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17399874-DS-22 | 28,166,689 | Discharge Instructions
Spine Surgery without Fusion
Surgery
· Your incision is closed with staples. You will need staple
removal. Please keep your incision dry until staple removal.
· Do not apply any lotions or creams to the site.
· Please avoid swimming for two weeks after staple removal.
· 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. ___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· No contact sports until cleared by your neurosurgeon.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
· It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· New weakness or changes in sensation in your arms or legs. | Ms. ___ represented to the ER with severe LLE radicular
pain. MRI was stable and she was admitted for pain control. Pain
onset was immediately following physical therapy session where
weights were attached to her bilateral ankles.
#LLE radiculopathy
She complained of L calf tenderness and bilateral LENIS were
negative for DVT. Chronic pain was consulted and recommended
toradol. She underwent epidural injection on ___. After the
procedure she had L foot weakness but reported the sensation in
her left leg had improved. The epidural injection alleviated her
proximal leg pain, however she continued to have severe pain and
tingling in her left foot. She continued on multimodal pain
regimen including toradol, gabapentin, lidocaine patch, epidural
injection, oxycodone, and Tylenol without significant
improvement. Risks, benefits, and expectations pertaining to
surgical intervention were discussed with the patient after a
trial of nonoperative management, and the patient elected to
proceed with surgery. The patient was taken to the operating
room on ___ for L5-S1 re-exploration. Please see the operative
report for full details. The patient tolerated the procedure
well and was transferred from the PACU to the floor in stable
condition. No postop imaging or brace was needed. Her
medications were titrated for ongoing pain. Her oxycodone was
decreased for somnolence on POD2 with improvement. She was
evaluated by ___ who recommended rehab at discharge. | 275 | 221 |
11801645-DS-8 | 25,152,697 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and found to have an infection in your
appendix. You were taken to the operating room and had your
appendix removed laparoscopically.
You are now doing better, tolerating a regular diet, pain is
controlled with oral medications, and you are ready to be
discharged to home to continue your recovery from surgery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of LLQ abdominal pain. Admission
abdominal/pelvic CT revealed acute appendicitis with extensive
periappendiceal inflammation. WBC was elevated at 10.6 The
patient underwent laparoscopic appendectomy complicated by
colonic puncture and therefor repair of a colonic puncture. A JP
drain was left. Please refer to operative report for details.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor on IV fluids, and oral meds for pain control. The
patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. 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 with a JP drain.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 475 | 219 |
10066489-DS-11 | 26,697,349 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with abdominal pain and some inflammation of
your colon. This is likely due to constipation and mild
dehydration. You have passed several stools and have not had any
pain. You were briefly on antibiotics for the inflammation, and
they have been stopped.
You had another cat scan of your head, and your operation is
healing well.
Finally, you were not able to pee, and a urine catheter was
placed and you were found to have a urinary tract infection. You
will need two more days of ciprofloxacin.
MEDICATION CHANGES:
STOP- Labetolol, restart if you have high blood pressure at
rehab
STOP- Salt tabs
STOP- Oxycodone
START- Bisacodyl PR daily prn constipation
START- Senna daily | ___ year-old female without significant PMH admitted from ___
to ___ for traumatic left convexity acute SDH s/p fall. The
___ was stable on repeat imaging, and she was discharged to
rehab in stable condition with no focal neurologic deficits, and
then to home. She returned to the ED on ___ with headache
and difficulty ambulating and was found to have increased size
of the subdural hematoma with increasing midline shift. On
___ she underwent left-sided craniotomy for resection,
intraoperative evacuation, adhesiolysis, fenestration of
membranes, and duraplasty for implantation of subcutaneous
drain. Her post-operative course was unremarkable, her drain was
removed, and she was discharged to rehabilitation on ___.
She now returns with fecal impaction and CT showing rectal wall
thickening, surrounding stranding and small volume free pelvic
fluid suggestive of stercoral colitis. In the ED she was started
empirically on cipro/flagyl for colonic inflammation and rebound
on exam.
FECAL IMPACTION/STERCORAL COLITIS: Based on CT findings, empiric
cipro flagyl x48 hrs, improved exam, so abx stopped.
HYPONATREMIA: Patient with hyponatremia during recent
hospitalization, likely related to CNS trauma, and discharged on
salt-tabs which were dc'd, no hyponatremia.
HYPERTENSION: Mild hypotension; hold labetolol.
DEPRESSION: Stable, continue celexa.
RECENT SDH: Stable, continue prophylactic keppra, had repeat CT
head which was unremarkable.
NUTRITION: Regular as tolerated
UTI: Had urinary retention, foley placed with 700cc output, UA
>180 WBC, continued on PO cipro for 5 day course, foley to be
DC'd and voiding trial ___. | 122 | 235 |
10985484-DS-4 | 24,211,708 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were recently admitted for an event in which you lost
consciousness and had trauma to you face and chest. CT scans of
your head were normal, but the CT scan of the chest showed two
nondisplaced fractures of the ___ and 6th ribs on the left. The
pain from these fractures responded well to percocet. In
determining the cause of the fall, we consulted neurology who
recommended an EEG and further cardiac workup. There were no
abnormalities found on the EEG. There were no abnormalities
found on your carotid artery ultrasound of your neck. The image
of your heart did not show us any abormalities that could
explain your falling.
In the meantime, continue you take Keppra 500 twice a day to
prevent a possible seizure. Wear the event monitor to assess for
any heart abnromalities. If you feel that you are seeing faces
or are about to fall press the button, tell your family and
friends to press the button if you cannot. DO NOT DRIVE as we
cannot guess when you may have another attack. Please talk to
your neurologist about resuming driving.
We wish you all the best!
Your ___ care team | ___ year old female who presented with syncope while sitting at
work. Pt was evalauated for cardiogenic and neurogenic causes of
syncope. No acute events were captured on telemetry, EEG
monitoring or symptomatically per the patient. She was
discharged in stable condition.
BRIEF HOSPITAL COURSE
========================
ACTIVE ISSUES
# Syncope: Given patient's unusual presentation of visual
hallucinations preceding syncope, but without postictal or other
signs indicative of seizure, patient was worked up for both
cardiogenic as well as neurogenic causes. Orthostatics were
negative, no signs of dehydration, diarrhea or signs of dumping
syndrome. She was placed on continuous, 24-hour vEEG monitoring,
which revealed no seizure events. Pt placed on continuous
telemetry throughout hospitalization with no events noted on
monitoring. TSH and B12 within normal limits, no signs of
infection. She subsequently received a transthoracic eECHO was
negative to valvular abnormality. Did reveal ___ and
borderline pulmonary hypertension. Carotid ultrasound revealed
no stenoses. Patient was started on Keppra 500 BID for
presumable seizure prophylaxis. She was advised to continue her
home dose wellbutrin, despite its ability to lower the seizure
threshold, given her history of severe depression. Patient was
discharged on an event monitor ___ of Hearts), for four weeks.
Patient has been counseled to discontinue driving until able to
follow up with neurology for further recommendations.
# L sided hematoma: Patient presented with left side hematoma
encompassing zygoma and orbit after striking her head. CT
negative for acute intracranial abnormality, neuro exam WNL.
Hematoma steadily improved during course of hospitialization.
# Rib fracture: Patient with evidence of left-sided ___ and ___
rib fractures on CT and CXR. Her pain from the rib fractures
responded well to oxycodone/acetaminophen. Patient was
discharged on oxycodone, acetaminophen, and lidocaine patch for
pain.
STABLE CHRONIC ISSUES
# Anxiety: Patient was continued on home dose Xanax 1mg TID
prn:anxiety.
# Depression: Patient was continued on fluoxetine 40mg PO BID.
Wellbutrin initially discontinued due to concerns for seizure,
but restarted upon dicharge. No acute episodes of mood
instabiliyt whilst hospitalized.
TRANSITIONAL ISSUES
===================
[] Neuro/Psych follow-up: Wellbutrin contineued despite ability
to lower seizure threshold given her history of severe
depression. Consider alternative psychiatric regimen.
[] Neuro follow-up: Consider transitioning from Keppra to
Trileptal or Lamictal for seizure prophylaxis given side effect
of mood disturbance
[] Neuro follow-up: Patient has been counseled that she wil be
unable to drive until at least consulted by outpatient
Neurologist for further workup.
[] Cardiac monitoring: Given negative workup, patient being
discharged on event monitor for 4 weeks. Patient will need F/U
with cardiology.
[] PCP: ___ was hypertensive while inpatient with SBPs in 140s,
does not take antihypertensives at home | 210 | 433 |
17762038-DS-7 | 20,272,877 | Dear ___ ,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office with
any questions or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the gynecology
service after undergoing right diagnostic laparoscopy,
evacuation of hemoperitoneum, laparoscopic right salpingectomy
for ruptured right ectopic. Please see the operative report for
full details.
Immediately post-op, her pain was controlled with IV
dilaudid/toradol. On post-operative day 1, experienced symptoms
of dizziness and fatigue, and her hematocrit nadir was found to
be 21.3. She was given 2 units of packed red blood cells, with
symptomatic improvement. Her diet was advanced without
difficulty and she was transitioned to
ibuprofen/acetaminophen/oxycodone (pain meds).
By post-operative day 2, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled. | 227 | 121 |
12783878-DS-17 | 28,450,323 | You were admitted to the hospital with seizures in the setting
of having a urinary tract infection. You received an EEG which
showed that you might have a seizure disorder. The neurology
service recommended that you start on lamotrigine. Otherwise you
will complete a course of antibiotics for your urinary tract
infection. | On admission, the patient was empirically started on
ceftriaxone. Urine grew a pansensitive Klebsiella pneumonia, and
the patient was switched to oral ciprofloxacin. She will finish
a 14 day course (12 additional days of therapy) for a
complicated UTI, and will restart her suppressive fosfomycin
after therapy. An EEG was performed on admission, which showed
frequent right temporal discharges. She was evaluated the
neurology service, who recommended starting lamotrigine (chose
against Keppra given her history of mood disorders). She was
started on 25 mg daily, with the taper as described below. She
will follow up with the outpatient neurology team when she is
therapeutic (100 mg BID) for a trough level. | 52 | 112 |
11640277-DS-3 | 26,636,571 | Mr. ___,
You were admitted to ___ due to dizziness. A ___ MRI was
obtained and did not show any stroke.
Based on your symptoms and your neurological examination, we
diagnosed you with 'Vestibular Neuritis'.
Vestibular neuritis is an inflammation of the nerves connecting
the inner ear to the ___. The inner ear is made up of a system
of fluid-filled tubes and sacs called the labyrinth. The
labyrinth contains an organ for hearing called the cochlea. It
also contains the vestibular system, which helps you keep your
balance.
This is mostly caused by viruses. This can lead to dizziness or
vertigo (feeling like the room is spinning, trouble keeping your
balance and nausea.
We have therefore prescribed you a medicine called Meclizine to
be taken as needed to reduce nausea and dizziness. If your
nausea and vomiting cannot be controlled, you may need to go to
the hospital.
It usually takes 3 to 4 weeks to recover from vestibular
neuritis or labyrinthitis. You may need bed rest for 1 or 2
weeks. You may be left with some mild dizziness when you move
your head, which can last longer.
If you are having a lot of nausea, drink clear fluids only, such
as water, weak tea, and bouillon. Eat bland foods such as soda
crackers, toast, plain pasta, noodles, bananas, and baked or
broiled potatoes.
When you are feeling dizzy, avoid stairs, heights, and driving.
Do not operate machinery that could be a danger to yourself or
others.
We are changing your medications as follows:
[ ]Continue to take your usual home medications
[ ] If having any nausea/vomiting, take meclizine as prescribed
when needed.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ year old right-handed man with PMH of DMII
with granuloma annularre, HTN, and HLD who neurology has been
consulted because of vertigo and incoordination.
On presentation to ED, his symptoms had resolved. He felt close
to normal and was not vertiginous and uncoordinated on exam.
___ test was negative in ED. A detailed posterior
circulation examination was reassuring, only remarkable finding
were that pursuit was not smooth and was jerky when looking to
either left or right. He also had a wider based gait than
expected and he did stagger to the left once. He could not walk
in tandem.
The following day, his exam improved and he was able to have a
narrow based gait. No nystagmus on exam. Head impulse test was
reassuring. Unterberger teast showed patient was losing balance
and falling to left. No dizziness. It was able to ambulate
without any difficulty.
CT obtained in ED was reassuring and did not show ant acute
intracranial abnormality. Normal CTA head, neck. MR ___ showed
no evidence of hemorrhage, edema, masses, mass effect, midline
shift or infarction. Mild generalized cerebral, cerebellar
atrophy. Mild chronic small vessel ischemic changes. It also
showed opacification of the right maxillary sinus, likely from
mucous retention cyst.
Labs showed WBC count of 11 with 62% neutrophils, Hb 16, Plt
313. Reassuring chemistry and LFTs. Elevated HbA1c of 9.9, per
patient this is better than his previous A1c of 11. Cholesterol
of 102, Triglycerides 170, HDL 29, LDL 39. TSH 3.1, CRP 2.5. Tox
screen of serum and urine was negative.
Patient was given aspirin and Plavix in the emergency
department, these were discontinued when patient's MRI did not
show any stroke.
Orthostatic vital signs were obtained and were reassuring. Blood
pressure 127/84 while lying down, heart rate at 67 bpm while
lying down. Blood pressure increased slightly to 133/90 mmHg
while sitting up, heart rate increased slightly 71 bpm. On
standing up blood pressure was 131/88, heart rate was at 72 bpm.
We recommend to follow-up with primary care physician if the
symptoms persist.
Due to this, a diagnosis of vestibular neuritis was made.
Patient was counseled about the diagnosis and PRN meclizine was
prescribed, patient was then discharged home | 381 | 370 |
13733398-DS-17 | 20,734,261 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
worsening cough with one episode of coughing up blood. You were
found NOT to have tuberculosis, a potential cause of coughing up
blood. But you were found to have pneumonia, for which you were
treated with antibiotics. It is very important for you to
continue taking the cefpodoxime and azithromycin as indicated
and follow up with your providers. The next dose of cefpodoxime
is due at 8pm on ___. The next dose of azithromycin is due
8AM on ___.
Please see below for your upcoming appointments.
Sincerely,
Your ___ team | In brief, Mr. ___ is a ___ M h/o well-controlled HIV (last
VL = 0, CD4 > 400) p/w 7 d of productive cough, night sweats,
and one recent episode of small volume hemoptysis, who was found
to have community-acquired pneumonia (which improved with
ceftriaxone/azithromycin and transitioned to cefpodoxime/azithro
on discharge). Patient ruled out for TB while inpatient.
ACTIVE ISSUES:
==============
# Hemoptysis:
Patient presented with one episode of small volume hemoptysis in
the setting of severe coughing, with no further episodes after
admission. CTA showed no evidence of PE and hemoglobin remained
stable during admission. During admission, patient was ruled out
for active tuberculosis with three negative concentrated AFB
smears. Hemoptysis likely secondary to underlying pneumonia or
trauma from coughing. Hemoptysis resolved on discharge.
# Community-acquired pneumonia
Patient presented with 7-days of productive cough and night
sweats. Laboratory studies showed leukocytosis and CT was
notable for right upper lobe ___ ground-glass nodular
opacities compatible with small airways infection, and workup
was otherwise unrevealing. Patient thought to have
community-acquired pneumonia. Treated with IV ceftriaxone and
azithromycin and transitioned to cefpodoxime and azithromycin
with plans to complete a 5-day course on discharge (projected
end date ___. | 106 | 192 |
14072816-DS-15 | 28,811,836 | Dear Ms. ___,
It was a pleasure caring for you in the hospital. You were
admitted for lightheadedness and sweating. We feel this is due
to elevated blood pressures. It is very important that you
continue to take your medications at home as instructed. You
should also continue to take your torsemide (a medication to
make you pee) at home.
Sincerely,
Your ___ Team | ___ with PMH significant for HFpEF, CKD, HTN with recent
admission for CHF exacerbation, who presents with
lightheadedness and diaphroesis and elevated BP.
#Lightheadedness/diaphoresis - vague symptoms on admission.
Given elevated BP on admission to ED felt that symptoms may be
related to blood pressure. EKG without ischmia and trops
negative x2 so low suspicion for cardiac ischemia as etiology.
Per granddaugther/hcp, patient has had issues with symptomatic
hypertension in the past and there was concern that patient not
taking medications as prescribed. Restarted home hydralazine,
labetalol and amlodipine and patient's BPs rapidly stabilized.
Furthermore, she remained symptom free fur the duration of her
admission.
#___ - In ED, initial concern for CHF exacerbation and given
20 IV lasix, however appeared euvolemic on exam, BNP decreased
from prior admission, and wt 83kg at last discharge and 81kg
this admission, did not feel that patient decompensated.
Continued home torsemide 10mg qD. | 61 | 149 |
11484862-DS-14 | 21,609,741 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because you developed fever,
fatigue, and weight loss. You were found to have infection with
a parasite known as "Babesia." We suspect that this may have
been caused by a blood transfusion, although this is currently
being investigated by the Department of Public Health, the Red
Cross, and our blood bank.
This parasite infects your red blood cells. Therefore, you
initially underwent treatment with a procedure called "red blood
cell exchange," in which your red blood cells were taken out and
replaced with healthy ones. You were also treated with
antibiotics, and you improved. The parasite has been almost
entirely eliminated from your body. You will need to continue
these antibiotics for several weeks to completely clear the
infection.
You were also evaluated by urology and noted to have an ongoing
stone in your right kidney. As such, your percutaneous
nephrostomy tube was left in place and you will follow-up with
urology as an outpatient to consider removal of the tube.
You will now be returning to rehab to continue your recovery.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below.
We wish you the very best!
Warmly,
Your ___ Team | ___ is an ___ gentleman with a history of
T1DM from ___ procedure, asplenia, CKDIII w/ right
obstructive nephropathy s/p PCN placement, recent upper GI bleed
(___), and hypertension, who was recently admitted for RLE DVT
and was subsequently re-admitted with B symptoms of low-grade
fever and >50 lbs weight loss <2 months.
ACTIVE ISSUES
--------------------
# Severe Babesiosis. He was found to have severe Babesiosis. It
is unclear how he contracted babesia given he has largely been
indoors in rehab. The blood bank was contacted to investigate
whether this could be a case of transfusion-related babesiosis
from recent blood transfusions; investigation is still underway
at this time. He was initially admitted to the MICU for pheresis
with RBC exchange, and he underwent two cycles. He received
antibiotic therapy with clindamycin (___), quinine
(___), and doxycycline (___), and was switched to
treatment with triple therapy atovaquone, azithromycin, and
doxycycline (please see course below, doxycycline for possible
anaplasma), with a plan to treat for 6 weeks including two weeks
from date of negative parasite burden. Lyme serologies and blood
cultures were negative. Anaplasma antibody was negative, but PCR
was pending at the time of discharge. Parasitemia of ~20% on
admission, which downtrended to 0.4% on discharge. He was
followed with frequent hemolysis labs, which were all improved
at the time of discharge. He required no further transfusion
after his RBC exchange. He was continued on iron and folate
supplementation as well as zinc supplements.
.
# ___ on CKD III. His infection and septic physiology led to the
development of ___ on his chronic kidney disease from renal
hypoperfusion to a peak Cr of 2.5, which improved to 1.5 (below
recent baseline) at the time of discharge. He was supported with
fluids and diuresis was initially held. His nephrostomy tube
output was stable, and serial imaging of his right renal pelvis
stone showed stability.
.
# Acute, decompensated diastolic heart failure. Likely due to
fluid resuscitation as above as patient was positive 11L at the
time of his transfer from the ICU, which led to decompensated
diastolic heart failure requiring 5L O2. He was intermittently
diuresed with 40 mg IV Lasix and then was allowed to
auto-diurese to a dry weight of 89.0 kg at time of discharge.
.
# Right renal pelvis stone: Patient with obstructing right renal
pelvis stone on prior admission s/p percutaneous nephrostomy
tube placement. His nephrostomy tube output remained stable this
admission. He was re-evaluated by urology on ___ who felt that
stone was stable on repeat imaging (CT on admission and KUB on
___ and thus recommended follow-up as an outpatient for
management of PCN and stone.
.
# Hyponatremia: Na of 131 on discharge. Sodium ranged from
129-134 on this admission. Stable from prior admissions. ___
have been due to autodiuresis following ___. Improving at time
of discharge. Patient would benefit from work-up of hyponatremia
as outpatient.
.
==============
CHRONIC ISSUES
==============
# Chronic Right Lower Extremity DVT: Had a prior DVT on his last
hospitalization thought to be provoked secondary to prolonged
hospitalizations. Warfarin was initially held in the setting of
sepsis and concern for DIC. He was bridged with heparin and was
discharged on warfarin 2.5 mg daily with a goal INR 2.0-3.0. INR
3.0 on day of discharge. Needs repeat INR on ___.
.
# Diabetes Mellitus, Type I. Secondary to Whipple procedure.
Continued on home glargine and humalog sliding scale. Glargine
and Humalog sliding scale increased as inpatient given elevated
sugars in the 200s-300s.
.
# Hypertension: Initially held amlodipine due to concern for
sepsis and hypotension. This was restarted at a reduced dose of
5 mg daily.
.
# Pancreatic enzyme deficiency. Secondary to Whipple procedure.
Continued on Creon TID with meals.
.
# Anemia: Baseline hemoglobin ___, thought to be secondary to
to hemolysis in the setting of babesiosis. Hemoglobin was stable
and was 8.6 g/dL at the time of discharge. He was continued on
pantoprazole 40 mg daily, sulcralfate, folate, and iron
supplements.
.
# BPH. He was continued on tamsulosin 0.4 mg qhs.
.
===================
TRANSITIONAL ISSUES
===================
# Discharge Cr: 1.7
# Discharge weight: 89.0 kg
# Antibiotic regimen. Continue current abx regimen of
atovaquone/azithromycin. Will plan to treat for 6 weeks
including at least 2 weeks from date of negative parasite burden
(through at least ___, pending tolerance of the medications.
Continue doxycycline until ___.
# Lab monitoring. Please check weekly CBC, parasite smear,
hemolysis labs (haptoglobin, LDH, Tbili), and INR. Please follow
up pending anaplasma PCR.
# Anticoagulation. Will be discharged on warfarin 2.5 mg daily.
Please check INR weekly (goal 2.0-3.0).
# Hyponatremia: Please check sodium on ___. Consider outpatient
work-up for hyponatremia if persistent as outpatient.
# EKG monitoring. The patient should undergo intermittent EKG
testing
for QTc while on macrolide therapy
# Nephrolithiasis. Will continue with PCN tube with plan for
outpatient urology follow-up.
# Medication changes. Antibiotics as above. Amlodipine
dose-reduced to 5 mg daily from 10 mg given low blood pressures.
Please titrate as outpatient. Trazodone stopped because of
potential QT prolongation with concurrent azithromycin.
# CODE: FULL
# CONTACT: Son, ___ ___ | 209 | 831 |
18002691-DS-9 | 27,048,722 | Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted with chest pain. You were found to have elevated
cardiac enzymes. You underwent cardiac catheterization and
underwent placement of two stents to relieve obstruction in the
arteries supplying blood to your heart. Your symptoms improved.
You are being discharged with new medications and instructions
for follow-up.
DO NOT STOP taking your ASPIRIN ever. DO NOT STOP taking your
PLAVIX until instructed to do so by your Cardiologist.
We are also starting you on two blood thinners, coumadin and
enoxaparin. You will take coumadin indefinitely. You will need
to be on enoxaparin only until your coumadin level is at an
appropriate level. Please follow up with your primary care
doctor to have your blood drawn within 2 days of discharge.
We wish you well!
Your ___ Medicine Team | Mr. ___ is a ___ year-old gentleman with PMH of paroxysmal
afib (not on Coumadin), HTN, HLD, CHF, GERD, ___
esophagus, who presented to ___ with chest
pain, and was found to have an NSTEMI, now s/p DES to LAD (80%
lesion) and D1 (90% lesion).
# CORONARIES:
Pt presented with NSTEMI with evidence of stenosis in LAD and
D1. He underwent placement of ___ 2 to these lesions. He did
not have subsequent pain or new EKG changes. He was treated with
Plavix 75mg po daily, Atorvastatin 80mg po daily, Metoprolol XL
50mg, and Lisinopril 2.5mg po daily.
# PUMP:
Depressed EF of ECHO from ___. Pt received Lasix 20mg
po daily. LVEF by cardiac MRI was 38%. There was also moderate
to severe mitral regurgitation secondary to leaflet tethering
from wall motion abnormalities.
