a day
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
ACTIVITIES:
When you go home, you may walk and go up and down 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 on that 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
You should NOT have an MRI scan within the first 4 weeks after
carotid stenting
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
FOR 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 at ___.
If bleeding does not stop, call ___ for transfer to closest
Emergency Room. | Mr. ___ is a ___ who was admitted to ___
___ on ___ for right lower extremity pain and
duplex at the outside hospital showing a right femoral artery
thrombus. He was immediate started on heparin anticoagulation
which he tolerated well. Once he was started on therapeutic
heparin infusion, he reported feeling better afterwards with
regards to the leg pain. He underwent CT angiography of aorta,
femoral arteries and iliac arteries. On ___, he underwent
angiogram of the lower extremities that showed a patent
superficial femoral artery down to the mid thigh at which point
there was an occlusion. The distal anterior tibial artery was
perfused via collaterals and would be visualized and continues
down to the foot. It was decided that Mr. ___ would
continue anticoagulation and follow-up if he continues to have
symptoms, at which point he would need a femoral to anterior
tibial artery bypass.
On the day of discharge, he was therapeutic on heparin gtt and
was started on Lovenox ___ mg BID (1 mg/kg weight dosing) for
bridging anticoagulation in addition to Coumadin. His last INR
in the hospital was 1.1. He was taught how to perform the
injections himself, to which he acknowledged understanding. He
will receive ___ care to monitor if he is doing the injections
correctly. His PCP was contacted to check INR levels and manage
the Coumadin dose. He was tolerating a regular diet, voiding on
his own, out of bed and ambulating, and pain was controlled with
oral pain medications. He was given the appropriate discharge
instructions and has scheduled follow-up in ___ with repeat
noninvasive studies. We will plan to schedule him for an open
repair in ___. | 251 | 279 |
11070829-DS-4 | 26,952,453 | You were admitted due to dizziness and were found to have an
abnormal heart rhythm called atrial fibrillation. When you were
given a medication to treat the atrial fibrillation your heart
rate dropped too low. A pacemaker was implanted to allow
treatment of your heart rhythm and prevent a dangerously low
heart rate.
You are being started on Apixaban 5mg twice daily. This
medication helps prevent life threatening blood clots that can
occur with atrial fibrillation. Do not stop taking this
medication without instruction from your cardiologist.
You are also being prescribed an antibiotic called Keflex to
prevent infection at the pacemaker site. You will receive a
total of 3 days of antibiotics. Today you should take one this
afternoon and one this evening before bed. Tomorrow and the day
after you will take one three times daily.
You may take Tylenol ___ to 1000mg every ___ hours with a
maximum dose of 3000mg daily. Do not drink alcohol while taking
Tylenol.
You should continue all your other medications.
Your nurse ___ review activity restrictions and care of the
pacemaker site. If you have any questions prior to your follow
up appointment please call the heart line at ___. | ___ Patient presented to the ER with c/o dizziness found to be
in AF with V rates in 130 bpm, BP stable. Given metoprolol 12.5
mg PO and converted to sinus bradycardia with rates in the ___,
stable BP. He was given apixiban and was sent the EP lab for
placement of PPM. He had uncomplicated insertion of dual chamber
PPM via cephalic access.
___ Discharged home with antibiotics and apixaban. | 196 | 72 |
16599386-DS-4 | 25,993,035 | 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 had chest pain
and palpitations.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you were found to have blood test and ECG
results that showed you were having a heart attack. You also had
high blood pressures.
- We gave you medications to lower you blood pressure and thin
your blood and your chest pain resolved.
- You underwent a cardiac catheterization that found only mild
heart disease. We suspect that the blood thinning medications
caused a clot to dissolve.
- Ultrasound imaging of your heart showed some reduced movement
in several areas of your heart, which may have been caused by
damage from a clot (that then dissolved) or possibly as a result
of stress. You will need another ultrasound in 6 months to see
how much your heart was able to recover
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your ___ appointments listed below.
- If you have chest pain, shoulder pain, jaw pain, chest
pressure, or shortness of breath, please notify your doctor
immediately or go to the nearest emergency room.
- Please notify your doctors in the future that you may have an
allergic reaction to ACE inhibitors (flushing and feeling
shaky).
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
====================
Ms. ___ is a ___ history of complex partial seizure disorder,
osteoporosis, chronic UTI, chronic hyponatremia, initially
presenting to ___ with several day history of chest pain
found to have NSTEMI with troponin T elevation of 0.273, started
on heparin and nitro gtt and transferred to ___, now s/p cardiac
catheterization ___ finding only mild disease (possible
re-canalization with heparin/ASA), and echo showing anterior,
septal, and apical hypokinesis suggesting ischemic vs. stress
cardiomyopathy.
CORONARIES: mild coronary artery disease
PUMP: EF 45%
RHYTHM: NSR | 242 | 82 |
10841633-DS-13 | 26,237,340 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital for
shortness of breath, lightheadedness, and chest discomfort. You
were found to be in atrial fibrillation with a fast heart rate,
which was a major cause of these symptoms. You were started on a
medication (Metoprolol) to slow down your heart rate and a
medication (Rivaroxaban) to keep your blood thin and prevent
blood clots. You also underwent an echocardiogram and
cardioversion, which converted your heart rate back to a normal
rhythm, however this was complicated by your heart beating very
slow. You were then given medication to increase your heart rate
(dopamine) and your metoprolol was stopped. Given that your
heart rate continued to be slow, you received a pacemaker to
help control your heart rates.
Your shortness of breath was also thought to be from mild
congestive heart failure for which you were given diuretics to
remove fluid from your lungs. Your breathing improved after
these interventions.
Please follow-up with the appointments listed below and continue
taking your medications as instructed below.
Wishing you the best,
Your ___ team | This is a ___ yo F with PMHx of CHF and SVT presenting with
shortness of breath, chest discomfort, and lightheadedness
likely ___ new atrial fibrillation with RVR and heart failure
exacerbation s/p TEE/DCCV c/b bradycardia s/p PPM.
ACUTE ISSUES
===============
# SOB/CP/Lightheadedness: Patient presenting with SOB, chest
pain and lightheadedness in the setting of new atrial
fibrillation on EKG and likely some elements of heart failure
exacerbation. Unlikely ACS, as trop x 2 negative, EKG without
signs of ischemia/infarct. Patient's atrial fibrilliation and
heart failure were treated as below and patient's symptoms
resolved.
# Atrial Fibrillation with RVR s/p TEE/DCCV c/b bradycardia:
Patient symptomatic with EKG showing Afib with RVR.
Precipitating factor of Afib unlikely ACS (trops neg, no signs
of inschemia/infarct on EKG), no signs of infection, TSH normal.
Patient was started on Metop Succ 100 mg PO with good rate
control and rivaroxaban 20 mg QHS for anticoagulation. and
aspirin discontinued. Patient underwent TEE/cardioversion that
was complicated by long pause for which she was started on
dopamine. She was then transferred to the CCU where she was
maintained on dopamine with HRs in 50-60 and MAPs ___. Patient
ultimately received a ___ dual chamber PPM on ___ with
adminstration of prophylactic antibiotics (vancomycin =>
Clindamycin). She was discharged on Rivaroxaban for
anticoagulation.
# HFpEF: Patient presenting with subacute cough, acute SOB and
chest discomfort. Appears euvolemic on exam, however, TTE with
enlarged right atrium suggests that heart failure may be
contributing to these symptoms. Patient was started on Torsemide
5 mg daily and tolerated it well with no further symptoms of
dyspnea.
TRANSITIONAL ISSUES
=====================
-code: full
-contact: ___ (husband) H: ___ W:
___ ___ (SON) C: ___ | 188 | 280 |
12443860-DS-21 | 20,417,413 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
-You were admitted for chest pain and significant alcohol
withdrawal
What was done for me while I was in the hospital?
-You were given a medication called phenobarbital to manage your
withdrawal symptoms
-You were followed by our addiction social worker while here who
tried to coordinate enrollment in a day program
-Your EKG and blood work were not suggestive of a heart attack
at this time.
-You decided to leave against medical advice after discussing
the risks and benefits of leaving including worsening withdrawal
symptoms, seizures, hallucinations, high blood pressure, damage
to internal organs and even death.
What should I do when I leave the hospital?
-Please arrange to follow up with your primary care physician
-___ arrange to follow with psychiatry
-Please arrange to follow up with your liver doctor
Sincerely,
Your ___ Care Team | Mr. ___ is a very pleasant ___ year old male with a history of
ETOH use disorder who presented after binge drinking with chest
pain,
weakness, nausea and vomiting. He was placed on phenobarbital
taper for severe withdrawal. He eventually left AMA with plan to
follow up with ___ day program for further
management.
#Alcohol withdrawal. Patient presented with significant nausea
and vomiting as well as significant withdrawal symptoms in the
ED requiring multiple doses of diazepam and then phenobarbital
IV loading dose. He was placed on phenobarbital PO taper per
___ protocol. His last drink was ___ at 7pm. He was monitored
with CIWA Q4H but did not have scores above 10 after starting
phenobarbital protocol. He has never had an ICU stay and
previous detoxes were controlled with benzodiazepines. On ___
he opted to leave AMA. Our team explained the risks of leaving
just short of 48 hours after last drink including worsening
withdrawal symptoms, seizure, ischemia and even death. Patient
was also counseled against using benzodiazepines while
phenobarbital was still in his system. He was not continued on
phenobarbital in the outpatient setting but will have some
coverage over the next few days given phenobarbital's long
half-life. Addiction social work followed patient while
in-house. Follow-up with PCP and ___ day
program was arranged.
#Nutrition
#N/V. Likely iso alcohol intoxication. LFTs with mild
transamanitis. Lipase wnl at 40 making pancreatitis less likely.
Was tolerating PO on discharge. At risk for refeeding syndrome.
# Thrombocytopenia. Platelets 139 ___ from 216 on ___ and
150s-300s in ___. Possibly spurious vs liver disease related.
Also
may be some component of dilution given acute drop with
concurrent drop in Hb. Also to consider ITP, drug induced
thrombocytopenia, malignancy, DIC. Plan was to follow on morning
of ___, consider smear, d-dimer, fibrinogen and assessment of
HIT risk but patient left AMA. Should have recheck during PCP
___.
#Dyspnea, cough. Likely iso alcohol intoxication and viral URI.
No evidence of
aspiration on CXR. Low threshold to start abx given asplenia.
#Alcoholism w/ steatohepatitis. Transamanitis as above. Imaging
of liver last done in ___, should get another ultrasound
given worsening alcoholism in outpt follow up and should have
follow up with Dr. ___.
#Anxiety
#Depression
#Bipolar depression
#Panic attacks. Suppose to be on lithium but stopped this
medication. Did not restart inhouse given acute withdrawal.
Should follow up with psych outpatient. Stated that he was
taking his step mother's amitriptyline weekly PRN.
#HTN
Not taking amlodipine. SBP 140s while in-house.
#Chest pain
#Palpitations
Palpitations likely iso anxiety. Chest pain history- chronic,
fleeting sharp left sided. Clicks with deep inspiration with
some
pain. Non reproducible. Not concerning for ACS. Echo done with
his outpatient cardiologist recently with no concerning
features.
Started on atenolol for palpitations. Continued atenolol
inhouse. EKG reassuring, trop negative x 2.
TRANSITIONAL ISSUES
=================
- Blood cultures pending on discharge
- On ___ pt opted to leave AMA. Our team explained the risks of
leaving just shy of 48 hours after last drink including
worsening withdrawal symptoms, seizure, ischemia and even death.
Patient was also counseled against using benzodiazepines while
phenobarbital was still in his system. He was not continued on
phenobarbital in the outpatient setting but will have some
coverage over the next few days given phenobarbital's long
half-life. Addiction social work followed patient while
in-house. Follow-up with PCP and ___ SECAP day
program was arranged.
- Only received ___ doses of thiamine 500 mg IV. Sent on
thiamine 100 mg TID x1-2 weeks followed by thiamine 100 mg daily
per pharmacy recommendations.
- Needs outpatient psych follow up, per patient, his
psychiatrist is leaving ___ and he needs a new one. He is
nervous about this.
- Suppose to be on lithium but stopped this medication. Will
hold off on restarting it given acute withdrawal. Should follow
up with psych outpatient.
- Thrombocytopenia. Platelets 139 ___ from 216 on ___ and
150s-300s in ___. Possibly spurious vs liver diz related. Also
may be some component of dilution given acute drop with
concurrent drop in Hb. Also to consider ITP, drug induced
thrombocytopenia, malignancy, DIC. Plan was to follow on morning
of ___, consider smear, d-dimer, fibrinogen and assessment of
HIT risk but patient left AMA. Should have recheck during PCP
___.
- Alcoholism w/ steatohepatitis. Mild transamanitis while
inhouse. Imaging of liver last done in ___, should likely get
another ultrasound given worsening alcoholism in outpt follow up
and should have follow up with Dr. ___. | 161 | 716 |
13905109-DS-8 | 26,179,679 | Dear ___,
___ were admitted to the hospital with acute symptomatic
cholelithiasis. ___ were taken to the operating room and had
your gallbladder removed laparoscopically. ___ tolerated the
procedure well and are now being discharged home to continue
your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o ___ may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless ___ were told
otherwise.
o ___ may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
___, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if ___ take it before your
pain gets too severe.
o Talk with your surgeon about how long ___ will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
-------
Estimado ___ señora ___,
Usted fue ___ ___ hospital con colelitiasis sintomática
aguda. Usted fue ___ de operaciones y había
___ vesícula biliar por vía laparoscópica. Usted toleró
el procedimiento bien y ahora están ___ de ___ para
___ recuperación con las siguientes instrucciones.
Por favor, el seguimiento en ___ clínica de Cirugía ___
___ aparece a continuación.
ACTIVIDAD:
o No conduzca hasta ___ de tomar medicamentos para
el dolor y ___ sensación usted podría responder ___ de
emergencia.
o ___ subir escaleras.
o Usted ___ viajar largas
distancias hasta ___ vea el ___ próxima visita.
o No levantar más de ___ libras ___ 4 semanas. (Esto es
sobre el peso de un maletín o ___ bolsa de comestibles.) Esto ___
aplica a los niños de elevación, ___
___.
o Usted ___ comenzar algo de ejercicio ligero cuando ___ sienta
cómodo.
o Usted tendrá ___ permanecer fuera de bañeras o ___
___ un tiempo, mientras ___ incisión está sanando.
Pregúntele ___ médico cuándo ___ volver a baños ___
___.
CÓMO USTED ___ SENTIR:
o Usted ___ sentirse débil o "lavado" ___ un par de
semanas. Es posible ___ desee tomar ___ siesta a menudo. Las
tareas simples pueden agotar usted.
o Usted ___ dolor de ___ por un tubo ___ tenía en
___ cirugía.
o Usted podría ___ para concentrarse o ___
para dormir. ___ te sientas un ___ deprimido.
o Usted podría ___ apetito por un tiempo. ___
parecer ___ atractivo.
o Todos estos sentimientos y reacciones son ___ y ___
desaparecer en un corto tiempo. Si no lo hacen, dígale ___
___.
___ incisión:
Mañana o ___ ducharse y quitar las gasas sobre las incisiones.
Bajo estas vestirse usted tiene pequeños vendajes de plástico
llamadas cintas estériles. No extraiga ___ estériles ___ 2
semanas. (Estas son las ___ de ___ pueda estar en
___ incisión.) ___ si ___ caen antes de ___ eso está bien).
o Sus incisiones pueden ser ___ de ___ sutura. Esto es normal.
o ___ lavarse suavemente material seco ___ de ___
incisión.
o Evitar ___ exposición ___ de ___ incisión.
o No utilice ungüentos sobre ___ incisión, a menos ___
lo contrario.
o Usted ___ pequeña cantidad de ___ líquido
___ tiñendo ___ o ropa. Si ___ tinción es grave, por
favor ___.
o Usted ___ ducharse. Como ___ señaló anteriormente, consulte a
___ médico cuándo ___ reanudar baños ___.
Sus intestinos:
o estreñimiento es un efecto secundario común de analgésicos
narcóticos. Si es necesario, ___ tomar un ablandador de heces
(como ___ cápsula) o un laxante suave (como ___ de
magnesia, 1 cucharada) dos veces ___ día. Usted ___ obtener
tanto de estos medicamentos sin receta.
o Si ir de 48 horas sin defecar, o tiene dolor de mover el
vientre, ___.
EL MANEJO DEL DOLOR:
o Es normal sentir cierto malestar / dolor después de ___ cirugía
abdominal. Este dolor es a menudo descrito como "el dolor".
o ___ dolor debe mejorar día a día. Si encuentra ___ el dolor
está empeorando en vez de mejorar, por favor póngase en contacto
con ___.
o Usted recibirá ___ receta para analgésicos para tomar por vía
oral. Es importante tomar este ___ según las
indicaciones. o No lo tome con más frecuencia de lo recetado. No
tome más cantidad de ___ mismo tiempo ___ lo
recetado.
o ___ para el dolor ___ a funcionar mejor si ___
antes de ___ dolor sea demasiado ___.
o ___ con ___ acerca de cuánto tiempo tendrá ___ tomar
analgésicos recetados. Por favor, no tome ningún otro
___ para el dolor, incluyendo dolor ___ sin
receta, a menos ___ ha ___ está bien.
o Si usted está experimentando dolor, ___ está bien para
saltarse ___ dosis de ___ para el dolor.
o Recuerde ___ "almohada ___ para entablillado cuando
tosa o cuando usted está haciendo sus ejercicios de respiración
profunda.
Si usted experimenta cualquiera de ___, póngase en
contacto con ___:
- Dolor ___ o dolor ___ dura varias horas
- Dolor ___ empeora con el tiempo
- Dolor acompañado de fiebre de más de 101
- Un cambio drástico ___ dolor
MEDICAMENTOS:
Tome todos ___ encontraba antes de ___
operación tal como lo hizo antes, a menos ___ de
___.
Si usted tiene alguna pregunta sobre qué ___ tomar o no
tomar, por favor ___. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission gallbladder ultra-sound revealed cholelithiasis
measuring up to 1.7 cm without evidence of cholecystitis. The
patient underwent laparoscopic 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
oral medications 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. | 1,407 | 196 |
14315145-DS-4 | 20,166,295 | Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had chest discomfort and you were found to have had a
heart attack.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent a procedure to look at the blood vessels of your
heart. There were blockages seen and you received 4 stents.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- We encourage you to quit smoking to reduce your risk of
another heart attack.
- Please continue to take the medications which reduce the risk
of clotting in your stents and your risk of another heart
attack.
- Aspirin and ticagrelor keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents, and you may die from
a massive heart attack.
- Follow up with your doctors as listed below
- No driving or excessive wrist motion in the next week.
- Seek medical attention if you have new or concerning symptoms
or you develop chest pain, swelling in your legs, abdominal
distention, or shortness of breath at night.
We wish you the best!
Sincerely,
Your ___ Team | ___ with a PMH of smoking (0.5 ___ years) who p/w chest pain,
diaphoresis, nausea found to have EKG changes concerning for
NSTEMI. | 228 | 23 |
12766828-DS-12 | 22,086,983 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came in with a cough. We found that ___ have a viral
infection called parainfluenza virus. ___ most likely caught
this from your husband who has similar symptoms. ___ are now
feeling better and your symptoms are resolving. ___ should use
an albuterol inhaler as needed for wheezing. | Ms. ___ is a ___ with h/o HTLV-1 positive T-cell lymphoma
s/p auto MUD transplant ___, DM, and HepB who presented with
cough for three days, found to be positive for parainfluenza.
# Parainfluenza viral infection: The patient presented with a
three day history of cough and was found to be positive for
parainfluenza infection. This was most likely etiology of her
persistent cough. Her cough improved with benzonatate. She did
have wheezing on exam which improved with albuterol nebulizer
treatment. She was discharged with an albuterol inhaler for prn
use until outpatient follow up. Given travel to history, a quant
gold was sent and should be followed up as an outpatient.
# HTLV-1 T-cell Lymphoma: Disease appears to be well controlled
at this time. She continues to have a low CD4 count therefore
has been on acyclovir and bactrim prophylaxis.
# Hypopituitarism: Patient appears to be doing well on her
current regimen. SHe was continued home hydrocortisone regimen.
# Lower Extrmeity Edema: Patient has persistent ___ edema likely
from venous insufficiency. She was continued on lasix 20mg
daily. | 61 | 178 |
12209668-DS-17 | 21,914,137 | Dear Mr. ___,
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 short of
breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given medication to help remove fluids.
- You had an echo that showed improved heart function.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor, ___,
at ___ if your weight goes up more than ___ lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 150 lbs (67.9kg). You should use this
as your baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT
==================
Mr. ___ is a lovely ___ year old man with a history of
___ body dementia, HLD, CAD with dense
calcific disease involving the LAD, now s/p POBA to LAD
(___), medically managed with ASA, Atorvastatin, and
Ticagrelor who presented with episode of paroxysmal nocturnal
dyspnea.
ACTIVE ISSUES
=============
#Acute on Chronic HFpEF (55-60% - newly recovered)
#Ischemic cardiomyopathy
Patient presents with episode of paroxysmal nocturnal dyspnea,
found to have mild pulmonary edema and pro-BNP 1100 on
admission. Cath end ___ with elevated LVEDP. Concern for
volume overload and HFpEF exacerbation. Unable to tolerate beta
blockade due to bradycardia. EKG without any acute ischemic
changes and trops neg. TTE showed improved ejection fraction
55-60% and resolution of wall motion abnormalities seen on echo
___. Denies any dietary indiscretions. Patient tolerated
IV Lasix with
symptomatic improvement. Stable on PO Lasix 20 mg at time of
discharge, BP stable on Lisinopril 2.5 mg.
-Preload: PO Lasix 20mg
-NHBK: holding beta-blockade iso bradycardia
-Afterload: Continued on Lisinopril 2.5 mg (recently started as
outpatient)
#CAD: Admitted in ___ with anterior STEMI, found to have dense
calcific disease involving the LAD now s/p POBA to LAD.
- Continue aspirin 81mg, ticagrelor 90mg BID, atorvastatin 80mg
CHRONIC ISSUES
===============
#Post-nasal drip
Patient's daughter reports patient having excessive rhinorrhea.
Prescribed Flonase.
___ body dementia
___ disease:
Continue home sinemet, donepezil, memantine
#Macular degeneration:
Holding home eyedrops as not on formulary
GREATER THAN 30 MINUTES SPENT ON DISCHARGE PLANNING
TRANSITIONAL ISSUES
====================
[ ] Patient continued on Lisinopril 2.5 mg during hospital stay.
His BPs ranged from 82/54 to 149/74. Please continue to monitor
his BPs.
[ ] Patient needed repletion x1 with Potassium while on IV
Lasix. K stable on PO Lasix. Please check his electrolytes in
next few weeks while on PO Lasix and consider adding 20 mEq KCl
supplement prn.
[ ] Patient complaining of rhinorrhea/post-nasal gtt. Discharged
him with script for Flonase. Please continue to monitor. | 183 | 312 |
12574098-DS-18 | 25,294,222 | You were admitted with shortness of breath and cough due to
asthma exacerbation. You will need to complete a short course
of Prednisone and antibiotics, in addition to your inhalers | COPD/Asthma exacerbation: based on history and clinical exam
without evidence of infection or acute ischemia. Placed on IV
steroids and azithromycin with improvement in symptoms after 48
hrs. Transitioned to PO prednisone to complete a short ___ day
taper, as well as a 5 day course of Azithromycin. Continued
Advair and home nebulizers with good effect. Arranged for home
nebulizer machine on discharge.
Chest pain: atypical. Enzymes negative. Likely related to COPD
Hematuria: Consistent with menstruation
h/o cancer with unknown primary: close outpatient follow up | 31 | 88 |
15511207-DS-20 | 28,385,888 | Dear Ms. ___,
You were admitted to ___ after
you had weakness in your legs and right arm along with
difficulty getting out of bed in the morning. Imaging confirmed
that you did not have a new stroke, which was important to rule
out. A CT of your head did show evidence of an old stroke which
may be related to some of your chronic left leg weakness and
history of hypertension. An MRI of your neck also showed that
you had some arthritis in your neck around your spinal cord that
might be related to the weakness you experienced in your right
arm and your legs. To help with your symptoms you were given a
soft cervical collar that you should wear at night while you
sleep.
You also reported a low blood sugar around the time of your
presenting symptoms. Your sugars were monitored closely in the
hospital. Because they were running low at times and this can be
dangerous, we suggest that you stop taking your glyburide. You
will follow up with your primary care physician and she can
further address this with you.
We also wrote you a new prescription for Gabapentin at a
decreased dose since you mentioned feeling drowsy on your
current dose.
Although you did not have any evidence of a new stroke we
assessed you for medical conditions that might raise your risk
of having stroke. In order to prevent future strokes, we plan to
modify those risk factors. Your risk factors are:
<> diabetes, currently well controlled
<> high blood pressure
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure taking care of you,
Your ___ Neurology Care Team | Ms. ___ is an ___ female with a hx of CAD, type 2 diabetes,
hypertension, left subclavian steal syndrome and a recent
diagnosis of MGUS, admitted following a transient episode of
right arm weakness and difficulty getting out of bed in the
setting of hypoglycemia (FSBG 41). History appears most
consistent with a cervical radiculopathy with possibly some
degree of cervical myelopathy. Patient's deficits returned to
her baseline prior to discharge.
ACUTE ISSUES
============
#Bilateral lower extremity/Right arm weakness: On further
history the patient reported transient episodes of weakness in
her right arm occasionally associated with parasthesias over the
past several months. She also endorsed neck tightness. CT on
admission was negative for acute stroke, however demonstrated an
old right lacunar infarct. CTA showed a chronic left subclavian
thrombus, but otherwise patent vessels. On examination patient
demonstrated signs of lower extremity weakness as well as
proximal right upper extremity weakness (deltoid and biceps),
and restricted range of motion at the neck. Symptoms were
concerning for hypoglycemia vs cervical spondylosis vs less
likely acute stroke. Subclavian steal was thought to be
unrelated to present episode given lack of dizziness,
lightheadedness, changes in vision or explanation for right arm
weakness. MRI was negative for acute infarction. MRI ___
noted cervical canal narrowing with CSF space effacement but no
cord signal abnormality along with foraminal narrowing at
bilateral C4-5, right C5-6, and bilateral C6-7. Based on imaging
and physical exam, right arm symptoms were thought to be related
to cervical radiculopathy in the C5-6 levels. Symmetric leg
weakness may be related to a degree of cervical myelopathy.
Patient was discharged with a soft cervical collar to wear
during sleep.
#Diabetes, Hypoglycemia: HbA1c 6.2%. Prior to admission, patient
reportedly had a blood glucose of 41 near the time of her R arm
weakness. Glyburide was held on admission and blood sugars were
managed with an insulin sliding scale. Before lunch and dinner,
pre-meal glucoses were recorded in the low 200s requiring
sliding scale insulin however am blood glucose again appeared to
be low at 61. After discussion with patient's PCP ___ decision was
made to stop glyburide on discharge due to risks associated with
frequent hypoglycemic episodes.
#Chronic R lacunar infarct: CT on admission notable for old
right basal ganglia stroke and small vessel ischemic disease.
Patient was assessed for stroke risk factors. HbA1c of 6.2%
showed well controlled diabetes and LDL was 81. She is already
well managed on anti-hypertensive medications. No further
changes were made to her stroke/CAD secondary prevention
regimen. She will continue to take asa 81mg and rosuvastatin
10mg daily.
Transitional Issues
[]Hypoglycemia- glyburide 5mg daily discontinued on discharge
due to frequent episodes of hypoglycemia.
[]Gabapentin decreased to 200mg qhs as patient noted excessive
drowsiness with her current dose
[]If lower extremity or R arm weakness is worsening can consider
MRI L-spine/referral to ___ | 405 | 472 |
19421851-DS-15 | 27,178,419 | Dear Ms. ___,
It was an absolute pleasure taking care of you here at ___.
You were admitted for surgical repair of a fracture in your hip
after a fall at your nursing home. After your operation, you
were admitted to the intensive care unit for low blood pressure.
During your hospitalization, you also developed pneumonia, which
was treated with antibiotics. The stress from the surgery and
pneumonia induced a rapid heart rate in the ICU, which required
a medication called meotprolol to lower your heart rate. You
were also confused during the day and occasionally agitated
during the night. After your medical conditions had been
stabilized, you were then transferred onto the general wards for
observation.
During your stay on the general wards, your blood pressures and
heart rate remained very stable. Your confusion improved a
little and you were more responsive to your daughter, doctors,
and nurses.
___ are the recommendations for you after your discharge:
1. Wound care of your right hip:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
2. Activity and weight-bearing: Weight bearing as tolerated
right lower extremity
3. Familiar faces, familiar environment, synchronizing your
day/wake cycle, and good nutrition will help with your
confusion. This should get better with time.
4. Please continue to take your antibiotic for your pneumonia
until your doctor stops this medication. | ___ s/p unwittnessed fall found to have right
intertrochanteric femur fracture.
# Hip fracture: Fell at home, underwent right hip pinning with
orthopedic surgery on ___, tolerated procedure well and was
able to be transferred to the regular medical floor. Received
standing tylenol and low dose IV morphine for pain in the MICU.
On enoxaparin for DVT prophylaxis.
# ?Aspiration v PNA/Septic Shock: Pt had an O2 requirement and
briefly hypotensive to ___ requiring pressors in MICU.
Vanc/cefepime started on admission (day 1 = ___, then
changed to levofloxacin on ___ to be completed on ___.
#Hypotension: Patient presented in pain with systolic BP in
150's. After 7mg morphine, BP dropped to 60-70's while sleeping
and in setting of ?septic shock with pulmonary source. Pt was in
MICU and given briefly pressors.
# Afib with RVR: After surgery patient developed heart rates in
the 160s, noted to be atrial fibrillation, with systolic BPs in
the ___, cardiology was consulted and patient received 2.5mg
IV metoprolol and HR came down to ___ to 120s but pressures
dropped to systolics ___ and she was noted to be more confused.
Pressures improved with gentle with IVF bolus, and rates
improved with PO metprolol that was titrated up for rate
control. At time of discharge she was anticoagulated for her
recent orthopedic surgery. | 278 | 221 |
10894591-DS-2 | 20,264,351 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of chest pain and as a result you had a stress
test. The stress test was normal. Your chest pain is NOT due to
blockages in your heart. It may have been a result of anxiety.
Your cholesterol was elevated and we started you on a medication
to help better control your cholesterol. | ___ woman with PMHx of left-sided weakness s/p auto
accident in the ___ who presented with chest pressure,
shortness of breath, and left lower extremity swelling, normal
myocardial perfusion study but some social concerns.
# Chest Pain: Patient presented with chest pressure and
shortness of breath for 2 days, initially concerning for
unstable angina. She had no prior history of CAD, however, she
has not been regularly followed in the medical system. She had
four sets of troponin which were negative and no acute ischemic
EKG changes. She was intermediate risk for adverse events given
her age. After waiting over the holiday weekend following
admission to Cardiology by the ED physicians, she underwent
pharmacological nuclear stress testing which was completely
normal without any perfusion deficits or wall motion
abnormalities (similar to her prior BWH study). She was
monitored on telemetry without arrhythmias. She was started on a
statin for her hyperlipidemia (LDL 161, HDL 49) and a baby
aspirin. Metoprolol on admission was discontinued given no
objective evidence of flow-limiting or symptomatic CAD.
# Left lower and upper extremity swelling: In the ED, D-dimer
was negative and LENIS was negative for DVT. No evidence of
infection. The patient denied any new topical exposures (e.g.,
detergent, perfume, animals). Unclear etiology. Swelling
eventually resolved without specific intervention. She was
maintained on subcutaneous heparin for DVT prophylaxis.
# Social concerns: Nursing initially with some concern about
discharging patient and her ability to take care of herself
independently at home alone. This was also further corraborated
with Ms. ___ family who also thought there may be some
decline in her previous functionality baseline. Physical therapy
was consulted prior to discharge and ___ rehab which
she adamantly refused. Social work was also consulted and
reccommended initiation of elder services to further support her
as an outpatient. Her family agreed to check-in on her at home,
she was given a rolling walker and she was also set-up with ___. | 75 | 321 |
19526366-DS-19 | 24,226,803 | Dear Ms. ___,
You were admitted for evaluation of your increased number of
seizures. We did not find a cause such as infection that would
explain the increase you were having. You were started on
scheduled ativan and depakote for your seizures. You were also
placed on EEG that preliminarily did not capture any seizure
events (although formal results are still pending). They did
improve in frequency over your hospital stay so you will be
discharged home on these medications with plans to follow up
with ___ as an outpatient.
The following new medications were started:
Ativan 0.5 mg twice daily
Depakote ER 500 mg once daily
Please do call Dr. ___ office to make a follow up
within the next 2 weeks.
It has been a pleasure to care for you. | ___ y/o F with h/o GBM s/p resection, cyberknife and temozolomide
in ___, last treatment with Temozolomide in ___ and also h/o
NSCLC s/p stereotactic radiosurgery, who presents with seizures.
.
# Seizures: Pt with past history of seizures, but had not had
since ___ and these are different in nature. HCT done in ER
did not show any new masses. Neuro Onc ___ contacted and
initially recommended VPA load with neurontin. She however
continued to have increased seizures, up to 10 per hour of right
leg tingling sometimes rising upwards to progress to twitching
of foot and trunk. She was transfered to the epilepsy service
for further EEG monitoring and med ajustment. We discontinued
neurontin and initiated scheduled ativan 1mg TID which
significantly decreased the frequency opf episodes. She was
tapered off the depakote prior to discharge. The preliminary EEG
results did not show any electrographic seizures during the
monitoring period, but official reports are pending. She was
discharged on ___ mg ativan to take BID in addition to her home
zonegran 400 mg at bedtime. She will follow up with her primary
epileptologist as outpatient shortly after discharge.
.
# Glioblastoma Multiforme: Last MRI in ___ did not show
recurrence, will repeat now due to new onset of seizures
.
# NSCLC: s/p stereotactic radiation to LUL in ___ with
recent PET CT in Fev ___ negative for recurrence.
.
# HLP: cont zocor
.
# HTN: cont lisinopril and HTCZ, ibersartan not on formulary
.
# GERD: cont PPI (tid) and reglan | 129 | 248 |
16057886-DS-17 | 29,132,786 | Mr. ___,
___ had been a pleasure taking care of you at ___
___. You presented as an emergency transfer to
our hospital after physicians at another hospital had to creat
an artificial airway for you to breath. You have a very large
cancerous growth in around your breathing tube and focal cords
which has made it impossible for you to breath through your
mouth and nose. While at ___, you had a surgical tracheostomy
placed as well as a percutaenous enteral gastric tube placed so
you can receive tube feeds. You had a week long stay in the
intensive care unit, where a peripherally inserted central line
was placed so you can receive IV medications and blood draws.
You were transferred to the general medical floors for further
stabilization. You had a stent of diarrhea with drops in your
red blood cell count that are concerning for a gastrointestinal
bleed. You were transfused red blood cells and your bleeding
stopped. We stopped your aspirin to prevent further bleeding.
You will be going to ___ for further care. | Hypoxic respiratory failure: Initial transfer to ___ after
emergent tracheotomy and pulseless cardiac arrest, leading to
surgical endotracheal tube placement for respiratory failure.
Patient was initially cooled for cardiac arrest. After
rewarming, patient was following commands and moving
extremities. Further imaging revelaed patient had an extremely
large obstructing mass in the upper airway/larynx precluding
airway movement. Thoracic Surgery was consulted regarding his
airway and he had a trach placed. He was able to be weaned from
the vent and was stable from a respiratory standpoint on trach
mask. Given neck mass, PEG tube also placed for nutrition.
Neck sutures were removed ___. Found to be erythematous
and someone purulent. Bacitracin topical was started.
Infiltrative neck mass: biopsied by ENT found to be squamous
cell carcinoma. Mass required placement of trach and PEG per
above. In the OR during the trach revision, ENT was able to
biopsy the mass multiple times, noting it was advanced having
eroded through the thyroid cartilage. Thoracic pan scan was
performed to look for metastatic disease, which was negative.
Goals of care discussion were frequent with patient's legal
___. Legal Medical Affidavit was ascertained,
and patient's code status was changed to DNR DNI. Goals of care
were discussed and Mr. ___ determined that Mr. ___ may
benefit from comfort measures and not repeated hospitalizations.
Ultimate decision to head to ___ for attempts at
improvement in patient's baseline functioning status. Mr. ___
made aware that if patient cannot tolerate physical therapy that
can focus care on comfort measures only.
Ileus/Diarrhea: In the ICU, patient experienced severe ileus
likely related to critical illness. Had imaging that was not
concerning for mechanical obstruction or volvulous. Paucity of
bowel sounds and large residuals were noted during tube feeding
assessments. Patients PEG tube was placed to suction, and bowel
regimen with stimulant laxatives was increased. After about 5
days of ileus, patient had return of bowel sounds and diarrhea,
resolution of abdominal distention, and was able to tolerate
tube feeds. During the ileus period and wall suctioning,
patient experience metabolic alkalosis with bicarbonate levels
to the 40's. An intravenous PPI was started to avoid insensable
gastric acid loss to wall suction. With resumption of tube
feeds, alkalosis resolved. After resolution of ileus, patient
had diarrheal episodes with guiac positive stool and a noted HCT
drop from 29 to 22. Due to this drop, 2 unit PRBC transfusion
was performed. HCT rebounded to about 30, with leveling off at
25. Placed empirically on PPI drip for 2 days. Aspirin for
cardioprotection was discontinued. GI consult not pursued as
oropharyngeal mass would preclude endoscopic evaluation, and if
patient were to rebleed would need ___ guided embolization. HCT
remained stable and no further evaluation was pursued.
CKD: unknown baseline but Cr ~1.3 on admission, improved to 0.8
with foley placement and medical management. Of note patient's
creatinine acutely tripled with accidental removal of foley
(patient pulled it out). This is due to extremely enlarged
prostate and likely obstructive uropathy. Foley replaced and
will need to remain in place with interval change every month.
-Make sure to change foley catheter every month to avoid
iatrogenic urinary tract infection.