# RHYTHM:
Paroxysmal AF. Not on Coumadin. CHADS2 score was 3. Flecanide
was discontinued, given pro-arrhythmic properties in setting of
ischema. Pt was started on Lovenox as a bridge to Coumadin. Rate
control was achieved with metoprolol.
# HTN
Well-controlled on metoprolol and lasix
# HYPOXIA
Pt was found to develop nucturnal hypoxia to mid ___. Likely
COPD, given smoking hx. DDx includes OSA vs. pulm HTN vs. hiatal
hernia depressing ventilation. No evidence of CHF on exam. PE
was in ddx but thought to be unlikely given low Well's score
(0). He received nebs and supplemental O2 prn. He remained
asymptomatic.
#? Cardiac Mass - noted on TTE and thought to be likely external
compression of atrium by hiatal hernia. DDx included atrial
thickening vs. atrial mass. Pt underwent cardiac MRI on ___,
with preliminary report of absence of atrial thickening or
masses. There was evidence of external compression on both atria
w/o hemodynamic compromise.
# ___ Esophagitis/Hiatal hernia: Continued
pantoprazole
TRANSITIONAL ISSUES:
# CODE: Full Code
# CONTACT: Patient, Son ___, ___
- Please follow up final report of cardiac MRI
- Please consider outpatient sleep study for eval of possible
OSA.
- Please consider follow-up TTE in several months to assess
progression of systolic function | 145 | 346 |
19055229-DS-6 | 29,367,199 | Dear Mr. ___,
It was our pleasure caring for you during your admission to
___.
You were admitted to ___ due to shortness of breath. Your
shortness of breath was felt to be due to low blood counts
(anemia). You received two blood transfusions. You were
evaluated by the gastroenterology (GI) doctors who ___
likely had GI tract bleeding. THey performed an endoscopy and
colonoscopy and did not find any evidence of bleeding. You will
see the GI doctors in follow up and may require additional
testing to find the source of your bleeding. We also found that
you had a urinary tract infection that we treated with
antibiotics. We also tested your stool and found that you had an
infection called "C.diff" that we treated with antibiotics. You
will continue these antibiotics after discharge.
It is important that you continue lovenox at home to help reduce
your risk of stroke from afib. You should take both lovenox and
Coumadin together. When your INR is at its therapeutic level,
your doctor ___ stop your lovenox.
We wish you a speedy recovery,
- Your ___ Care Team | SUMMARY:
================
___ M on coumadin for Afib with h/o GIB ___ ileal ulcer s/p SBR
in ___ who presented with melena and dyspnea on exertion.
ACUTE ISSUES:
================
# Acute blood loss anemia/lower GI bleed: Per OMR, had operation
___ for likely Crohn's disease of the ileum in which a
phlegmon and fat wrapping were noted and 6 inches of bowel was
resected with creation of an end to end anastomoses in
normal-appearing ileum on both sides of the disease. No
granulomas seen on path. Was subsequently admitted in ___
for GIB (hgb on admission then was 13.1) at which time
EGD/Colonoscopy was performed demonstrating ileal ulcerations
c/w either Crohn's disease or malignancy. No active bleeding was
noted but a non-bleeding erosion was noted in the terminal ileum
at that time. Patient presented with symptomatic anemia
(dyspnea). On admission hgb was 7.6 and went down to 6.6 on
recheck, requiring transfusion of 1 unit pRBC. Patient was
additionally started on BID IV PPI. Given history of dark tarry
stool, etiology for current bleeding was thought to be flare of
possible crohn's disease, bleed from anastomotic ulceration, or
bleed from previously noted ileal erosions. CRP 100 on
admission. Patient was evaluated by GI who performed endoscopy
and colonoscopy, neither of which demonstrated evidence of bleed
or source of bleeding. GI felt there was no active bleeding and
recommended outpatient capsule endoscopy. Anticoagulation was
held given bleeding, though was discharged on ___. On
day of discharge, hgb 7.6 with no recently reported dark tarry
stools. Patient was transfused 1u pRBC prior to discharge.
# Sepsis ___ Urinary tract infection: Patient was febrile to
101.5 in ED with leukocytosis to 19.4. UA with WBC, mod
bacteria, sm blood, negative nitrites on admission. Patient was
empirically started on CTX that was briefly broadened to
cefepime due to intermittent rigors and fevers on cefepime.
Urine culture grew pan sensitive ecoli and patient was narrowed
to ciprofloxacin for ___nd date ___.
# C diff colitis (mild): Assay came back positive. Patient
denied abdominal pain and none was noted on physical exam
throughout admission. Colonoscopy the day before showed normal
mucosa, so may be a mild infection. We started treatment with IV
vancomycin 125mg po q6h for a ___ay one was ___.
# Dyspnea: Patient reported worsening dyspnea for weeks prior to
admission. Thought to be secondary to acute blood loss anemia.
No PNA on CXR. No wheezing suggestive of COPD exacerbation. EKG
with non-specific T wave inversions and troponin negative,
ruling out ACS given duration of symptoms. BNP elevated but no
evidence of volume overload or CHF exacerbation on exam. Home
Tiotropium Bromide 1 CAP IH DAILY was continued. Dyspnea
improved by discharge.
# Acute on chronic CKD: Creatinine 1.8 on admssion, uptrended to
2.0. Likely pre renal component given reported low po intake as
outpatient, blood loss, and NPO status. Improved to baseline
with IVF.
# Atrial fibrillation: Patient monitored on telemetry where
irregular rhythm was repeatedly detected. Patient is on warfarin
as outpatient which was held prior to admission and started on
lovenox in anticipation of prior scheduled colonoscopy ___. At
discharge, patient was restarted on lovenox and Coumadin at
discharge with plans to bridge. | 188 | 534 |
16860825-DS-42 | 23,298,913 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because shortness of breath and chest
tightness.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We gave you medications to manage your breathing. We
monitored your breathing, and set you up with an outpatient
appointment with your lung doctor.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Weigh yourself every morning, call doctor 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 ___ Team | ====================
PATIENT SUMMARY:
====================
___ female with a history of COPD, Asthma, CHF, OSA, and
diabetes admitted for SOB, chest tightness, congestion, and O2
requirement, concerning for COPD exacerbation. Notably, she
endorsed symptoms consistent with an upper respiratory
infection. She was treated with steroids and antibiotics, and
walking comfortably on room air by time of discharge.
====================
TRANSITIONAL ISSUES:
====================
#stopped meds: none
#changed meds: none
#new meds: prednisone 40 mg PO daily (___nding
___, azithromycin 250 mg PO daily (___nding
___
[ ] Please follow-up on breathing status. She was on room air at
time of discharge; however she endorsed more frequent use of
inhalers in the weeks leading up to her admission. She was
discharged on prednisone and azithromycin.
[ ] Please follow-up on tobacco use. She wanted lozenges at
discharge to continue to help her stop smoking.
[ ] Discharged with plan for pulmonology follow up
====================
ACUTE ISSUES:
====================
# Hypoxia
# Dyspnea
# COPD exacerbation
# HFpEF
Suspect that her respiratory status is largely ___ COPD
exacerbation, with URI trigger given associated symptoms of
congestion and clear phlegm. No overt signs of volume overload
and CXR did not show frank pulmonary edema. She received 80 mg
of methylpred and 20 mg IV Lasix in ED (patient takes 80 mg PO
at home). She was given another IV Lasix 80mg after admission,
and transitioned back to her home dosing of 80 mg Lasix p.o. She
was started on standing albuterol nebs and Duonebs q 6 hrs. O2
requirement decreased over course of admission; notably, she was
on room air by the morning after admission, and remained stable
on room air. Her ambulatory O2 sat was in the ___. Her exam
remained euvolemic. Her blood culture showed no growth to date
by time of discharge. She was breathing and speaking comfortably
at time of discharge.
#Chest tightness:
Patient reported similar chest tightness last year. No clear
association with activity. Patient states that the pain is
"constant. "Last year she received a stress test. After
regadenoson infusion she noted that the chest tightness and neck
pain worsened, however no EKG changes were noted on stress test.
EKG in the emergency department unchanged from baseline
collected 2 months ago. Troponins negative x2 in the emergency
department. Low suspicion for ischemic etiology given recent
normal stress test and above negative work-up. Her symptoms of
chest tightness resolved with COPD exacerbation treatment. She
was not complaining of chest tightness by time of discharge.
====================
CHRONIC ISSUES:
====================
# OSA on CPAP:
Continued CPAP
# DMII:
# Weight control
LDSSI while inpatient; transitioned back to home medications at
discharge (Home regimen is GlipiZIDE XL 10 mg PO DAILY;
Trulicity
(dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK; MetFORMIN
(Glucophage) 1000 mg PO BID). Patient states that she takes
Trulicity for weight control on ___. Per pharmacy, we do
not carry Trulicity but she can take her medication when she
arrives at home (within 3 days of missed dose) and resume her
weekly schedule.
# HTN:
Continued home regimen of HydrALAZINE 25 mg PO TID and
amLODIPine 10 mg PO DAILY
# HLD:
-Continued home simvastatin | 131 | 507 |
15497723-DS-13 | 24,595,197 | Dear ___,
___ were hospitalized with a decompensation of your neurological
disease. Your anti-epileptics were adjusted.
___ will be started on Campath (alemtuzumab) as an outpatient.
Your liver tests show some mild elevation and will be followed
by your outpatient doctors. | Neurology Inpatient Course:
Pt is a ___ F w/ PMH of inflammatory brain lesions (? STEART
vs. ADEM) c/b seizures on keppra, Vimpat and Dilantin who was
transferred from OSH for an episode concerning for seizure.
#Neuro:
Pt was initially admitted to Neurology General Service and
monitored on continuous video EEG. She was continued on her home
AEDs. At this time, her mental status was seen to improve and
she had no clear seizures on EEG. Her home Phenytoin was
increased to 200mg twice daily. She underwent MRI Brain which
showed some improvement in her brain lesions but no new foci. An
alpha-enolase level was obtained to be utilized as biomarker for
potential STEART.
#Cards:
Pt was monitored on telemetry and continued on her home
Amlodipine with adequate blood pressure control.
#Endo:
-Pt was continued on her home levothyroxine and TFTs were
obtained showing mildly elevated TSH.
Due to plan for patient to receive immunosuppressant therapy
prior to admission (particularly IVIG), after discussion w/ Dr.
___ was transferred to ___ in preparation for Campath
therapy. | 40 | 171 |
14722002-DS-12 | 29,975,461 | Dear ___,
___ were admitted with right lower facial weakness and sensory
changes concerning for a transient ischemic attack. In the
hospital a code stroke was called and your brain was imaged with
CT and MRI, your vessels were also imaged and no acute process
was found. this is concerning for a bell's palsy, as well as
transient ischemic attack or MRI negative stroke. At this time
we recommend:
1. Please continue all your medications as directed by this
document. Note that we have started ___ on aspirin 81mg oral
daily.
2. Please keep all your follow up appointments as below.
3. ___ should see your primary care doctor within ___ week from
discharge, as well as follow with neuro urgent care. The clinic
will call ___ with an appointment.
4. ___ will need outpatient work up which includes: checking
your glycated hemoglobin, a fasting lipid panel, Lyme serology,
and an echocardiogram. | ___ is a ___ right handed woman with PMH significant for
HTN and RA who presents with acute onset of right facial
weakness. Code stroke was activated. tPA was not given due to
NIHSS of 1. MRI brain with contrast did not show an acute
infarct, neoplasm, or enhancement of right CN 7. MRA of the
brain did not show intracranial stenosis. In light of her age
and relatively minimal risk factors (though RA and HTN are
stroke risk factors), the differential includes an MRI negative
stroke versus a peripheral ___ nerve palsy (bells) that may
still be evolving. Given that there was no right upper facial
weakness and that her right lower facial weakness was improving
slightly over the course of the day, and the lack of hearing or
taste changes on the right side, this argues against a right
peripheral ___ nerve palsy. Ms. ___ did not want to stay in
the hospital to complete the brain ischemia workup. She will be
discharged with neuro urgent care follow up and outpatient
workup.
TRANSITIONAL ISSUES:
1. COMPLETE STROKE W/U WITH:
-glycated hemoglobin
-fasting lipid panel
-Lyme serology
-echocardiogram | 151 | 184 |
18858092-DS-13 | 26,316,506 | Dear Ms. ___,
It was a pleasure to be part of your care.
What happened during your hospital stay?
- You were admitted to the hospital because you noticed bright
red blood in your stool for 5 days. Your blood level was checked
and it was low. The GI team consulted and recommended a
colonoscopy. A colonoscopy was done which showed 2 small polyps
that were not bleeding in your colon and mild inflammation in
your stomach. The cause of your bleed was likely from
hemorrhoids. Your anemia is likely multifactorial with some GI
losses, but also decreased production of your blood secondary to
your kidney disease. You are receiving EPO with your dialysis
sessions which will improve your blood count. The GI team
recommends you increase your antiacid medication to twice a day
and get a repeat colonoscopy in ___ years.
- The renal team saw you as well to ensure everything was going
well with your kidneys. They no longer feel like you need
dialysis as frequently.
What to do on discharge?
- Please follow up with your primary care doctor, GI doctor and
renal doctor. If you notice any blood in your stool or black
tarry stool, please seek medical attention immediately.
- We found that your blood level was low and so you received a
blood transfusion. Avoid beets and cranberries as this can make
your stool red which can be mistaken for blood. Also avoid
NSAIDs such as advil, aspirin, motrin, naproxen, ibuprofen.
These medications increase the risk of bleeds.
We wish you the best,
Your ___ Team | ___ year old woman with with past medical history of
granulomatosis with polyangiitis c/b left central scotoma and
RPGN now on HD (previously T, Th, ___, DVT on warfarin, and
recent diagnosis of PNA treated with vanc/cefepime (end date
___ who presented with 5 days of BRBPR and hbg 7.2.
# Acute blood loss anemia due to lower GIB likely secondary to
hemorrhoids: Patient presented with Hgb 7.2, down from recent
baseline of ___. Patient recieved 1uRBC on ___ with good
effect. GI consulted and did a colonoscopy as well as an EGD and
found a polyp in the sigmoid colon (polypectomy), a polyp in the
rectum (polypectomy), no fresh blood or old blood was seen,
internal hemorrhoids, otherwise normal colonoscopy to cecum, on
EGD several non-bleeding nodules with overlying erosions ranging
in size from 3 mm to 5 mm were seen in the antrum. GI
recommended increasing PPI to BID. Biopsies from EGD and
colonoscopy are normal. Etiology of lower GI bleed likely from
hemorrhoid. Anemia attributed to multifactorial, anemia of
chronic disease, anemia of kidney disease and LGIB. Patient is
on EPO with dialysis.
# RPGN: Found to have acute renal failure ___, diagnosed with
pauci-immune crescentic RPGN on biopsy ___. HD dependent MWF.
Renal followed and patient received dialysis. She started to
make more urine and the renal team felt that her kidneys are
starting to recover. They recommend having Dr. ___
___ at ___ check labs and determine the
need/schedule for dialysis while at rehab.
# R common femoral DVT: RLE U/S at ___ identified R
external iliac and R common femoral DVT. Warfarin for patients
DVT initially held iso bleed, but given clean colonoscopy, hep
gtt restarted with bridge to warfarin. She will need to continue
heparin bridge until therapeutic at rehab.
# Pneumonia: CXR from ___ at rehab showed possible RLL
pneumonia. Given adiographic findings and cough, pt was started
on HCAP therapy. Completed Vanc/cefepime on ___. Symptoms
resolved. Repeat CXR showed improvement of infiltrate.
# Granulomatosis with polyangiitis. Diagnosed in ___ after she
was found to have elevated ESR/CRP and was found to have
necrotizing small vessel vasculitis on renal biopsy ___. Of
note, MPO IgG antibody positive, ANCA positive. Vasculitis c/b
GN and left visual field deficits. Started on rituximab ___,
last dose ___. Discharged on prednisone 60 mg QD during last
admission, down-titrated to 40 mg QD on ___, decreased to 30mg
per nephrology recs. Continue Bactrim ppx. Added calcium 500mg
daily, vitamin D 800U daily, PPI per GI bleed above.
# Malnutrition: H/o of significant weight loss (70 lb from
___. Extensive work up during last admission was
unrevealing and weight loss was attributed to systemic
inflammation from GPA. Recent mammogram was unremarkable.
colonoscopy/EGD negative. Needs pap smear. Continued thiamine,
folic acid, MVA, B complex. Nepro TID.
# NSVT/pAfib: H/o NSVT and afib. CHADSVASC 4. On warfarin. Held
ASA 81 (started during last hospitalization in ___.
Continued home metoprolol.
# RLE/RUE Weakness: Chronic. H/o fall on right side. Weakness is
thought to be ___ mononeuritis monoplex neuropathy vs. myopathy.
# HTN:
- Increased amlodipine to 5 mg QHS
- Continued home metoprolol succinate 25 mg QD
- Continued losartan 25 mg QHS
# GERD:
- increased pantoprazole to 40mg BID
- Continued reglan 5 mg PO prn
# Depression:
- Continued home citalopram 10 mg QD
# Asthma:
- Continued home albuterol
# T2DM: A1c 5.3% ___. No standing insulin per ___
# Pain. ___ ___ ankle/feet neuropathy
- Continued home Tylenol ___ mg Q6H:PRN
- Continued home gabapentin 100 mg QD and 100 mg post-HD
# Constipation:
- Continued home bisacodyl, Colace, miralax, senna
# Insomnia
- Continued home trazodone 25 mg QHS
TRANSITIONAL ISSUES
=================
1. Recheck INR QD until therapeutic, then discontinue heparin
gtt.
2. Consider repeat colonoscopy in ___ years if within goals of
care for cancer screening.
3. Medication changes:
- Increase pantoprazole 40mg BID
- Increase amlodipine to 5mg QD
- Tapered prednisone dose to 30mg QD (further taper to be
determined)
- Added Vitamin D and calcium given long term prednisone use
- holding ASA 81mg (had been started in ___ for Afib)
4. Follow up ophthalmology for central scotoma
5. Repeat CBC to monitor leukocytosis, discharge WBC: 12.8,
discharge Hgb:9.0
6. Renal team recommends continued evaluation via labs by Dr.
___ at ___ to determine need/schedule for future
dialysis. On day of discharge, patient made >800cc urine.
7. ___
calTIBC Ferritn TRF
226* ___* 174*
8. Consider DEXA scan given long term steroid usage
9. Patient is usually hypoglycemic in the mornings, FSBG ___.
Resolves with juice. This is a chronic issue, please continue to
monitor.
#CODE: Full
#CONTACT: ___ (husband) ___ | 260 | 761 |
14893545-DS-13 | 24,979,225 | Dear ___,
___ was a pleasure taking care of you at the ___
___. After you came to the hospital with
weakness in your right arm, we performed several imaging studies
that showed a lesion in your right lung and in your neck near
your spinal cord, which may have been causing the weakness that
you were experiencing.
Biopsies of the lung lesion and the lesion in your neck were
consistent with lung cancer. The orthopedics team performed
surgery on your spine to keep it stable and we kept you on pain
and steroid medications and a neck brace. The radiation oncology
and hematology/oncology teams were working with us and would
like to follow-up with you after you leave the hospital.
An MRI of your ___ showed two small lesions and we would like
to perform another MRI scan in ___ weeks to see if there is any
change in these lesions.
Because of your history of blood clots, we gave you heparin to
thin your blood and then transitioned to oral Coumadin. Please
continue to take your Coumadin and have your INR checked after
you leave the hospital.
We did not give you your rheumatoid arthritis medications
because you were receiving a strong steroid medication. You
should talk to your out-patient doctors about when it is safe
for you to restart these medications (Etanercept and
Methotrexate).
During your hospitalization, we found that your ___ blood
count was elevated suggesting an infection and bacteria were
seen in your urine suggesting a urinary infection. We then
started you on ciprofloxacin, an antibiotic for a urinary tract
infection.
We continued your home oxybutynin for your incontinence.
We used senna, Colace, miralax, and lactulose for your
constipation, which was likely due to your strong pain
medications.
We continued your home amlodipine, metoprolol, and atorvastatin
for your cardiovascular disease.
Please follow up at your appointments listed below.
It was our pleasure taking care of you. We wish you the very
best.
Sincerely,
The ___ Team | ___ yo F with a history of rheumatoid arthritis on methotrexate,
recurrent DVT/PEs with Factor V Leiden mutation, breast CA
status post R mastectomy and chemotherapy in ___, who presented
on ___ with acute on chronic worsening R arm weakness.
# Metastatic lung adenocarcinoma/RUE Weakness:
Patient reported that for ___ months her right arm pain had
worsened and she described it as a "nerve pain" that radiated
from her neck down into her arm. She says it had progressed to
the point that now she is unable to actively move the arm since
___. Prior to the weakness, she had been treating the pain at a
pain ___ suspected degenerative disc disease with
narrowing seen on CT spine in ___.
CT cervical spine was ordered on ___ that showed a poorly
defined 2x3cm paravertebral soft tissue mass extending from
C5-C6 with possible extension into the foramen. CXR found a
right lower lobe density that was followed by a CT chest showing
a 6.4x6.7x5.0 cm RLL mass extending to the diaphragm and is
suspicious for malignancy. A hypoattenuating lesion on the dome
of the liver was also seen.
She underwent C5/C6 corpectomies with C4-C7 anterior spinal
fusion for tumor on ___ and C4-T1 posterior fusion on
___. Biopsies of the soft tissue over C5-C6 and the RLL
consolidation were notable for metastatic poorly differentiated
adenocarcinoma consistent with a lung origin. She received IV
dexamethasone at 10mg q6hours starting prior to her spine
surgery which was continued during her hospitalization and was
transitioned to 10mg q6hours PO and then tapered to 4mg q6hr PO
for 3 days (___), then dexamethasone 4mg q12hr
(___), with a continued planned taper: dexamethasone 2mg
q12hr (___), then dexamethasone 2mg daily (___),
and afterwards home prednisone 5mg daily.
She was placed in a soft ___ J collar while sleeping/in bed
and a hard ___ J collar otherwise, which should be used for 6
weeks. She also had a ___ MRI that showed two lesions which may
represent infarct versus early metastatic disease.
She was transferred to the medicine service on ___ in
stable condition. The hematology-oncology, radiation therapy,
orthopedics, and palliative care teams were following her during
her admission. Her pain was managed with IV morphine,
acetaminophen, and dilaudid 4mg q3hours.
# Factor V Leiden mutation: Anti-coagulation was initially held
in the setting of surgery. After surgery, she was started on a
heparin bridge to Coumadin and was discharged on Coumadin 3mg
daily with a target INR of 2.0-3.0.
# UTI: She had a leukocytosis and a urinalysis from ___ with
170+ WBC and a urine culture grew >100k E.coli sensitive to
ciprofloxacin. She initially received two doses of clindamycin
and was subsequently put on ciprofloxacin 500mg PO
(___). Her blood culture was negative and her
leukocytosis was attributed to her UTI and high dose steroids.
She remained afebrile during her hospitalization.
# Rheumatoid Arthritis: We held her home methotrexate,
etanercept, and prednisone given that she was receiving
dexamethasone and in anticipation of possible chemotherapy in
the future.
___ ISSUES
# Overactive bladder: We continued her home oxybutynin.
# H/o CVD: We continued her home amlodipine 2.5mg PO daily,
metoprolol succinate XL 50mg PO daily, and atorvastatin.
TRANSITIONAL ISSUES
- pt should f/u with urology as an out-patient for sacral nerve
stimulator removal given difficulty obtaining MRI imaging with
sacral nerve stimulator
-Pt needs repeat ___ MRI in ___ weeks given concerning lesions
seen on brain MRI
-please consider further out-patient f/u with palliative care
-Please monitor INR with goal INR of ___. Pls check next INR on
___. Last INR 2.6 on ___.
-Pt is normally on MTX and Etanercept for RA. Please discuss
with out-patient providers when to restart these medications
given possibility of chemotherapy. Please monitor for flare of
RA as these medications have been held during admission
-Tapering Decadron: decadron 4mg q12hr (___), then
decadron 2mg q12hr (___), then decadron 2mg daily
(___), and afterwards home prednisone 5mg daily
-Patient's former PCP ___ recently retired. Dr. ___
was notified of patient's new diagnosis and the pt has been in
communication with him. The pt will talk with his 3 former
providers and then choose a new primary care provider. His
office phone number is: ___. On discharge from rehab,
please ensure that pt has chosen a new PCP and has close PCP
follow up.
-___ discharge from rehab, pls ensure that pt's former PCP office
will continue to monitor her INR.
-Soft ___ J collar while sleeping/in bed and a hard ___ J
collar otherwise for 6 weeks.
-Follow-up appointment with Dr. ___ spine surgery)
-Follow up with Onc and XRT as an out-patient
# CODE STATUS: Full Code (yes to chest compressions, shock, and
intubation), but would not want to be kept on mechanical
ventilation for long term.
# Emergency Contact: HCP is ___ ___, ___
___ (son) ___, ___ (daughter) ___ | 322 | 798 |
19663491-DS-7 | 23,099,981 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for shortness of
breath and an episode of coughing up blood. You were first in
the intensive care unit and then transferred to the regular
floor. Imaging of your chest showed signs of infection. Cultures
of your sputum showed multiple bacteria and you were placed on
appropriate antibiotics. Subsequently, you had more coughing of
blood and were transferred back to the intensive care unit,
where a bronchoscopy showed bleeding in the lung. This was
treated by embolizing the bleeding blood vessel. Your bleeding
subsequently improved.
After discharge, please follow up with your usual medical
providers. You will also have additional specialist appointments
(see below). | Mr. ___ is a ___ year old man with a history of HIV (CD4 441
(23%), VL 13,000 ___, COPD with chronic bronchiectasis (on
home ___ NC), HCV, recent ___ esophagitis (EGD ___,
s/p 2 weeks fluconazole) and hx of IV opiate dependence (on
methadone 55 mg daily) who was admitted with one month of
hemoptysis and was found to have sputum positive for
Pneumocystis jirovecii and MRSA.
#Hemoptysis:
Had hemoptysis on admission causing Hct drop from 43 to 26. This
was likely secondary to bronchial artery bleed due to erosion
from MRSA pneumonia in the setting of longstanding
bronchiectasis. On ___ he had ~400cc of hemoptysis and was
re-transferred to the ICU. On ___ he had bronchoscopy showing
RLL bleeding, and ___ embolization of the right bronchial artery
was performed. His bleeding subsequently improved. His
hemoptysis was attributed to MRSA pneumonia in the setting of
chronic bronchiectasis.
# MRSA and PCP ___:
History of profound dyspnea on exertion, hemoptysis, and HIV
positive (CD4 400s). PJP positive and MRSA from sputum culture
on ___. He also had sparse Klebsiella from sputum that was
resistant to bactrim, but likely contaminant so specific
treatment was deferred. CT chest from ___ with extensive
progressive bronchiectasis also raises concern for
superinfection. Covered initially with vanc/unasyn/bactrim,
switched to bactrim only ___ after sputum showed MRSA sensitive
to bactrim. He had 3 negative AFB's to rule out TB, and MTB
probe was also negative. His antibiotics were subsequently
switched to atovaquone/doxycycline given concern for worsening
hyperkalemia on Bactrim. At time of discharge he was on baseline
O2 requirement of 3L with no further hemoptysis. Plan was made
to treat PJP for total 21 days and MRSA for total 14 days
(details below).
# HIV:
HIV viral laod 240 in ___, however he has had ___
infection since that time (___). CD4 441, viral load 13,100
copies/ml during this admission. He did endorse missing some
doses at home of his HAART. We continued Lopinavir-Ritonavir and
Emtricitabine-Tenofovir during this admission. Infectious
disease was consulted, with suspicion that he may have another
source of immunosuppresion given PJP and ___ despite CD4
count >400.
# Hyponatremia:
History of SIADH and hypovolemia. He had urine electrolytes
checked with Na of 112 consistent with SIADH, likely
attributable to acute lung process. Review of his medication
with pharmacy revealed that Lopinavir-Ritonavir may contribute
to SIADH; however, this is not a new medication. He was
initially given salt tabs and fluid restriction, which were
discontinued prior to discharge with stabilization of serum Na.
# Suspicion for adrenal insufficiency:
Random cortisol was low at 3.0. He had ACTH stimulation test
3.0->12.9->15.3, however baseline and ACTH-stimulated total
cortisol concentrations are lower in ill patients with
hypoproteinemia. Given controversy regarding interpretation of
ACTH stimulation in acute illness, may need further assessment
as an outpatient.
# Hyperkalemia:
Treated with kayexelate x1. This was thought secondary to high
dose Bactrim, and improved after high dose Bactrim was
discontinued.
# Constipation:
Gave aggressive bowel regimen with
bisacodyl/senna/docusate/miralax/lactulose prn.
# Weight loss: Infection vs malignancy. Mediastinal/hilar
lymphadenopathy seen on CT may represent a lymphoproliferative
disorder or Kaposi's sarcoma or reaction to infection. Consider
biopsy of hilar/mediastinal LN biopsy in future as below | 120 | 523 |
11042902-DS-18 | 21,584,308 | You were admitted to the hospital with abdominal pain and were
found to have perforated appendicitis. You were taken to the
Interventional Radiology and had some fluid drained from the
perforation. You were given IV antibiotics and bowel rest. You
tolerated the procedure well and your diet has been advanced and
are now being discharged home to continue your recovery with the
following instructions. You will need to complete the course of
antibiotics, and follow up in clinic to discuss an interval
appendectomy once the swelling and inflammation around your
appendix subsides.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications. | Ms. ___ was admitted for perforated appendicitis. She was
placed on IV cipro/flagyl and underwent ___ guided aspiration of
the fluid around the appendix. They aspirated 1cc of fluid, sent
for culture and came back as rare growth of gram positive cocci.
She remained afebrile, and by HD 2 her abdominal pain was
completely resolved. She was advanced to a regular diet on HD2
which she tolerated well. Her antibiotics were switched to oral
without any issues and she was discharged on oral cipro/flagyl
to complete a 14-day course. She was tolerating a regular diet,
in no abdominal pain, and stable for discharge on ___. | 312 | 106 |
18459379-DS-9 | 26,578,727 | .
You were admitted with a syndrome of nearly complete right
facial droop, mild left-sided facial weakness, left-sided
radiculopathy (most prominently in C7 distribution), meningitis,
tachycardia and leukocytosi. Although the infectious disease
titers are still pending at this point, we believe that your
presentation is most consistent with neuroborreliosis (i.e.,
Lyme disease affecting the nervous system). We started you on
antibiotics for this condition; initially, you received
doxycycline, and then you were switched to ceftriaxone after
undergoing a desensitization protocol. You had no reaction to
this desensitization, which means that you are not allergic to
ceftriaxone.
At this point, we are still waiting for microbiology results
from the tests for Lyme disease as well as for other infections
that are sometimes transmitted by the same ticks (babesiosis and
anaplasmosis). These results will be reviewed at your follow-up
appointment in neurology.
We checked an EKG and cardiac enzymes to rule out Lyme carditis,
and both these tests were normal.
You will need to complete your 2-week course of ceftriaxone for
Lyme disease, as well as the 9-day steroid taper for facial
palsy. | Ms ___ is a ___ year old previously healthy right handed woman
who presented to the ED on ___ for acute right sided facial
droop in the setting of 10 days of neck pain/stiffness. A code
stroke was called, NIHSS was 2 for R facial paralysis involving
both upper and lower face. CT head was negative. CTA of head and
neck was performed to r/o dissection in the setting of neck
pain, there was an incidental finding of a "focal narrowing of
the left vertebral artery at the C4 level" which is not likely
to be related to her current presentation. The patient's vitals
were wnl except for tachycardia to the 110's. Labs revealed an
elevated WBC of 18.2. No TPA was given as her presentation was
not consistent with stroke. The patient was admitted to
neurology for workup.
.
On the floor an LP was obtained which showed: WBC-32, RBC-1,
polys-18, lymphs-58, monos-14, macroph-2 and other-8. Gram stain
was negative. Cytology and Lyme serology was sent which and is
pending at discharge. HSV CSF was negative.
.
Patient's presentation was most consistent with neuroborreliosis
given significant right and mild left facial weakness,
multifocal radiculopathy (Left C4, C7, C8 vs T1, right L5), and
question of mild myelitis. Pt was started on empiric IV
Doxycyclin.
.
ID consult was called on ___ (HD2) because the patient had
persistent tachycardia (110-120), and a rising leukocytosis to
25.2. ID recs included switching the patient to ceftriaxone via
a desensitization protocol given her history of allergy to
penicillins. For this protocol the patient was transferred to
the CCU on HD3 (___). Desensitization was uneventful and the
patient was transferred back to the floor, Doxy was DCed, Pt was
continued on Ceftriaxone. Per ID recs HIV test was also sent
which was negative.
.
Patient was started on a 9 day taper of prednisone on ___
for facial palsy.
On HD4 (___) Pt's leukocytosis was resolving (11.9). PICC
line was placed without event. | 177 | 328 |
10946421-DS-13 | 24,266,393 | Dear Ms. ___,
You came into the hospital because you were having severe
abdominal pain. We found that you had inflammation of your
pancreas called pancreatitis. We treated you with IV fluids and
your pain improved. You will need to follow up with Dr. ___
(___) to ensure that the pancreatitis has fully
resolved. You were found to have severe iron deficiency anemia
without evidence of active bleeding. We gave you IV iron therapy
and you will need outpatient endoscopy and and colonoscopy to
complete evaluation. We also treated you for a possible
pneumonia. You continued to need O2 despite Lasix for pleural
effusion, so a CT scan chest was done which showed persistent
lung opacity (mass) and fluid in the chest cavity. You will need
repeat chest imaging to whether it has resolved or whether it
remains and further workup is needed to rule out cancer. You
were given a diuretic to assist in removing fluid off the lungs
and you were placed on oxygen and will need to use it
consistently. | Ms. ___ is a ___ female with a past medical history of
HTN, hypothyroidism, and recent compression fracture, who
presented with abdominal pain. | 175 | 23 |
17460070-DS-48 | 22,374,592 | Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you had acute onset back pain. Reassuringly we
did not find any new fractures or spinal cord compression. Your
were treated for your pain, underwent radiation therapy, and
chemotherapy for your multiple myeloma. You also recieved a new
spine brace which you should wear when ambulating. As we
discussed you should no longer drive as this ___ be dangerous to
both you and the public. Wishing you a speedy recovery!
All the best,
The ___ Team | # Back Pain: Patient with chronic back pain and recent admission
for similar complaints. Missed radiation treatment ___ because
of pain. Initial concern for pathologic fracture given acute
onset of intense pain and patient's risk for fractures without
trauma. Spine xrays ___ revealed stable disease process,
possible increase in T12 compression fracture. Completed course
of radiation (5 treatments to T12 spine, ___ hip and left
humerus) Ortho/spine did not reccommend surgical intervention at
this time as pain is improving and he is able to receive
radiation. Should pain worsen and his clinical status further
decompensates, surgical intervention via kyphoplasty is an
option. Was initially controlled with IV Dilaudid 2mg q2h and
then gradually tapered down to his home regimen. He was started
on a dexamethasone taper with 10mg IV one time dose and then 4mg
by mouth twice daily to taper over the next week. Home
medications including oxycontin, oxycodone, tizanidine and
gabapentin were continued throughout admission.
#BRBPR: Patient with an episode of bright red blood per rectum.
He remained hemodynamically stable with SBP in the 130-140s HR
___, and was asymptomatic. Has reported this happened in the
past and that he has both internal and external hemorrhoids that
bleed occasionally. On rectal exam, a large external hemorrhoid
was noted with small amount of rectal prolapse, no active
bleeding at this time. H/H stable. He did not have any more
acute bleeding events. He was advised to follow-up with
colorectal surgery as an outpatient r/t bleeding hemorrhoids and
rectal prolapse
#Left humeral fracture: On previous admission, left upper
extremity swelling on XRay revealed a lytic lesion with
pathologic fracture at the proximal humerus. Received full
course of 5 radiation treatments. Hard brace was maintained by
orthopedics who did not recommend surgical options at this time.
# Hx of UTI: enterococcus sensitive to macrobid from previous
admission. During this admission was treated for one more day of
antibiotics to complete a 7 day course for complicated UTI. UA
clear. Repeat culture with <10,000CFU. Completed 7day course of
Macrobid.
# Multiple Myeloma: Was started on Velcade during previous
admission. Had two previous doses on ___ and ___, now with
dose ___ and ___. Also with lesions to left humerus, and
spine (T12) and missed radiation appointment ___. As per
above, completed 5 total treatments to L arm, R hip andT12 spine | 91 | 388 |
10191316-DS-10 | 22,285,904 | Dear Mr. ___,
You came into the hospital with chest pain and to get a biopsy
of your chest mass.
During your stay, you had a biopsy of the chest mass as well as
an ultrasound of your liver. It may take several days for the
results of the biopsy and imaging studies to come back. You have
a doctors ___ on ___ at 4 pm to discuss these
results.
Please keep your appointments. It was a pleasure caring for you
at ___.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ M with PMH of HTN who presents with
2 days of substernal chest pain in the setting of a newly
identified large anterior mediastinal mass on ___, admitted for
expedited workup of mass: | 90 | 39 |
14234424-DS-11 | 20,645,480 | You were admitted for work up of nausea, vomiting, and diarrhea.
This was likely due to a viral gastroenteritis for which your
symptoms resolved and your diet was successfully advanced. You
stool studies were negative and your antibiotics were
discontinued.
While you were here, your colorectal surgical team recommended
placing a port a cath which was cancelled on ___. Please call
Dr. ___ ___ to see when this can be rescheduled.
You also had new shortness of breath and a Chest Xray revealed
pulmonary edema. This improved with Lasix, restarting your blood
pressure medications. Please be sure to have your labs (chem 10)
rechecked next week. You should discuss with your primary care
and/or oncology team whether you will need an echo to evaluate
your heart function. | Ms. ___ is a ___ female with a PMH notable for
sigmoid colon cancer s/p resection and chemotherapy and recently
diagnosed recurrent metastatic disease who presented with acute
onset diarrhea, vomiting, and fever, now resolved, course c/b
acute pulmonary edema, now resolved. | 125 | 38 |
15885972-DS-11 | 25,880,843 | Dear Ms. ___,
You were admitted to the ___
for GI bleeding from your stoma and a fever, which you reported
at home.
While you were here Interventional Radiology exchanged your
biliary drain due to your report of decreased output. They also
placed 2 new drains since your bilirubin continued to be
elevated. Once your bilirubin began to come down, the ___ team
placed 3 internal metal stents and capped the tubes of your
drains. You should follow up with ___ on ___.
If you experience any fevers or pain, please uncap your tubes,
use bags, and call ___ at ___ or page them at
___, pager number ___.
It was also noted that your stoma had some bleeding and mucosal
irritation. Your bleeding was initially controlled and blood
counts remained stable. However, you began to have a lot of
bleeding through your stoma. You were transferred to the ICU for
stabilization and seen by ___. You were found to have several
engorged blood vessels around your stoma, mostly likely due to
increased pressures from your liver. A shunt was placed to help
relieve that pressure. After the shunt was placed, the bleeding
from your stoma stopped.
During a drain placement procedure, ___ took a sample of the mass
in your bile system. It was found to be positive for
cholangiocarcinoma. Please follow up with your oncologist as an
outpatient for treatment options.
After one of the ___ procedures, you became acutely worse and
were taken to the Intensive Care Unit. While there, a some bile
was taken from your drain and sent for testing. It was found to
be infected with bacteria and you were started on antibiotics.
Please continue to take the antibiotics until ___.
You also underwent an EGD with GI this admission. They found
that you had a duodenal bulb ulcer and some gastritis. We tested
you for H. pylori, which was positive, and thus you were started
on medications for treatment of this H. pylori infection. You
should continue to take these medications until ___.
Please continue to take all of your medications as prescribed.
Do not take any NSAIDs, as these may cause worsening of your
stomach bleeding.
We wish you the best,
Your ___ Care Team | Ms. ___ is a ___ with a PMHx notable for UC s/p total
colectomy, s/p cholecystectomy, and hilar cholangiocarcinoma
(not on therapy, CT/MRI negative from 2 months ago) who
presented with new bleeding and clots from her ostomy site, and
rising Bilirubin, elevated from her baseline.
# GI Bleed:
Patient noted blood at her ostomy site with clots. This bleeding
was new for her. She continued to have clots and episodes of
bleeding during her admission. These clots and episodes of
bleeding were a change from her usual stomal irritation, and she
reported that she has never had problems with her stoma bleeding
before. For her bleeding, GI was consulted, and did an EGD on
___, which found a duodenal bulb ulcer and gastritis. It was
originally thought that the ulcer explained her bleeding.
However, patient had frank hemorrhage of bright red blood from
her stoma. She was found to have stomal varicose and a
parastomal hernia. ___ placed a mesocaval shunt. Afterwards,
patient with only minimal blood (~2 cc) and clots through stoma.
#Hypotension:
After the mesocaval shunt placement, patient's systolic blood
pressures remained in the ___ 100s with some dips to the
high 80's without symptoms. She was given a trial of midodrine
to improve pressures with no effect so the medication was
discontinued. She was given intermittent boluses of IVFs for
systolic pressures in the ___.
# Hyperbilirubinemia:
Her bilirubin was found to be elevated above baseline, and on
admission she reported decreased drain output and cloudiness of
output over the past few days prior to admission. She has a
history of recurrent biliary drain obstruction. ___ did several
PTBD exchanges and placed 2 new drains. When her bilirubin began
to slowly come down, ___ placed 3 internal stents and capped her
drain. She will follow up with them on ___ for drain removal.
#Cholangitis:
Upon admission, patient reported fever to 101.8 on ___. At the
time she did not have a leukocytosis and had been afebrile since
admission. She received zosyn in the ED and one dose of
meropenem for possible infection, however these were
discontinued and she was monitored for fevers. However, after an
___ procedure with new drain placement, patient because acutely
ill with hypotension, increased abdominal pain, hypoxia, and
transferred to the ICU. During her ICU admission, bile cultures
were sent and grew ESBL E. coli and enterococcus. She was
started on meropenem for a 10 day course. ID was consulted about
the enterococcus growth given her history of VRE. The ID team
felt that since she was clinically stable without enterococcus
coverage, she is likely an enterococcus colonizer and there was
no need to broaden her antibiotic coverage. She was switched to
ertapenem for continued treatment as an outpatient until ___.
# Hilar Cholangiocarcinoma:
Patient was diagnosed with stage IIIa cholangiocarcinoma s/p
resection (___) c/b perihepatic abscess (___) and
persistent cholangitis s/p PTBD. No active chemotherapy at this
point. She stated that her recent abd CT/MRI as an outpatient
were negative. However, during an ___ PTBD revision, brushings
were taken which were cytology positive for cholangiocarcinoma.
She should follow up with her oncologist as an outpatient.
#Duodenal Bulb Ulcer/Gastritis:
During EGD on ___, a duodenal bulb ulcer and gastritis were
seen. H. pylori studies were ordered, and her blood antibody
test was positive, stool antigen negative. She was started on
triple therapy. Her home omeprazole was switched to IV while she
was in the hospital, and switched to pantoprazole PO prior to
discharge.
#Thrombocytopenia:
On routine labs she was noted to have a new thrombocytopenia,
which was not present on admission. She did not receive any
heparin so HIT was unlikely. It was thought that her
thrombocytopenia could be secondary to her bleeding vs.
initiation of IV PPI or other drug side effect. Her platelets
were trended and she was monitored for signs of bleeding. Her IV
PPI was switched back to PO, as she had been regularly taking it
at home. She had a normal fibrinogen and her blood smear was
normal.
# Abdominal Pain:
Per the patient's report on admission, her pain had lead to
decreased PO intake and weight loss. She reported pain hours
after eating. ___ exchanged her biliary drain and placed 2 new
ones. She also had a brushings of her biliary system which was
cytology positive for cholangiocarcinoma. She should follow up
with her oncologist, as above. GI also found a duodenal ulcer,
which likely contributed to her postprandial pain. It is likely
that her ulcer is related to H. pylori and she was started on
triple therapy. She was also started on simethicone as needed
for gas and crampy abdominal pain.
# Dysuria:
New complaint morning of ___. UA on admission was negative.
Repeat UA negative, and culture were negative. Her dysuria
resolved without treatment.
# DM2:
She was taking 10mg po glipizide at home, which was held on
admission. Her fasting blood sugars were monitored and she was
placed on SSI prn.
#Anxiety:
Patient noted increased anxiety during admission, but reluctance
to take her home clonazepam due to medication side effects. Her
dose was reduced from 0.5mg to 0.25mg qHS PRN. Patient
experienced some relief with the new dose but continued to
exhibit reluctance to take the medication. However, her anxiety
level increased after her second ICU admission and she her dose
was changed to 0.25-0.5mg BID PRN. She was also started on
seroquel 25mg qHS to help with insomnia caused by her anxiety.
However, she did not like how drowsy she felt after taking it
once and decline further doses. | 370 | 923 |
15463686-DS-17 | 28,906,356 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
You were here because you were having diarrhea and increased
output around your j tube site. While you were here, the
interventional radiologists were able to change this tube. You
were also seen by wound care who helped to give you instructions
on how best to care for your site. You were seen by nutrition
who recommended increasing the amount of time and the rate of
your tube feeds to get the nutrition you need.
When you go home, it is important you take your medications as
prescribed. You should also attend your follow-up appointments
as listed below.
If you have any fevers, chills, worsening nausea, vomiting, or
severe diarrhea, please call your oncologist.
We wish you the best of luck!
Your ___ Care Team | Mr. ___ is a ___ male with HTN, HLD, T2DM,
iron deficiency anemia, and metastatic esophageal adenocarcinoma
s/p MIE complicated postoperative dysphagia requiring J-tube
feedings currently on ___ who is admitted from the ED with
diarrhea and increasing drainage from his J-tube site. This was
upsized by ___ while in house. His diarrhea improved while tube
feeds were held and these were slowing increased while in house.
# Diarrhea
# Low grade temperature
Initially presented with a low grade fever of 100.1 as an
outpatient, though remained afebrile while here. C.diff and
stool cultures remained negative.
Symptomatically improved while holding Tube feeds. Seems most
likely the diarrhea was ___ to chemotherapy and contrast, though
could have been limited viral gastroenteritis. His bowel
movements slowed down while tube feeds were held. After
restarting his tube feeds, he did have several BMs, though were
better formed than before. He was given PRN immodium to help
with this.
# J-Tube leakage
# Abdominal rash
Followed by Dr. ___ as outpatient. J-tube was upsized by
___ while in house and output decreased. He did have skin
irritation from the output, but did not seem consistent with
cellulitis, more consistent with ___ infection. He was seen
by wound care who recommended cleansing and antifungal cream.
# Hypokalemia
# Hypophosphatemia
# Hypomagenesemia
Required frequent replacements while in house. Was give
potassium phosphate on discharge. This should continued to be
monitored
# Anemia in malignancy
# Thrombocytopenia
Pt with known thalassemia trait. Most likely anemia due to
malignancy. Seems to be stable w/ Hg ___. Did require two
transfusions while in house due to slow downtrend. Last one on
___. CBC was stable at discharge
# T8 Compression fracture
-Noted on CT ___, remained with minimal symptoms while in
house
# Right bladder wall nodularity
Noted on CT from ___, needs a bladder ultrasound to further
characterize this.
# GERD
Continue on home ompeprazole
# DMII
- Diet controlled; not on meds
TRANSITIONAL ISSUES
=======================
[] Patient was instructed by nutrition how to uptitrate the rate
and cycle time of his tube feeds. He will need ongoing
monitoring for this to ensure he is meeting his caloric needs/
[] Patient required frequent replacement of potassium,
phosphate, and magnesium while in house. Would check chem 10 in
1 week
[] Right bladder wall nodularity noted on CT from ___, needs a
bladder ultrasound to further characterize this.
[] Would continue to monitor skin around J tube site to ensure
it continues to heal and does not develop cellulitis | 134 | 394 |
19624478-DS-14 | 23,223,272 | Ms. ___, you were admitted to the hospital with bleeding from
your gastrointestinal tract. An area of bleeding in your colon
was identified on CAT scan but stopped bleeding on its own
during an angiogram procedure, so no intervention was performed.
Your blood count was stable after transfusion of three units of
red blood cells. We have held your plavix and are now giving you
one baby aspirin daily.
Of note, you were also found to have Clostridium Dificille
colitis, which you have had in the past. We are treating you
with three weeks of an oral antibiotic, vancomycin, which you
should complete as directed as an outpatient. | Ms. ___ is an ___ w/ Hx of GIB in ___ without identified
source, suspected ___ diverticulosis, Hx of diverticulitis s/p
partial colectomy, Hx of esophagitis, CAD s/p DES in ___ on
plavix, HTN, Hx of TIA, Hx of C. diff x2 (___) who presented
with 4 episodes of BRBPR and active extravasation from a vessel
in the hepatic flexure seen on CTA. Mesenteric angiography was
performed which revealed no ongoing contrast extravasation. She
spent < 1 day of observation in the MICU and after three blood
transfusions, her HCT was stable at 33. Given her ongoing
diarrhea and abdominal pain, a C. Diff PCR test was sent which
was positive. She was therefore started on a course of PO
vancomycin to complete as an outpatient.