Hypertension: BP was labile this admission. Was initially on
pressors in the setting of cardiac arrest but these were quickly
weaned in MedFlight prior to arrival. However over the next few
days he was hypertensive to SBP 200; in the setting of
bradycardia this was concerning for ___ reflext but imaging
did not suggest edema or mass effect in the brain. Eventually
after his trach/PEG his hypertension resolved. On the medical
floors, amlodipine 2.5 mg qday was started for hypertensive
episdoes as high as 190 mm Hg systolic.
DM2: Patient is usually on home glipizide. Placed on sliding
scale insulin in house with good glucose control. On glucerna
tube feeds.
Hyperlipidemia: stable. Statin was continued in house.
Anxiety/Depression: Patient was initially on Sertraline,
Trazodone and Lorazepam. Sertraline and trazodone were held in
the ICU in the presence of patient's severe ileus per above, and
not restarted. Symptoms were managed with IV morphine and
lorazepam with good effect.
EtOH-related dementia: chronic issue. Patient reportedly at his
recent baseline prior to this admission was able to walk,
converse, get dressed, and feed himself. He was continued on
Donepezil in house. Has legal guardian ___. | 184 | 758 |
14587635-DS-6 | 21,441,232 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to ___ for a
right foot infection. You went to the OR for hardware removal,
debridement procedures, and wound closure. Your x-rays showed
osteomyelitis, which requires long-term IV antibiotics. While
you were here your fever work-up showed that you had
endocarditis, which means that you have vegetation on the mitral
valve of your heart. You received a PICC line ___ order to
continue receiving IVs at home. You will have visiting nurses
assist you with the PICC line and with dressing changes daily.
Please follow up with Dr. ___ ___ ___ days. You will also
have follow up with Infectious Disease on ___. | Mr. ___ is a ___ yo man admitted for current hospitalization on
___ with a history of uncontrolled DM2 c/b neuropathy, HTN,
OSA who presented with fevers, chills, malaise, headaches and
increased redness and swelling of the right foot x 2 days.
ACTIVE ISSUES
# Endocarditis:
# Osteomyelitis:
Pt was admitted to the podiatry service on ___ after
presenting to the ED with fevers to 103 and redness and swelling
to his R foot, which had previously undergone a second
metatarsal osteotomy on ___. ___ the ED, an I&D was performed
to allow prurulence to drain. Wound cultures grew out MRSA.
Foot x-rays were taken on ___ and showed loosening of the
screw and bony changes to the ___ metatarsal head. ___ the OR the
screw was removed. Foot x-rays showed normal post-operative
changes along with continued radiolucency of the ___ metatarsal
head and cultures taken ___ the OR grew out MRSA. On ___, pt
began spiking fevers to 103 and blood cultures grew MRSA. He
was started on IV Vancomycin. Patient taken back to the OR
___ for further debridement. Pt began experiencing
shortness of breath on ___ and medicine was consulted, no
change ___ EKG and CXR w/ small bilateral plueral effusions. Dual
nebulizers were prescribed along with incentive spirometry which
helped. Pt received a PICC line on ___. Taken back to OR
on ___ for R foot debridement and wound closure. TEE on
___ showed small vegetation on the mitral valve. ID
recommended continuing IV vancomycin for a total of 6 weeks, to
end ___.
CHRONIC ISSUES
# DMII, uncontrolled, complicated:
Seen at ___ and followed ___ house, diabetes very difficult to
control and very insulin resistant. He was continued on insulin
U500 BID and glipizide and started on an insulin sliding scale.
His metformin was initally held but restarted when his renal
function normalized. He will continue to follow with ___.
# Microcytic Anemia
No active bleeding. Last colonoscopy ___ w/ polyps,
hemorrhoids, and diverticulosis w/ recommended f/u ___ ___ years.
H/H normal prior to ___ and since has had multiple surgeries
and infection. Most likely due to blood loss and bacteremia.
# HTN
His home dose lisinopril was continued.
# GERD
He was continued on Pantoprazole 40 mg BID
# Neuropathic pain
We continued gabapentin and cymbalta
# Primary Prevention
We Continued ASA 81mg
TRANSITIONAL ISSUES
- Continue Vancomycin IV 1250mg q8h for a total of 6 weeks, to
end ___.
- For ___, please get labs for CBC w/ diff, CMP, ESR, CRP, and
Vanco trough every ___ starting ___ and fax results to
Infection Disease RNs at ___. SASH protocol for IV,
flush with NS 10mL and Heparin 50 units after each dose. ___
line care weekly.
- Please change dressings daily using betadine to incision and
dry sterile gauze.
- Insulin U500 dosing changed to 110 units qAM and 110 units
qPM.
- Recent anemia since surgery ___ most likely due to
surgeries and infection, would consider repeating CBC ___ ___
months. | 121 | 509 |
16443087-DS-14 | 21,683,664 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
-You were sent to the emergency department with low blood
pressure after getting dialysis by the doctor at your dialysis
___.
What was done for me in the hospital?
-You had a chest x-ray that showed no signs of fluid in your
lungs, which could cause difficulty breathing.
-You had an EKG that did not show any acute problems with your
heart. -You had some blood tests that showed a low number of
platelets and red blood cells.
-You had dialysis to take off the extra fluid building up in
your legs.
-You had an echocardiogram to look at your heart's ability to
pump blood.
What should I do for the next few days?
-We have changed your midodrine dose to 10 mg twice a day on
non-dialysis days, and 15 mg in the morning and 10 mg at night
on dialysis days. The 15 mg morning dose should be taken 1 hour
before dialysis.
-We recommend trying not to eat or eating less before dialysis,
because this may affect your low blood pressures.
-Please follow up with your cardiologist about low blood
pressure after dialysis.
-Please follow up with your ophthalmologist about your eye drops
to determine which are necessary, what doses, and what
frequency. While you were here, we decreased your timolol eye
drop dosing from twice daily to daily.
-Please follow up with your PCP.
-Please follow up with hematology/oncology about your low
platelet and red blood cell counts.
We wish you the best of health. Take care,
Your ___ Care Team | ___ year old man with history of ESRD on dialysis, sCHF and dCHF
with ___ EF ___, CAD with NSTEMI s/p PCI, COPD, and afib
presents with hypotension (SBP ___ s/p dialysis. His BP was
stable in ___ throughout admission. Pt had signs of
volume overload likely ___ CHF on admission, and dialysis x2 was
done to take off excess fluid. Hypotension after dialysis was
controlled by increasing midodrine. Pt also had asymptomatic,
intermittent bradycardia down to ___. TTE demonstrated new RV
dysfunction, worsening MR and TR, and EF 43% though likely
overestimated because of MR. ___ during admission were
significant for thrombocytopenia, macrocytic anemia, and
macrocytosis.
ACTIVE ISSUES:
==========================
# Asymptomatic hypotension after dialysis: Patient's SBP was in
___ after dialysis on ___, increased to 65 after IV fluid bolus
(750cc NS). Baseline BP normally ___. BP has been
decreasing after dialysis for the past few months, was seen by
cardiologist recently who had recommended increasing midodrine
to 10mg daily. Hypotension likely ___ intravascular hypovolemia
after dialysis I/s/o diabetic autonomic dysfunction and
decreased cardiac reserve from CHF. TTE ___ demonstrated new
RV dysfunction and worsening MR compared from ___, consistent
with the idea that intravascular hypovolemia and decreased
filling pressures after dialysis contribute to hypotension.
Patient received dialysis x2 during admission. Hypotension after
dialysis improved to SBPs high ___ with increasing midodrine
as detailed in his transitional issues below.
# Volume overload ___ sCHF/dCHF and ESRD: Patient had signs of
volume overload on presentation, including severe B/L ___, sacral
edema, and abdominal swelling. No signs of pulmonary edema on
history, exam, or imaging. Likely I/s/o ESRD, h/o dCHF and sCHF
with ___ EF ___. TTE ___ demonstrated LVEF 43%, though
likely overestimated given severity of MR, worsening MR and TR,
and new RV dysfunction. Volume status improving s/p dialysis x2.
On discharge, patient had decreased ___ edema, but still with
abdominal and sacral swelling (1+). ___ weight is 73.6kg
(162lbs), patient reported normal dry weight is 160lbs.
# ESRD on dialysis: Patient usually gets dialysis 3x/week MWF.
Continued home dialysis meds and had 2 rounds of HD in house.
Dialysis on ___ only able to take off -1.2 L, dialysis on ___
able to take off -3L. Increased midodrine dosing appears to be
helping control hypotension after dialysis, which was the
limiting factor on how much fluid could be taken from dialysis
before.
# Bradycardia: Asymptomatic, intermittent episodes of
bradycardia down to ___ and pauses <3 seconds, occurred every
night during admission and during first dialysis. EKG ___
showed very low voltage. Unknown cause of bradycardia, likely AV
node and/or conduction dysfunction in a chronically diseased
heart. Could also be from OSA. Patient is currently clinically
stable. Outpatient cardiologist does not recommend pacing at
this time, would consider if HRs are consistently low.
# Thrombocytopenia: Plt 54 on admission, down from 93 in ___.
No signs of bleeding. Has h/o heparin-induced thrombocytopenia
but no known recent heparin exposure. Differential includes ITP,
drug-induced ITP, occult liver disease, myelodysplastic
syndromes. HIV Ab, HCV Ab negative. Hemolysis ___ showed LDH
270 in sample with slight hemolysis, Hapto WNL, and only mild
reticulocytosis of 2.1% (RI=1.1), which may be indicative of
suboptimal response to anemia, which may further favor
myelodysplastic etiology of thrombocytopenia and anemia.
Recommend f/u with heme/onc as outpatient.
# Macrocytic anemia: H/H 11.0/34.3 with MCV 116 on admission.
Causes of macrocytic anemia include B12 deficiency, folate
deficiency, drug-induced, myelodysplastic syndromes, or action
of epoetin. B12 normal. Peripheral smear showed variable
cellular morphology and size with 3+ macrocytosis, 2+
ovalocytosis, and 1+ teardrop, which is concerning for
myelodysplastic process. Reticulocytosis of 2.1% (RI=1.1), which
may be indicative of suboptimal response to anemia, which may
further favor myelodysplastic etiology of anemia. Recommend f/u
with heme/onc as outpatient.
# Hypoxia, increased O2 requirement: Patient admitted on 2L NC,
uses 1L O2 at home intermittently. Likely ___ CHF
decompensation, though no evidence of pulmonary edema. Was
weaned off O2 and remained clinically stable on room air.
# Troponinemia: Troponin on admission was 0.56, stable from 0.57
on ED presentation. Likely ___ chronic stress on heart from CHF.
Currently clinically stable, no signs of MI.
CHRONIC ISSUES:
==========================
# AFib: Patient has h/o afib, not on anti-coagulation because of
severe bleeding on warfarin. Continued home aspirin and
clopidogrel. Currently clinically stable.
# COPD: Patient has h/o COPD, uses 1L O2 intermittently at home.
Continued supplemental O2 as needed and home meds.
# T2DM: Patient has h/o T2DM, continued home Lantus ___ U once
a day and insulin sliding scale.
# HLD: Patient has h/o HLD, continued home atorvastatin
# Glaucoma: Patient has h/o primary open-angle glaucoma,
continued home meds. Some medications were found to be
administered at home differently than on patient med list. This
was corrected in house but should be evaluated as outpatient as
well. There was also some question of whether eye drops (ex:
timolol) could have systemic symptoms. Recommend f/u with
ophthalmologist to see which eye drops are necessary.
# HSV: s/p R corneal transplant for herpes simplex keratitis,
continued home acyclovir.
# CAD: s/p MI w/ PCI and in-stent thrombosis with subsequent new
stent placement. Has multi-vessel disease, continued home
aspirin, clopidogrel. | 259 | 847 |
18013449-DS-7 | 28,201,166 | ================================================
Discharge Worksheet
================================================
Dear Mr. ___,
It was a pleasure taking part in your care here at ___.
Why was I admitted to the hospital?
- You were admitted because you had a seizure and were feeling
unwell with dark urine and belly pain.
What was done for me while I was in the hospital?
- In the hospital, you were diagnosed with an infection called
Hepatitis A that affects your liver.
- You were also newly diagnosed with HIV for which we had the
infectious disease team come see you.
- Blood tests were done to monitor your liver's recovery from
the infection.
- Unfortunately, you decided to leave against medical advice
before you were medically ready to leave the hospital.
What should I do when I leave the hospital?
- When you leave the hospital, it is our hope that you attend
your primary care appointment tomorrow on ___. Once you see
primary care provider, you should be connected to the liver
doctor for your hepatitis C and infectious disease for your HIV.
- There is a place called ___ on ___ in
___ that has many support systems in place for clean
needs, HIV counseling, and counseling. Please ___ this center
as soon as you are able.
We wish you the best Mr. ___.
Sincerely,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
___ y/o M with PMH of HIV, hepatitis C, history of IV opiate
misuse, polysubstance use, epilepsy presented from outside
hospital after seizure and elevated LFTs, found to have acute
hepatitis A infection and newly diagnoses HIV infection. The
patient's LFTs continued to trend downward during his hospital
course, indicating recovery from acute HAV. He did not progress
toward acute liver failure. Infectious disease was consulted to
manage his newly diagnosed HIV in the setting of acute HAV and
chronic HCV. Patient on ___ left AMA.
***********LEFT AMA************* | 225 | 90 |
18602000-DS-12 | 25,967,308 | Dear Ms. ___,
You were admitted to the hospital with fevers. You underwent an
extensive infectious work-up, which revealed and abscess in your
colon as well as bacteria in your blood. You were seen by our
infectious doctors and ___ require several weeks of
antibiotics. You will continue treatment at home.
Please have your thyroid function tests repeated in ___ weeks.
You will also need your liver enzymes and blood counts checked
on a weekly basis as part of your antibiotic therapy.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best.
Sincerely,
Your ___ Team | ___ female with past medical history of ulcerative
colitis w/ recent flare (___) requiring high dose steroids
and initiation of remicade, recent diagnosis of afib with acute
stroke (initiated on apixaban) admitted with fevers now found to
have sigmoid abscess and GPC bacteremia.
# Fevers:
# GPC Bacteremia:
# Sigmoid abscess:
Initially unclear etiology so CT torso obtained and notable for
~2cm x 1cm abscess in the sigmoid colon also with PVT that is
likely due to septic thrombophlebitis. ___ Blood Cx positive
for GPCs in pairs. ID consulted and recommended IV ceftriaxone
2g daily and PO flagyl TID, for an extended course of 6 weeks.
Per discussion with radiologist, abscess not likely amenable to
___ drainage due to size. She will be seen by ID as an
outpatient for clinical monitoring. Case discussed with both ID
and GI, will need a repeat CT scan as an outpatient to
accurately determine duration of antibiotic therapy but planning
for 6 weeks from discharge. A PICC line was placed before
discharge.
-Ceftriaxone 2g daily x 6 weeks
-Metronidazole 500mg po TID x 6 weeks
-Labs per OPAT recs
-PICC lined placed ___
# Ulcerative colitis:
# Recent UC flare:
She was initially on rectal mesalamine but in early ___
had sigmoidoscopy showing diffuse inflammation so she was
initiated on remicade and IV steroids, and eventually discharged
on ___ on prednisone 40mg daily with plan for outpatient
remicaide and prednisone taper. Prednisone taper continued to
20mg at time of discharge with outpatient plan to stay on 20mg
daily until seen by GI as an outpatient. If her steroids are not
tapered further she should be evaluated for prophylactic
calcium/vit D (already on GI ppx).
# Atrial fibrillation:
# Recent embolic stroke:
Recently admitted ___ for small R frontal infarct, likely
due embolic from afib for which apixaban was initiated.
Currently in NSR with well-controlled rates. CHADsVASC 3.
Continued apixaban and metoprolol. ___ covering MD discussed
with neurology, does not need to be on atorvastatin as her CVA
was embolic in setting of atrial fibrillation. Based on lipid
profile, does not require statin based on ASCVD risk score.
Additionally her LFT's are slightly elevated at the time of
discharge so it is held for this reason as well.
# Leukocytosis
Likely in the setting of infection and now trending down
appropriately. Still elevated but trend improved. Will need this
followed as an outpatient
# ___: continued home omeprazole.
# HTN: Was previously taking losartan which has been held due to
normotension.
# Low serum TSH without hyperthyroidism:
TSH undetectable this admission and last but FT4 WNL, likely c/w
nonthyroidal illness vs steroid effect. Needs repeat TFTs in ___
weeks.
# Influenza prophylaxis: Tamiflu x 7 additional days
# Chronic dry eye: Continue restasis
# Transitional
-TFTs ___ weeks
-CBC within the next week (part of OPAT labs)
-Repeat LFTs within the next week (part of OPAT labs)
-f/u with GI and ID as an outpatient to help determine duration
of antibiotic treatment
Time spent: 50 minutes | 106 | 492 |
15928338-DS-5 | 24,144,623 | Dear Miss ___,
You were admitted given a myasthenia crisis that required
intubation. You also had a pneumonia during this stay that was
treated with IV antibiotics. After the plasmapheresis, your
strength is normal and does not fatigue with repetitive
movements. You should continue your CellCept and follow-up with
neuromuscular as scheduled. | In the ED she was seen by Neurology with concern for pending
respiratory failure given significant fatigue and respiratory
muscle use. Etiology most likely gastrointestinal viral
syndrome given otherwise negative infectious evaluation. NIFs
ranged from -10 to -30 in the ED, with an elevated End Tidal CO2
in the ___. After conversation with patient and mother and
bedside, decision was made for elective intubation. She was
taken to the ICU.
She was transferred to the floor on ___ after extubation. She
intermittently required NC and was weaned to RA. She received 5
PLEX treatments (___) and continued on
Cellcept 1500 mg BID, with clear improvement in strength and
respiratory function. Steroids and Mestinon were deferred as it
was unclear whether they provided benefit in the past.
On day of discharge, she was able to count to 35 in 1 breath,
with no fatigable weakness on exam. NIG/FC stable at -60/>2L.
She also developed VAP with BAL revealing pan-sensitive Coag+
Staph aureus. She was started on Ceftriaxone and Vancomycin (D1
on ___ --> Vanco/Cefepime/Flagyl (D1 on ___ --> Vanco/Cefepime
___ --> Cefazolin ___ based on sensitivities.
She completed a total of ___nd was discharged without
antibiotics. She was stable on RA with clear lungs fields and no
tachypnea on the day of discharge. | 51 | 216 |
15034336-DS-17 | 29,782,655 | Dear Mr. ___,
it was a pleasure to take care of you at ___
___. You were admitted to the hospital because of the
numbness and weakness of your leg. MRI of your spine was done
and showed compression of your spinal cord from your melanoma.
You were seen by spine surgery, who thought that you were not a
candidate for surgery. You were started on steroids and
radiation treatment.
These CHANGES were made to your medications:
INCREASE dexamethasone 4 mg every 6 hours
INCREASE OxyContin (long acting pain medication) to 40 mg twice
daily. Take this without missing doses.
INCREASE Oxycodone (short acting pain medication) to ___ mg
every 4 hours as needed for pain. Take this only if needed.
INCREASE docusate (Colace) to 1 tablet twice daily
INCREASE senna to 1 tablets twice daily
START omeprazole 40 mg daily (take this instead of famotidine)
START polyethylene glycol (Miralax) daily for constipation
START bisacodyl (dulcolax) daily as needed for constipation
START sliding scale insulin while you are on high dose
dexamethasone.