Active Issues
# Acute blood loss anemia:
# Lower GI Bleeding:
She has a history of GIB without clear source identified,
possibly ___ diverticulosis given blood with clots visualized in
colon on last colonoscopy. Patient also with history of
esophagitis on EGD, though currently low suspicion for upper GI
contribution to bleed given no melena, and pt has been on PPI.
CTA in ED showed active extravasation into hepatic flexure of
colon. GI evaluated patient in ED and recommended ___ evaluation.
She was admitted to the MICU where she was hemodynamically
stable but had continued rectal bleeding and maroon stool. She
underwent mesenteric angiogram with ___ where no extravasation
was seen. After angiogram, she had no bleeding and GI offered
colonoscopy but she declined. She was transfused 3 u pRBC to
keep HCT>30. Her HCT remained stable around 33 after leaving the
MICU. She had no further episodes of bleeding from her rectum.
In discussion with her cardiologist, her plavix was held during
hospitalization and she was restarted on aspirin.
# Diarrhea: (C. Diff)
She presented with 2 days of diarrhea and crampy abdominal pain
preceding her GIB, no recent hospitalizatons and no recent
antibiotics. However, patient with history of C diff colitis x2
in ___, treated with flagyl both times. Had mesenteric
stranding in her colon on CT concerning for possible early
diverticulitis. She had no fevers. Diverticulits was considered
as a source for her symptoms, and she has a history of this
requiring a partial colectomy in the past, but it would be
unusual for diverticulitis to also present with a bleed. C. Diff
PCR assay from her stool was sent and came back positive. She
was therefore initiated on a three week course of Oral vancomyin
125 mg q6H for third recurrence of mild C. Diff infection. Her
PCP ___ be instructed to perform a vancomycin taper if loose
stools persist.
# Coronary Artery Disease
Currently no Signs or symptoms of ischemia, ECG with prolonged
QTc, which is new, and ST depressions in I and aVL, and biphasic
T waves in V3-V6, all of which are old. She had a DES in ___
and was supposed to be on ASA/clopidogrel but has only been
taking clopidogrel. Home metoprolol and atorvastatin were
initially held but subsequently restarted once stable. Per
discussion with her outpatient cardiologist, Dr. ___,
___ was stopped. She had received this medication for
almost a full year, since last ___, so this medication was
permanently stopped and she was discharged on a baby aspirin.
Chronic Issues
# Hypertension: Initially held home amlodipine in the setting of
active bleed. Restarted on floor.
# Depression/anxiety: Initially held home paroxetine, trazodone,
and clonazepam. Restarted on floor.
# Hypothyroidism: Held home Levothyroxine while NPO, restarted
once tolerating full diet.
# Osteoarthritis: cont'd home acetaminophen, oxycodone. | 112 | 594 |
15467188-DS-22 | 29,779,665 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for bleeding in your gut
What was done for me while I was in the hospital?
- You had procedures done to look for a source of bleeding in
your stomach and your colon. Ultimately, the bleeding was
thought to be from your stomach.
- Your medications were adjusted.
- You received hemodialysis on ___
What should I do when I leave the hospital?
- Please take your ciprofloxacin 500mg every day and take it
after HD on days when you have HD
- Continue to take your medications as prescribed (see below).
- Be sure to make it to your follow up appointments (see below).
Sincerely,
Your ___ Care Team | ___ with PMHx notable for HFpEF, ESRD on HD on TTrSa, LUE AV
graft), NASH/EtOH cirrhosis c/b esophageal varices (Childs A,
GAVE, G1 EV), EtOH use disorder, Hx of CVA, HTN, DM2, HLD who
presented to the ED on ___ with hypotension (60s/30s) and
bright red blood per rectum from HD center and acute on chronic
anemia c/f GI bleeding. EGD on ___ notable for multiple
erosions with stigmata of recent bleeding in antrum, without
esophageal or gastric varices. Non bleeding polyps in the
duodenal bulb, benign appearing, were also noted. ___ on ___
notable for 2 inflammatory polyps (TI and sigmoid) and
diverticulosis. His ESRD is also contributing to his chronic
anemia. He remained hemodynamically stable and discharge with
plan for outpatient sigmoidoscopy and possible capsule study. | 140 | 129 |
11109718-DS-21 | 21,833,293 | Dear Mr. ___
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for an exacerbation of your lower back pain
and lower leg pain.
What was done for me while I was in the hospital?
- - We worked with a team of health care providers, including
pain specialists, psychiatry, and podiatry, to treat your pain.
- We gave you medications to treat your nerve pain, including a
new medication called gabapentin.
- You were seen by pain specialists who recommended outpatient
___ to consider a spinal nerve stimulator to improve your
pain.
- We offered you information to contact patient resources at
___ given your concerns about management of your pain and
medications while you were here.
What should I do when I leave the hospital?
- Please continue to keep all of your appointments and take all
of your medications.
We wish you the best of luck!
Sincerely,
Your ___ Care Team | This is a ___ year old male with past medical history of
rheumatoid arthritis, spinal stenosis, chronic back pain,
peripheral neuropathy, HCV s/p Harvoni, ITP, DVT on rivaroxaban,
recent termination of narcotics contract being maintained on
weekly opiate prescriptions via his HCA PCP, admitted ___
with worsening pain and suicidal ideation after running out of
home morphine supply, restarted on home regimen, cleared by
psychiatry, ___ recommending rehab
# Lower back pain
# Peripheral neuropathy
Patient presented with chronic worsening of back pain,
punctuated by acute worsening after he missing a PCP
appointment, potentially ___ his medications, and
ran out of morphine. Per discussion with PCP, recent outpatient
care had been focused on non-opiate methods of pain control and
avoiding escalation of his opiate regimen, with his case
previously referred to narcotics committee. In consultation with
his PCP, no additional diagnostic testing for his pain was
pursued, and we focused on optimizing his pain regimen. Changed
morphine SR from 45 mg PO q12h to 30 mg POq8h (same total daily
dose). Continued home morphine sulfate ___ 15 mg PO q4h:PRN.
Added acetaminophen 1000 mg q8h, uptitrated gabapentin to 400 mg
TID. We also continued his home topical ointments for his lower
extremity neuropathy as well as lidocaine patches for both lower
extremities. Pain improved. At PCP suggestion he was seen by
chronic pain service, who suggested outpatient evaluation
regarding candidacy for an implantable spine electrical
stimulator. He was seen by ___ who recommended rehab. He was
discharged with followup pain appt. Continued home bowel regimen
with Senna PRN.
# CHRONIC VENOUS STASIS
# BILATERAL LEG ULCERS
# B/L TOE ULCERS
Presented with open ulcerations and discoloration of the ___
bilaterally, consistent with chronic venous stasis without
drainage or surrounding erythema or warmth. We placed a wound
care consult and were also in touch with his ___ podiatrist,
Dr. ___ recommended inpatient podiatry evaluation. He
was seen by podiatry, who recommended no surgical intervention
and suggested local wound care and off-loading in a waffle boot.
For wound care, podiatry recommended continuing adaptic to the
ankle wound and adaptic/betadine to the heel wound. Wound care
was continued per wound care nurses. ___ also continued his home
Lasix 80 mg daily and home topical agents for the lower
extremities.
# PSYCHOSOCIAL
# HOME SUPPORTS
Lives at home. Collateral concern for poor self care recently.
Sister also concerned given recurrent falls. Likely mechanical
as significant pain w/o medications and use of bilateral canes
w/poor stability. Patient with concern for de-conditioning and
impaired mobility, with a reported recent fall at home. As
above, he was seen by physical therapy and occupational therapy,
who recommended discharge to rehab facility.
# Depression
# Suicidal ideation
# PTSD
# ADHD
# Generalized ANXIETY Disorder
Expressed SI to ED providers in the setting of acute pain. On
arrival to the floor, he denied wish to harm himself and
explained that prior statements were in the setting of his acute
pain. Psychiatry was consulted who felt patient was safe, did
not require inpatient psychiatric care. Continued on his home
amphetamine-dextroamphetamine 60mg PO BID and oxazepam 30 mg PO
QID:PRN. He also appreciated support from our hospital
chaplaincy. He expressed interest in outpatient therapy with a
psychologist.
# Behavioral issues
His course was complicated by labile mood and frequent
frustration, primarily related to management of his home pain
and anxiety medications, particularly as we worked to clarify
and resume his outpatient regimen. Team set expectations with
patient re: team's role, our joint goals to help him improve,
and the importance of mutual respect.
# Chronic lower extremity DVT
Continued home xarelto 20 mg daily
# RHEUMATOID ARTHRITIS:
Patient has been holding Enbrel ~3 mo due to concern that it may
be worsening his chronic wounds and infection risk. Given
possible contribution of RA to his pain symptoms, would consider
coordination between podiatry and rheumatology as outpatient to
determine ideal approace.
TRANSITIONAL ISSUES:
======================
- Discharged to rehab
[ ] CXR had incidental finding of possible new 4 mm right upper
lobe pulmonary opacity was seen on ___ CXR; radiology
recommended non-urgent non-contrast chest CT for further
evaluation.
[ ] He has outpatient psychiatry ___ scheduled for ___,
@ 2:30pm with his psychiatrist, Dr. ___.
[ ] He is scheduled for ___ with Dr. ___ on
___ at 8:10am at One ___, ___, ___
floor in the pain management ___ evaluation for spine
stimulation.
[ ] He will need ___ in ___ clinic with Dr. ___
___ at ___ in 1 week
[ ] Patient would strongly prefer to be connected with
PSYCHOLOGIST and a PHYSIATRIST. Primary team is contacting his
PCPs as well to suggest this referral
> 30 minutes spent on this discharge | 175 | 773 |
19712781-DS-9 | 28,904,191 | Dear Ms. ___,
It was a pleasure caring for you on your recent admission to
___. You were admitted to the hospital because you had pain
and swelling in your right hand after having injured and cut
your hand on a glass window. In addition you were also bitten
in the hand by a dog that had not been vaccinated. An x-ray of
your hand showed that there were no broken bones. While you were
hospitalized you received antibiotics to prevent an infection in
your hand and you also received a vaccine and immunoglobulin to
try to prevent rabies. You were also instructed on how to soak
your wounds 3 times per day. You were given a thumb splint and
should wear it until your appointment with the hand clinic next
week.
We also treated the ulcers on your legs. Continue to take your
furosemide (water pill) to help prevent fluid accumulation in
your legs. Please follow up with your wound care clinic for
continued management of these ulcers.
Dear Ms. ___,
It was a pleasure caring for you on your recent admission to
___. You were admitted to the hospital because you had pain
and swelling in your right hand after having injured and cut
your hand on a glass window. In addition you were also bitten
in the hand by a dog that had not been vaccinated. An x-ray of
your hand showed that there were no broken bones. While you were
hospitalized you received antibiotics to prevent an infection in
your hand and you also received a vaccine and immunoglobulin to
try to prevent rabies. You were also instructed on how to clean
and care for your wounds. You were given a thumb splint and
should wear it until your appointment with the hand clinic next
week.
We also treated the ulcers on your legs. Continue to take your
furosemide (water pill) to help prevent fluid accumulation in
your legs. Please follow up with your wound care clinic for
continued management of these ulcers.
You should also receive 2 more Rabies vaccines, one on ___
and a second one on ___. Please call the ___ clinic to
schedule these appointments ___. Otherwise, you can
go to your local emergency department.
You may also schedule an appointment with Vascular @ ___ for evaluation of your varicose veins.
Your medications changes include:
Augmentin 825mg Q12H for 4 days to prevent wound infection
Oxycodone 5mg Q6H PRN for pain
Please see wound care recommendations below:
For your leg ulcers:
Apply Commercial wound cleanser to irrigate/cleanse all open
wounds.
Pat the tissue dry with dry gauze. Apply moisture barrier
ointment to the periwound tissue with each dressing change.
Apply Aquacel AG to all open wounds (silver ion dressing). Cover
with dry gauze, Sofsorb sponge, Kling wrap. Change dressing
daily.
Wound Care for your hands:
Please soak your hand wound in betadine and warm water soaks
three times per day.
Apply Spiral Ace Wraps to B/L ___ from just above toes to just
below knees before patient gets OOB or after elevating ___ for
30 minutes.
Remove Ace Wraps at bedtime. | Ms. ___ is a ___ WF with a PMH of drug abuse, venous stasis
ulcer who presents with right hand swelling after sustaining a
laceration further complicated by a dog bite to the same hand.
#Hand laceration: Pt apparently punched her right hand through a
glass window 1 day PTA. She was subsequently bitten by her
non-immunized dog at a different site on the same hand. She
then noticed increased pain and swelling which brought her to
medical attention. An x-ray of her hand showed no fracture or
retained foreign body. Due to concern for possible infection
due to increased pain, erythema, and swelling she was put on
unasyn 3g Q6H for polymicrobial coverage from bite wound and was
transitioned to Augmentin. Hand wound was managed by plastic
surgery who recommend OT consult for a custom orthoplast thumb
SPICA splint which the patient received. She was instructed on
TID hand soaks with ___ strength betadine and warm water for
20min daily. Dressing changes daily with non-adherant dressing,
vasoline gauze, and kerlix. She was also instructed keep arm
held above head to minimize bleeding.
#Dog Bite Wound: Please see above. Pt has received 2 dose of
rabies vaccine in the hospital as well as rabies Ig. She will
need rabies vaccine (___ or PCECV) 1mL IM tomorrow then again
on ___ and ___ as an outpatient. Pt was referred to
___ and if can't make it there to go to local ED to get
rabies vaccine.
#Venous stasis ulcers: Chronic medical problem that is active
due to significant wounds present on both shins. Pt states that
she has had MRSA in the past and thought the uclers were
infected. However ulcer don't appear to be infected. Wound care
nurse for ulcer care and pt was instructed to elevate ___ while
sitting.
#Anxiety and Depression: Chronic problem that is stable on
buspar, paxil, and klonopin.
#H/O Opiod abuse. She was given methadone 35mg PO Daily.
#Alcohol Abuse: Pt has a history of significant alcohol abuse.
She was placed on withdrawal precautions (CIWA protcol, given
diazepam if CIWA>10) but did not show signs of withdrawal. | 515 | 354 |
16901210-DS-5 | 23,744,268 | Mr. ___,
You presented to ___
due to increased size of your abdomen and nausea. It was found
that you have a condition called cirrhosis which is scarring of
your liver. This is a severe condition that can continue to
worsen over time. The good news is that during this
hospitalization you were started on a number of medications that
should stabilize your disease. These medications may need to be
adjusted in the coming weeks and months and it is extremely
important that you keep all appointments with your primary care
doctor and liver team.
Furthermore, it will be important to limit your salt intake to 2
grams daily, and no more than ___ milliliters (2 liters) of
fluid intake daily. Most importantly, taking all of your
medications daily and completely abstaining from alcohol will
help stabilize your liver disease. Please weigh yourself daily,
and if you gain more than 3 pounds after discharge then
immediately contact your doctor.
Due to your history of blood clots you were switched to a new
blood thinner called Dabigatran.
It has been a pleasure caring for you here at ___, and we wish
you all the best.
Kind regards,
Your ___ Team | ___ y/o M hx of PE and DVT, dual Protein C and Antithrombin
deficiency on Rivaroxaban who presented to the ER for worsening
abdominal distension, ___ edema, and nausea likely ___ cirrhosis
___ C, MELD of 15 on ___ likely ___ combination
of alcohol use and autoimmune hepatitis.
Cirrhosis and Transaminitis:
Patient's new onset cirrhosis and transaminitis was initially
felt to be due to alcohol abuse and likely portal vein
thrombosis seen on ultrasound. On CT abdomen w/contrast, no
evidence of HCC or portal vein thrombosis. Labs showed ___ titer
of 1:80, ___ titer of 1:40, and elevated IgG. These findings
may support autoimmune hepatitis, particularly in the context of
negative antibodies for viral hepatitis. As per the ___,
diagnosis of autoimmune hepatitis requires clinical signs and
symptoms and lab abnormalities that are consistent including
cirrhosis, elevated IgG levels, ___ and ___, and ___
kidney ___ antibodies (pending).
Scoring systems that have been developed include one by the
International Autoimmune Hepatitis Group which is 88% sensitive
and 97% specific. By this calculation, the patient has 2 points
for ___ >=1:80, 2 points for IgG >1.1x normal, and ___ue to negative Hepatitis B or C, which leads
to ___nd further makes Type 1 autoimmune hepatitis
highly probable (type 1 involves circulating ___ and ___.
These findings were discussed with the ___ team. They
will hold on autoimmune hepatitis treatment given the common
confounding of results of these tests due to alcohol. Mr. ___
will follow up in clinic with Dr. ___ for lab
retesting and appropriate treatment if labs are still consistent
with autoimmune hepatitis.
During his hospitalization, in addition to extensive lab
testing, he had daily I/Os measured as well as daily weights. He
was kept on a 1.2L fluid restriction. He received the first dose
of 3 of the Hepatitis B vaccine. In addition he was started on
Nadolol 20mg daily, Spironolactone 150mg daily and Lasix 60mg
daily for his liver disease. These doses were downtitrated due
to hyponatremia, with final discharge dosing of Nadolol 20mg
daily, Spironolactone 100mg daily and Lasix 40mg daily. He
remained on a 2g sodium restricted diet during his
hospitalization. He was counseled extensively by the primary
medical team and by social work on the importance of full
alcohol abstinence, as this is the only way he will qualify for
future liver transplant and his alcohol use is likely further
exacerbating his underlying liver disease. | 196 | 400 |
11428497-DS-22 | 29,498,141 | Dear Mr. ___,
You were ___ to ___ with abdominal
pain, diarrhea and poor oral intake. You were also found to be
dehydrated. While you were here we gave you IV fluids and IV
nutrition. You are now able to eat and your pain is
well-controlled, thus it is now safe for you to return home to
continue your recovery.
1. Please monitor your bowel function closely. Some loose stool
and passage of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or are having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over-the-counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
2. You have a few small incisions on your abdomen. These
incisions have an adhesive called Dermabond in place. Please
monitor the incisions for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
3. No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by your surgical team. You may gradually
increase your activity as tolerated but clear heavy exercise
with your surgical team.
4. You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Your ___ team | Mr. ___ was ___ to ___ on ___. He was
discharged from the hospital on ___ after intraoperative
colonoscopy, subtotal colectomy incorporating the right colon,
transverse colon and splenic flexure, with ileocolonic
anastomosis on ___ for two
for surgical
removal of his colon polyps. He was found two polys (one at the
hepatic flexure and another at the splenic flexure) not amenable
to resection by colonoscopy. Therefore, he underwent a subtotal
colectomy incorporating the right colon, transverse colon and
splenic flexure with ileocolonic anastomosis. For a complete
description of the procedure please refer to Dr. ___
___ report. His hospital course was characterized by
post-op ileus. He was unable to advance his diet secondary to
emesis and significant abdominal distention on POD #2 requiring
placement of a NG tube with immediate output of approximately
500cc of bilious fluid. His NG tube was removed on POD #6 and he
began passing flatus and having bowel movements that evening.
His diet was slowly advanced to regular on POD #7, which was
well-tolerated.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. He was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. He received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 417 | 213 |
12947350-DS-32 | 23,298,431 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital with
perforated acute appendicitis. You were managed conservatively
and were placed on bowel rest, received IV fluids and
antibiotics. Your diet was gradually advanced and you are now
tolerating a regular diet. Your pain is better controlled and
you are tolerating oral antibiotics. You were also seen by the
Geriatric service to help review your medications and you should
follow-up with your Primary Care Provider at your listed
appointment (please see "Recommended Follow-up" section below).
You are now ready to be discharged home to continue your
recovery.
Please follow the discharge instructions below to ensure a safe
recovery at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Mr. ___ is a ___ y/o M who was transferred to ___ after he
had a CT at an OSH which revealed perforated appendicitis. The
patient was admitted to ICU for close hemodynamic monitoring,
PRN fluid boluses. He was started on IV zosyn. He received a 1L
bolus for low blood pressure with good effect. He did well over
night and was afebrile, although he still has moderate pain at
the right abdomen, so oxycodone and dilaudid were added for
breakthrough pain. He remained afebrile on antibiotics and was
advanced to a clear liquid diet which he tolerated well. He did
not require any pressors. He had occasional desats with
activity but overall maintained his saturations on room air.
After remaining hemodynamically stable, he was called out to
floor for further care.
On ___, the patient received 5mg Ambien (home medication)
for sleep, but became agitated overnight and slept walked. He
was reoriented and mental status returned to baseline. His
clinical abdominal exam improved and he was written for a
regular diet which was well-tolerated. His IV fluids and IV
zosyn were discontinued, and he was written for PO augmentin.
On ___, the Geriatric Service was consulted for medication
reconciliation.
The patient remained stable from a cardiovascular and pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation and incentive spirometry were encouraged throughout
hospitalization. The patient's intake and output were closely
monitored The patient's fever curves were closely watched for
signs of infection. The patient's blood counts were closely
watched for signs of bleeding, of which there were none. The
patient received subcutaneous heparin and ___ dyne boots were
used during this stay and was encouraged to get up and ambulate
as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with a walker, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
scheduled in the ___ clinic. | 337 | 350 |
18255308-DS-21 | 27,806,141 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital with left leg
weakness and difficulty walking. CT of your head did not show
acute hemorrhage or bleeding and CT angiogram (study of the
blood vessels) of your head which showed the same narrowing of
the blood vessels in your neck. Unfortunately, because of the
metal implants in your ears, MRI could not be obtained, but your
symptoms are consistent with a stroke.
It is CRUCIAL to take your medications to reduce the risk of
another stroke.
These medications were STARTED:
1. Zetia 10 mg daily to decrease cholesterol
2. Fish oil 1 gram twice a day to decrease cholesterol
3. Plavix 75 mg daily to keep your blood thin
Omeprazole was changed to famotidine. | [ AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 136) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL >100, Reason Not Given: patient tried statins
in the past and unable to tolerate them, started on zetia
instead)
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No (if LDL >100,
Reason Not Given: as above, patient tried statin in the past and
unable to tolerate them)
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
___ yo M with HTN, HL, prior TIA thought to be secondary to
atherosclerotic disease. He had recent hospitalization for TIA
(left leg weakness), discharged home on ASA 325 and Zetia
re-presenting with left leg weakness/numbness and ataxia,
thought to be due to noncompliance with medications at home in
setting of his known significant atherosclerotic disease and
carotid artery stenosis. Unable to get MRI due to cochlear
implant, but patient improved clinically throughout the
hospitalization. He was screened by physical and occupational
therapy and they thought he would be a good candidate for an
acute rehab.
#NEURO: He was hospitalized in ___ and discharged with
increased dose of ASA and zetia 10 mg, with instructions to
obtain outpatient TTE. However, it appears that patient did not
take full dose aspirin or zetia at home and also did not obtain
outpatient TTE. Given that he did not have a fair trial of
increased antiplatelet therapy and cholesterol control, he was
started on plavix 75 mg (to increase compliance, as patient
reported concern with taking aspirin), zetia 10 mg and fish oil
(patient reported significant myalgia with all statins he has
tried in the past).
His cholesterol was found to be elevated during this
hospitalization. TTE was also obtained during this
hospitalization given that it was not obtained after the last
hospitalization, and did not show PFO or other cardiac sources
of embolus. He was monitored on telemetry, and though it showed
some sinus arrhythmia, it did not show any atrial fibrillation.
#CV: Patient with HTN and HLD. He was started on zetia and fish
oil for his HLD (LDL 136). His telemetry showed episodes of
"irregular" HR but it was sinus rhythm. His blood pressure was
allowed to be auto-regulated in the acute setting. He was
restarted on his metoprolol during this hospitalization.
#FEN: he was started on regular heart healthy diet after he
passed bedside speech/swallow screen.
#ID: No fevers, or other evidence of infection
#MSK: patient complained occasional left sided low back pain,
thought to be from the fall he sustained prior to admission.
Pain was controlled with tylenol.
#GU: BPH, continued on home tamsulosin.
#GI: ?GERD, home omeprazole was changed to famotidine to avoid
the possible interaction with Plavix.