STOP Phenazopyridine
Please follow directions from the radiation oncologist regarding
your dexamethasone taper. | ___ yo M with metastatic melanoma (BRAF wild-type) s/p whole
brain radiation and cyberknife therapy to the left occipital
lesion on Ipilimumab (cycle 1 Day 21 on admission) presenting
with few days of lower extremity weakness and MRI findings of
compression fractures and spinal mets, concerning for cord
compression. Patient was started on high dose dexamethasone and
was evaluated by ortho spine and neurosurgery, both of whom
determined that patient was not a surgical candidate. He was
started on radiation treatment to his spinal lesions, but
unfortunately had progressive neurologic deficit.
# Spinal cord compression with neurologic deficits: patient with
new neurologic deficits starting few days prior to admission,
complaining of weakness in left leg and numbness in lower
extremities bilaterally. Initial exam concerning for decreased
sensation below T6 lesion and L sided weakness in lower
extremity. Ortho spine consulted in the ED, discussing possible
surgical options, however, given the intradural mass, they do
not feel comfortable operating on this patient. Neurosurgery
also evaluated the patient and given the complexity and
multiplicity of the lesions, did not feel that patient was a
surgical candidate. He was started on high dose dexamethasone
and radiation therapy, with planned treatment course of 10.
Patient was also started on prilosec and insulin sliding scale
given the high dose dexamethasone. He was monitored on q4 hr
neurochecks, and his neurologic function unfortunately worsened
through the hospitalization to the point that he is ___ on L leg
throughout, and ___ on R leg throughout. He was evaluated by
physical therapy in ___, who recommended that patient be
discharged to acute rehab. However, given his need for further
radiation therapy, he will be discharged to ___ rehab and
be transitioned to acute rehab afterwards.
During this hospitalization, he was fitted with TLSO brace for
his compression fractures and will need to wear it whenever he
is out of bed until cleared by radiation oncology.
# Metastatic melanoma: s/p brain met resection and recent spinal
met XRT. Followed by Dr. ___ as an outpatient.
Concerning for progression of disease and new mets despite
recent XRT to spine. Dr. ___ Dr. ___ contacted after
patient's admission and agreed with XRT treatment for the spinal
lesions with possibility of further chemotherapy in the future.
His Ipilimumab was held during the hospitalization.
# Depression/Adjustment disorder: patient with flat affect
throughout the hospitalization, concerning for adjustment
disorder. Social work saw the patient in ___. Starting the
patient on SSRI as an outpatient for further management should
be considered.
# Flushed face/neck: does not appear to be drug rash, no
pruritus or swelling in the area. somewhat concerning for drug
reaction, dilaudid changed to morphine given concern for
reaction. Will monitor for worsening/development and can do a
trial of benadryl if concerning. ?ipilimumab reaction, though
patient received the first dose a while ago.
# HTN: continue home lisinopril and nadolol with holding
parameters
# HL: continue home pravastatin | 174 | 482 |
16326772-DS-13 | 22,144,162 | Mr. ___, you were admitted due to worsening abdominal pain.
You underwent a liver biopsy that revealed a diagnosis of
pancreatic cancer. You were seen by the oncology team and your
pain medications were adjusted. You will be following up with
our oncology team on ___. | Active Issue:
# Abdominal Pain / Pancreatic Adenocarcinoma: Most recent
biopsies were inconclusive, but did report atypical cells. Of
note CA ___ was elevated to 29,000 which is concerning.
Discussed case w/ ERCP who recommended liver biopsy with ___.
This was completed on ___. Pt started on IV dilaudid and
oxycodone. His pain remained poorly controlled. CT showed a
splenic vein thrombus but in discussion with ERCP there is no
benefit to anticoagulation. On ___ cytology returned from liver
biopsy with adenocarcinoma. This is presumed pancreatic primary
with mets to liver. Oncology was consulted, spoke to patient and
follow up arranged in clinic to discuss treatment after final
pathology has returned. Pt was started on MS ___ on ___ now
that it was determined that this will be chronic pain.
.
TRANSITIONAL
1. The pt was discharged on Oxycodone 30mg (15mg x 2) q3-6hr PRN
and Morphine CR 30mg BID. | 46 | 147 |
17118029-DS-15 | 20,513,524 | You were admitted to the hospital for right leg weakness and
numbness. You were found to have a spine (T11) metastasis
invading into the spinal cord. Surgery was performed (T11
laminectomy) on ___ and your symptoms quickly improved. You
were evaluated by physical therapy and pain was controlled
initially with a PCA pump before changing back to your home pain
regimen.
.
MEDICATION CHANGES:
1. Increased oxycodone for post-operative pain.
.
YOU NEED TO WHERE THE TLSO BRACE WHENEVER STANDING OR WALKING. | ___ man with metastatic melanoma to spine and liver admitted as
a transfer from ___ with concern for cord compression.
MRI showed T11 lesion invading cord. Because of previous
radiation to that area in ___, re-radiation was not
advisable. T11 laminectomy ___.
.
# T11 cord compression: Weakness and numbness in legs improving
post-laminectomy ___. No radiation given since that area
was irradiated ___. Dexamethasone stopped post-op. TLSO
brace whenever standing until Ortho F/U. Bowel regimen as
needed. Changed methadone to PO outpatient regimen 50mg TID.
Stopped hydromorphone PCA and restarted PRN oxycodone. Physical
therapy.
.
# Metastatic ocular melanoma to the lung, liver, and vertebrae:
Pain management as above.
.
# Fever: Likely post-op fever. UTI treated with ciprofloxacin.
Repeat U/A and urine culture negative; no culture done with
initial specimen. CXR negative.
- Blood cultures PENDING.
.
# UTI: Unclear if this is secondary to prostatitis, rectal exam
deferred. Initial urine culture not done. Pyuria resolved on
repeat U/A after starting cipro. Empiric ciprofloxacin started
___, plan for 7 days.
.
# Leukocytosis: Possibly due to UTI + malignancy.
.
# Constipation: Due to opioids, surgery, and/or malignancy.
Resolved with aggressive bowel regimen.
.
# HTN: Chronic, stable. Continued HCTZ and felodipine.
.
# Hyperlipidemia: Chronic, stable, continued statin.
.
# Depression: Chronic, stable, continued bupropion.
.
# Glaucoma: Chronic, stable, continued eye drops latanoprost and
timolol.
.
# Allergic rhinitis: Started fexofenadine.
.
# FEN: Tolerated regular diet. Maintenance IV fluids.
.
# DVT PPx: Venodynes.
.
# GI PPx: PPI PO. Bowel regimen PRN.
.
# Pain: As above.
.
# IV access: Peripheral.
.
# Precautions: None.
.
# CODE: FULL. | 80 | 259 |
18409446-DS-21 | 22,755,997 | You came in with back pain and findings suggestive of
osteomyelitis/discitis on your MRI. You had biopsy done from
your spine that confirmed bacterial infection and you were
started on IV antibiotics in consultation with Infectious
Disease service. You also developed neck pain and had neck MRI
done that was normal. The plan is that you will continue on IV
antibiotics for about a ___nd follow up with the
infectious disease doctors for ___.
Please follow with your PCP, ID and spine doctor as outpatient
within a week from discharge. | ___ yo woman w HTN, glaucoma, Bell palsy, subacute to chronic
back pain with previous findings of previous possible discitis
p/w progressive back pain. Neurologically intact. Now s/p ___ bx
and culture demonstrating VRE discitis/osteomyelitis.
Transitioned to Daptomycin with plans to complete a course and
follow up as an outpatient.
# Acute VRE vertebral osteomyelitis/discitis
# Cervical and Lumbar back apin
s/p ___ biopsy of concerning area. VRE with final sensitivities
reviewed. Due to upper neck pain MRI of the C spine was
performed which was negative. ID was consulted and she was
transitioned to Daptomycin. Her pain was controlled with
Tylenol and Cyclobenzaprine. A PICC was placed and she was
discharged on Daptomycin to take through ___ with OPAT
monitoring and ID follow up at ___. She will need weekly labs
as described in the OPAT note dated ___/
# Antibiotic Assoc Diarrhea:
Mild. C. diff neg. Give low dose loperamide
# Hypothyroidism
- cont home LT4
# HTN
- cont home meds (Toprol, amlo, losartan)
# Glaucoma:
- not on meds
# psoriasis: not on meds
# gout: not on meds
# MGUS: f/u as o/p | 90 | 184 |
10819468-DS-10 | 28,511,056 | Please call Dr. ___ office office ___ if you
have any of the following: temperature of 101 or greater,chills,
nausea, vomiting, increased pain, abdominal bloating, incision
redness/bleeding/drainage, constipation or diarrhea
-no heavy lifting/straining (do not lift anything heavier than
10 pounds)
DO NOT TAKE ANY MOTRIN/ADVIL/IBUPROFEN/ALEVE OR NSAIDS
(non-steroidal anti-infammatory medication)
You may take tylenol for headache or malaise after dialysis, but
no more than 2000mg per day.
-you may shower, but no tub baths or swimming
-do not apply powder/lotion or ointment to incision
-no driving while taking pain medication
-continue your usual hemodialysis schedule | ___ y.o. male with ETOH Cirrhosis (Child A) and HRS admitted to
Dr. ___ service with reducible umbilical hernia. No
evidence of strangulation. Hct was low and repeat was 17. 2
units of PRBC were transfused. Hct increased to 26.
Hepatology was consulted and on ___, they performed an EGD
noting severe esophagitis with ulcerations, moderate erosive
antral gastritis and duodenitis suggestive of chemical
gastritis, NSAIDs induced. Misoprostol, Carafate and bid
omeprazole was started per hepatology recommendations. HCT
remained stable. H. pylori was negative. He was instructed on
multiple occasions to not take NSAIDS (takes after HD for
headache/malaise). Instructed to take tylenol (no more than
2grams per day).
0n ___ he was dialyzed then went to the OR for umbilical hernia
repair with mesh. Surgeon was Dr. ___. Please refer to
operative notes for details. A CXR was done the next day on ___
for fever. A right, partially, loculated pleural effusion and
bibasilar atelectasis was noted. The right mid and lower lobes
were concerning for infiltrate. Blood cultures were sent and
then he was started on Levaquin. Blood cultures were pending. UA
and urine culture were negative. Repeat CXR was unchanged on
___.
Diet was advanced and tolerated. IV omeprazole was switched to
oral. He was passing flatus and had a BM. Incision was intact
without redness or drainage. An abdominal binder was placed on
him. He was ambulating independently and felt well enough to go
home on ___ after his dialysis session. Follow up appointment
with Dr. ___ was set for ___. Visiting nurse services were
arranged to follow him at home.
He will f/u with Dr. ___ in ___ and at that time plans for
f/u EGD will be determined. | 90 | 288 |
10363072-DS-10 | 22,250,148 | You were hospitalized for cellulitis (an infection of your
legs).
We recommended that you stay for ongoing treatment but you
strongly preferred to go home instead of completing treatment.
Please continue to take antibiotics as prescribed, and care for
your wounds as instructed | ___ y.o male with h.o chronic paranoid schizophrenia, hypoxic
brain injury, h.o ETOH abuse, reported recent admission for
cellulitis, who presents with increased purulent drainage from
apparently chronic lower extremity wounds. He left against
medical advice before completing a full course of antibiotics.
# Cellulitis, lower extremity ulcers - Increased purulent
drainage is suggestive of bacterial superinfection of apparently
chronic wounds. Location and exam suggestive of venous stasis
ulcers and unknown whether patient has a history of vascular
disease or diabetes. No clinical evidence or history of CHF,
albumin within normal limits at 3.7. Arterial studies within
normal limits. TSH and HbA1c normal. Arterial and venous
studies as above were within normal limits. Vascular surgery
was consulted and recommended 5 days of antibiotics, no surgical
intervention. The patient was treated with vancomycin,
ciprofloxacin, metronidazole, and wound care for 3 days. On the
day of discharge he was transitioned to doxycycline,
ciprofloxacin, and metronidazole to complete a ___oordination of care - ___, social, and psychiatric
history are unclear as the patient is unable to provide reliable
history and has not been seen at ___ since ___. Most
information is based on discussion with nurses and case managers
at ___ ___. Social work
also helped to corroborate information. On the day of discharge
it was discovered that the patient has a PCP, ___ at
___ for the Homeless ___.
# h.o ETOH abuse with h.o prior withdrawals: Reports last drink
2 days prior to admission. He was maintained on the CIWA scale
but had no signs of withdrawal. He was given thiamine, folate,
multivitamins
# Chronic paranoid schizophrenia, history of anoxic brain
injury: Patient denies taking any medications; ___ confirmed
that patient refuses all medications. Patient makes his own
medical decisions and does not have a legal guardian. While he
has poor insight and judgment, he is not felt to be an imminent
danger to himself or others.
Patient left against medical advice before completing his
recommended course of antibiotics. He was able to state the
risks and benefits of leaving before completing the course of IV
antibiotics and stated he was willing to take the oral
medications prescribed. It is unclear based on the patient's
history whether he will adhere to the recommended treatment. I
communicated with ___ nurse and case manager, and our social
work and case managers did the same. They will do their best to
reinforce the plan of care and a copy of the discharge summary
will be sent ___ from ___ ___.
[x]Pt is medically stable for discharge.
[x]Time spent coordinating discharge: > 30 minutes, coordinating
with outpatient providers and arranging home services | 44 | 453 |
18630757-DS-13 | 26,402,396 | 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 be instructed by your doctor to take one ___ a day
and/or Plavix. If so, do not take any other products that have
aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
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 | #Subarachnoid Hemorrhage
The patient was admitted to the Neuro ICU from the ED and noted
to have a diffuse SAH with IVH with a ACOMM aneurysm on CTA. A
right-sided EVD was placed and she was started on Nimodpine. On
___, the patient was taken to the angio suite and underwent a
coiling of an ACOMM aneurysm. A left-sided EVD was placed
intra-operatively. On ___, the right EVD was removed. She
underwent a CTA on ___ which was negative for vasospasm. The
EVD remained in place at 10 above the level of the tragus on
___. She underwent a repeat CTA on ___ which was negative for
vasospasm. TCD negative for spasm. Patient was extubated after
endoscopy on ___ however required reintubation later that
evening for tachypnea with paradoxical breathing. She completed
a 7 day course of Keppra for seizure prophylaxis. Hyponatremia
was treated with PO salt tabs. EVD remained at 15cm above the
tragus on ___. On ___, EVD was clamped at 0900, CT Head on ___
showed stable ventricle size thus EVD was removed and patient
does not require VP shunt. Patient was transferred to the Neuro
Step Down Unit on ___. She remained neurologically stable. She
was transferred to the floor on ___. She remained stable
throughout the weekend until discharge on ___.
#Respiratory
The patient remained intubated in ICU and was unable to be
weaned from the vent. Tracheostomy was placed at the bedside on
___. On ___, she was tolerating trach collar.
#GI/GU
The patient was unable to have diet advanced due to poor mental
status. PEG was placed at the bedside on ___. Tube feedings
were recommended by nutrition and adjusted for diarrhea.
#Hypertension: While in the ICU her home Losartan was held to
allow for auto-perfusion. Will monitor closely.
#Hyperlipidemia Patient was re-started on Lipitor.
#PNA
The patient underwent a bronch for BAL on ___ and she was
started on Vanc and Cefepime on ___ for treatment. A cdiff
specimen was sent for loose stool which was negative.
#Tooth fragment within the esophagus: Patient underwent
endoscopy to remove tooth from her esophagus on ___. Oral
surgery consult was recommended as outpatient after discharge to
assess for broken teeth.
#Impetigo on legs: Patient was started on Bactroban while in the
ICU.
#Hyponatremia
The patient developed slight hyponatremia, subsequently started
on salt tabs for goal serum NA of >140. | 339 | 393 |
11021643-DS-57 | 25,383,630 | Dear Ms. ___,
You came in with blood in your stool and shortness of breath.
You had an endoscopy and colonoscopy that did not show any
active bleeding. We started you on iron pills and Vitamin B12 to
help treat your anemia.
You were also having difficulty breathing. This was due to extra
fluid caused by your heart failure. We gave you medication to
remove the fluid, and your breathing improved.
You also experienced hearing loss in both ears. It is unclear
why this happened, but could have been a rare side effect of
Lasix. You were seen by the ear doctors, and started on steroids
to help recover hearing loss. Your steroid course should
continue as follows: Take 60 mg through ___. Take 50 mg on
___. Take 40 mg on ___. Take 30 mg on ___. Take 20
mg on ___. Take 10 mg on ___. You will follow up with
the ear doctors after ___ finish your course. During your
steroid course, you will need to take additional insulin in the
morning called Insulin NPH. You should take 30 units of NPH in
the morning from ___, 25 units on ___, 20 units on ___, 15
units on ___, 10 units on ___ and 5 units on ___ and then you
can stop taking this extra insulin.
Please make sure to take your Torsemide every day. You should
also weigh yourself every day, and call your doctor if your
weight goes up or down by more than 3 pounds. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs. Your
weight on discharge was 62.3 kg or 137.3 lbs.
You have a follow up appointment scheduled on ___ for follow-up
of your medical issues after your discharge from the hospital.
You have also been scheduled to see a diabetes specialist at
___ on ___ at ___. Please keep your
appointments as scheduled and please take your medications as
directed.
It was a pleasure caring for you.
- Your ___ Team | Ms. ___ is a ___ y/o female with a past medical history of
DM, asthma, CAD s/p CABG ___, LIMA to LAD, SVG to OM, and SVG
to
RPDA) and multiple PCIs (BMS to RCA in ___ and PCI to SVG-RCA
in ___, HFpEF (EF 55%) who presented to the ED c/o dyspnea,
cough and b/l shoulder pain x2 days as well as BRBPR x1 day. | 335 | 70 |
16119653-DS-23 | 20,572,696 | You came ___ with fevers and low blood pressure. We did a CT
scan of your abdomen which showed that the fluid collections are
improving. You were treated with broad antibiotics for 36 hours
and these were stopped when your cultures remained negative.
You were seen by the ID team who recommended continuing your
home levaquin and fluconazole until you get to your surgery at
___.
We also gave you some fluid boluses and your blood pressures
improved.
It was a pleasure taking care of you at ___ ___
___. | ___ PMH of intraabdominal desmoid tumor (c/b collections s/p
abdominal drain with multiple adjustments, on levofloxacin and
fluconazole), FAP (s/p colectomy w/ ileorectal anastomosis,
Whipple procedure ___, and prophylactic total gastrectomy with
RNY esophagojejunostomy ___ ___, who presented to ED with fever
and hypotension, c/f sepsis.
#Fever
#?Sepsis
Pt presented with temp of 100.8 prior to admission. Given
history of complicated abdominal collections ___ the recent past,
this was initially c/f worsening infection. However, CT a/p on
admission showed improved collections and no other obvious new
findings. He otherwise denies any localizing symptoms including
any changes ___ drain output and flu swab negative. Possible
this could have been transient gut translocation given
complicated anatomy. Blood cultures remained NGTD and he
otherwise was afebrile during the hospitalization. He was seen
by the ID service who agreed with 36 hours of broad spectrum abx
(Vanc/Zosyn) until his blood cultures were negative. Abdominal
drain cultures grew polymicrobial organisms but it is unclear if
any of these were causing true infection. He was restarted on
home levaquin/fluconazole and remained afebrile.