#PPx:
DVT: SQ heparin/pneumoboots
Bowel regimen
#Precautions: falls and aspiration
#CODE:FULL | 131 | 554 |
16969625-DS-13 | 28,058,229 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because you had shortness of breath that awoke you from
sleep. This was concerning for us because we thought you might
have a new blockage in the arteries of your heart. Your enzyme
levels when you arrived were elevated, indicating that you had
had some damage to your heart before coming in. We started you
on a heparin drip and continued your home medications to
stabilize the clot and watched you very closely. Your cardiac
catheterization did not show any acute issues requiring
intervention, but did note some significant narrowing of two
arteries that may need intervention if you continue to have
symptoms in the future. We started you on new medications and
changed some of your old ones to control your blood pressure and
you should continue these as an outpatient. | ___ M with metastatic prostate Ca, CAD s/p CABG ___ and PCI
___, DM, HLD, HTN, CKD presenting with NSTEMI, acute on
chronic diastolic heart failure exacerbation s/p cath on ___
without intervention.
#NSTEMI: Pt's symptoms, cardiac enzymes (Trop T 1.00) and EKGs
were consistent with NSTEMI, but cath was delayed out of concern
for pt's lone remaining kidney. Pt has baseline creatinine of
1.9-2.0, and attempts were made to help minimize risk to his
kidneys by using minimal cath dye and pre-diuresing so fluids
could be given post-cath without precipitating symptomatic CHF.
On the cath, there were stentable lesions, but they were distal
and would have required significantly more contrast. If the pt
does have angina in the future, consider re-cath for possible
stenting if creatinine is improved. With no stenting from cath,
pt was medically managed with heparin drip and nitro drip for BP
control. Atorvastatin 40, Asa 325 and plavix were continued.
Once the nitro drip was stopped, pt was placed back on
isosorbide mononitrite at a higher dose of 60mg QD. He was
switched from metoprolol to carvedilol for CHF, and his lasix
dose was reduced to 20mg QD. Clonidine patch 0.2mg weekly was
also required for BP control.
# CHF: Grade II diastolic and mild systolic CHF with acute on
chronic exacerbation. Pt was initially diuresed to minimize
symptoms of shortness of breath and was felt to be euvolemic on
discharge with a weight of 84.1Kg. Pt was then discharged on
carvedilol 6.5mg BID and 20mg Lasix QD.
#IDDM: Pt did not initially remember home dose of insulin so was
put on sliding scale initially. Once home dose of 27 units of
glargine BID was found, pt was started on it and maintained on
ISS for breakthrough. Pt was d/c'd on home insulin and diabetes
regimen.
#HTN. He has had difficulty with blood pressure control, not
tolerating hydralazine or ACE inhibitors, the latter causing
worsening renal function and hyperkalemia. This admission he was
started on a clonidine patch 0.1 mg, which was subsequently
increased to 0.2 mg with better control. Other BP medication
changes were made as above.
#HLD. Lipid studies at ___ in ___ showed total
cholesterol 128, LDL 39, HDL 75 and triglycerides 71.
#CKD. Renal-protective measures for cath were pre-diuresis and
post-cath fluids, and minimizing contrast load. Cr on d/c was
2.1, which is the same as in ___.
#Metastatic Prostate ca
-Pt to discuss Xtandi with oncology
#Neuropathy - Home dose of gabapentin 300 mg BID was continued.
# Transitional issues
- On the cath, there were stentable lesions, but they were
distal and would have required significantly more contrast. If
the pt does have angina in the future, consider re-cath for
possible stenting if creatinine is improved. | 148 | 462 |
16339049-DS-52 | 20,760,364 | Dear Mr. ___,
It was a pleasure caring for you at ___.
You came to the hospital because you were having knee pain from
your fall, you had a fever at home, and you were also feeling
weak and fatigued. You were found to have a fracture in your
knee. Based on all of the tests we did, we do not think you
were having a heart attack. We were worried that you had an
infection because of your fever, and we did many blood and
imaging tests, and there was no sign of infection and you never
had a fever in the hospital. We briefly treated you with
antibiotics and stopped this prior to your discharge.
For your knee pain, you were seen by an orthopedic surgeon and
found to have a small fracture in the right knee. This does not
require surgery. You should continue to wear the ___ knee
brace and follow-up with the orthopedic surgery team.
Important instructions for when you leave:
- You should continue all of your normal home medications,
including your usual insulin regimen.
- Your blood sugars were high in the hospital. You should make
an appointment to see your ___ doctor to discuss your insulin
regimen.
- You will follow up with an orthopedic doctor for your knee
injury.
- Watch out for warning signs below. If these develop, then call
your doctor immediately.
It was our pleasure caring for you! We wish you the best.
Sincerely,
Your ___ care team | Mr. ___ is a ___ year old male, with prior history of ESRD on
HD (___), Systolic CHF with Reduced EF (20%) (Combination of
Chagas cardiomyopathy, ETOH and CAD), CAD s/p 4-V CABG
(LIMA-LAD, SVG-D1, SVG-D2, SVG-AM), Type I DM, PVD, SSS s/p dual
chamber ICD, HTN, who presented to ___ from PCP with fever and
fatigue. | 244 | 57 |
19930769-DS-12 | 29,077,714 | Dear ___ were admitted with nausea and worsening abdominal pain. ___
were found to have a large hiatal hernia. The surgical team
evaluated ___ and felt that your symptoms were related to this
hernia. No operations done during this hospitalization. ___
have outpatient follow up scheduled.
Best of luck in your recovery.
Your ___ care team | ___ woman with history of duodenal ulcer, hiatal hernia, and
retinal vasculitis leading to legal blindness, who presents with
three days of abdominal pain and bilious vomiting.
# Nausea with vomiting
# r/o choledocholithiasis
# sphincter of oddi dysfunction
# hiatal hernia
Patient has abdominal pain worse with PO intake, colicky in
nature located over epigastrium and RUQ, with associated nausea
and vomiting as well as CT findings demonstrating dilated
intrahepatic and extrahepatic bile ducts and possible impacted
bile stone in the proximal common bile duct all consistent with
choledocholithiasis and obstruction as etiology to symptoms.
However LFTs did not support this, MRCP without obstruction
(just sphincter of oddi dysfunction). EUS non-diagnostic as
unable to bypass hiatal hernia; EUS was also concerning for
subacute volvulus. Failed NGT removal and PO challenge. Was
evaluated by surgery and GI. She was gradually able to
introduce PO intake, without any vomiting or abdominal pain.
The bulk of her symptoms thought related to her hiatal hernia.
She is safe for discharge today, now that she has tolerated PO
intake, and has not vomited. To complete workup before surgery,
she will need esophageal manometry, to conclusively rule in/or
out, any dysmotility issues.
# Duodenal Ulcer: had some red emesis at times, but this has
fully resolved., continued PPI. Hgb stable.
# Retinal Vasculitis: held MTX/pred while NPO and gave IV
steroids in the interim. Transitioned back to PO once able to
take.
# Depression: held lexapro/trazodone/buprion while NPO
Patient seen and discharged on ___. This note was entered
late on ___. | 57 | 267 |
13790660-DS-6 | 22,676,655 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Ms. ___ was admitted on ___ under the acute care surgery
service for management of his acute appendicitis. she was taken
to the operating room and underwent a laparoscopic appendectomy.
Please see operative report for details of this procedure. she
tolerated the procedure well and was extubated upon completion.
she was subsequently taken to the PACU for recovery.
she was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. she was initially given IV
fluids postoperatively, which were discontinued when she was
tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. she was voiding adequate amounts of urine
without difficulty. she was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic. | 777 | 171 |
10996527-DS-12 | 22,038,989 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with a COPD exacerbation. You were treated with steroids and
azithromycin as well as around the clock nebulizers. Your
symptoms improved and you were discharged.
You should followup with your PCP and your pulmonologist.
Regards,
Your ___ Team | ___ with a PMHx notable for COPD (Gold II, FEV1/FVC 50% in
___, remote PE (not on anticoagulation), severe GERD, and
T2DM (last HgbA1c 9) who presents from clinic with a COPD
exacerbation. She was treated with nebs, steroids and
azithromycin and her symptoms improved. | 53 | 46 |
12799041-DS-3 | 25,646,608 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___.
You were admitted because your kidneys were injured. It is not
clear how this happened, but their function improved with
fluids. You were also noted to have low blood pressures, in the
range of 90/50 (normal range 120/80). This may have played a
role in your kidney injury. An evaluation of your heart was
overall normal. It is important that you stop taking
hydrochlorothiazide and atenolol unless told to do so by your
doctor. | ___ with a history of ___ III-IV and recurrent nephrolithiasis
referred to the ED from clinic for acute on chronic renal
failure and worsening proteinuria.
# ___: H/O ___ stage III-IV c/w IgA nephropathy considering
atopy and coexistant flares, dysmorphic reds on microscopy, no
biopsy. Current ___ c/w prerenal azotemia vs. ATN given casts on
microscopy. Etiology unclear, no events by history. Persistent
hypotension concerning for adrenal insufficiency and
hypothyroidism. Renal u/s ruled out post obstructive. Since she
has hives, elevates concern for vasculitis pattern, though hives
quickly resolved without intervention. No evidence of
renal/pulm process (no lung symptoms). Creatinine trended down
with fluids to 2.3 at discharge HD 3. CXR unconcerning for
renal-pulmonary process. Patient made excellent urine, producing
equivalent output to 4L NS daily. She will followup with her
primary care physician and obtain repeat renal function tests.
# Bradycardia: HR in ___, atenolol stopped.
# Hypotension: H/O HTN, but BP's in mid 90's while off atenolol
and HCTZ. AM cortisol and TSH wnl. BP meds were stopped and
patient was asymptomatic, pressures remained in mid 90's to low
100's systolic. Echocardiogram unchanged from prior in ___, no
dilated cardiomyopathy, no focal wall abnormalities, no
significant valvular deficits except mild aortic stenosis that
was unchanged.
# Anemia: Crit dropped from 40's to 30 since ___, etiology
unclear. Most likely ___, no trend was available from outside
records from ___, Fe and lysis studies wnl, has normal
colonoscopy ___.
# Hypothyroid: TSH at lower limit of normal, no adjustments to
levothyroxine dose.
# Hyperlipid: Cont crestor | 87 | 256 |
17350977-DS-7 | 28,292,726 | Dear Ms. ___,
It was a pleasure to care for you during this hospital stay. You
were admitted with weakness and an episode of confusion. You
were also found to have impairment in your kidney function which
may have been caused by retention of urine in your bladder, and
impaired swallowing putting you at risk for aspiration
(accidentally inhaling food or drink into the lungs). All of
these symptoms were most likely caused by your recent MS flare,
and will hopefully continue to improve with time.
However, in the near term you will require rehab for physical
therapy to work on your strength and balance. You will also
require a Foley catheter in your bladder to prevent
overdistension. Finally, our speech and swallowing specialist
recommended that you drink thickened liquids and eat pureed
solids until your swallowing improves; however after a long
discussion, you have decided that you would prefer to continue
eating normal food despite the risk of lung infections and
respiratory failure.
Please take your medications as prescribed and follow up with
your doctors as recommended below. | HOSPITAL SUMMARY: ___ with history of relapsing-remitting MS
presents with acute-on-chronic weakness and recent falls.
Transferred to ___ from ___ to get CT scan of head; found to
have urinary retention and impaired swallowing. Her symptoms are
most likely due to a recent MS flare; however, she will require
rehab to support her during the recovery phase. | 178 | 57 |
16408991-DS-25 | 23,024,055 | Dear Ms. ___,
It was a privilege taking care of you at ___. You were brought
into the hospital because of concerns that you were not eating
enough due to depression. After a brief stay in the hospital and
consultation with the Geriatricians, we agree that your
depression is contributing to your lack of appetite. We
recommend you try to get involve in social activities and see
your psychiatrist to continue to manage your depression.
Please make appointments to see your primary care physician and
psychiatrist within the next week.
Because of your anemia and lower iron we have started you on
iron pills and you should also follow up with your primary care
doctor.
We found a bladder infection and you will need antibiotics by
mouth for the next couple of days. | ___ yo F with h/o depression, HTN, HLD, hypothryoidism who
presents with uncomplicated UTI and
#Depression with Anorexia: Due to her anorexia records of cancer
screening were reviewed. She is up to date with cancer
screening. While she has a history of tubular breast CA, no
evidence of reoccurence after resection in ___. While CXR
showed possible new inflammatory changes in her lung which can
be due to scarcoid, COP, or even pulmonary manifestation of her
UC she has been previously worked up and does not suggest
malignancy. Less than 24 hours after admission she stated she
was feeling better and attested to the fact that she usually
gets depressed around the holiday season with poor appetite and
she knows she is feeling better in the hospital because she is
around people, as she is a "people person". She was very
insightful as to her issues with isolation as she lives alone,
and she has felt better in the past when participating in
community programs for the elderly. Geriatrics was consulted and
also felt patient needed to be treated for her depression (not
requiring inpatient admission for this) and encouraging
involvement in groups for the elderly. She may need help from
her Psychiatrist or PCP to plug her into these venues. The topic
of assisted living has been broached in the past with her and
she is on the fence about that. She has no suicidal ideation.
She is independent of ADLs and IADLS. No further need for acute
inpatient care at this time. Discharged home to follow up with
psychiatrist and PCP. Home antidepressants were continued during
her stay: Citalopram. Also continued Ativan, and Mirtazapine.
# Uncomplicated UTI. UA c/w cystitis. Treated with Rocephin the
transitioned to po Ciprofloxacin for a 3 day course of Abx.
#Hypothyroidism :Stable with TSH of 4.0. Continued synthroid
# Iron Def Anemia : Low iron stores with ferritin of 14 on
___. Started po iron supplements with daily stool softener to
avoid constipation
# Ulcerative Colitis: stable. On mesalamine weekly | 130 | 341 |
17663033-DS-13 | 28,087,418 | General instructions:
* Please use the medications you went home with after your last
hospitalization. The only new medication you are getting is an
antibiotic called Augmentin, which is treating a rash on your
skin that looks like cellulitis. Take the antibiotic three
times a day for seven days.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex) for 6
weeks
* Nothing in the vagina (no tampons, no douching, no sex) for 3
months
* No heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was re-admitted to the gynecology service
after undergoing a diagnostic laparoscopy, reduction of
incarcerated bowel, and hernia repair for SBO/port site hernia
s/p LAVH on ___. Please see the operative report for full
details.
Immediately post-op, her pain was controlled with IV pain
medications. She received 24 hours of antibiotics (Flagyl)
post-operatively for prophylaxis given bowel injury. She had an
NGT in place post-operatively and was kept on IVF until
post-operative day 2. On post-operative day 2, she began
passing flatus and had a bowel movement. She underwent a clamp
trial with her NGT and tolerated it well with no nausea or
emesis, so her NGT was removed on post-operative day 2. Her
electrolytes were checked daily and repleted as needed. Her
diet was advanced slowly, without difficulty, and by
post-operative day 4 she was tolerating a regular diet. She was
transitioned to oral medications on post-operative day 3.
She had a foley catheter placed intra-operatively. Overnight on
post-operative day 0, she experienced low urine output that was
attributed to hypovolemia and resolved with 1L bolus of IVF.
Her foley catheter was removed on post-operative day 1 and she
was able to void spontaneously and ambulate independently for
the remainder of her hospitalization.
She was diagnosed with cellulitis on her abdomen upon admission,
with erythema noted inferior to her umbilicus. The cellulitis
was not ___ and there was no drainage or pus. She
was started on cefazolin ___ and was transitioned to PO
augmentin on post-operative day 4 with instructions to complete
a 10 day course total.
By post-operative day 4, she was tolerating a regular diet,
voiding spontaneously, passing flatus and bowel movements
regularly, ambulating independently, and pain was controlled
with oral medications. She was then discharged home in stable
condition with outpatient follow-up scheduled. | 181 | 312 |
19064289-DS-8 | 25,302,669 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having upper
abdomen/chest pain with nausea and vomiting that was very
concerning for a heart attack. Your EKG was unchanged from the
last one but your levels of cardiac enzymes showed evidence of
some damage to your heart. A heart catheterization revealed a
blockage in one of your arteries (left circumflex artery) where
the old ___ had been; this was reopened with a new ___. We
also managed your high blood pressure with new medications. You
were discharged discomfort free, with no arrhythmias, and with
no procedure-related complications. Best of luck to you in your
future health.
Please take all medications as prescribed, attend all doctor
appointments as scheduled, follow a heart-healthy diet and
lifestyle, and call a doctor if you have any questions or
concerns.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Care Team | ___, a ___ yo F PMHx CAD s/p CABG, T2DM on insulin,
HTN, HLD, and CVA presented with epigastric/left chest pain with
nausea/vomiting, was found to have elevating troponin concerning
for NSTEMI, was found to have 99% instent restenosis of the
mid-left circumflex now status-post restenting. Her course was
also complicated by hypertensive crisis requiring nitroglycerin
drip at times. She was discharged chest pain free, arrhythmia
free, normotensive, and without any procedural complications to
outpatient cardiology followup.
# Non-ST Elevation Myocardial Infarction status-post
Drug-Eluting ___ to Left Circumflex Coronary Artery: Patient
p/w with nausea, vomiting, epigastric/left chest pain found to
have rising cardiac enzymes here. EKG similar to prior with LBBB
and LAD, negative Sgarbossa's criteria. Patient was pain free on
nitroglycerin drip and was given heparin drip, clopidogrel,
atorvastatin, aspirin, and labetolol due to need for ongoing
blood pressure control. She was found to have a restenosis of
her left circumflex lesion and had another drug-eluting ___
placed in the same area. She was evaluated by physical therapy
would recommended outpatient cardiac rehabilitation. She was
also given a prescription for a walker due to impaired baseline
mobility.
# Hypertensive: Patient presented with SBP 190s on admission;
her pain and blood pressure were initially controlled by
nitroglycerin drip with satisfactory resolution of both issues.
Post-catheterization when the team attempted to stop the drip,
her blood pressure again increased to the SBP180s. Her
anti-hypertensive regimen was increased to valsartan 320mg,
amlodipine 10mg, hydrochlorothiazide 12.5mg, and labetolol which
resulted in normotension.
# Chronic Systolic Congestive Heart Failure / Ischemic
Cardiomyopathy: Last EF ___. Patient was euvolemic currently
with no JVD, lung crackles, or peripheral edema and requiring no
diuresis at home or as an inpatient. She was maintained on a
low-sodium heart-healthy diet along with appropriate
beta-blockers and angiotensin receptor blockers.
# Type II Diabtes Mellitus: Patient is on BID glargine with ISS,
last A1c > 10% ___. Complicated by nephropathy with baseline
Cr. 1.1-1.3. She was maintained on her home dose of glargine
and her home metformin was held.
# GERD: Chronic stable issue maintained on home pantoprazole
BID. Patient did have some heartburn sensation (distinct from
anginal pain) which was effectively palliated with viscous
lidocaine-diphenhydramine-Maalox(R).
# HLD: Chronic stable issue continued on home atorvastatin and
holding fenofibrate as it is non-formulary.
# Stage III Chronic Kidney Disease: Chronic Cr 1.1-1.3 and
1.3-1.5 as an inpatient with eGFR<60. CKD likely secondary to
diabetic and hypertensive nephropathy.
# Code Status: Full Code confirmed. Emergency contact is
___ (husband and healthcare proxy) at ___.
# ___ Issues:
[]Cardiac Rehabilitation referral once seen by cardiologist
[]Consider discontinuing isosorbide mononitrate if blood
pressures remain under control
[]Emphasize the important of medication compliance and following
a heart-healthy and diabetes-healthy diet and lifestyle
[]Titrate CAD/HTN/DM medications to optimize overall
cardiovascular health
[]Followup on self-described anxiety (patient requested
alprazolam but was deferred to outpatient providers) | 171 | 481 |
14588384-DS-5 | 23,056,215 | Dear Mr. ___,
You presented to the hospital with acute liver failure. You
chose to leave against medical advice, and understood that the
risk of leaving could include worsening confusion, bleeding,
infection, and potentially death.
We would like you to be as comfortable as possible at home.
We have arranged an appointment with your primary care physician
for ___ morning. He will be able to refer you to hospice
services which will provide you with home care focused on
comfort.
We are sending you home with several new medications. It is
very important that you take them as prescribed. | ___ yo M with h/o EtOH and HCV cirrhosis presenting with
confusion and jaundice, developing over several weeks,
concerning for acute alcoholic hepatitis.
# Jaundice- Tbili elevated to 26.1 on admission. Differential
included alcoholic hepatitis, decompensated liver cirrhosis, and
infection (hepatitis B of most concern as patient had prior
negative hepatitis B serologies). Urine, blood and CXR were
negative for infection.
DF score was 38, MELD 23, ___ EtOH hepatitis score of 9
on admission. Steroids were deferred until infection was ruled
out. Focus was on nutritional support and electrolyte
repletion.
On HD1, patient demanded to leave AMA. After extensive
discussion with both the patient and his HCP about the risks of
leaving AMA (risk of worsening confusion, developing ascites,
bleeding, infection and probably death), the patient continued
to request to leave. Psychiatry was consulted and felt that
patient did not have capacity to leave AMA, however his health
care proxy still wanted him discharged as she believed that it
would be his wishes to die at home and not remain in the
hospital for further treatment. Health care proxy was able to
verbalize the risks involved in his leaving AMA, and was willing
to accept these risks. Ethics was consulted and agreed that the
HCP had the ability to make this decision for the patient.
With palliative care's assistance, patient was offerred
hospice, but we were unable to arrange these services within the
same day. Patient refused to stay in the hospital until these
services could be established, but expressed a desire to have
the services placed, if possible, by his PCP after he returned
home.
He was discharged against medical advice, with ___ services
to assist in the home for the time being. He was given
prescriptions for thiamine 500mg x 1, then 100mg daily,
multivitamin, and instructions to continue to take folic acid
daily. In addition, he was encouraged to drink 3 Ensure's daily
to support his nutritional needs.
A follow-up appointment was scheduled with patient's PCP for
___ morning to discuss further management and possible
hospice referral.
Patient was encouraged to return to the hospital if he
desired further medical care.
# Alcohol abuse- Patient was placed on CIWA protocol while in
patient but scored only ___ throughout admission. He was given
a banana bag on admission, and electrolytes were otherwise
repleted as above.
# Transitional issues-
- PATIENT LEFT AGAINST MEDICAL ADVICE
- patient given prescriptions for thiamine, ursodiol (for
pruritus secondary to hyperbilirubinemia), and MVI.
- Appointment scheduled with PCP for ___ @
8:45am
- Please assist patient with referral to hospice if he still
desires these services | 102 | 462 |
17980434-DS-17 | 20,994,476 | Dear ___
___ were admitted to the hospital for high blood pressure and
anemia. ___ were started on your home medications and found to
have microscopic blood in your stool. Your blood counts
remained stable from previous lab reports. Your blood pressure
is elevated, but it is your normal pressure. Your PCP, ___.
___ and saw ___ in the hospital to help plan your
further outpatient work up. Your later stated that over the past
several months ___ have been a little short of breath while
walking. We obtained a CT scan of your Chest and abdomen that
showed a very small "pulmonary nodule" in your lungs. ___ need
to have a repeat CT scan in one year to follow this.
___ stayed in the hospital another night so ___ could receive
dialysis.
We have not changed any ov your medications at this time.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ with CHF, ESRD on HD ___ and h/o colonic perf during
colonoscopy s/p colostomy admitted for HCT ___ over 7 months
(and 31->29 over past 4 months). Slight fatigue but otherwise
asymptomatic. Guiaic positive brown stool. HD stable. The
patient's PCP is ___ ___ resident who was contacted and spoke
with the patient.
#anemia/GI bleed - No gross blood in stool, guiac positive.
HDS. Not clinically anemic. Current HGB 9.8 with 10.3 on ___.
Does not appear to be actively hemorrhaging. Not on
anticoagulation, Coags are WNL. T&S on file incase of
hemorrhaging . Occult blood loss could be ___ malignancy, but
patient is hesitant to undergo a colonoscopy given her previous
experience. CT scan showed no intraabdominal malignancy. She
also takes EPO injections for chronic anemia.
#fatigue - may be secondary to anemia or CHF. The patient's
symptoms are mild. She had an ambulatory O2 Sat with a brief
desaturation to 89% on RA. Because of her fatigue, anemia, and
Hx of breast cancer, a CT scan was obtained which was
significant for 3-mm pulmonary nodule within the left lower lobe
pt was notified of this finding and information was placed in
the discharge paperwork.
#hypertension - Pt has assymptomatic htn running from SBPs of
180s - 190s. According to the PCP, she gets dizzy when her BPs
are less than 170. Her home medications were started.
# ESRD - Had dialysis the day of admission with a K of 3.6.
Renal was contacted for dialysis because the patient was still
in the hospital on the morning of scheduled dialysis. | 164 | 278 |
10322592-DS-7 | 26,023,713 | Dear Ms. ___,
You were admitted to the hospital because of severe back pain.
An MRI did not show any signs of nerve damage. It is very
important that you take the naproxen as an anti-inflammatory for
2 weeks and that you continue to stay mobile. Staying in bed
will worsen your pain. You can follow up with your PCP about ___
referral to ___ if necessary.