#Hypotension
BP's were soft ___ the 90's on admission. Per pt, this happens
on occasion as he has a difficult timekeeping up his PO intake
to match his GI losses. He was bloused with 7L IVF's during
this hospitalization with improvement ___ BP's to the 120's on
discharge.
___
Likely pre-renal ___ setting of insensible losses from fever and
GI losses. Improged to <1.0 with IVF's per above.
#Intraabdominal desmoid tumor (c/b collections s/p abdominal
drain with multiple adjustments, on levofloxacin and
fluconazole). Pt seen by Onc and Surgery. Plan to d/c ASAP and
have pt f/u ___ ___ for surgery, scheduled on
___. Held sulindac given ___, restarted on discharge.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care. | 91 | 305 |
17821946-DS-7 | 21,315,944 | Patient left AMA prior to discussion with MD, citing a family
emergency. | NOTE: PATIENT LEFT AMA BEFORE I COULD TALK WITH HIM ABOUT HIS
DECISION TO LEAVE, CITING FAMILY EMERGENCY TO RN. AS SUCH, NO
COUNSELLING, DISCHARGE PLANNING, ETC WAS DONE THIS ADMISSION.
This is a ___ with sickle cell disease s/p splenectomy
reportedly on Hydrea and chronic opiate therapy, recently lost
to outpatient followup with no current PCP or ___, who
presented with worsening back and chest discomfort consistent
with prior sickle cell crises. He was admitted, given IVF and
pain medication overnight. After I saw and examined him in the
morning, he reported to RN that he had a family emergency and
had to leave urgently. He did not wait for me to talk with him
prior to leaving.
# Acute anemia and
# Acute on reportedly chronic pain likely due to
# Sickle cell disease with acute sickle cell crisis: No signs of
acute chest syndrome, CNS manifestation/stroke, MI, infection.
He reports medication compliance but his social history of
recent move and no active pharmacy in the area calls
this into question, as does his normal MCV (expect higher MCV
with Hydrea). Iron studies unremarkable.
- B12 pending at discharge
# Reported smoking: This is inimical to the goal of crisis
relapse reduction. He declined nicotine patch. No cessation
counseling provided as he left before we could do this.
# Social issues
# Loss to followup: He needs a PCP and new hematologist. He left
AMA before we could do this, and before he could be seen by
social work. | 12 | 243 |
14894272-DS-2 | 21,729,846 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with abdominal pain. You had a
CT scan of your abdomen, and blood tests, all which were normal.
Your pain improved while in the hospital, and you were able to
eat per usual so we feel it is safe for you to go home.
We recommend that you follow up with your primary care doctor
within the next month to ensure that your symptoms have resolved
completely. | ___ y/o hx of panic attacks, kidney stones and ___
transferred from OSH out of concern for cholecystitis. CT
Abdomen here reveals no acute intra-abdominal process
# Dyespepsia: Likely functional vs. GERD. CT abdomen has ruled
out an acute abdominal process. LFTs, lipase and chem7 were all
normal. Her symptoms improved with bowel movement, anti-emetics
and PPI. Patient was discharged once she was eating per usual
and her symptoms were controlled. She will be discharged with
PPI, simethicone, anti-emetics and encouraged to follow up with
PCP.
# UA positive for blood: Patient states that she is actively
having her period. No UTI, or risk factors for malignancy
# Leukopenia: Chronic.
# Anemia: Patient has a history of thalassemia. Clinically no
signs of bleeding. Hct stable
Transitional issues
- PCP follow up | 83 | 126 |
14663808-DS-16 | 27,787,026 | Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because of fevers and lethargy. Although
we couldn't determine the exact cause of your fevers, we think
you likely had an infection in your sinuses. We started you on
antibiotics, which you should continue through ___. You will
be taking: ertapenem 1gram one a day, vancomycin 1000mg twice a
day, and fluconazole 400mg once a day through ___.
We stopped you atenolol as your blood pressure was slightly low.
You should speak with your primary care doctor about restarting
this medication.
Your blood levels were low. You will need to have these
rechecked as an outpatient on ___. These can be checked by
your ___ and faxed to your primary care doctor at ___.
Please take all of your medication as prescribed. Please keep
all of your outpatient appointments. | This is a ___ gentleman with a pmhx. significant for DM
II, HTN, and sinonasal SCC admitted with fevers about 2 weeks
after right maxillectomy and palatectomy.
# FEVER: Likely source is sinus, ?ethmoidal sinus. Patient
continued to improve on vanc, zosyn, and fluconazole.
Post-surgical area without evidence of exudate or infection;
just fibrinous and granulation tissue. ID was consulted and
patient will continue on vanc, ertapenem (once/day dosing), and
fluconzaole through ___. He will have labs faxed to
infectious disease clinic on ___. He will also have
follow-up in ID and ___ clinic. On discharge, patient was
afebrile and feeling well. Blood and urine cultures remained
negative. Patient dramatically improved from admission to
discharge with above antibiotics and fluids.
# HCT DROP: Patient with fluctuating hematocrit during
admission. Hemodynamically stable, though BPs a little low
(though patient was also febrile and had poor PO intake).
Hemolysis labs were negative. Lab was contacted and no evidence
of clumping on smear. A CT scan of abdomen/pelvis without
evidence of bleed. Patient will need to have hct followed-up as
outpatient by PCP.
# DIABETES II: Patient was continued on an insulin sliding
scale during admission. He will continue on his oral
hypoglycemics upon discharge.
# HTN: Patient was continued on lisinopril. His atenolol was
held in the setting of slightly low blood pressures and desire
to look for tachycardia if patient were in fact bleeding. This
can be restarted by outpatient provider if necessary.
# PAIN: Patient was continued on his home MS ___ and
gabapentin. He was given dilaudid for breakthrough pain. He
does not need a fentanyl patch on discharge as his pain was
controlled.
# HYPERLIPIDEMIA: Pravastatin was continued.
# SINONASAL TUMOR: Patient will follow-up with outpatient
hematologist/oncologist.
# TUBE FEEDS: Nutrition was consulted. Patient was discharged
on isosource 1.5 at 65ml/hour for 12 hours overnight. | 152 | 333 |
15307141-DS-26 | 20,651,670 | Dear Mr. ___,
It was our pleasure caring for you while you were at ___.
Why was I admitted to the hospital?
- You felt week and sustained several falls, but had previously
refused to be taken to the hospital; you were ultimately found
to have a high fever and low oxygen levels in your blood
What was done for me while I was in the hospital?
- You were found to have a urinary tract infection that was
treated with antibiotics
- You were found to have heart strain which was treated
medically, but also found to have heart failure which was
treated with medication to remove fluid from your body
- You had a low platelet level which was monitored
- You had anemia which was monitored
- You had low sodium which was treated with increased food
intake
- You were found to aspirate when you attempted to eat, and
based on this you were kept without food and had a tube placed
for nutrition supplementation
- You decided that you wished to forgo further treatment for
your medical problems after having lived a long life and wished
to spend you remaining time with your wife and being comfortable
What should I do when I leave the hospital?
- We encourage spending time with your wife and family and
enacting comfort measures and aspiration precautions during the
time you spend at the extended care facility
Thank you for allowing us to participate in your care!
Best regards,
Your ___ Care Team | Mr. ___ is a ___ year-old, independently living, gentleman
with a history of HFpEF ___ iCMP, Afib and recent PEs on
apixaban, BPH s/p SPT presenting to the ED with weakness,
hyporexia and history of a fall, found to be in septic shock
with urinary source. He had persistent fevers on ceftzidime and
vancomycin with CXR findings c/f HCAP, CT abd/pelvis c/f
diverticulitis, C diff s/p abx., and acute UGIB with e/o AVM on
EGD now s/p APC with stable H/H. S/p vascular stenting for R
popliteal pseudoaneurysm. Recurrent aspiration proven by video
swallow study. Now wishes to be made CMO for transfer to ___.
___ with hospice to be with wife.
#Functional status/GOC: Per discussion with patient and son over
the course of several days, the patient wished to be made focus
his care to comfort measures only without use of NG or PEG,
willing to assume risk of aspiration with modification eating
habits. He had previously failed video swallow studies twice and
had been with Dobhoff for tube feeds. Modified med list
accordingly and added pain medication and morphine for air
hunger and pulled NGT, patient was made CMO with plan for
hospice care at ___, where wife is a resident.
# Volume overload: Patient had been receiving treatment for
volume overload in setting of HF with gentle diuresis, but
treatment minimized in setting of being made CMO.
# Hyperglycemia: Previously on tube feeds, now made CMO; glucose
checks stopped.
# Non-ST elevation myocardial infarction: Likely Type 2 NSTEMI
due to demand, in setting of hypotension and known coronary
artery disease, but made CMO.
# R popliteal pseudoaneurism and rupture: S/p stent placement.
H/H stable after initiation of eliquis and clopidigrel. Will
continue Plavix until ___ (30 days s/p stent placement) per
vascular to prevent in-stent thrombosis, primarily for comfort
measures.
# Atrial fibrillation: Previously both rate controlled and on
apixaban for anticoagulation, both stopped when patient was made
CMO.
# Skin ulcers: Present on heels and back, but not causing pain
to patient. When made CMO, ulcers were dressed and topical
antibiotics applied.
# C. diff diarrhea: Patient completed treatment course with PO
vancomycin by NG tube, was not exhibiting symptoms at time of
discharge. | 238 | 360 |
16644916-DS-13 | 29,594,843 | Dear Ms. ___,
You were admitted to the hospital for leg weakness and numbness.
You had MRIs of your spine to look for evidence of inflammation
or a structural problem causing your weakness. These were
initially negative. You were seen by the neurosurgeons who did
not recommend any surgery.
Given your symptoms we gave you steroids to help reduce the
inflammation due to something called transverse myelitis. While
your initial MRI was normal, we repeated the MRI which showed
inflammation in your thoracic spine that is consistent with
causing these symptoms. You received 5 doses of steroids and
were doing much better after this. You saw the physical
therapists who recommended you go to rehab. It is not entirely
clear what caused this to occur at this point. We looked at your
spinal fluid for signs of infection or inflammation, and this
was normal.
Thank your for allowing us to participate in your care!
- Your ___ Neurology team | Ms. ___ is a ___ woman with a medical history
notable for HTN, HLD, GERD and vulvar carcinoma s/p vulvarectomy
who presents with subacute onset of asymmetric bilateral
sensorimotor changes concerning for thoracic myelopathy,
initially w/ negative imaging found to have transverse myelitis.
She clinically improved following a course of steroids and will
be discharged to rehab.
Transitional Issues
====================
[ ] Started B12 supplement given low normal B12. MMA was still
pending at discharge
[ ] F/u AQP4 antibodies, syphilis, Sjogren's antibodies
#Idiopathic Transverse Myelitis
Pt presented w/ right leg weakness, decreased proprioception in
R. leg, numbness (and lack of pinprick) on left leg w/ mid
thoracic spinal levels suggestive of a brown-sequard syndrome
(hemicord syndrome). Initially MRI of the whole spine, C/T/L
spine, and subsequent MRI brain were unrevealing. Diffusion
weight imaging of the spine was also unremarkable. Started
steroids empirically (1g methylpred x 5 days ___. Repeat
spine MRI ___ days later showed patchy longitudinally extensive
transverse myelitis from T4-T8, sometimes in a hemicord fashion.
LP was done on initial presentation and results were: TNC 0, RBC
1, Prot 40, glu 62. CSF VZV, HSV, ACE, MS profile were all
negative or within normal limits. Serum ACE, SSA/B wnl. Serum
AQP4 was sent given the longitudinally extensive myelitis, and
was pending at discharge. There was no history of optic neuritis
or brain lesions suggestive of NMO. Chest x-ray without without
hilar lymphadenopathy or obvious granuloma. We considered a
vascular etiology (such as dural AVF or cord infarct) of her
symptoms, however given her onset of symptoms over 24 to 48
hours and imaging presentation this was thought to be less
likely. Radiology did not think there would be utility in a CT
myelogram if her suspicion was overall low for an AV dural
fistula. There were no vascular abnormalities noted on either
spine MRI, which both were performed with contrast. Overall she
symptomatically improved with a 5-day course of steroids, and ___
is recommending rehab, which she was discharged to.
#Low B12
Low-normal range B12 at 308, doesn't explain her presenting
symptoms (imaging certainly not consistent with a b12
myelopathy) but should be supplemented. started on PO 1000mcg
B12, recheck as outpatient. MMA pending at time of discharge
#UTI
Patient found to have urinary tract infection with positive UA
with greater than 100 WBCs, dysuria and question of flank pain.
Received 3 days of ceftriaxone (___). Culture showed pan
sensitive E Coli >100k CFU
#Chronic issues
- No other changes to home medications | 157 | 417 |
12887083-DS-2 | 27,579,433 | Division of Vascular and Endovascular Surgery
Lower Extremity Thrombectomy & Fasciotomy Discharge Instructions
WHAT TO EXPECT:
It is normal to have slight swelling of the effected leg:
Elevate your leg above the level of your heart with pillow
during down time throughout the day and at night.
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
WOUND CARE: What activities you can and cannot do
You may shower
-You may shower and let the warm, soapy water run over your
graft site and your thigh donor site. Pat both sites dry very
gently. Re-dress your graft site.
- If your left graft site or donor site begins to worsen after
discharge with an acute change in swelling or pain, please call
the office of Plastic Surgery.
- You should keep your left donor site open to air and leave
the yellow xeroform dressing in place to dry out.
- Your left skin graft/repair site will be dressed with an
adaptic dressing to graft area, fluffed gauzes covered with
kerlix wrap.
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 that is draining, as needed
ACTIVIES:
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow arm incision 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
You are free to walk around and complete your activities of
daily living (bathroom, food preparation, etc) but you should
return to bed or chair and elevate your left leg.
MEDICATION:
Take Aspirin 81mg(enteric coated) once daily
Please take Coumadin 2mg on ___ as prescribed.
After your ___ clinic appointment on ___, please
take Coumadin as prescribed by your ___ clinic.
Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
Several new medications have been prescribed (detailed in Key
Information for Outpatient Providers). A primary care provider
has been appointed to you at the Greater ___
___ in ___. Your PCP ___ reconcile your medical
regimen on ___.
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber. | Mr. ___ was evaluated in the ___ ED for acute left lower
extremity pain with exam and CTA imaging consistent with
diagnosis of acute arterial thrombosis and acute limb threat of
LLE. He was initiated on therapeutic heparin gtt and was
emergently taken to the operating room by Dr. ___ on
___ and underwent L CFA cut down, L SFA and popliteal
thrombectomy. He was extubated and transferred to the PACU, but
given lack of improvement in LLE sensorimotor deficits following
revascularization, the decision was made to proceed with
prophylactic bedside fasciotomies of superficial leg
compartments while in the PACU. Both procedures were well
tolerated and without immediate complications (for further
details regarding these procedures, please refer to the
operative reports). Upon transfer to the floor, patient was kept
on bed rest and his diet was advanced without issue. The Acute
Pain Service was consulted for difficulty managing his pain
postoperatively, and gave recommendations for PO pain regimens
resulting in adequate pain control for the duration of his
hospitalization.
Patient's CPK labs were significantly elevated on POD1, but
these continued to downtrend throughout admission and patient
was maintained on IV fluids for several days postoperatively
without any subsequent evidence of ___. His labs were trended
for several days, without any additional abnormalities noted
during hospitalization.
CT imaging on presentation and subsequent TTE did not
demonstrate source of arterial thrombosis. Heme/Onc Service was
consulted who did not feel that patient's presentation was
consistent with an inherited hypercoagulable state. Thus, given
unknown etiology of arterial thrombosis, the patient was
transitioned from heparin gtt to therapeutic lovenox and bridged
to Coumadin. His INR was initially difficult to maintain in
therapeutic range (goal ___, but he was eventually maintained
on alternating 1 and 2mg daily doses of Coumadin and was
arranged to follow up with a ___ clinic 2 days after
discharge.
LLE fasciotomy sites were serially monitored to assess viability
of muscle groups, which remained stable. Wound vacs were placed
to aid in resolution of edema, at which point Plastic Surgery
Service was consulted for closure of fasciotomy sites. He was
taken to the OR on ___ and underwent primary closure of
medial fasciotomy site, skin graft closure of lateral fasciotomy
(L thigh donor site), with wound vac placement x 5 days. On
POD5, wound vac was taken down and Plastic Surgery recommended
daily dressing changes.
From a neurologic standpoint, patient slowly regained some motor
function of the L toes and with plantar flexion of L ankle, and
some sensation was regained to foot and leg. He was fitted with
a postoperative boot to prevent foot drop and worked with
Physical Therapy in the postoperative period to achieve adequate
mobility with acquired LLE weakness. By the time of discharge,
plastic surgery and physical therapy recommended that the
patient could bear weight as tolerated.
Given that patient did not have health insurance prior to
admission, Social Work and Case Management were involved to
establish PCP follow up for antiocoagulation management in the
outpatient setting. Primary care was established and
antiocoagulation management was arranged with ___
___ prior to discharge.
On POD ___, patient was ambulating with assistance, tolerating
a regular diet, voiding appropriately, his pain was well
controlled, his LLE incisions were clean, dry and intact, his
INR was therapeutic on a stable Coumadin regimen, he had
adequate follow up arranged, and he remained hemodynamically
stable. He was thus deemed ready for discharge home with follow
up scheduled with Dr. ___ on ___. | 511 | 577 |
18242864-DS-19 | 29,934,051 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You were admitted with worsening heart failure. While you were
here, we gave you diuretics, which are medications to help you
urinate. First, we did this through your IV and then we switched
you to an oral regimen.
At discharge, you weighed 213 pounds. 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.
You underwent a cardiac catheterization which showed diffuse
disease, but nothing that would benefit from stent placement at
this time. Your heart failure medications were optimized to best
treat you given your diastolic heart failure.
MEDICATION CHANGES:
NEW MEDICATIONS:
-Spironolactone 12.5mg daily
-Metoprolol succinate 37.5mg daily
-Atorvastatin 80mg at bedtime
CHANGED DOSE:
Furosemide 20mg
SAME DOSE:
Aspirin 81mg daily
Valsartan 40mg daily
We wish you all the best,
Your ___ Cardiology team | ___ with prior inferior MI seen on stress echo in ___ with
reduced ejection fraction (LVEF 40% ___ and known LBBB who
presents with 12 hours dyspnea and nonradiating chest pain found
to have elevated BNP and pulmonary edema on CXR.
# Acute exacerbation of heart failure with reduced ejection
fraction
-After initial diuresis with ___ IV furosemide, she
underwent R and L heart cath which showed severe LV diastolic
heart failure and mild diffuse atherosclerosis without high
grade angiographically apparent flow-limiting CAD. Mild
pulmonary htn. As small vessel ischemia could not be excluded,
advocated for anti-ischemic therapy. She was started on
metoprolol XL, high-intensity atorvastatin, and continued on
home ___ and aspirin. She was discharged on furosemide 20mg and
spironolactone 12.5mg for diuresis and should have electrolytes
checked in 7 days. | 159 | 131 |
10705890-DS-8 | 21,242,261 | You were admitted with symptoms of shortness of breath and
lethargy and diagnosed with a heart failure exacerbation likely
because of both your diet and your renal disease. A heart
failure exacerbation occurs when the heart cannot effectively
supply the body with as much oxygenated blood as it needs. This
can be made worse by eating a diet high in salty foods which
increases blood volume making the heart work harder. This can
also be made worse with renal failure and uncontrolled high
blood pressure when the kidneys are not able to get rid of
excess fluid efficiently.
Since your admission we have titrated your medications and
started you on dialysis to help your kidneys get rid of the
extra fluid and toxins that it is not able to do on its own. You
have both an indwelling line for hyemodyalisis that was placed
as well as a surgical fistula that will need to mature before it
can be used.
You are now doing well enough to be discharged home with the
plan for outpatient hemodyalysis.
WE have made quite a few changes to your medications that are
listed in your paperwork.
For your diagnosis of heart failure it is important that you
weigh yourself every morning, call Dr. ___ your weight
goes up more than 3lbs in 1 day or more than 5 pounds in 2 days. | ___ with CAD s/p CABG in ___, DM, HTN, HLD, stage ___ CKD, PVD
s/p stent in the
RLE, who presents with SOB and DOE concerning for acute systolic
CHF exacerbation.
ACUTE ISSUES:
==============
# Hypoxia: Patient significantly hypoxic (to mid-80s) on
admission, requiring NIPPV and high-flow nasal cannula for most
of his ICU stay. In addition to pulmonary edema, concern for
pneumonia or pulmonary embolus. Patient developed productive
cough and fever during hospitalization so was started on HCAP
antibiotic coverage. Also empirically started on heparin IV drip
for presumed PE; eventually ruled-out by CTA once bedside HD was
initiated. Respiratory status improved with ongoing diuresis by
dialysis, with patient sat'ing well on room air on discharge.
# Acute on Chronic Systolic Heart Failure Exacerbation: TTE
showed EF 38% w/LV hypokinesis (unchanged from previous echo in
___, BNP elevated, CXR with bibasilar fluid collection, 7kg
up from last documented weight (82kg) and 8lbs up from
self-reported dry weight, and presented with symptoms of dyspnea
on exertion and orthopnea consistent with acute exacerbation.
Thought most likely due to volume overload from worsening kidney
function and increased resistance to diuretics. Other
contributing factors include his highly resistant hypertension
(per ___ PCP visit note and patient report, systolic BPs have
been in the 170s recently, and he is on 3 medications for
attempted control) and dietary non-compliance. When patient did
not respond adequately to high dose furosemide, he was initiated
on dialysis with resolution of his symptoms. Discharge weight
was 78.9Kg.
# End Stage Renal Disease, now on Hemodialysis: Gradually
worsening since ___, but Creatinine 7.5 on admission was
acute jump from baseline of 5.5-5.6. Not hyperkalemic. He has
marked increase in his BUN since last admission (92 from 64),
and a mildly worsening metabolic acidosis (delta/delta = 1).
Initially suspected to be secondary to poor forward flow from
___ exacrebation, but creatinine and uremia actually worsened
in setting of diuresis. A tunneled line was placed and dialysis
was initiated, which the patient tolerated well. He was started
on Sevelamer and nephrocaps. Sensipar was continued. A
left-sided AVF was placed prior to discharge.
# Healthcare-Associated Pneumonia: Patient was febrile with
productive cough. He was treated with vancomycin and cefepime
for HCAP coverage x8 days.
# Anemia: Admission H/H 8.5/___.1 (baseline range 8.3-9.1/___-30
in ___. MCV 88, low-normal iron studies ___. Likely
represents progression of renal disease, with contribution from
anemia of inflammation / anemia of iron deficiency. On oral iron
supplementation per Nephrology.
# Hypertension: Poorly controlled on home regimen with SBPs in
the 170s, which may represent worsening of his renal disease.
Carvedilol recently added to his regime. Nifedipine, Carvedilol
and hydralazine were discontinued after initiation of dialysis.
Patient was started on metoprolol XL 100mg and losartan 25mg
daily.
# Type 2 Diabetes c/b Nephropathy: Well-controlled on insulin
# Dyslipidemia: Continuing home rosuvastatin.
# Hypogonadism: Patient has not been on testosterone cream at
home. To follow up outpatient with endocrinology for further
management.
# Gout: Per last D/C Summary, was supposed to have started 100mg
allopurinol. Was started on this medication here.
# Papillary Thyroid Ca s/p Thyroidectomy: Per last D/C Summary,
on levothyroxine 175 6x/week and 262.5 1x/wk. Last TSH ___
0.95. TSH on recheck here 0.41. Discharged on levothyroxine
175mcg daily. | 229 | 543 |
19027745-DS-19 | 29,032,098 | Dear Mr. ___,
You were admitted to ___
(___) due to your flu infection and elevated heart enzymes
that were concerning for an acute event causing stress on you
heart tissue. We continued running tests on your heart with labs
and electrocardiograms (ECGs) and fortunately, there was no
evidence of an acute event on your heart. Also, on admission you
were a little volume overloaded and we took some fluid off with
IV Lasix (furosemide). For the flu, we started you on Tamaflu
(oseltamivir)on ___ for a course of five days. Please complete
the course of this medication.
Please follow up with your outpatient providers at your
scheduled appointments. Thank you for allowing us to be a part
of your care.
Sincerely,
Your ___ Care Team | ___ is a ___ with a PMHx of NPH s/p VP shunt c/b
seizures and stage III CKD (baseline 1.9-2.3) found to have
influenza, elevated troponins, and heart failure exacerbation.
Patient presented with one week of cough and weakness. Found to
be flu-A positive at OSH, for which we started oseltamivir for 5
day course. Patient was started on IV ceftriaxone ___ for
question RLL pneuomonia, but final read negative for pneumonia.
Patient also presented with elevated BNP and evidence of
pulmonary congestion on CXR, consistent with CHF exacerbation.
Denied CP and SOB, but was requiring O2 and on exam had
significant edema. We diuresed with IV Lasix 40mg x2, SCr bumped
up to 2.5, and thus we stopped IV Lasix and restarted his home
PO regimen. Ambulating O2 sats prior to discharge was 91-94%.
Discharge standing weight 101.7kg.
He had elevated troponins, felt to be likely demand ischemia in
the setting of influenza and heart failure exacerbation,
especially since MBI is within normal limits. Cardiology was
consulted and saw him in the ED, recommended serial cardiac
enzymes, serial ECGs, and consideration for TTE to assess for
new wall abnormalities. He was given ASA 325mg. Serial ECGs
demonstrated no evidence of acute ischemia and troponins
downtrended.
#Influenza A with respiratory symptoms:
#Cough/Fever/Weakness
Found to be flu-A positive at OSH. No clear evidence of
pneumonia on chest x-ray. Treated with empiric antibiotics -
CTX in ED (___), levofloxacin started (___) and stopped
(___) but discontinued in the absence of clear pneumonia.
- Treated with oseltamivir x5 days (___)
# Acute on chronic diastolic heart failure exacerbation: Patient
presented with elevated BNP, evidence of pulmonary congestion on
chest x-ray, increased leg edema, hypoxemia, and orthopnea. He
was diuresed with IV lasix 40mg for 2 days, volume status and
symptomsm improved, and SCr bumped up to 2.5, so IV diuresis was
discontinued. Home furosemide 40mg daily was restarted on
discharge and patient was instructed to closely monitor his
weights. Continued carvedilol and lisinopril
# Troponin elevation: Elevation likely demand in the setting of
influenza and heart failure exacerbation, especially since MBI
is within normal limits. Asymptomatic. ASA 325 x1 given in ED,
trended CK/CK-MB/Trop x3 which downtrended.
- Started aspirin and statin
- Outpatient TTE to evaluate EF and to assess for wall motion
abnormalities
- Cardiology follow-up upon discharge
# Hypertension: Elevated BPs. Increased amlodipine 5mg->10mg,
which he seemed to have responded to well. BPs decreased to 130s
to 150s, but HR dropped to ___. Decreased carvedilol to 6.25mg
PO BID. Continued lisinopril 40mg daily.
# Acute on chronic renal failure (CKD stage IV): Mild acute
renal failure in the setting of diuresis. Stable near baseline
upon discharge.
CHRONIC ISSUES:
# NPH s/p VP shunt in ___, c/b seizure: continued home
keppra
# Depression: continue home sertraline | 126 | 474 |
14416150-DS-18 | 27,676,243 | Dear Mr. ___,
It was pleasure taking care of you at ___!
You were admitted because you had breakthrough seizures at home.
Your sodium was found to be very low. In addition your heart
rate was very slow because the top part of your heart was not
communicating with the bottom part. Your seizure medications
were changed and your sodium improved.
You will need to follow up with Neurology and Cardiology as an
outpatient.
All the best,
Your Neurology Care Team | ___ with PMH left traumatic IPH complicated by epilepsy,
psychiatric disease, early onset dementia and HTN who presents
with seizure, hyponatremia and new 2:1 AV block.
#Seizure: Breakthrough seizures were felt to be due to
hyponatremia and UTI. Due hyponatremia and AV block his oxcarb
and phenytoin were held. He was continued on Keppra and started
on At___ bridge. Onfi was started and increased and he was able
to be weaned off At___ bridge. He did not have any additional
seizures while he was admitted. We did not monitor him on EEG
during admission because patient refused.
#Hyponatremia: Most likely due to oxcarbazepine. Patient
received 100mL 3%saline
at OSH, which was discontinued here. Na corrected with holding
oxcarbazepine.
#AV Block
Patient had 1st degree AV block on EKG ___. 2:1 AV block on
EKG on admission. Likely d/t Oxcarb w/ hyponatremia, PTH, and
seizures possibly causing increased vagal tone. Has history of
PR prolongation on lacosamide. Electrophysiology was consulted
and followed him during the admission. He was monitored on tele
and repeat EKGs. He remained hemodynamically stable in 2:1 AV
block with short QRS. Cardiology felt that this did not require
intervention during this hospitalization but will follow him as
an outpatient as he will likely require pacemaker in the future.
His telemetry and EKGs were reviewed an additional time by EP
prior to discharge and felt he was safe to follow up as an
outpatient.
#Microcytic anemia: Iron studies suggestive of iron deficiency
anemia. Repleated with IV ferrous gluconate and discharge on PO
iron. He will need colonoscopy as an outpatient to evaluate iron
deficiency anemia.
#UTI: treated with ceftriaxone
#HTN: After discussion with cardiology continued his home
amlodipine.
#Psych: patient expressed passive SI on admission due to
repeated hospitalizations, attempted to be evaluated by psych
but patient refused to speak with them. Felt by team that he was
not immediate risk to himself and SI was passive,
without a plan and was intermittent. He did not repeat these
thoughts or ideations during admission.
Transitional Issues
=====================
[] needs outpatient colonoscopy to workup iron deficiency anemia
[] Please monitor HR and interval EKG at PCP follow up
[] F/U with EP: Dr. ___
[] f/u with Epilepsy
[] Do NOT use oxcarb, vimpat, or phosphenytoin for AEDs | 81 | 369 |
11619087-DS-36 | 29,215,880 | Ms ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because your blood pressure and blood sugar
was elevated. We started you on new medications to help with
your blood pressure. There was some concern that your insulin
pump was not working correctly. You were given insulin shots
until your pump could be replaced. You blood sugars were
improved.
We made the following changes to your medications
1. START Labetalol 200 mg three times a day
2. INCREASE lisinopril 20 mg daily
3. START Ciprofloxacin twice a day for 4 more days
You should continue to take all other medications as instructed. | PRIMARY REASON FOR ADMISSION
___ yo female with T1DM (insulin pump), chronic lumbar disk
disease (chronic narcotics), hypertension, hyperlipidemia,
severe peripheral vascular disease with right BKA (___),
orthostatic hypotension (on salt tabs) recently admitted for
hypertensive emergency (altered mental status), mild DKA and now
presents with poorly controlled hypertension and hyperglycemia.
.
# Hyptertensive urgency: SBP >200s with mental status changes
concerning for poor perfusion. CT head did not show any acute
changes. She does not have any other signs of end organ
failure. She has had an extensive workup for her HTN including
urine metanephrines (pending), protein electropheresis wnl,
serum and urine tox recently neg for cocaine/amphetamines, no
signs of hyperaldosteronism, no h/o OSA and normal renal US
recently. It is likely that her hx of DM has led to some renal
parechymal vs microvascular disease leading to progressive HTN.
HTN has not been aggressively controlled as outpt because of
severe autonomic dysfunction resulting in orthostasis. She was
initially admitted to the MICU where she was started on
labetalol 400 TID. She remained hypertensive with BP in the
180s. Therefore lisinopril was increased to 20 mg daily. On
this regimen she was noted to be orthostatic so labetalol was
decreased to 200 TID. Prior to discharge she was able to
ambulate with ___ without feeling dizzing, and with adequate
control of her BP. The patient will follow-up with her PCP. It
is also recommended she see Neurology for evaluation of
autonomic instability.
.
# Altered mental status: Given sedation in the setting of
hypertension there was intial concern for hypertensive
emergency. Head CT showed no acute process and ultimately AMS
was felt to be due to sedation from medication as well as
possibly due to her UTI. Mental status greatly improve in the
MICU and she was at her baseline when she was transferred to the
floor.
.
# Diabetes/ r/o DKA: On admission she was noted to have
hyperglycemia in the setting of a malfunctioning insulin pump.
She did not have an anion gap to suggest DKA. UTI also likely
contributing to hyperglycemia. ___ was consulted and the
patient was maintained on lantus and HISS until mental status
improved and she was able to manage her pump.
.
# UTI- UA was grossly positive. Patient was started on
ceftriaxone. Urine culture grew pan-sensitive E.coli. She was
transition to cipro to complete a 7 day course.
.
STABLE ISSUES
.
# Chronic pain: Patient endorses worsening RLE pain,
predominantly in her toes (s/p BKA). RLE warm and well perfused
with palpable pulses. ?Worsening peripheral vascular disease.
She was continued on her home gabapentin, oxycodone and MScontin
with holding parameters. Peripheral vascular disease was managed
as below.
.
# Peripheral Vascular Disease: Patient was continued on her home
plavix and zocor
.
# Depression: Patient was continued on her home citalopram
..
# Hypothyroidism: Patient was continued on her home
levothyroxine
.
TRANSTIONAL ISSUES
Full Code
monitor for orthostatic hypotension
Patient might benefit from evaluation by neurology for autonomic
instability | 115 | 515 |
16703618-DS-16 | 29,968,828 | Dear Ms. ___,
WHY WERE YOU HOSPITALIZED?
You were admitted because you experienced blood clots in both of
your legs as well as in your lungs. This caused you to feel ill
with fever and chest pain.
WHAT HAPPENED IN THE HOSPITAL?
You underwent a series of diagnostic tests including blood
testing, chest x-ray, Doppler ultrasound, and echocardiogram.
These tests helped us diagnose you with a pulmonary embolism and
deep venous thromboses in both legs. Furthermore, one of your
blood cultures were positive for bacteria; however, we were not
sure if this was a contaminant or a true infection. As such, you
were started on broad spectrum antibiotics intravenously, but no
further growth was noted so you no longer need antibiotics.
Your oxygen saturation was also closely monitored until you were
deemed stable for discharge.
WHAT TO DO NEXT?
====================
Please take your lovenox (enoxaparin) shots twice a day for 2
more days, to ensure your blood stays thin enough. You will
continue your home warfarin at 2.5 mg daily.
If not in range of 2.0-3.0, please contact Dr. ___
adjustment to dosage. Please follow up with PCP ___
___ management of warfarin going forward
Please follow up with your PCP for your blood thinner
monitoring.
We are working on a follow up appointment with Dr. ___.
You will be called at home with the appointment. If you have not
heard within 2 business days or have questions, please call
___
Best,
Your ___ care team | SUMMARY IN BRIEF:
___ y/o female with h/o Factor V Leiden and DVT/PE admitted to
the hospital for evaluation and treatment of symptoms consistent
with DVT/PE on ___. Patient initially presented to the ED
with chest pain and shortness of breath. Patient had recently
undergone a colonoscopy (___) and was not taking her Coumadin
after the procedure. She came to the hospital after experiencing
worsening chest pain. Doppler ultrasound demonstrated bilateral
DVTs, and she was started on her home dose of warfarin 2.5 mg.
Given her chest pain and difficulty breathing, she was also
treated for PE with IV heparin at 1500 units/hour. She received
a TTE which demonstrated adequate right ventricle function and
severe pulmonary hypertension. CT was not obtained due to
contrast allergy. Furthermore, one blood culture from ___ grew
GPC in clusters which was likely a contaminant. Nonetheless,
patient received 24 hour duration of IV vancomycin 1 gm, which
was discontinued on ___. Patient's pleuritic chest pain
symptoms were managed with tramadol and buprenorphine, and
improved throughout admission. She was on 2L of oxygen initially
but weaned off throughout her stay and was discharged sating
well on Room Air. She was bridged from heparin/enoxaparin to
warfarin over the course of 2 days. She was in the therapeutic
window for INR (2.6) upon discharge. She was discharged with
supplies for lovenox x2 days with specific instructions on
anti-coagulation plan. She will follow up with her PCP ___.
___ discharged.
PROBLEM BASED SUMMARY:
# PE/DVT on warfarin
Patient with Factor V Leiden and history of PE/DVT on
Coumadin. However, she was subtherapeutic on admission with
lapse in therapy
for 5 days due to colonoscopy (Crohn's). Clinically patient was
HD stable although
with persistent tachycardia, and SOB with hypoxia to low ___ on
RA.
Bilateral DVT noted on ultrasound. BNP was elevated but trop was
negative
and there were no acute EKG changes (no s1q3t3, no st changes)
in ED. TTE was performed on floor and showed severe pulmonary
hypertension, hyperdynamic left ventricle, and adequate right
ventricle function. Heparin gtt was started and home dose of
warfarin 2.5 mg was continued. PTT and INR were monitored daily.
Switched heparin to enoxaparin 80 mg bid and bridged
successfully to warfarin (INR: 2.6). Patient noted slightly
worsening pain on ___ prompting chest xray which demonstrated
possible small pulmonary infarct right lower lobe, not
recognized on official radiology read. Patient will continue
enoxaparin x2 days at home. Anti-coagulation will be managed by
Dr. ___.
# Hypoxemia: Patient was admitted on supplementary oxygen (2L).
Does not use oxygen supplementation at home. Hypoxemia likely
due to clot burden from pulmonary embolism. Oxygen saturation
continued to improve during stay. Eventually able to transition
to room air, sating well in the ___. Patient also received
orthostatic vital signs as well as oxygen saturation
measurements while ambulating on room air (94%). Patient
discharged breathing comfortably on Room Air.
# Leukocytosis: Likely secondary to clot burden and inflammatory
response during admission. Continued to decrease throughout
hospital course. Patient remained afebrile, and with no
neutrophilic predominance. No sx/signs of
infection. Of note, one blood culture on ___ was positive for
GPC in clusters. This was likely a contaminant however IV
vancomycin was started for 24 hours. Abx were discontinued due
to lack of further growth on cultures. WBC continued to decrease
after abx were held. Patient not discharged on antibiotics,
normal WBC at discharge.
# Hypothyroidism: Patient with labs consistent with central
hypothyroidism during admission: TSH 0.20 and free T4: 0.9.
Benign cytology last obtained in ___ with FNA. Prior chest
x-rays have demonstrated enlarged mediastinal mass consistent
with thyroid goiter. Patient did not demonstrate clinical sign
of hypothyroidism during admission. PCP with plan to obtain
thyroid ultrasound on outpatient basis. Patient will also follow
up with ___ clinic as outpatient.