Sincerely,
Your ___ Team
PAIN CONTROL:
-If you continue to have muscle spasms, please take Flexeril
10mg for a maximum of three times per day
-If you continue to have pain after taking the Flexeril, please
take Naproxen 500mg every 12 hours
DANGER SIGNS:
-Please call your PCP ___ return to the emergency department
if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns | ___ w/ hx ADHD, HTN, OSA admitted for lower back pain most
likely due to left lumbar muscle spasms.
#Acute on chronic back pain - Patient called EMS on day of
admission because she could not get up from bed due to back pain
x 3 days. Only red flag sign was age > ___, without any
urinary/fecal incontinence, trauma, malignancy, weight loss, or
fever. Not immunosuppressed or on steroids. Previous MRI lumbar
spine in ___ showed lumbar disk herniation and degenerative
joint disease. Due to weakness to hip flexion bilaterally, MRI
lumbar spine repeated, unchanged from prior without signs of
cord compression. Pain most likely due to muscle spasms which
limited her mobility. Pain controlled with Flexeril, Tylenol,
Oxycodone and Naproxen. Patient ambulated with assistance and
pain improved before discharge.
#Hypertension - On admission, SBP remained on low ___ (baseline
130s). Received Received 1L IVF and improved to SBP 120s. Held
home lisinopril and HCTZ while in house and held lisinopril on
discharge.
#Depression - Continued home citalopram
#ADHD - Held home Adderall as nonformulary
#Hypothyroid - On thyroid pork (non-formulary), held while in
house
#OSA - not using CPAP at home past ___ due to insurance.
Restarted CPAP while in house.
TRANSITIONAL ISSUES:
1. Naproxen 500mg PO Q12h for 14 days for acute lower back pain.
Can follow up with ___ as outpatient if not improving with simple
mobility and anti-inflammatories.
2. BP within low-normal range while holding HCTZ and lisinopril.
Lisinopril held on discharge. Can restart as outpatient if
elevated at follow up.
Code: Full
Contact: ___ ___ | 160 | 264 |
16605495-DS-28 | 27,565,730 | Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
with abdominal pain and vomiting. You had a CT scan that was
concerning for a small bowel obstruction. You were given bowel
rest and IV fluids. You symptoms improved and your diet was
gradually advanced from clears to regular with good
tolerability.
You are now ready to be discharged to home to continue your
recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
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. | Ms. ___ is a ___ yo F with history of multiple abdominal
surgeries was admitted to the Acute Care Surgery service on
___ with abdominal pain, nausea, and vomiting. CT scan was
concerning for small bowel obstructions. She was made NPO, given
IV fluids, and admitted to the floor for further monitoring.
On HD3 the patient had return of bowel function, decreased
abdominal distention, and reported passing flatus. On HD4 diet
was advanced to clear which was tolerated. Speech and swallow
was consulted and recommended return to baseline diet of pureed
solids and thin liquids. Patient has known history of Zenker's
diverticulus and is aware of the risk of aspiration associated.
On HD5 diet was advanced to regular with modified consistency
which was well tolerated.
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 with ___ services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 291 | 220 |
16908032-DS-3 | 20,387,572 | It was a pleasuer taking care of you during your stay at the
___. You presented following
progressive leg weakness following a diarrheal illness. On
examination, you were found to have featires consistent with a
condition called Guillain ___ syndrome where your body's
immune system attacks your peripheral nerves. As treatment for
this, you were started on plasmapheresis where the plasma is
exchanged to remove bad antibodies. You clinically improved and
after finishing your last plasmapheresis were ready to be
transferred to rehab. You had shooting/stabbing pain in your
legs and were seen by the pain team who recommended starting
venlafaxine for this. They have also suggested alternatives if
this is ineffective which we will communicate with your rehab.
You were also found to have evidence of cervical spondylosis
(due to wear and tear in the neck) on MRI and you should wear a
soft cervical collar at night for this. Follow-up with Dr
___ as below.
Medication changes:
We started venlafaxine 37.5mg twice daily for pain on the advice
of the pain team
We started Pregabalin 150mg twice daily for nerve painWe started
heparin to reduce risk of DVT (blood clots)
We started trazodone at night as required for sleep (only to be
taken in hospital not for home)
We started diazepam 10mg every 8 hours as needed for anxiety
We started lidocaine patches for pain
We started a nicotine patch
We started laxatives
Wear a soft cervical collar at night | ___ h/o left arm trauma, polysubstance abuse p/w bilateral
lower extremity and hand weakness, sensory loss, paresthesias,
areflexia and neuropathic pain after an antecedent diarrheal
illness, most consistent with acute inflammatory demyelinating
polyneuropathy with arreflexia and consistent pattern of
weakness. The patient also as noted to have a left paracentral
disc osteophyte at C6-C7 level indenting the left side of the
spinal cord.
# Acute Inflammatory Demyelinating Polyneuropathy - Patient was
transferred from OSH. The patient's syndrome with a preceding
diarrheal illness, arreflexia and LMN pattern of weakness in
legs>arms with minimal sensory symptoms (seems most of his pain
is down to radicular pain)is most consistent with ___
Syndrome. LP at OSH revealed RBC 1 WEBC 0 Pr 38 Glc 82 with no
significant pleocytosis and no elevated protein as this was
likely too early in the course of his illness. Other workup
included Urine porphobilinogens negative, Stool culture neg, CRP
25.5, CK 126-129, IgA 389, UA negative, TSH 1.1, Lyme negative.
He was treated with plasmapheresis for 5 cycles, having the last
on ___ with some evidence of improvement in strength. He
received ___ and was deemed appropriate for rehab
# Cervical spondylosis: MRi showed a left paracentral disc
osteophyte at C6-C7 level indenting the left side of the spinal
cord with no intrinsic spinal cord signal abnormalities or
abnormal enhancement. There were mild degenerative changes at
other levels. He should wear a soft cervical collar at night.
Patient also has an L5/S1 on outside MRI which can be addressed
as an out-patient.
# Pain - The patient consistently reported leg pain and
frequently asked for opiates. Per records from the OSH and
reports from his family, the patient has a longstanding history
of opiate dependence (recently tapering off methadone) and hoped
to not have the patient relapse. The patient was offered
neuropathic pain medications to address the etiology and nature
of the pain from AIDP but he refused most doses. His initial
roommate claimed to his transporter that he had sold the patient
Percocets; a room sweep revealed Percocets hidden in the
former's bag, but none on the person of the patient. Room
assignments were then switched. He was started on pregabalin
latterly 150mg bid with possibly some effect. He was also
started on bilateral lidpcaine patches. Cyclobenzaprine wa
started but discontinued as ineffective. He was seen by the pain
team on ___ and per their recommendations, we started
venlafaxine 37.5mg bid for pain. If this is insufficient can try
a tricyclic antidepressant and if all else fails for divided
dose methadone. His PCP can arrange pain team follow-up if
deemed necessary. He had one episode of dark stool which did not
recur and Hb remained stable throughout.
Follow-up: Patient has neurology follow-up on ___ with
Dr ___. | 233 | 459 |
19309091-DS-8 | 23,938,659 | Mr. ___,
It was a pleasure caring for you here at ___
___.
Why I was admitted to the hospital?
- You were admitted for placement of a tunneled hemodialysis
catheter. This is a thin tube that is tunneled under your skin
for initiation of hemodialysis.
What was done for me while I was here?
- You had your tunneled line placed
- You underwent dialysis under the supervision of of our
nephrology team.
- You received a total of 2 units of packed red blood cells for
persistent anemia.
Patient ID when I leave the hospital?
- Please go to your scheduled appointments as detailed in this
discharge summary
- Please take all of your medications as detailed in this
discharge summary
- Please go to your first dialysis appointment at ___
___ dialysis, ___ at 3:30pm. You
will then undergo dialysis every ___ & ___
under the guidance of your outpatient nephrologist.
- Please get Tacrolimus level drawn on ___ and follow up Tacro
dosing with your Nephrologist.
- Please call your outpatient provider or return to the
emergency department if you experience any of the danger signs
listed below.
Best Wishes,
Your ___ Care Team | ___ with a background history of renal transplant in ___, now
with advanced allograft nephropathy, awaiting HD initiation,
gout, hyperparathyroidism and squamous cell carcinoma, now
presenting with possible atrial fibrillation with RVR prior to
planned placement of HD line and fistulagram.
==================== | 186 | 41 |
10630336-DS-14 | 26,938,538 | Dear Mr. ___,
Thank you for allowing us to participate in your care while you
were at the ___.
You were admitted to the hospital after you had shortness of
breath at your urology appointment. When you were here, your
heart was beating slower than it normally should, which
prevented blood from reaching your organs. Your heart was also
not beating normally, which was most likely because of some of
the medications that you took. We stopped you from taking these
medications, and your heart function improved. Please do not
take amiodarone until you see your cardiologist next month.
Please continue to take your beta blocker. You will also need to
follow up in ___ clinic in ___ with ___
___, RN & Dr. ___.
It was truly a pleasure to participate in your care. | # Tachyarrhythmia: Upon admission, the patient had markedly
prolonged QT interval in association with frequent VPDs, and
episodes of torsade de pointes (polymorphic nonsustained VT).
No episode required cardioversion. The initial K+ was 4.2, but
the specimen was hemolyzed. He had not been eating much for 5
days, and our initial impression was long QT syndrome due to
hypokalemia, superimposed on marked sinus bradycardia (due to
metoprolol and amiodarone) plus some contribution of amiodarone
to the long QT. Superimposed upon this background was
administration of 2 QT prolonging antibiotics in the ER
(azithromycin and levaquin). A cephalosporin was substituted
for treastment of pneumonia. Electrolytes were repleted to
achieve K > 4 and Mg > 2. The patient was initially admitted to
the CCU, then transferred to ___ 3. He was given a lidocaine
drip overnight, which suppressed VT. VT stopped within 12 hours.
Amiodarone was held during hospital stay. Metoprolol was held
given bradycardia. EP team was involved in his care and will
follow up with patient in one month.
.
# Syncope: initially thought to be due to bradycardia to the ___
so BB was held. HRs on discharge were ___. Metoprolol
held on discharge.
.
# Atrial fibrillation: previously rate controlled and
anticoagulated. No known episodes of Afib during admission.
Betablocker and amiodarone held. Warfarin continued at
alternating doses of 1.25 and 2.5 mg. Patient was 2.2 on
discharge. Further mgmt by PCP which was discussed via email.
Next INR check ___. Unclear if actually needs amiodarone,
and will be addressed by ___ clinic visit.
.
# Right neck hematoma: pt has hematoma in his right neck which
stopped spontaneously. ASA and plavix were not held during
hospitalization. Coumadin was held but restated on ___
afternoon after Hct has been stable.
.
# PNA: Per CXR and symptoms. Finished 7 day course of CTX.
Further azithromycin and levaquin was held as above due to QTc
prolongation. Discharged on baseline O2.
.
# Urinary obstruction: issue last admission thought to be due to
BPH. Failed voiding trial after catheter was removed.
Discharged w/ Foley. Started on tamsulosin. Will f/u w/ Urology.
.
# sHF: Etiology ischemic. ECHO ___ LVEF ___. Continued
home furosemide. Euvolemic on discharge.
.
# CAD: s/p cath ___ with significant disease (70% ___ LAD;
80% OM; fully occluded RCA) s/p PCI on ___ with DES to LAD
and OM lesions. Continued on aspirin and clopidogrel.
Metoprolol held for bradycardia w/ hypotension until sees EP.
.
# HTN: SBPs ranged ___. Continued on home lisinopril.
.
# COPD: on 4L NC at home. Continued on home albuterol and
symbicort to advair.
.
# Hematoma on face: self resolved.
.
# Hyperlipidemia: Lipids last checked ___. Chol 130. LDL 76.
Continued on statin.
.
#### TRANSITIONAL ISSUES ####
- Needs INR checked ___ (confirmed with PCP). Coumadin for
Afib, goal 2.0-3.0
- CHF Cardiology appointment: follow up Dr. ___ heart
failure
- EP Cardiology appointment: follow up with Dr. ___
need for amiodarone and when to reinitiate metoprolol (held for
sinus bradycardia & hypotension)
- Urology: follow up regarding acute urinary retention. | 139 | 518 |
15229355-DS-13 | 29,074,135 | You were admitted with weakness and difficulty moving. You were
found to have a urinary tract infection and dehydration. You
were treated with antibiotics and you improved. | Brief summary:
This is a ___ with ___ disease, esophageal dysmotility,
reactive airway disease presenting from home via EMS with
inability to ambulate. In the ED she was hypotensive,
transiently mildly hypoxic, and clearly weak and
encephalopathic. She was found to have a UTI and also thought to
be hypovolemic. She improved very impressively with fluid
resuscitation and antibiotic therapy, to near-baseline (though
very poor functional status at this baseline). Her antibiotics
were transitioned to a narrowed spectrum oral regimen prior to
discharge. | 27 | 83 |
13327132-DS-8 | 20,062,486 | Mt. ___,
It was pleasure taking care of you during you hospitalization at
___. You were admitted due to an upper airway infection and
COPD exacerbation. Your symptoms improved with
We made the following changes to your medications:
Please restart all of your blood pressure medications including
hydrochlorothiazide, losartan and nifedipine
Started prednisone 40mg daily, last day ___
Started levofloxacin 750mg daily last day ___
Started guaifenasin as needed for cough | ___ y/o M w/ PMHx COPD and empyema, tobacco abuse with 40+ pack
year, HTN, prostate ca s/p cyberknife and radiation p/w gradual
onset dyspnea and productive cough c/w COPD exacerbation.
# COPD exacerbation: Likely in the setting of URI and missing
home medications. Patient was weaned from BiPAP to supplemental
oxygen for nasal cannula in the ED (on BiPAP for ~1 hour).
Patient afebrile, no leukocytosis or focal infiltrate on CXR to
suggest pneumonia, although he does have increased cough and
shortness of breath, and COPD frequently triggered by infection.
Levofloxacin was used given patient's age ___ and moderate
underlying COPD (FEV1 54). Symptoms improved with prednisone
40mg, albuterol and ipratropium nebs. Patient uptodate on
influenza and pneumococcal vaccinations. On discharge,
ambulatory O2 sat on room air ___. Discharged on prednisone
(planned 10 day course without taper), levofloxacin (5 day
course), and home dose albuterol, tiotropium, and flovent.
# Hypertension: Patient severely hypertensive in the setting of
respiratory distress and missing home antihypertensives. BP
improved with home dose nifedipine, HCTZ, losartan.
# Gout: Continued home dose allopurinol.
# Transitional issues:
- code status: full code
- follow up with PCP
- new medications: prednisone, levofloxacin | 68 | 196 |
10522575-DS-4 | 24,097,143 | Mr. ___,
You were admitted with elevated bilirubin and abnormal liver
testing. Your imaging was normal and lab tests positive for
lyme disease and you were started on doxycycline, which you
should continue for 14 days. You will continue outpatient
follow up with gastroenterology to ensure your liver numbers
have resolved.
Your hospital course was complicated by ileus, which improved
with aggressive bowel regimen. You can continue a bowel regimen
as needed to ensure you have 1 soft bowel movement every ___
days.
It was a pleasure taking care of you.
-Your ___ team | ___ w/ no significant medical history presents with 4 days of
abdominal pain and nausea/vomiting found to have transaminitis
and cholestasis.
1. Lyme disease
-IgM positive and initiated doxycycline treatment ___, which
will be continued for 2 weeks through ___.
2. Transaminitis, cholestasis, hyperbilirubinema (conjugated),
and abdominal pain
-Mixed picture with unclear etiology in setting of normal MRCP.
As per ERCP team no indication for ERCP at this time. Initial
diagnosis broad including infectious, autoimmune, and
infiltrative process. Lyme IgM resulted positive ___, which
is likely cause of lab abnormities and liver biopsy not
indicated at this time. He will follow up w/ GI/hepatology
outpatient follow w/ Dr. ___ to ensure LFTs normalize
following lyme treatment.
3. Constipation and ileus
-Unclear etiology potentially related to decreased activity,
decreased PO intake, and acute illness. There is not a common
association with lyme and ileus but may be related. Patient will
good response to suppository and will continue w/ docusate &
senna outpatient.
4. Asymptomatic pyuria
-Urine culture with 10,000-100,000 alpha hemolytic strep without
indication for treatment. Gonorrhea and chlamydia negative.
5. GERD, hiccups
-Patient with good response to Chlorpromazine. At discharge
patient requests short course of antacid and antinausea meds
given prescriptions for ranitidine and metoclopramide PRN.
>30 minutes spent on discharge planning | 95 | 216 |
13410702-DS-14 | 28,219,965 | Dear Ms. ___,
You were hospitalized at ___ and treated by Neurology due to
severe headache found to be due to blood clot formed in cerebral
vein (i.e. cerebral venous sinus thrombosis). Due to this
finding, you were started on anticoagulant therapy with Heparin
as well as Coumadin. You were symptomatically treated with pain
medications. Due to appearing clinically stable, you will be
discharged from the hospital.
Please continue taking Lovenox 90mg (0.9mL) subcutaneously twice
daily until your INR (a laboratory level that measures whether
Coumadin is effective) is between ___ on laboratory testing.
Please also continue taking Coumadin 5mg daily. You will need to
take this medication for at least 6 months.
Please follow up with your primary care provider, Dr.
___, at ___ on
___, at 3:00pm. At this appointment, you will
have your INR checked to determine if Coumadin is effective. You
will need repeat visits to ensure it is stable between ___.
Please take lab requisition form and have hypercoagulable labs
checked as outpatient here at ___. Please also follow up with
Neurology and Hematology as listed below. Please discuss with
your primary care doctor about following up with Gynecology for
possible contraceptive therapy, as while on anticoagulation your
menses may be heavier than normal.
It was a pleasure taking care of you,
___ Neurology Team | Ms. ___ was hospitalized at ___ due to persistent
headache with nausea, vomiting, and photophobia. She underwent
CTA Head and Neck and had OSH MRI read, with findings suggestive
of venous sinus thrombosis. She was admitted to Neurology and
started on heparin drip as well as Coumadin 5mg. During hospital
course she was symptomatically treated for her pain. Due to
appearing clinically stable, she was discharged home with
Lovenox bridge to Coumadin. | 216 | 72 |
18213042-DS-10 | 27,733,343 | 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 found to have a low
hemoglobin level.
What happened while I was in the hospital?
==========================================
You were transfused with 1 unit of blood (after having received
one at ___. After the transfusion, you were short of
breath, so you were transferred to our ICU. After your
respiratory status improved, you were transferred to the regular
medicine floor. Our GI colleagues did not think that you had an
active GI bleed, but because you had difficulty with bowel prep
in the past, we performed EGD/colonscopy which did not reveal
bleeding. You received a larger dose of diuretics than you
normally take at home due to your respiratory distress.
You will be discharged on your home medications.
What should I do after leaving the hospital?
============================================
You should continue to take the medications and attend the
follow-up appointments as listed in your discharge summary.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | ___ year old lady with complex history most notable for breast
cancer on aromatase inhibitor, with massive PE ___ [R mainstem]
requiring embolectomy & filter; recurrent submassive PE ___
w R heart strain in setting of holding coumadin due to GI bleed,
second filter placed and on life-long anticoagulation, atrial
fibrillation, and history of CAD with STEMI x ___ who
presents with malaise, fatigue, and acute on chronic anemia, s/p
transfusion c/b hypoxic respiratory failure requiring BiPAP, now
transferred to medicine for further management. | 187 | 84 |
18127204-DS-19 | 24,046,344 | Discharge Instructions
Brain Tumor
Surgery
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ w/ metastatic RCC s/p R nephrectomy and partial hepatectomy
treated with pembrolizumab on clinical trial ___ complicated
by immunotherapy-induced hepatitis and T12 paraspinal mass s/p
CK who p/w word finding difficulty x 1 wk and several hours of
intermittent RUE clenching, found to have hemorrhagic brain met,
s/p resection by NSGY ___
#Secondary Neoplasm of Brain
#Possible Seizure
Found in setting of right arm clenching and word finding
difficulty that may represent seizure activity. Since admission,
patient had been on dexamethasone/Keppra, and has had no focal
deficits on exam. Given resolution of symptoms and return to
baseline, dex decreased to BID as per discussion of prior
hospitalist and neuro-onc fellow. EEG not pursued given return
to baseline. fMRI performed which revealed operative approach
for resection which was done on ___. Patient received remaining
care on ___ service.
# Metastatic Renal Cell Carcinoma
# Secondary Neoplasm of Lung
# Secondary Neoplasm of Bone
Currently on active surveillance but last imaging concerning for
growing lung nodules. Dr. ___ updated regarding
plan for resection, will need outpatient f/u scheduled prior to
discharge. Will also need neuro onc and rad onc followup
appointment
#s/p Left parietal craniotomy for tumor resection
Patient was transferred to the ___ for elective left
parietal craniotomy for tumor resection on ___ with Dr. ___.
Procedure was uncomplicated; please see dedicated operative
report for further detail. Postoperatively, the patient was
extubated without complication and recovered in the PACU. On POD
1, the patient was reporting adequate pain control and feeling
well. She was made floor status. ___ and ___ were removed
POD 1. Postoperative MRI was obtained on POD 1 that showed
expected postsurgical changes. Patient was on dexamethasone
preop which was tapered with goal off over 1 week. She was seen
by physical therapy who cleared her for home. | 457 | 297 |
10797885-DS-13 | 20,865,551 | Dear Mr. ___,
It was our pleasure taking care of you at the ___
___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were seen in the oncology (cancer medicine) clinic, and you
were found to be very sleepy.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have a urinary tract infection (UTI). For
this, you were treated with IV antibiotics.
- You started receiving treatment for your cancer (adult T-cell
leukemia/lymphoma) with a chemotherapy regimen called mini-CHOP.
You tolerated this regimen well.
- You were diagnosed with hepatitis B and started on treatment
for this as well.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Please take your medications as prescribed and attend your
doctor's appointments.
- You will need to return to clinic to see Dr. ___
your ___ cycle of chemotherapy. Please see below for the
schedule.
We wish you all the best!
Your ___ Care Team | ===================
SUMMARY
===================
___ with progressive ATLL who presents after recent discharge to
rehab with progressive lethargy, found to have an UTI. During
this admission, he was initiated onto mini-CHOP for treatment of
his progressive ATLL with good symptomatic response.
===================
ACUTE ISSUES
===================
#Adult T-cell lymphoma
Patient was diagnosed with ATLL in ___ and was not treated
previously. During this admission, he was noted to have
bilateral cervical lymphadenopathy and submandibular nodules,
which were initially quite tender, as well as diffuse skin
nodules which are nontender. PET scan this admission showed
diffuse lymphadenopathy most prominently in cervical region,
multiple nodules in lungs and liver, diffuse cutaneous nodules,
and increased uptake near lumbar spine including body of L5.
Ultrasound before mini-CHOP showed severe external compression
of the left jugular vein without thrombosis. CT neck did not
show any impingement upon the aerodigestive tract. HTLV1
positive. Initiated onto mini-CHOP on ___ (C1D1). Tolerated
well. ANC nadir 4,800 on growth factor support. Main side-effect
otherwise has been constipation which was treated with a strong
bowel regimen. Symptomatically, bilateral cervical and
submandibular lymphadenopathy shrunk significantly and became
nontender. Skin nodules also shrunk.
#Hepatitis B
HBsAb negative, HBsAg positive, HBcAb positive. VL detectable at
<1.3 log IU/mL just before initiation of chemotherapy. AST/ALT
normal this admission. No known history of treatment or
resistance and as such started on entecavir 0.5mg daily. Weekly
viral load afterwards were undetectable.
#Isolated systolic HTN
#Labile blood pressures
Patient noted to have isolated systolic hypertension and labile
blood pressures in general. This may be due to autonomic
dysfunction from ?___ disease (see below). As such,
blood pressure goals were made liberal.
#UTI
#Toxic metabolic encephalopathy
Presented with somnolence from his oncology appointment. UA
showed large leuks, 176 WBCs. Urine culture was unfortunately
contaminated. Treated with ceftriaxone with rapid improvement in
mental status back to baseline. Received ~2 week course. Repeat
UA after treatment was clean.
===================
CHRONIC ISSUES
===================
#T2DM
At home is on glipizide and metformin. Put on insulin sliding
scale while in-house.
#Right toe gangrene
#Peripheral vascular disease
Patient recently underwent angioplasty by vascular surgery.
Extremity is warm and toe does not appear to have drainage or
other signs of infection. Continued on aspirin 325mg,
clopidogrel 75mg, and atorvastatin 80mg (see below).
#History of stroke
#History of ___
Per notes, patient's wife states right sided facial droop is at
baseline for him. In addition, has noted involvement of his
basal ganglia in prior CVAs and demonstrates occasional
spasticity and stiffness. Saw neurologist in the past who made
diagnosis of ___ disease; possible that baseline
cognitive dysfunction related to ___. Was not on
___ treatment upon admission. CT in ED on admission was
without acute process.
#Thrush
Given nystatin rinse. Initially had odynophagia, improved with
nystatin.
#BPH
Treated with home tamsulosin.
#Hyperlipidemia
Atorvastatin held in the setting of chemotherapy. Restarted once
chemotherapy finished.
#HCP/CONTACT: ___ (Wife) ___
#CODE STATUS: full
===================
TRANSITIONAL ISSUES
===================
[] Hepatitis B: please check viral loads weekly
[] Atorvastatin: please stop before receiving cycle 2 of R-CHOP,
in case patient develops LFT abnormalities of unclear etiology.
[] ___ disease: it is unclear if the patient has
___ disease. Please consider re-evaluation and treatment
if within goals of care.
[] R toe gangrene: please follow up with Podiatry and Vascular
appointments.
[] Hypertension: please consider being liberal with BP goals as
patient appeared to have labile blood pressures this admission.
[] TSH: mildly elevated in the setting of infection. Consider
repeating as an outpatient.
[] Access: please consider placement of port for access. | 142 | 546 |
14487404-DS-16 | 20,241,852 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Hold your home coumadin until your follow up appointment in 2
weeks.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
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.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ yo M involved in MVC, on coumadin for afib, found to have
small left tentorial SDH. INR 3.7. Neurologically intact on
examination. INR was reversed with Kcentra in the ED. Coumadin
was held. He was loaded with 1000mg of Keppra. He was admitted
to the neurosurgery service for observation.
On ___ He remained neurologically stable. Repeat CT head
revealed stable SDH. He continued on Keppra 500mg BID. He
complained of headache and neck pain.
On ___ He was neurologically intact. Neck and back pain
improved. Repeat CT head was stable. He was discharge home in
good condition with instructions for follow up. | 403 | 104 |
14076293-DS-14 | 21,281,818 | Dear Ms. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted to the hospital because you passed out
at your primary care doctor's office. We ran some tests, and we
do not think that your heart caused you to pass out.
You were also nausea and had vomited the day you passed out,
making dehydration a possible reason why you fainted, as well.
It will be VERY important for you to continue to eat and drink
well. You will also need to follow up with the infectious
disease doctors on ___.
We are also treating you for a infection in your urine. Please
take one more day of antibiotics tomorrow. | Ms. ___ is ___ with HIV/AIDs c/b toxoplasmosis on
high dose Bactrim therapy who is being admitted in the setting
of syncopal event at ___'s office, and concern for loss of pulse
and initiation of CPR.
# Syncope: Given the patient's history and being back to her
baseline so soon after this syncopal event, it is most likely
that the patient had vagal episode in the setting of hear bad
new about not being able to go back to ___ in ___. The
patient has also been having intermittent issues with nausea and
vomiting in the setting of her medications that could have led
to a orthostatic hypotensive event. The patient was mildly
orthostatic while here, and was given 2L IVF total during her
stay. Initial set of troponins were negative, ruling out cardiac
etiology of her syncope, and EKGs were consistent with priors.
No events were noted on telemetry. The patient did have dirty
UA, so possible that infection could have been contributing.
Upon discharge, the patient was walking around the floor without
any issues.
# pyuria: The patient was noted to have dirty UA, though
asymptomatic. In spite of being on high dose Bactrim, was
started on Ceftriaxone on admission. The patient was given 2
days of Ceftriaxone and discharged on one day of Cefpodoxime to
complete three day course. Urine culture was noted to be mixed
flora. Of note, TB can also lead to pyuria; she will need to
have repeat UA at ID appt on ___.
# chest pain: The patient has been having midsternal chest pain,
likely in the setting of chest compressions. No fractures noted
on chest film. EKGs unchanged, and cardiac work up was
negative, as noted above. The patient was given a lidoderm patch
for pain control.
#Nausea/vomiting/poor PO: The patient reports that she has been
taking good PO since leaving the hospital, and has been gaining
weight. She reports that she vomited once the morning of
presentation. She was continued on her home anti-emetics while
in house. She was tolerating POs without any issues.
# Toxoplasmosis: The patient is being treated with high dose
Bactrim for her toxo, in the setting of not being able to
tolerate first line therapy due to nausea. She was continued on
her high dose Bactrim therapy while in house. She has an ID
follow up appointment on ___.
# HIV/AIDS: Pt recently diagnosed and started on antivirals. She
was continued on her antiretrovirals while in house. She has an
ID follow up appointment on ___.
# Elevated LFTs: Labs revealed new elevated LFTs ALT 97 AST 119
and AP 114, which were trending down by discharge. It was
thought that these abnormalities could be medication related.
# anemia: The patient was noted to have crit drop from 35.4->
27.4 ->26.7. It was likely that the was hemoconcentrated on
presentation, and subsequent crits were dilutional. Rectal exam
was notable for brown, guiac negative stool. There was also
concern that she could be hemolyzing from her high dose Bactrim
therapy, but LDH and haptoglobin were both normal. | 118 | 512 |
11198855-DS-15 | 24,651,101 | Miss ___,
You were admitted due to significant back pain. We did imaging
on you which showed it is due to degenerative changes from
osteoporosis. You improved with pain medications and we are
sending you off on a good pain regimen.
However you also developed acute kidney injury in the hospital
linked to your multiple myeoloma. You were treated with fluids
and steroids and it resolved. A kidney biopsy was ruled out. We
started you on omeprazole for Gastrointestinal prophylaxis and
bactrim ___ and ___ for lung prophylaxis due
to the steroids you are meant to take every ___ and ___
morning (20mg of Dexamethasone)
We are sending you to rehab to help you regain your strength.
It was a pleasure being part of your care.
Your ___ team | ___ year old female with dementia, a history of R breast
carcinoma in situ (dx'd ___ ___, IgG lambda paraprotein who
is sent fromt he clinic for two days of acute, severe
lumbar/sacral back pain found to have osteoporetic compression
fractures
# Back Pain ___ Osteoporetic Compression Fractures: MRI spine
showed compression fractures at T12-L1 and multilevel
degenerative changes. There were no lytic lesions. Kyphoplasty
was rejected per family. Treated with pain meds. On a regimen of
Tylenol, Tramadol 50mg BID:PRN and Dilaudid ___ PO Q4H:PRN.
#Acute Renal Failure: Resolved. Patient had sudden rise of
creatnine from 0.8->3.0 on ___. It improved to baseline of
0.7 with fluids and dexamethasone 20mg IV daily for 4 days. Most
likely ___ was from dehydration/hypovolemia which caused
precipitation with cast nephropathy due to her multiple myeloma.
Was started on PPI and Bactrim prophylaxis. Bone marrow biopsy
was held off per family and team recommendations. Kidney biopsy
was also held off per family and team recommendations.
# Diarrhea: Resolved. Patient had significant bowel movements.
C.Diff ruled out on ___. Diarrhea was most likely in
setting of new PPI for prophylaxis due to steroids.
#Shortness of breath/hypoxia: Resolved and weaned off oxygen.
Unclear cause, most likely due to fluids. But had no oxygen
requirement the rest of hospital stay
#Dementia: Patient waxing and waning. Able to have normal
conversation and sometimes seems to have completely normal
mental status. However easily repeats things and at times
confused.
# Hypercalcemia: stable. previoulsy received zometa
## TRANSITIONAL ISSUES:
- Better pain control. On dilaudid 2mg Q4H, standing (patient
may refuse) Also on dilaudid 2mg-4mg Q4H:PRN
- F/u on free light chains ordered
- On Bactrim prophylaxis on ___ and ___
- On dexamethasone 20mg PO every ___ and ___ morning
- Omeprazole started for GI prophylaxis
- Please arrange ___ care for patient | 124 | 296 |
16974113-DS-3 | 23,989,389 | Dear Ms. ___,
You were hospitalized due to symptoms of R hand clumsiness and
speech problems resulting from an TRANSIENT ISCHEMIC ATTACK, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is temporarily blocked. The brain is the part of
your body that controls and directs all the other parts of your
body, so damage to the brain from being deprived of its blood
supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high cholesterol, cigarette use, pre-diabetes
We are changing your medications as follows:
Start atorvastatin 40 mg daily and aspirin 81 mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Ms. ___ is a ___ year-old female smoker who has a history of
hyperlipidemia and thyroid nodules who presented as a transfer
from ___ after few hours of right hand
clumsiness, slurred speech, and unsteady gait. Given the rapid
resolution of her symptoms and negative MRI, she was diagnosed
with a TIA. Etiology was determined to be atherosclerotic small
vessel disease. She was worked up for stroke risk factors (see
plan below). Her neurological deficits resolved and she was
safely discharged home.
- atorvastatin 40 mg daily for LDL 124 (new medication)
- aspirin 81 mg daily
- smoking cessation - patient was counseled and offered
cessation aids, though she declined these
- low carb diet - patient has been told she is pre-diabetic
although HgbA1c 5.6 (usually cutoff is 5.7), so reducing
carbohydrates in the diet can prevent her from becoming diabetic
- follow up in Stroke Clinic with Dr. ___ | 306 | 147 |
19526366-DS-21 | 23,960,844 | You were admitted with a partial complex seizure. You underwent
an EEG and an MRI of your brain. The preliminary EEG report did
not show seizure activity. The final results of the MRI are
pending and you should follow this up with Dr. ___. Your
zonisamide dose was increased to 450 mg at bedtime and Depakote
was added as a second medication. You should hold your aspirin
because it interacts with Depakote until you have discussed its
use with Dr ___ Dr. ___. Your decadron dose was changed
to 4 mg every morning.
.
YOU ___ OR OPERATE HEAVY MACHINARY
. | Assessment/Plan: Patient s/p recent ___ craniotomy for
excision of a left parietal grade I fibroblastic meningioma
admitted with partial complex seizures with tonic clonic
movements of RUE(new) and RLE(c/w prior sz activity). Treated
with ativan and valium at OSH and transferred to ___.
.
# Partial complex seizures: The patient was placed on bedrest
with seizure precautions. She had no further seizure activity
during her admission. Her presentation was reviewed with the
patient's primary neurologist, Dr. ___
neuro-oncology services (Drs. ___ with the
decision to treat her with a scheduled dose of ativan for two
days and increase her zonisamide to 450 mg QHS (a zonisamide
level is pending at discharge since it is a send out lab). A
repeat MRI was obtained and reviewed by Dr. ___. Preliminary
read did not show acute change or progression of the patient's
prior GBM or meningioma. An EEG was obtained and preliminary
review did not show frank seizure activity. The patient's
decadron was increased to 4 mg QAM. The patient was noncompliant
with seizure precautions throughout her hospitalization and
insisted that she wanted to leave the hospital before EEG or MRI
results were available. Her affect was confrontational, angry
and borderline inappropriate. She was evaluated by both
neuro-oncology and psychiatry and felt to be competent to make
her own medical decisions. Her preliminary EEG & MRI results
were available by the time of discharge and reviewed with the
patient. She was advised to contact Dr. ___ and Dr.
___ office to schedule follow up. She was also
started on Depakote as a second antiseizure medication at the
time of discharge per neuro-oncology consultation.
.
# Diabetes: Has been an issue on steroids but otherwise normal
serum glucose. She was followed with Finger sticks QACHS and
continued a normal diet.
.
# HTN: continued lisinopril- HCTZ.
.
# Asthma exacerbation: continued albuterol MDI and received
albuterol nebs Q6H prn
.
# chronic nausea: continued reglan 5mg BID
.
# Hyperlipidemia: continued simvastatin
.
# GERD: continued omeprazole 20 TID
.
# FULL CODE
.
# Precautions: fall and seizure
. | 98 | 370 |
13558097-DS-8 | 22,293,142 | You were admitted with fever however we did not find any sources
of infection. You were found to have low white blood cell count,
low red blood cell count, and low platelets. You received a unit
of blood and your white blood cell count improved quickly for an
ANC of 1,794! Your aspirin was held because of your low
platelets. Please talk to your doctor about when you can resume
aspirin. | Mr. ___ is a ___ w/ neuroendocrine pancreatic cancer s/p
recent cholangitis
and biliary stent placement who presented w/ neutropenic fever.
#Neutropenic Fever
He had no clear localizing signs/symptoms and was HD stable. Has
hx recurrent biliary obstructions/cholangitis and Pseudomonas in
___ but LFTs stable
and bili remains normal after CBD stenting on ___. ERCP team
did not feel strongly about RUQ imaging in absence of abd pain
or transaminitis. He was initially afebrile on cefepime/flagyl
but this was stopped on ___ as his ANC was 600+. He was
monitored for 24 hours without any further fevers and ANC rose
to 1,700 at time of discharge. Since all cultures NGTD he was
not prescribed any antibiotics. He did have thrush and was
prescribed nystatin will follow up with his oncologist.
#Pancreatic neuroendocrine carcinoma
Currently on palliative, topotecan. C2 due on ___ pending
resolution of cytopenias. Did receive neulasta w/ last cycle
#Chronic constipatio
Felt to be related to abdominal carcinomatosis. Reports BM now
regular qod cont colace, senna.
#Anemia. ___ marrow suppression from malignancy and chemo. Given
PRBCs ___, Hgb stable, another 1u on admission ___. Vit
B12/folate levels were WNL.
#Thrombocytopenia - holding ASA until Plt >30. He had no signs
bleeding,
#T2DM
We held metformin while inpatient and administered ISS.
#CAD/HTN
S/p CABG, currently stable. holding ASA as above. cont
isosorbide, losartan, HCTZ
DVT PROPHYLAXIS: due to TCP, TEDs placed
ACCESS: port
CODE STATUS: Full code
CONTACT INFORMATION: ___
Relationship: wife
Phone number: ___
___: >30 min were spent coordinating care for discharge | 71 | 240 |
16243656-DS-12 | 29,962,996 | You were admitted to the hospital after you fell off a ladder.
You were found to have a laceration to your liver, rib
fractures, a pelvic fracture, and fluid in your lungs. You had
a chest tube placed to remove the fluid. Since removal of the
chest tube,your vital signs have been stable. You have been
seen by physical therapy and cleared for discharged home with
the following instructions:
Because you had a liver laceration:
You sustained an injury to your liver/spleen. You should go to
the nearest Emergency department if you suddenly feel dizzy or
lightheaded, as if you are going to pass out. These are signs
that you may be having internal bleeding from your liver/spleen
injury.
Your liver/spleen injury will heal in time. It is important that
you do not participate in any contact sports or any other
activity for the next 6 weeks that may cause injury to your
abdominal region.
You also had rib fractures:
* Your injury caused right rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered. | The patient was admitted to the acute care service after a 20ft.
fall off a ladder landing on his left flank. THere was no loss
of consciousness. Upon admission, he was made NPO, and
underwent imaging. He was reported to have right rib fractures
___, a grade ___ liver laceration, a pelvic fracture, and an
apical pneumothorax and hemothorax. Because of his injuries, he
was seen by the Acute pain service for placement of a epidural
catheter for pain control. Intravenous analgesia was given for
the rib fractures and an epidural catheter was not placed. He
underwent serial abdominal examinations and serial hematocrits.
Despite a stable hematocrit he was found to have worsening of
the hemothorax and the decision ws made to place a chest tube.
A chest tube was placed on HD #5 with the removal of 2 liters of
bloody fluid. The chest tube was placed to suction and later
converted to waterseal. His hematocrits remained stable and the
chest tube was removed on HD #8. On HD # 9, he was reported to
have swelling of the right leg and he underwent an ultrasound of
his lower extremities which showed no deep vein thrombosis. His
pulmonary status remained stable with an improvement of his
chest x-ray.
The patient was evaluated by physical therapy and
recommendations were made for discharge home with physical
therapy. The patient's vital signs were stable and he was
afebrile. He was tolerating a regular diet and his pain was
controlled with oral analgesia. The patient was discharged home
on HD # 10. Appointment for follow-up was made with the acute
care and orthopedic service. | 558 | 289 |
19385269-DS-20 | 26,725,668 | 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:
Pt may bear weight on the affected extremity as tolerated.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
Antibiotics:
You will be discharged on a 6 week course of ceftriaxone 2g IV
daily for which you have been given a picc. You should follow up
with the OPAT ID physicians who will contact you.
ANTICOAGULATION:
- Please take Lovenox 40mg 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.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
Activity as tolerated
Right lower extremity: Full weight bearing, range of motion as
tolerated.
Treatments Frequency:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
NAFCILLIN,CEFTRIAXONE,MEROPENEM,ERTAPEMEN: WEEKLY: CBC with
differential, BUN, Cr, AST, ALT, TB, ALK PHOS
*PLEASE OBTAIN WEEKLY ESR/CRP | Hospitalization Summary
The patient presented to the emergency department for pain and
purulent drainage from a recent arthroscopy incision and was
evaluated by the orthopedic surgery team. The patient was found
to have a septic joint and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for arthroscopic irrigation and debridement of his
infected joint, 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. Aspirate of the joint fluid
resulted KLEBSIELLA OXYTOCA. The patient was started on
ceftriaxone and was monitored for signs of infection. A picc was
inserted and the patient was scheduled for follow up with OPAT
with antibiotics as an outpatient. The patient worked with ___
who determined that discharge to home with at home intravenous
services was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the affected extremity, and will
be discharged on enoxaparin for DVT prophylaxis and ceftriaxone
for antibiotic treatment of his infection.. The patient will
follow up with Dr. ___ original orthopaedic surgeon at
his office on ___. 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. | 256 | 330 |
10090148-DS-12 | 26,354,377 | Dear Mr ___,
WHY YOU WERE ADMITTED TO THE HOSPITAL
- You had a fall after which you developed a small bleed in your
brain
WHAT WE DID FOR YOU HERE
- We checked your imaging and had the neurosurgeons evaluate
you. They said the bleed was stable and there is no need for
intervention or further imaging
- We stopped your aspirin with the bleed and your low platelet
counts
- You were monitored on telemetry and had your ICD interrogated
that showed no abnormal heart rhythms
- You had an echocardiogram of your heart that was stable from
your prior echocardiograms
- Your ___ laceration showed evidence of infection and you were
evaluated by the ___ Surgeons. An xray of the ___ was negative
for any fracture or infection in your bone. You will take a 7
day course of an antibiotic called Clindamycin to treat the
infection and continue an ACE-wrap ___ elevation to
help with your swelling.
WHAT YOU SHOULD DO WHEN YOU LEAVE
- You should continue taking all your medications as prescribed
- You should follow up with your primary care doctor,
___, and ___ specialist
- You will need to keep an ACE compression bandage on your left
wrist and elevated your ___ as much as possible to help relieve
the swelling in your left ___. Please follow-up with the ___
Surgeons for monitoring of your wound.
-Please use your 2L of oxygen at all times to ensure your oxygen
levels stay at a safe level
WHEN YOU SHOULD COME BACK
- If you are experiencing headache, dizziness, weakness,
paresthesias, visual changes, shortness of breath, chest pain,
fevers, chills, worsening left ___ swelling, pain, redness, or
any other symptoms that concern you
It was a pleasure caring for you here!
Sincerely,
Your ___ Team | Mr. ___ is a ___ with ischemic HFrEF 40% s/p ICD, HTN, HLD,
COPD on O2 overnight intermittently, macular degeneration,
hearing impairment, pAF on ASA who initially presented to an
outside hospital after suffering a fall found to have a small
intraparenchymal hemorrhage on CT head and a left ___
laceration (repaired at OS___) prompting transfer to ___. Upon
arrival to ___, she was evaluated by the neurosurgery team who
deemed that no further intervention or imaging was needed. He
was admitted to the medicine service for further monitoring.
His hospital course was complicated by cellulitis of the left
___ laceration site initially on vancomycin/clindamycin (severe
PCN allergy) later transitioned to clindamycin alone per ___
Surgery recommendation.
# Intraparenchymal hemorrhage: Patient found to have small right
frontal intraparenchymal hemorrhage 1.6cm s/p fall. Evaluated by
neurosurgery, with recommendations for no acute intervention and
no keppra prophylaxis. Patient without headache or focal neuro
deficits. Held home aspirin in the setting of thrombocytopenia
and bleed. Will need to discuss restarting aspirin as an
out-patient given underlying risks of bleed with fall and
thrombocytopenia versus known CAD.
# Fall
# ?Syncope
As per patient report, fall sounds mechanical in nature as
patient says his right leg tripped on the side of the rug in the
setting of neuropathy in that leg. Denied prodromal or
neurologic symptoms prior to or after the incident. No SOB, CP,
palpitations, dizziness, warmth, post-ictal confusion,
incontinence, or other concerning symptoms. With history of VT
and pAF but no arrhythmias or therapies detected on ICD
interrogation. EKG without concerning findings other than PVCs.
TTE with EF 40% and mild-mod MR but no other significant
valvular pathology. Trop negative and no ischemic signs on EKG
to suggest MI. No hypoxia/tachycardia to suggest PE. No report
of LOC, patient remembers falling and getting up. Monitored on
telemetry with no acute events. Orthostatics negative, ___
cleared for discharge. Will need close monitoring as an
out-patient.
# Left wrist laceration c/b cellulitis: Patient suffered a left
___ laceration with the fall (injury caused by the watch he was
wearing) which was repaired at the OSH. He developed increased
swelling, pain and erythema along the ___ and suture site with
concern for cellulitis. ___ surgery was consulted and xray
imaging was negative for any fracture, subcutaneous gas, or
osteo. He was initially on Clinda/Vanc IV later transitioned to
clindamycin PO for planned 7 day course (clinda chosen as he
cannot take beta lactams given allergy, or fluoroquinolone given
QTc concerns on sotalol, and Bactrim would not adequately cover
streptococci), and clindamycin monotherapy would cover CA-MRSA,
MSSA, streptocci, and anaerobes. Will continue to apply
ACE-wraps and elevate the ___ to ensure swelling improves.
Will need stitches to be removed ___ with planned follow-up
with PCP and ___ surgery for further monitoring. Of note,
patient received tetnus booster while at ___.
# Positive UA: asymptomatic with no dysuria, hesitancy,
frequency. Afebrile, HDS. In the setting of the fall treated
empirically with ceftriaxone in the ED. Given lack of symptoms,
however, further antibiotics for UTI were held. Urine culture
positive for gram positive bacteria, speciation with mixed flora
and the patient remained asymptomatic. His home finasteride and
terazosin were continued for his BPH.
# pAF: patient with history of PAF on past device checks, not on
most recent interrogation but irregularly irregular on exam.
High risk to start anticoagulation due to history of hematuria,
thrombocytopenia, and bladder cancer. CHADsVASc 5. Continued
sotalol. Held aspirin in the setting of thrombocytopenia and
fall with hemorrhagic bleed.
# Thrombocytopenia: patient with history of
thrombocytopenia/pancytopenia of unclear etiology, however, have
a high suspicion for MDS given relative pancytopenia. Last plt
count 74 in ___. Now down to 40-50s. Held subQ heparin with
plat<50, and held aspirin with ICH. Will need repeat CBC within
1 week of discharge and consider further work-up as out-patient
if within goals of care. He is pancytopenic, and this is most
likely due to MDS given his age - it was our understanding that
he had previously declined bone marrow biopsy and further
evaluation, which seems reasonable (to defer) given his age and
comorbidities.
# HFrEF (EF 40%): Stable during this admission and continued on
home furosemide 40mg daily, lisinopril 40mg daily, and sotalol
120mg BID. Desatted to the ___ with ambulation so will discharge
on home oxygen 2L to be used continuously.
# VT s/p ICD placement on sotalol: patient with no events or
therapies recorded on recent ICD interrogation. Patient denies
LOC or palpitations. PVCs on EKG. Maintained on home sotalol.
# Small pericardial effusion: noted on TTE, HDS stable without
concern for tamponade physiology. Unsure etiology but could be
malignant vs transudative volume from CHF. Stable from prior TTE
imaging.
# Pleural effusion: Known moderate right sided pleural effusion
on CT torso. Etiology unclear but likely volume from HFrEF or
malignant effusion in the setting of lung nodules. Patient was
discharged on 2L NC with plans to follow-up with PCP and
cardiologist for further monitoring.