# Nausea: Patient experienced nausea upon admission. This could
have been a result of her clot burden with subsequent systemic
inflammation. Her symptoms were initially refractory to Zofran
and Ativan. Eventually, her nausea symptoms resolved on ___
after further Zofran doses. She did not require any medication
for nausea on day of discharge ___.
# Crohns Disease: Patient being followed on an outpatient basis
by gastroenterologist. On prednisone at home. Recently had
EGD/colonoscopy performed (___). Patient had regular bowel
movements during admission aside from one large loose stool
while on vancomycin. Symptoms improved after discontinuation of
vancomycin. Will continue to be managed on outpatient basis.
===================
TRANSITIONAL ISSUES
===================
-Discharge INR : 2.6
-Discharging bridging on Lovenox 80 mg SC q12 for two more days
(4 more doses) to assure remains therapeutic
-We believe the chest x-ray on ___ demonstrated an area of
opacity in the right lung/lateral chest wall consistent with a
pulmonary infarct in setting of pulmonary embolism, although not
mentioned in official read. If pain persists in this area,
consider obtaining non-contrast CT Chest.
-Plan for bridge lovenox for 2 more days once discharged from
hospital. Continue warfarin 2.5 mg dial. Be sure to monitor INR
with home machine. If not in range of 2.0-3.0, please contact
Dr. ___ adjustment to dosage. Please follow up with
PCP ___ management of warfarin going forward
-Patient to see an endocrinologist regarding her thyroid
condition, notable thyroid enlargement on imaging (known
nodule), and TSH of 0.13 and Free T4 of 0.9. Please repeat TFTs
as outpatient.
-We advise patient receive an ultrasound of her thyroid gland on
an outpatient basis to followup
-Consider hematology referral outpatient in setting of recurrent
thrombosis
___ DPM, PGY-1
___ | 243 | 905 |
16755805-DS-15 | 25,028,755 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ w/ ___ (previously on warfarin), CAD s/p CABG, AS s/p
bioprosthetic AVR, recent NSTEMI, recent cholecystitis s/p perc
cholecystostomy tube and subsequent removal, prostate ca s/p
XRT,
admitted with hematuria likely ___ radiation cystitis. Course
c/b
R MCA stroke and incidental finding of amyloid angiopathy,
requiring cessation of warfarin.
#Hematuria likely ___ radiation cystitis
S/p cystoscopy and clot evacuation on ___, but with persistent
hematuria over many days, despite stopping warfarin, ___, and
much patience. Repeat cysto with findings of neovascularity at
trigone, right lateral wall, bladder neck and prostatic urethra.
Underwent extensive fulguration, which has markedly improved his
hematuria. ___ removed ___.
He has received multiple transfusions, most recently on ___.
- transfuse PRN for Hgb < 7
- Appreciate urology recs
- nurses instructed to restart ___ only if blood loss is
significant enough that urine turns opaque red, or if he clots
off
- continue Finasteride and Tamsulosin
___ diastolic heart failure
___ malnutrition, moderate
#Anasarca
___
The patient has diffuse doughy edema, which is in large part
oncotic edema in the setting of low albumin and poor nutrition
status after many days of delirium and poor PO intake. He also
is in ___ heart failure and has an elevated JVP.
Attempts to diurese him have resulted in ___, with rise in
creatinine up to 2.0. This was likely due to depleted
intravascular volume from active bleeding and hypoalbuminemia.
We are cautiously escalating torsemide dose under guidance of
the
renal team now that he is doing better.
- will likely need a prolonged, slow diuresis with PO torsemide
during a rehab course
- trend Cr
# Toxic metabolic encephalopathy:
Likely multifactorial secondary to ___, possible dehydration,
morphine in the setting of worsening GFR, recent stroke, and
hospital delirium from prolonged admission. No fevers or
leukocytosis to suggest infection.
- limit deliriogenic meds as much as possible
- encourage family at bedside (his wife has been great)
#New Right M1 MCA CVA
#Amyloid angiopathy
MRI showed R M1 MCA CVA, likely cardioembolic. It also showed
findings consistent with amyloid angiopathy.
- per neurology, continue aspirin but stop warfarin given risk
of
ICH in amyloid angiopathy
- cleared swallow screen, started regular solids and thin
liquids
- Cont atorvastatin 80 mg
#CAD with recent NSTEMI
- continue Lipitor 80.
- per neurology recs, aspirin 81 mg can be continued as benefit
likely outweighs risk despite amyloid angiopathy
#Afib
#Pacemaker for slow ventricular response
#Ventricular lead displacement
- s/p PPM interrogation - shows lead displacement. Needs
___ at a later date.
- hold home Coreg given soft BPs and history of bradycardia with
lack of ventricular pacing capability at present.
- warfarin discontinued given amyloid angiopathy.
#Recent hx of cholecystitis
On recent admission at OSH, bile was leaking from percutaneous
cholecystostomy tube; new percutaneous cholecystomy tube could
not be placed by ___. Ultimately discharged for ___ with
general surgery for consideration of cholecystectomy. He has
mild
RUQ pain on exam and it is hard to rule out an ongoing chronic
cholecystitis. If he turns septic, this will need to be urgently
readdressed but defer for now given prioritization of other
issues.
#Glaucoma:
-continue Dorzolamide and Alphagan drops
#Code Status: DNAR in arrest. Okay to intubate ___ for
reversible respiratory failure. Limit heroic measures per
patient. MOLST in chart
#HCP: ___ (wife) - ___ | 14 | 530 |
11053635-DS-12 | 22,297,461 | Dear Ms. ___,
You were admitted with shortness of breath and found to have a
mass in your right lung. A bronchoscopy was performed to biopsy
the mass. Preliminary pathology and microbiology are somewhat
unrevealing. You are scheduled to follow up with interventional
pulmonology in one week to discuss final pathology and
microbiology results and determine the plan going forward for
diagnosis and treatment. You will be discharged with oxygen and
antianxiety medication to help with episodes of shortness of
breath.
It was a pleasure caring for you,
Your ___ Care Team | ___ yo woman with PMH of remote thyroid cancer (s/p surgical
resection ___ with negative lymph node dissection ___
presenting with 1 day of dyspnea, found to have right hilar
mass.
#Right hilar mass/dyspnea: Dyspnea most likely ___ intermittent
bronchial obstruction by newly discovered hilar mass versus
intermittent mucous plugging. Patient had
no evidence of infection or volume overload on clinical exam.
EKG
and trops reassuring. CTA without evidence of PE. Patient
appeared
very well throughout admission aside from intermittent episodes
of dyspnea exacerbated by anxiety. Bronchoscopy performed ___
with cytology pending at time of discharge but preliminary
results showed some atypical cells and no clear malignancy. Will
follow up with IP in one week to determine plan going forward.
#Left adrenal nodule: Incidentally found on imaging. Will need
MRI follow up, especially given possibility of metastasis.
#Anxiety: No notable hx of anxiety, but very anxious about
breathing and possible malignancy. Responded well to lorazepam,
so discharged with short course of 0.5-1 mg q6h prn anxiety.
#Arthritis: Held home aleve, APAP prn continued.
#Cervical radiculopathy: Longstanding left sided neuropathic
pain. Patient recent decided to self-DC gabapentin due to side
effects. APAP prn continued. | 92 | 185 |
11978101-DS-18 | 29,461,721 | It was a pleasure providing care for you during this
hospitalization.
You were admitted to the hospital for fluid in your lungs. You
were given lasix to help you urinate out the fluid. Your
symptoms improved. You will now go home on a higher dose of
lasix. Previously you took 10mg a day, now you should take 40mg
a day.
For better blood pressure control, your home metoprolol regimen
was changed from 25mg a day to 50mg a day.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
If you lose weight, please half the lasix from 40mg to 20mg a
day.
Also, take your blood pressure every other day. Call your doctor
if the top number of your blood pressure is greater than 140.
Medication Changes:
CHANGE metoprolol succinate 25mg daily-> 50mg daily
CHANGE Furosemide 10mg daily-> 20mg daily
Please resume your other home medications as usual. | This is a ___ y/o female with PMHx of HTN induced cardiomyopathy
who presents with symptoms clearly indicating a CHF
exacerbation.
.
#Acute on Chronic Congestive Heart Failure: Patient has lost
significant function in the last year as echo from ___ with EF
of 40%, likely secondary to poorly controlled HTN. She presented
in marked shortness of breath. The patient responded well to
aggressive IV diuresis. Her shortness of breath improved and her
BP's normalized. On arrival she required BiPAP and by discharge
she was satting well on room air. She has been discharged home
on a higher dose of Furosemide (40mg daily from 10mg daily.
Patient has also been instructed on adhering closely to her
medications and following a low salt diet.
#Hypertension- Ambulance measured patient's systolic BP in
200's. Her BP normalized quickly during hospitalization with IV
diuresus. She was maintained on home dose of Valsartan.
Metoprolol was increased from 25mg daily to 50mg daily
initially. Her BP measurements appeared to be dependent on her
fluid status no other medications were added to her regimen
# Dehydration- Patient presented with elevated lactate, mild
hypernatremia, and elevated Hct. These normalized quickly after
fluid status was optimized with IV diuresis.
# Asthma
-Patient was continued on Albuterol nebs q 4 hrs prn.
GERD
-Patient was continued on ranitidine 150 mg
HLD
-Patient was continued on home simvastatin.
Transitional Issues
The patient was instructed to contact her PMD, Dr ___. and
her Cardiologist, Dr. ___ to make follow up appointments in the
next 2 weeks. During these visits, her BP's should be checked
and her fluid status monitored on her new PO furosemide dose of
40mg. She also should have her electrolyters rechecked.
If the patient's symptoms become refractory to maximum medical
management, she may be a candidate in the future for CRT
therapy. | 146 | 295 |
11418296-DS-15 | 23,421,967 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why did you come to hospital?
- You came to us with abdominal pain and vomiting.
What did you get while in the hospital?
- You were found to have evidence of recurrent ileus or small
bowel obstruction on CT scan of your abdomen.
- Dr. ___ placed a rubber catheter into your bowel
with resultant output of 4.25 liters of bowel contents.
- You were trained how to self-catheterize your bowel in the
case of recurrent obstruction at home.
What should you do when you leave the hospital?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you have recurrent symptoms, use a red rubber catheter as
we taught you, to attempt to relieve the obstruction. This will
require firm, continuous pressure but as we discussed, do not
try to force the catheter in.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team | ___ with PMH of familial visceral myopathy c/b recurrent
pseudo-obstructions s/p subtotal colectomy in ___, recent
suicide attempt (___), severe malnutrition on home TPN via
PICC, and recent admissions for ileus (___) who
presented with abdominal pain, vomiting, and absent output from
ostomy. Found to have pseudo-obstruction, seen by surgery in ED,
decompressed with ___ red rubber catheterization of his
ileostomy at the bedside with ~4.25L of brown liquid out upon
placement and immediate improvement in abdominal pain and
distention. | 186 | 79 |
16456693-DS-9 | 29,464,057 | Dear Mr. ___,
You were admitted for shortness of breath due to an asthma
flare.
WHAT DID WE DO IN THE HOSPITAL:
================================
- We gave you IV steroids to calm down the inflammation in your
lungs
- We gave you nebulizer treatments
- You improved and were ready to be discharged home
WHAT TO DO ONCE HOME:
- We have scheduled an appointment at ___ for ___. Please
call ___ on ___ to see if you can be scheduled any
time sooner with a provider.
- Take your medications as prescribed | Mr. ___ is a ___ with PMH of asthma who presents with
shortness of breath, admitted with recurrent asthma
exacerbation. | 85 | 20 |
11217880-DS-21 | 29,248,122 | Dear Mr. ___,
You were admitted to the hospital with severe back pain which
might have been due to pulling a muscle. You had an MRI of your
spine that did show worsening of your bones however since your
pain is better, you do not need any surgery. Please follow up
with our spine/neurosurgeons in a few weeks. Our infectious
disease team evaluated you and felt that you did not need a
change in your antibiotics, and you are scheduled to finish them
___.
You will go back to ___ for further managment.
We wish you the very best!
Sincerely,
Your care team at ___ | ___ yo M hx osteomyelitis and discitis at L2-3 with worsening
back pain. MRI shows worsening destructive changes at L2-3
without canal stenosis. | 104 | 24 |
17525478-DS-22 | 28,545,181 | Mr. ___,
During this admission, you presented with left hand weakness and
there was concern that you may have had a stroke. Fortunately,
we did brain imaging and there was no new stroke identified.
Based on your history and examination, we believe that you have
an injury to one of the nerves of your left arm/hand, the radial
nerve. This nerve is important in many hand functions,
particularly bringing your fingers away from each other during
pinching. This might be why you were having difficulty with
this. The nerve will repair itself with time and there is no
medication that needs to be prescribed. We have provided you a
number below to schedule an appointment with us to follow up as
an outpatient if you feel the need to.
Review of your laboratory studies reveals that you have
pre-diabetes which means that you are at high risk of developing
diabetes. We recommend that you follow up with your primary
care physician to discuss possible management options. In the
meantime, please try to engage in regular activity and reduce
the amount of carbohydrates and sugars that you eat.
Finally, we also encourage you to reduce your alcohol
consumption as it can put you are risk of many medical
conditions, including heart and brain disease.
Thank you for allowing us to care for you,
___ Neurology Team | Mr. ___ is a ___ year old male with PMH most pertinent for
right carotid endarterectomy for critical stenosis in ___ and
paroxysmal atrial fibrillation whom presented ___ with
complaints of left eye blurriness and left hand weakness.
Patient had MRI brain which did not show new stroke and CTA head
and neck only showed mild atherosclerotic calcifications at the
left carotid bifurcation. Patient's history and examination
most consistent with left radial mononeuropathy and this will
heal on its own without treatment. Patient was found to have
A1C of 6.0% and will need to follow up with PCP regarding
management of prediabetes. Patient also with possible alcohol
abuse and recommended reducing/cessation of intake. | 233 | 117 |
13371198-DS-11 | 25,410,912 | You were admitted to the hospital with fatigue, nausea,
vomiting, and worsening anemia and kidney function. You
received a transfusion for your anemia. You were treated for
stomach inflammation with twice daily Protonix. You were found
to have worsening hydronephrosis. You had a ureteral stent
placed for your worsening kidney function, and then had a
percutaneous nephrostomy tube placed, with subsequent
improvement in your kidney function. You developed a pneumonia,
which is responding well to IV antibiotics. You will complete a
course of IV antibiotics at home.
.
Please take your medications as listed.
.
Please follow-up with your physicians as listed.
. | ___ with HTN, solitary kidney, metastatic breast cancer with
recently diagnosed gastric metastases, here with
postprandial nausea/vomiting, anemia, and ___ with worsening
hydronephrosis.
# Acute on chronic renal failure
# Worsening hydronephrosis s/p stent placement ___, s/p PCN ___
# Flank pain, nausea, hematuria, resolving
# Recently poor UOP, now improved:
She presented with decreased UOP and ___, with Cr of 1.6.
Imaging showed worsening right sided hydronephrosis. A ureteral
stent was placed by Urology, but Cr continued to rise despite
intervention. ___ then placed a PCNT on the right kidney on
___, with subsequent improvement in her renal function. Cr
peaked at 3.9 and downtrended to 1.6 on day of discharge. Her
recent baseline Cr is approximately 1.2. She will f/u with
Urology and Interventional Radiology in the outpatient setting
for repeat stent placement +/- internalization of PCNT.
.
# Anemia /# Nausea/vomiting:
Suspect her acute Hct drop and her worsening GI symptoms were
related to some irritation and bleeding from her recent biopsy.
Hct remained relatively stable after appropriate bump to 3 unit
PRBC. She also had reason for some acute blood loss after
undergoing 2 procedures during the hospitalization. Also has
known gastritis, confirmed on her recent EGD. B12, folate were
WNL. Ferritin actually somewhat high, suggestive of chronic
disease or inflammation likely from her metastatic malignancy.
She was continued on BID PPI and an QHS H2 blocker was added for
acid suppression as well. Baby ASA was stopped. Can continue
to monitor her anemia in the outpatient setting.
# Renovascular disease / # Labile BP / # HTN: She remains
asymptomatic. Notably, has solitary kidney with renovascular
disease, so must be gentle with antihypertensive mangement. Also
has multiple allergies, which
complicate management. BP in acceptable range on home anti-HTN
regimen of nifedipine and atenolol.
# Roommate who tested + for flu: RN spoke with infection control
who said patient did not need PPX anti-viral. She was swabbed
and the flu swab was negative.
# Metastatic Breast Ca (gastric mets) - was followed by Atrius
Oncology during hospitalization. Will f/u with outpatient
Oncology approximately 1 week after discharge in Dr. ___
___ clinic for re-initiation of chemotherapy. | 101 | 362 |
11281568-DS-44 | 27,731,550 | Dear Mr ___,
You presented to ___ because your sodium level
was found to be high and there was a concern that you may be
having an infection.
While in the hospital, your blood pressure was found to be very
low and this improved after treatment with antibiotics and
medicines that raise your blood pressure. You had a foley
catheter placed to help you urinate and your kidney function
improved and is now normal. You have a followup with the
urologist for a voiding trial and at that point they will remove
the catheter.
You need to receive the antibiotic ertapenem for the next four
days.
It was a pleasure being part of your care.
Your ___ team | Mr. ___ is a ___ man with history of AIDS (CD4
178; ___ by PCP pneumonia, CNS toxoplasmosis
complicated by seizures on Keppra, chronic respiratory failure
status post trach but not ventilator dependent, history of C.
difficile, who presented with acute renal failure and
hypernatremia, transferred to the FICU for hypotension
concerning for sepsis.
#Hypotension requiring pressors
#Shock
#? due to pneumonia
___ have been hypovolemic from decreased fluid intake vs sepsis
from pneumonia. Initial concern for urosepsis, but no clear Ucx
growth. Patient had 1 episode of loose stools upon arrival to
the ICU, but Cdiff was negative. Patient was noted to be febrile
in the ED with leukocytosis. During previous admissions, BP in
the ___ with patient asymptomatic. He was transferred to the
ICU after an episode of hypotension to the ___ systolic and
required norepinephrine for blood pressure management. He was
eventually weaned off pressors but continued on midodrine TID.
His sputum gram stain showed rare GNRs. Per ID consult, he was
initially treated with meropenem and linezolid given his history
of MDR organisms in sputum and urine; however, linezolid was
discontinued after urine cultures did not grow any bacteria and
he was treated with a course of meropenem. He will continue
ertapenem for four additional days after discharge to complete a
10 day course. His sputum did eventually grow out acetinobacter
that was resistant to meropenem, but this culture was obtained
after treatment with meropenem. He showed clinical improvement
with meropenem, and despite clear culture data guiding
treatment, ID staff recommended 10 days of treatment given his
clinical improvement.
#Acute kidney injury
#Severe hydroureteronephrosis
Baseline creatinine 0.7; 2.4 on admission. Likely a combination
of ___ component in setting of dehydration and post renal
given bilateral, left greater than right, severe
hydroureteronephrosis seen on CTU. Urology determined that the
urolithiasis seen on CT scan are ___. Foley in
place, good urine output suggesting relief of obstruction likely
initially at level of bladder output. Repeat U/S still showing
some hydronephrosis. Cr normalized after placement of foley.
Per urology -continue foley catheter for now with plan for
follow up in ___ clinic in ___ weeks for void trial. He has
followup appointment booked with urology.
#Asymptomatic Bradycardia
Sinus brady on ECG w/ 1st degree heart block. Does not correlate
with symptoms or BP. Resolved. | 119 | 385 |
17070568-DS-11 | 21,072,039 | Dear Mr. ___,
You came to us with headache, fevers, and muscle aches. In the
ED we performed a lumbar puncture to rule out infection. The
fluid in your back and around your brain did not show any
evidence of infection. We also sent off a viral panel that was
negative for influenza A and B. Our physical exam of you did not
reveal any focal neurlogical issues and we believe you had a
viral illness that will self resolve. We recommend taking
Ibuprofen 400 mg every 6 hours for fever and pain. Drink plenty
of fluids to prevent dehydration and help prevent worsening
headache (your body burns more fluids during feverish states).
If you are getting worse instead of better, develop any new
onset weakness, confusion, worsening headache, or any symptom
that is conerning to you, get to the nearest ED ASAP.
We wish you all the best!
Your ___ Team. | ___ with no significant PMH p/w with 11 days of headache,
general malaise, cough, and photophobia.
CSF analysis was not indicative of bacterial or viral
meningitis; however, he did receive 4 days of Amoxicillin prior
to presentation. The most common viral etiologies include:
Enterviruses (Echo and Coxsacki), but these are more common in
___ and summer, EBV, CMV, HIV, HSV1/2, Mumps virus, HIV, ___, and VZV. He denied hiking or tick-bites making lyme and
RMSF less likely. He denied mosquito bites making ___ less
likely. He did not have vesicular lesions in the genital or OP
to implicate HSV. Furthermore, the patient did not have AMS,
focal cranial nerve deficits, hemiparesis, dysphasia, aphasia,
or ataxia, making HSV and Listeria still lower on the
differential. He is not immunocompromised (HIV negative) making
funal sourses less likely.
Our concern for bacterial meningitis was quite low and given his
contact with persons with similar symptoms who are recovering,
it appeared this was a viral infection that is self-limiting.
His LP was negative. His CXR and UA were negative for infection.
He never had a leukocytosis and was HD stable throughout
admission. He never had AMS. Viral respiratory panel was
negative and Influenza A/B were negative.
We provided supportive treatment with IVF and
Ibuprofen/Tylenol/cough relief with Benzonatate and monitored
clinically.
After 24 hours of IVF and Ibuprofen, patient felt much better
and HA was largely resolved as was his photophobia. He was
tolerating full diet and instructed to return for any symptoms
that concerned him. | 150 | 256 |
13031383-DS-13 | 21,652,061 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with weight gain and
shortness of breath that was consistent with a CHF exacerbation.
We diuresed you and your symptoms improved. We started you on
a new diuretic called torsemide that seems to be more effective
in removing fluid from you.
We stopped 2 of your blood pressure medications - one called
amlodipine as this can lead to swollen legs and the other called
lisinopril as your kidney function was not stable and lisinopril
can worsen that. Please discuss with your doctors whether ___
should restart these.
We also noted that you had some kidney injury. It is unclear
where this is coming from. It was stably elevated and you have
close follow up with your nephrologist on ___ so
after discussing the risks/benefits with you, decided it would
be ok to send you home. Please have labs drawn on ___,
___ and have them faxed to the ___ Dr.
___ to review.
You developed a cough prior to discharge, but a CXR showed no
signs of pneumonia. If your respiratory status worsens or you
develop a fever, please seek medical attention. | ___ with PMH HCV cirrhosis s/p transplant ___ with HCV
clearance and new diagnosis of diastolic heart failure
presenting with shortness of breath, primarily with exertion, 5#
weight gain, BLE edema in the last 2 days concerning for CHF
exacerbation.
# SOB/CHF exacerbation: patient reported only mild shortness of
breath that is worse with exertion. On arrival to the floor, he
felt well and no longer had any shortness of breath. He has a
recent diagnosis of diastolic heart failure with preserved EF
function per ECHO last month. On physical exam, he had no signs
of pulmonary edema but appeared fluid overloaded with 1+ ___
edema. Ultrasound of his abdomen was negative for ascites. He
was diuresed with IV lasix (about total of ___ net negative)
and switched to torsemide po at discharge given that he required
a greater dose of diuretics than his home dose. Etiology of
decompensation is unclear, but ACS ruled out given normal EKG;
infectious process also ruled out given normal WBC count, no
fevers, negative UA, negative urine culture, and no
consolidation on CXR. Per patient, he has been staying away from
salty food. Throughout the hospitalization, he remained
asymptomatic and was able to walk down the halls and climb two
flights of stairs without any shortness of breath or
desaturations.
# ___ on CKD: On admission, creatinine was 2.4, baseline is
1.5-1.8. Urine lytes were checked and FeNA was 1%. ___ was
thought to be in the setting of CHF as it appeared to improve
with diuresis. However, with further diuresis, the creatinine
trend was unclear - it would worsen when checked in the evenings
and improve in the mornings (2.4 AM --> 2.6 ___ --> 2.1 AM -->
2.5 ___ --> 2.3 AM). UA was negative for an infectious process
and there was only a small amount of protein in the urine.
His lisinopril was held. He was discharged with a low dose
torsemide and with plan to follow up closely with nephrology on
___. He will have his creatinine rechecked on ___.
# Lower extremity edema: patient states that his ___ has not
been responsive to his home diuretics which is likely a result
of his acute CHF exacerbation and starting norvasc last week.
His edema improved with IV diuresis. His norvasc was
discontinued.
# cough - patient developed a dried cough prior to discharge.
However, no fevers or leukocytosis. CXR was ordered and was
negative for any pneumonia. He was given Guaifenesin for
symptom relief.
# metabolic syndrome: increasing weight (no ascites in abdomen),
hyperlipidimia, and diabetes most likely exacerbated by side
effects of post-transplant immunosuppresants. His obesity could
be contributing to his shortness of breath. He was continued on
home crestor and his sugars were monitored while in house.
# s/p liver transplant: patient with mildly elevated
transaminases since last month which is likely secondary to
congestive hepatopathy since it resolved with diuresis. Patient
HCV VL has been negative. Abdominal ultrasound ruled out a
portal vein clot. He was continued on cyclosporine, cellcept,
allopurinol, calcium, and bactrim.
# Hyperlipidemia - continued on crestor
# Diabetes Mellitus - continued on home glargine and sliding
scale. His lantus morning dose was increased from 55 units to 60
units due to elevated sugars in the afternoons. His ___ dose was
kept at 55 units.
# Hypertension - continued on home clonidine, metoprolol,
prazosin. Lisinopril was held in setting of ___.
# TRANSITIONAL ISSUES:
-patient diuretics was switched from lasix 60mg daily to
torsemide 20mg daily. Please titrate diuretics as needed
-discontinued amlodipine given lower extremity edema and
lisinopril given ___. Please restart lisinopril when appropriate
-patient will have labs drawn on ___ and will be faxed to
Dr. ___ at the ___. Please follow up with the
creatinine to ensure it is trending down
-Lantus morning dose was increased from 55 units to 60 units for
better glucose control | 209 | 657 |
15770196-DS-16 | 25,720,109 | Have a friend/family member check your incision daily for
signs of infection.
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, and
Ibuprofen etc.
You were cleared to begin Coumadin for an INR goal of ___
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change ___ mental status.
Any numbness, tingling, weakness ___ your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101° F. | # Seizures, partial complex: He was noted to be seizing at home,
by EMS, and ___ our ___. Seizures consisted of left gaze deviation
and neck turning towards the left. Upon presentation, he was
managed with ativan and intubated for airway protection during
CT head. Neurology consulted and loaded with Keppra with
increase ___ dose to 1000mg BID. Cause of seizure unclear,
though felt to be slowly enlarging meningioma. Has been seeing
Dr. ___ Dr. ___ neurology and neurosurgery,
respectively. Volume depletion could also be playing a role, as
he had 1 episode of phlebotomy the day prior to the event. He
was admitted to the MICU. and stabilized, without any further
seizures. He was extubated, was more interactive, and was
transferred to the floor. The next morning he began having
multiple seizures (left eye deviation, left neck posutring to
the left) and was transferred again to the ICU. ___ the ICU, his
levetiracetam dose was again doubled. He was loaded with
phenytoin and started on this. Clinically, he continued to have
left gaze deviation and neck turning towards the left, but per
EEG team, this was not a true seizure, but frequent frontal
discharges consistent with known intracranial mass. CT head was
repeated without significant change. He was transferred to the
neurosurgery team with neurology following ___ order to undergo
expedited surgery.
- He was managed with keppra 2000mg q12h, phenytoin 100mg q8h,
and was started on vimpat. He was also managed with
dexamethasone 2mg q8h to manage any edema or inflammation.
- He was also started vancomycin/ceftriaxone/ampicillin for
empiric meningitis treatment, though low suspicion given other
more obvious causes, he did have a fever (denied neck stiffness
and lacked meningismus). | 182 | 286 |
13316281-DS-20 | 27,653,953 | Dear Ms. ___,
Thank you for choosing to receive your care at ___
___. You were admitted for headache and
shortness of breath. Workup of your headache did not reveal any
concerning cause, and your headache had resolved shortly after
admission. Your shortness of breath was determined to be caused
by increased spread of your lung cancer. You were started on a
new therapy, Crizotinib, with good response in your symptoms and
oxygen requirement. You also had fatigue and difficulty
sleeping, which were managed with a number of new medications.
You are now headed to rehab, where you can continue to work on
building your strength prior to getting home.
It has been an absolute pleasure working with you, and we wish
you the very best with your ongoing recovery.
Sincerely,
Your entire ___ care team. | ___ y/o female with NSCLC (multifocal adenocarcinoma) stage IV
s/p multiple cycles of chemotherapy (most recently with
carboplatinum, pemetrexed), h/o malignant pleural effusion s/p
pleurex cathether (placed in ___, removed ___ with recent
admit for pleurodesis and chest tubes placed for loculated
effusion now presenting with persistent headache and worsening
SOB. | 136 | 51 |
13899335-DS-7 | 26,518,303 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because you had
pain in your right side. Analysis of your urine showed some
blood, which we think is likely due to a kidney stone that you
passed. It does not look like you have an infection so we
stopped the antibiotics. We spoke with your primary care
physician ___. He would like for you to have a repeat
urinalysis on ___ (the same day as your appointment with Dr.
___. The order is already in the computer, you can just go
to the lab for this. | # Flank pain: Patient admitted with 1 day of severe right flank
pain and nausea. He was afebrile and no leukocytosis. UA showed
161 rbc, 8 wbc, and few bacteria. CT urogram did not reveal any
kidney stones though did show some fullness of the right
collecting system which could be related to a recently passed
stone. Upon questioning the patient admitted to a history of
kidney stones. Given this, and the description of the patient's
pain, it is likely that he passed a kidney stone. He was
empirically treated with 24 hours of ceftriaxone which was
stopped given no signs of a UTI. At the time of discharge the
urine and blood cultures were still pending. We will follow
these up and contact the patient and his PCP should either
return positive. A repeat urinalysis was ordered for ___
which the patient will do during his appointment with his
hepatologist Dr. ___. Dr. ___ patient's PCP, is aware
of this and will follow this up to ensure that the hematuria has
resolved. Should he continue to have hematuria he will require
further imaging to evaluate for malignancy of the GU tract.
.
# Transitional issues:
- Urine and blood cultures pending at time of discharge | 104 | 205 |
17597298-DS-4 | 25,919,376 | You were admitted to ___ as a
transfer from an outside facility where you presented with left
sided weakness and slurred speech. A blood clot was identified
in the brain and you were administered a clot-busting medication
(tPA) to treat your acute stroke symptoms. Fortunately, the
medication helped to improve your symptoms. An MRI demonstrated
a new subacute stroke in the deeper structures of the right side
of the brain.
In order to continue to protect you from further strokes, we
restarted your apixiban, and increased your aspirin dose to
325mg daily. Please continue to take these medications, as they
are crucial to preventing further damage. We also evaluated
your blood work for any vascular risk factors which could be
managed with medicine. Your blood sugars were within a good
range, but your cholesterol appeared to be elevated. As a
result of this we change your simvastatin to a stronger
anti-cholesterol medication, atorvastatin. We also noted your
blood pressure was elevated and restarted your home
antihypertensives with marginal effect; because of this, we
added a medication called Norvasc(amlodipine). We recommend
that you contact your primary care doctor or cardiologist for
further medical management or your high blood pressure. | ___ is a ___ year old man with a history of HTN, HLD,
OSA, MI s/p stents, and afib on ___ (s/p cardioversion the
day prior to admission), who presented after a fall and was
found to have slurred speech and left sided weakness with an ___
stroke scale of 11 at the outside hospital. He received tPA and
was transferred to ___ for post tPA monitoring.
# Acute Ischemic Stroke: ___ at ___ improved from 11 at the
___. He was monitored in the ICU for 24 hours of
post tPA care. Etiology of his stroke was felt to be
cardioembolic in the setting of atrial fibrillation (he did miss
one ___ dose ___ versus atherosclerosis
(has both intra and extracranial atherosclerosis). His aspirin
and ___ were held for 24 hours post tPA. He had an MRI head
which confirmed his stroke. His stroke workup included echo,
lipids, hemoglobin A1c, and carotid ultrasound. He was
transferred out of the ICU after tPA monitoring and was stable
on the floor.
# Atrial Fibrillation: He is chronically on ___ and status
post cardioversion ___. He was in sinus rhythm while
hospitalized.
# Coronary Artery Disease: Has a history of prior MI with 3
stents in place.
EKG shows RBBB and T wave inversions in the lateral leads.
Troponins were negative x 2. He was monitored on telemetry
during his hospitalization. He aspirin was restarted after being
held for 24 hours post tPA. His simvastatin was changed to
atorvastatin 80mg daily. He was restarted on his home sotalol
prior to discharge.
# Facial hematoma: Likely from his fall in the setting of his
stroke and may have been exacerbated by tPA administration. His
hematoma was stable at discharge.
# Heavy Alcohol Use History: He was monitored on a CIWA scale
while inpatient given heavy drinking at home. | 209 | 304 |
10036086-DS-22 | 27,288,283 | 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 or
the indwelling ureteral stent.
-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.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-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
aspirin until you see your urologist in follow-up
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-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
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | The patient was admitted to the Urology Service under Dr.
___. On HD1 he underwent a left ureteral stent placement.
Please see the dictated note for further operative details. The
case was uncomplicated and he tolerated the procedure well. He
was discharged on HD1 after the procedure. He will follow up
with Dr. ___ in 2 weeks for discussion of definitive stone
management. He will see his nephrologist on ___ for repeat
creatinine draw. On discharge his pain was well controlled, he
was tolerating a diet, and voiding without issues. | 319 | 91 |
19611364-DS-15 | 29,098,863 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for confusion. It may be that
you had a bad response to one of your medications -- possibly
choroquine. We recommend that you not take this medication in
the future. Your mental status improved throughout the day, and
you were discharged home; a visiting nurse ___ come for a few
days to monitor your vital signs.
Other medications on your list that can cause patients problems
with balance and cognition include gabapentin and diazepam; you
can discuss with your PCP whether these medications are needed.
We wish you the very best!
Your ___ care team | Mrs. ___ is a ___ with PMH signficant for several PEs- on
coumadin, HTN, chronic leg cramping and dementia who presents
with one day of altered mental status and lethargy at her senior
daycare, now returned to baseline mental status and found to
have AMS from likely recent medication changes and increased use
of diazepam. | 109 | 55 |
17910586-DS-24 | 27,525,660 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because you were having chest pain and
experiencing shortness of breath
What happened while I was in the hospital?
- Your blood pressure was very high when you were admitted to
the hospital. Your home blood pressure medicines were changed
and your blood pressure improved during your hospitalization.
- It was found that your shortness of breath was the result of
having too much fluid in your lungs. You were started on an IV
diuretic which resulted in improvement in your breathing. You
will be discharged on an oral diuretic to prevent fluid from
building back up in your lungs.
- We performed EKGs and checked blood work to evaluate your
chest pain and it was determined that you were not having a
heart attack. Your chest pain has resolved after controlling
your blood pressure and removing the fluid from your lungs.
- We monitored your kidney function during your hospitalization
via blood tests. These tests showed us that your kidneys were
working but not as well as they used to. The kidney specialists
(nephrologists) evaluated you and you will need to follow up
with them as an outpatient.
- You were found to have an area of redness surrounding an ulcer
on your foot. We were concerned that the ulcer might have become
infected and started you on antibiotics.
- It was found that your urine had bacteria in it. As you were
not having symptoms when you came to the hospital or while you
were in the hospital, we decided that it was not necessary to
treat the bacteria at this time.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ___ w/ significant PMH including HTN, HLD, diastolic and
systolic HF, several MIs, COPD on 2L home O2, sleep apnea,
severe pulmonary hypertension, hypothyroidism, prior stroke, and
prior seizures who presented for evaluation of chest pain in the
setting of acute decompensated heart failure and hypertensive
urgency. | 352 | 48 |
12631532-DS-16 | 20,166,440 | Dear ___
___ were admitted to the hospital because ___ were very confused
and not your usual self.
WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?
- ___ had blood work and imaging to look for any infection which
may have caused your confusion, but none was found.
- ___ were restarted back on your medications especially
lactulose and rifaxamin which helped improved your confusion.
- ___ also had a procedure called endoscopy which found dilated
blood vessels called varices in your esophagus
- ___ improved and were ready to leave the hospital.
WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?
- ___ must abstain from alcohol since your liver is already
sick.
- Please take medications as prescribed and follow up with your
appointments below
It was a pleasure participating in your care. We wish ___ the
best!
- Your ___ Care Team | SUMMARY:
Ms. ___ is a ___ yo woman with history significant for PBC
cirrhosis c/b portal hypertension leading to ascites, grade 1
EVs, PHG, and GAVE now s/p TIPS in ___ with redo in ___ and
___ presenting with AMS in setting of medication non-adherence
concerning for hepatic encephalopathy, improved with restarting
lactulose.
Her hospital course was notable for delirium. | 137 | 54 |
14703904-DS-20 | 28,641,677 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT, activity as tolerated
Physical Therapy:
WBAT, activity as tolerated
Treatments Frequency:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a tibial shaft and fibula fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for tibial IM nail fixation, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization.
The patient experienced hyperglycemia while hospitalized, ___
was consulted and their recommendations were followed. His blood
glucose remained difficult to control and on discharge his
glucose was 248. On POD#2 the patient became tachycardiac with a
sustained HR in the 120's-130's. An EKG showed sinus
tachycardia, and he remained asymptomatic throughout and was
monitored on telemetry until discharge. On POD#3 he was still
tachycardiac which prompted a CTPA to r/o PE. The official read
come back negative for PE, although they could not visualize the
sub-segmental vessels. On POD #2 he also developed a transient
fever of 102.3, which resolved spontaneously. Again, he
remained asypmtomatic. A workup for the fever yielded a negative
CXR and UA. Blood cultures were drawn and will be followed up.
On the morning of POD#4 the tachycardia resolved spontaneously.
The patient worked with ___ who determined that discharge to home
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the RLE extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up in two weeks per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. | 231 | 375 |
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