CHRONIC ISSUES
================
# CAD: continued rosuvastatin daily. Held aspirin iso
thrombocytopenia and ICH
# COPD: continued albuterol prn, symbicort BID, Spiriva daily
# HTN: continued amlodipine and lisinopril
# CT Chest Findings: moderate right sided pleural effusion with
RLL relaxation atelectasis, moderate pericardial effusion,
re-demonstration of bilateral pleural plaques. Also with LLL
nodule mildly increased in size since ___ (15mm), 10mm nodule
in RUL unchanged since ___. Patient has been on oxygen and
discharged on oxygen with ambulation. Hemodynamically stable
with no findings of diastolic LV/RV/RA collapse concerning for
tamponade on echo. Will need outpatient follow up for nodules.
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 158.07 lb
NEW MEDICATION:
home oxygen continuously
Clindamycin (___)
STOPPED MEDICATION:
aspirin 81mg daily
[] discharged to use oxygen at home continuously
[] left wrist laceration stitches to be removed by ___, follow
up ___ clinic
[] will need to have left limb wrapped from ___ up to elbow
with ACE compression, with dry gauze dressing underneath, and
careful surveillance by ___ of the edema and erythema for
resolution of cellulitis.
[] follow up of CT torso findings including nodules, pleural
effusion, and small pericardial effusion
[] follow up neuro exam to monitor for changes in the setting of
ICH
[] follow up CBC in 1 week to monitor pancytopenia, stable this
admission
[] please have ___ monitor for headache, dizziness, vision
changes, focal neurologic findings (concern for worsening of IPH
iso thrombocytopenia); also look for increase in weight,
shortness of breath for HF signs; worsened arm swelling,
erythema, tenderness, fevers (to suggest progression of skin and
soft tissue infection) | 286 | 1,079 |
12606543-DS-62 | 26,425,985 | It was a pleasure taking care of you while you were admitted to
___. You were admitted to the
hospital for increased lower extremity edema and hypoxia and
concern for CHF exacerbation. You were also noticed to have an
elevated white count and your urinalysis was concerning for
another UTI. You were given antibiotics for your infection and
given lasix and metolazone to help with your diuresis. We were
also concerned for a bateria called pseudomonas growing in your
sputum, so we are treating you with 8 days of IV antibiotics.
Your discharge weight was right at your dry weight of 227 lbs.
You will follow up with Dr. ___ as well as with ___
in heart failure clinic. | ASSESSMENT AND PLAN: Ms. ___ is a ___ y/o female with a history
of diastolic heart failure presenting with worsening lower
extremities edema concerning for acute on chronic right sided
heart failure.
# Acute on Chronic right sided heart failure: Resolved with
diuresis. Baseline sats 86-92% on 2L nasal cannula while awake
and desats while sleeping. Currently in the range of her dry
weight, 227 lbs. She was initially started on metolazone 5mg PO
30 minutes prior to afternoon dose of lasix and lasix 80mg IV
BID. Her I/O's were closely followed and she had a Foley in
place. She was not diuresing well and so we increased her lasix
to 100mg IV Q8H and metolazone 5mg PO BID. Despite her weight
not decreasing, her lower extremity edema seemed to be
improving. After ___ days of aggressive diruesis, her
creatining improved, but she started to develop a contraction
alkalosis and we decreased her diuretic regiment to lasix 80mg
IV BID and metolazone daily. Eventually she was transitioned to
a PO regiment of 100 mg torsemide, 2.5 metolazone 3x/week. By
discharge, she returned to her dry weight of 227 pounds. She
was trialed briefly on acetazolamide, however, developed
tranisent thrombocytopenia, so this was stopped. She will have
a follow up appointment with her ___ NP, ___
___, within the next week.
# Pseudomonas from sputum culture: Patient was producing very
thick green sputum from her trach. Despite this, given the
appearance of the sputum and her leukocytosis we sent off sputum
culture that is now growing gram negative rods, speciated to
pseudomonas, R to cipro, sensitive to cefepime. PICC line was
placed and she was started on cefepime for 8 days, first day
___, last day ___.
# Thrombocytopenia: Platelets decreased to 122 from the mid ___
in one day following initiation of acetazolamide. Upon
cessation, platelet count reurned to 203.
# Pulmonary HTN/OSA with cor pulmonale: Patient is s/p trach
which
she uses at night. She was restarted on her sildenafil during
her last hospitalization. Her home O2 requirement is about 2L.
She was continued on Sildenafil 20 mg PO TID.
# UTI: Growing providencia Stuarti the same resistence pattern
as her last urine culture. Initially on ceftriaxone, then
cefepime for + sputum culture as above.
# Gout: She was continued on her home dose of prednisone and
allopurinol.
# Elevated A1c and blood sugars: Last A1c 6.9%. Patient had
multiple blood sugar readings in the 200s - 300s; however were
mostly stable. She continued to insist that she does not have
diabetes and refused to be placed on an insulin sliding scale.
To be followed as an outpatient.
# Transitional Issues:
- Cardiology follow up appointment is very important for patient
to get to for management of her heart failure
- Cessation of PICC line with last dose of IV antibiotics on
___ for Pseudomonas PNA
- repeat CXR to assess for resolution of left lower lobe
infiltrate seen on CXR from ___ and ___ | 125 | 513 |
16664482-DS-18 | 28,206,996 | Dear ___
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
You were in the hospital because you were having chest pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
You had a procedure done to open up a blockage in a major artery
in your heart. During that procedure, a much smaller artery was
blocked off in order to save the larger one. That procedure was
partly responsible for the chest pain you had the night after
the procedure.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You should take all of your medicines as directed by your
doctors and make sure to go to all of your follow-up
appointments.
It is very important to take your aspirin and clopidogrel (also
known as Plavix) every day.
-These two medications 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.
-Please do not stop taking either medication without taking to
your heart doctor.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | Mr. ___ is a ___ y/o man with a history of HTN, HLD, sickle
cell trait who presented with chest pain s/p DES to LAD with
jailed D1 who had post-cath MI.
-CORONARIES:
The LMCA has 30% distal stenosis.
The LAD has a 90% proximal stenosis. additional 70% stenosis
very
distally in the LAD
The ___ Marginal has 40% ___ stenosis.
The RCA has 30% stenoses
-PUMP LVEF 65%
-RHYTHM: NSR
#Type IV NSTEMI
#CAD
#Chest pain: Patient presented to the hospital with atypical
chest pain more severe than his past episodes, initially
relieved with nitro. At presentation, troponin was negative and
there were no EKG changes. He underwent catheterization with DES
to LAD complicated by jailed D1. The night after cath, his trop
elevated to 2.4 with peak MB ___levation in V1 and V2
consistent with post-procedural MI. EKG changes resolved and
trops trended down during admission. Possible that the patient
also had post-mi pericarditis as pain is positional. He was
started on ASA and Plavix and continued on metoprolol succinate
25 mg. His atorvastatin was increased to 40 mg/day. An
echocardiogram showed mild pulmonary hypertension, normal
systolic function and mild LVH.
#Hypertension: Patient's BP slightly elevated on arrival to the
floor to 165/75. He was restarted on his home amlodipine and
metoprolol. His lisinopril was changed to ramipril and bp
normalized.
#Dyslipidemia: Non-HDL goal < 130 mg/dL, Previously on 10 mg
atorvastatin. Atorvastatin was increased from 10mg/day to
40mg/day.
___ Esophagus: ___ be a source of his non-anginal chest
pain. He was continue on home omeprazole, ranitidine, sucralfate
#Normocytic anemia: Patient has sickle cell trait. HGB stable at
11.6. Was 11.4 in ___. No interventions this admission.
#BPH: home Flomax was continued.
TRANSITIONAL ISSUES
[ ]Patient should continue taking aspirin and Plavix 75mg/day
until further instructed by cardiology.
[ ]Topical diclofenac has been discontinued until discussion
with outpatient cardiologist.
[ ]Lisinopril was discontinued and patient was started on
Ramipril 5mg daily.
[ ]Atorvastatin was increased to 40 mg daily.
[ ]Patient should get cardiac rehab coordinated by his
cardiologist.
[ ]Can consider colchicine if symptoms resemble pericarditis in
the setting of recent MI.
Discharge creatinine: 1.1
Code status: Full code | 222 | 345 |
16901707-DS-42 | 21,967,022 | Thank you for letting us take part in your care at ___
___. You came to the hospital because you
fell and fractured your ribs. Your rib fractures will heal on
their own, so you were given medications to manage the pain.
While you were here, your insulin regimen was decreased and you
were started on vitamin D. While you were here a CT of your
chest showed a small nodule in your lung. It is recommended
that you repeat the chest CT in 6 months to re-evaluate it.
While you were in the hospital, the physical therapists worked
with you and think that you will need 24 hour supervision while
at home to prevent you from working. We met with your husband
and spoke with your daughter who agreed to help you with this.
You should follow up with your primary care doctor in one week.
The following changes were made to your medications:
STOPPED bedtime NPH.
DECREASED morning NPH to 25 units.
***You should only take NPH in the morning now. This will
prevent your blood sugars from dropping too low. Do not use
sliding scale insulin (insulin lispro) at home. Please keep a
log of your blood sugar measurements at bring them to Dr.
___ office at your next visit.
STOPPED gabapentin
STOPPED metoprolol tartrate
STARTED metoprolol succinate XL 100mg by mouth daily
STARTED calcitriol 0.25mg by mouth daily
DECREASED aspirin to 81mg by mouth daily
STARTED lidoderm 5% patch, apply to affected area daily, 12
hours on, 12 hours off, as needed for pain
STARTED oxycodone 5mg take ___ tab every 8 hours as needed for
pain
STARTED docusate 100mg by mouth twice a day as needed for
constipation
STARTED senna 8.6mg 2 tabs by mouth daily as needed for
constipation
STARTED bisacodyl 10mg 1 tab suppository daily as needed for
constipation | ___ year old female with extensive past medical history
presenting to the ED s/p fall from standing with trauma to L.
chest secondary to the fall.
# FALL: Patient underwent basic trauma work-up including
CT-cervical spine which was negative for fracture or
dislocation. CT head was also negative for acute intracranial
hemorrhage or mass effect (note evidence of prior MCA infarct).
CT of the chest was obtained which demonstrated displaced
fractures of the ___ and 8th ribs on the left with a
non-displaced fracture of the 9th rib. The patient was otherwise
hemodynamically stable and at baseline mental status. She was
admitted to the ACS service for 24 hour observation given her
traumatic fall. Overnight the patient did well: remained stable
with pain adequately controlled with combination of
Oxycodone/Morphine/Acetaminophen, and saturation >95% on room
air. On hospital day 2 a tertiary trauma survey was completed
which was negative for further injury, and given her numerous
medical comorbidities, it was determined appropriate to transfer
the patient to the medical service for further work-up as to the
source of her falls. On transfer to medicine, patient was
stable and complaining only of rib pain with movement. This was
managed with good relief with tylenol, lidoderm patch, and
oxycodone. Work up to further evaluate cause of falling revealed
low vitamin D and elevated PTH. Started patient on calcitriol
supplement due to her ESRD. CK was WNL. Pt reported low blood
sugar at the time of the fall, so her insulin regimen was
titrated down. Stopped evening NPH administration and decreased
AM NPH to 25 units. Pt does not use sliding scale at home.
Also adjusted other medications - stopped gabapentin. Switched
metoprolol tartrate 50mg po TID to metoprolol succinate 100mg po
daily. Allowed pressures to run in SBP 160s-170s since pt has a
tendency toward orthostasis and tight BP control was thought to
have posssibly contributed to her falls. Also performed MoCA
and pt scored very poorly - ___ with deficits in visuospatial
skills, abstract reasoning, memory, and concentration. Husband
insisted pt not normally like this - informed him the test can
be repeated as an outpatient to compare patient's cognitive
abilities outside of an unusual environment. Physical therapy
and occupational therapy were consulted. Though rehab and 24
hour care would be optimal, pt and husband cannot afford this so
a family meeting was held and plan was made for 24 hour home
supervision. ___ and OT will visit home and help rearrange
furniture and work with patient on strength exercises. Husband
will arrange shifts with daughter to watch patient. Patient
already has a walker at home - arranged for a wheelchair for
better transport to and from home and when out of house.
# DM2: Husband notes AM ___ are 120-130s usually, though the
morning of the fall, her ___ was 82. ___ are 300s per husband.
Stopped ___ NPH administration as above and decreased AM NPH from
30 units to 25 units. Pt does not use sliding scale at home.
She will monitor her fingersticks and follow up with Dr.
___ further diabetic management.
# CAD s/p CABG and PCI: asymptomatic. continued atorvastatin,
clopidogrel, metoprolol, aspirin.
# dCHF: continued metoprolol, lisinopril.
# HTN: Switched metoprolol tartrate 50mg po TID to metoprolol
succinate 100mg po daily. Allowed pressures to run in SBP
160s-170s since pt has a tendency toward orthostasis and tight
BP control was thought to have posssibly contributed to her
falls. continued lisinopril, nifedipine.
# PVD, h/o CVA: continued atorvastatin, aspirin
# ESRD on HD: continued Dialysis MWF, Nephrocaps. Started
calcitriol 0.25mg po daily.
# Peripheral neuropathy: stopped gabapentin
# Pulmonary Nodules: incidental finding on CT chest. New 4-mm
nodule in the right upper lobe for which 6-month follow-up was
recommended. Imaging was compared to prior CT chest in ___.
Also noted a second 4mm RUL nodule that has been stable from the
___ CT. | 300 | 684 |
11689905-DS-3 | 28,022,233 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per ___ regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE: Upper back.
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Dry sterile dressing changed as needed over surgical site | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have a right femoral neck fracture and was admitted to the
orthopaedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated right lower extremity , and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 604 | 255 |
16715999-DS-24 | 28,512,324 | Dear Mr. ___,
It was a pleasure being involved in your care.
You were admitted due to recurrent upper back pain and anterior
chest pain accompanied with L hip pain likely due to worsening
of your known ankylosing spondylitis.
You were admitted and were initially treated with IV pain
medications in the Emergency room, and then transitioned to oral
pain medications once you were on the general medication
service. During your stay, the Chronic Pain service was
consulted and you underwent trigger point injections, which
provided some improvement in your pain. You were further
stabilized on an oral regimen of Dilaudid, Tylenol, Cymbalta and
topical Lidocaine cream.
As your pain has improved, you are asked to continue this
regimen and followup with your PCP for further management of
your medications, as well as present to the ___ Pain ___ to
establish a multi-modal approach to your pain including
evaluation for further trigger point injections, management of
your medication regimen, and working with social work and a Pain
psychiatrist to continue to optimize your pain and anxiety.
Please take your medications as listed below, and followup with
the appointments that have been arranged on your behalf.
It was a pleasure being involved in your care.
Your ___ care team | Mr. ___ is a ___ PMHx of HLA-B27-positive ankylosing
spondylitis, not on immunosuppressive agents (with prior failure
of sulfasalazine, etanercept, adalimumab, infliximab, golimumab)
with multiple hospitalizations for back pain and abdominal
pain/n/v with recent discharge on ___ for recurrent back
pain, now presenting with worsening upper back pain and anterior
chest wall/sterncostal articulation pain for the past 6 days and
2 days of significant hip pain likely due to worsening of known
ankylosing spondylitis in the setting of not being on
immunosuppressive therapy and recent narcotic tapering and
adjustment of adjunctive pain medication regimen.
# Back pain
# Anterior chest wall / sternocostal articulation pain
# Ankylosing spondylitis.
Patients presentation and exam was notable for joint pain
tenderness over the T1-T4 and T10 transverse processes,
tenderness diffusely over the anterior chest specifically at the
sternocostal articulations, and L hip pain. Patient had no focal
neurologic deficits, with no issues with urinary/stool
continence, full strength and no parasthesias in the upper or
lower extremities making cord compression an unlikely etiology,
and lab workup was reassuring making infectious etiology/abscess
unlikely. With regards to pts chest pain, his pain was worsened
with palpation at the sternocostal articulations indicating a
MSK etiology rather than cardiogenic in nature. Reassuringly,
patients EKG was unremarkable with no evidence of acute ischemic
changes. Patients current presentation is likely due to
worsening of his known Ankylosing spondylitis pain while not on
an immunosuppressive agents, and may have been further
worsesned./exacerbated in the setting of downtitration of his po
dilaudid and weaning from sertraline to cymbalta. Patient has
had frequent hospitalizations for back pain, with patient
evaluated by the chronic pain service during his ___ and
___ admissions. Unfortunately pt remains uninterested in
trying any biologic treatments given concern for infection,
making control of his inflammatory arthropathy difficult in this
setting, as patient has declined all immunosuppressive therapy
and has continued only opioid based pain control. On this
admission, pts ESR was elevated to 74, which is the highest it
has been previously (previously ranging from 40-50, as high as
68 in ___ and CRP also elevated to 18.1 (highest it has been
since ___, where it was 35.7). Elevation of inflammatory
markers may be consistent with worsening of his underlying
ankylosing spondylitis. Pt was stabilized on a regimen of
Dilaudid 8mg q4h, Tylenol 1gm q8h and topical lidocaine cream.
Patients Cymbalta was further increased to 30mg BID. Patient was
further evaluated by Chronic Pain service who carried out
trigger point injections which provided considerable reduction
of patients pain. Plan was made for patient to continue on
Dilaudid 8mg q4h, and to be seen in Chronic pain clinic to
establish a mutli-modal approach to his pain by assessing his
pain medication requirement, repeat of trigger point injections
on an as needed basis, working with pain psychiatrist for CBT
and biofeedback as well as social work to work on his anxiety
and pain requirements. Patient was agreeable to this approach,
and plan was made for patient to be discharged with followup
appointments with his PCP and to be seen in pain clinic.
Furthermore, patient was advised to work with his outpatient
Rheumatologist to consider alternative immunosuppressive
regimens, although currently he is currently resistant to
initiating any new disease modifying therapies at this time.
# BLE edema: on this admission, pt was continued on home Lasix
20 mg daily
# HTN: on this admission, patient was continued on home
lisinopril 20mg daily
# Asthma: on this admission, patient was continued on home
albuterol, budesonide, ipratropium and Montelukast regimen
# Anxiety: on this admission, patients Cymbalta was increased to
30mg BID (as note above) | 201 | 594 |
14252938-DS-18 | 23,693,172 | Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to a femur fracture. This was
repaired by the orthopedic surgeons. After the repair you had
ileus (decreased bowel function), vomiting, and were confused.
These improved with ___ medical care.
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:
- Touchdown weight bearing in unlocked ___ brace, range of
motion as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- **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.
- Please take ciprofloxacin (a new antibiotic) for 7 days (until
___ for possible urinary tract infection.
ANTICOAGULATION:
- Please continue to take your home Coumadin and follow up with
your ___ clinic as usual.
- You will continue to receive enoxaparin (Lovenox) shots during
rehabilitation.
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.
RESPIRATORY:
- Please continue to use the continuous positive pressure (CPAP)
machine at home at night. This will help you breathe at night
and keep you healthier long term. Obstructive sleep apnea can
lead to lung and heart problems if untreated long-term. | Mr. ___ is a ___ y.o. M with a history of afib on
Coumadin, DVT (___), HTN, COPD, OSA on CPAP, T2DM on metformin
who presents with femur fracture.
# R femoral fracture: ORIF performed ___. He was evaluated by
physical therapy and should follow up in orthopedics clinic.
# Coffee-ground emesis: Most likely cause is microbleeding in
the setting of postoperative ileus/vomiting, anticoagulation,
and possible EtOH gastritis. This resolved with supportive care.
EGD deferred until outpatient given patient stability. He
received Protonix IV BID while inpatient which was transitioned
to PO before DC. Warfarin was held and Lovenox SC continued due
to recent ortho procedure; anticoagulation resumed prior to
discharge.
# Abdominal distention: Likely postoperative ileus. KUB with
grossly dilated loops of bowel c/w post-operative ileus. This
resolved with bowel regimen including tap water enema, senna,
colace, and lactulose.
# Altered mental status: Likely postoperative delirium vs ETOH
withdrawal. He received 1 dose of diazepam on ___, and mental
status improved thereafter.
# A-fib: Failed cardioversion previously. He had episode of
A-fib with RVR rates 140s, resolved with 5mg IV metoprolol. His
PO metoprolol dose was increased to 25mg Q6H.
# Intermittent O2 requirement: Likely in the setting of
atelectasis from being bedbound since trauma. CXR with RLL
atelectasis v. PNA. Improved with incentive spirometry and
albuterol nebulizers, as well as resumption of CPAP overnight.
# Macrocytosis: Likely in the setting of chronic EtOH use versus
B12 deficiency versus reticulocytosis ___ acute bleed post-op.
Alcohol-induced macrocytosis occurs even in patients who are
folate and cobalamin replete and do not have liver disease.
Abstinence from alcohol results in resolution of the
macrocytosis within two to four months.
# HTN:
Continued Amlodipine and metoprolol.
# UTI: ___ complained of urinary urgency and frequency after
DC'ing Foley. UA with sm leuk, +9 WBCs, few bacteria. Bladder
scanned with e/o urinary retention (584cc), but he was able to
void ___ and refused replacement of Foley. He was initiated on
ciprofloxacin 500mg BID for seven days (last day: ___. | 304 | 332 |
13303049-DS-23 | 24,587,521 | Dear Mr. ___,
It was a pleasure being involved in your care.
Why you were here:
-You came in to the ___ ED from the ___ Ophthalmology
clinic for a loss of vision in your left eye that had not fully
resolved after a month.
What we did while you were here:
-We consulted with specialists in Neurology,
Neuro-ophthalmology, Rheumatology, and Vascular surgery
regarding your care.
-We treated you with high dose steroids to reduce any
inflammation in the blood vessels leading to your eyes, which
could have been causing your vision loss.
-We scanned the blood vessels in your head and neck to see if
anything could be cutting off the blood supply to your eye, but
we did not find anything.
-We scanned your brain to see if there was anything compressing
the nerve that allows you to see, but we did not find anything
that could be causing your loss of vision.
-We scanned your heart to look for sources of a possible clot
that could have traveled to the small blood vessels in your eye
and blocked them off, but there was nothing in your heart that
we believed could have led to a clot.
-We biopsied your temporal artery to test for a condition called
giant cell arteritis, which might have been causing your vision
loss. This biopsy should result next week.
-We changed your insulin regimen. Please follow the regimen
outlined below. Please call the ___ if your
blood sugars are running less than 80 or higher than 180.
INSULIN REGIMEN:
Levemir 25 units (u) Breakfast and Nighttime
Novolog 0 Units Breakfast
Novolog 7 Units Lunch
Novolog 7 Units Dinner
Plus Novolog sliding scale with meals (not at bedtime):
71-150: 0u
151-200: 1u
201-250: 3u
251-300: 5u
301-350: 7u
351-400: 9u
Your next steps:
-Take all of your medications as prescribed.
-Follow up with your physicians at the follow up appointments we
have scheduled for you.
We wish you well,
Your ___ Primary Care Team | SUMMARY
=======
Mr. ___ is a ___ year old man with CAD, ESRD (MWF),
OSA, HTN, DM (on insulin), CHF, glaucoma and cataracts who was
sent in from ___ for evaluation of left visual loss with
elevated ESR c/f GCA vs. embolic disease. Patient was initiated
on pulsed steroids with questionable mild improvement in vision.
Neuro-ophtho evaluation confirmed left central retinal artery
occlusion. TTE unimpressive for embolic sources. Temporal artery
biopsy was performed and was pending on discharge. Plan to
continue on 4 week course of high dose prednisone following
discharge, with further outpatient workup for possible embolic
sources.
ACUTE ISSUES
============
#Left Eye Central Vision loss
#Elevated ESR with normal MRI orbits:
Patient with ~1 mos vision loss of left central visual field.
Initial concern for vitreous hemorrhage as etiology when seen in
outpatient setting, but visual loss persisted after hemorrhage
resolution, prompting further work up. ESR was obtained and was
elevated which prompted patient's admission to the hospital
given concern for possible GCA versus other etiology.
Differential was initially broad, including optic nerve
compression and chronic optic neuritis. However, MRI was
negative for these etiologies and patient underwent further
evaluation by neuro-opthalmology who confirmed patient had
central retinal artery occlusion. Considered likely GCA vs.
embolic disease. Vascular, Rheum and Neuro were consulted.
Temporal artery biopsy was performed ___, results pending on
discharge. Started on 1g IV methylprednisolone ___ x3 days and
transitioned to projected 4 week course of high dose prednisone
(60 mg) (D1: ___. Plan to continue course regardless of
temporal artery biopsy results as biopsy is not ___ sensitive
and the risk of withholding treatment is high. Of note, elevated
ESR could be due to psoriasis with recent worsening per patient
rather than GCA. TTE was unrevealing of embolic source. Please
refer patient for outpatient holter to r/o AFib per
neuro-ophthalmology recommendations. Started Bactrim and
Omeprazole for PPX while on high dose steroids.
#DMII:
Consulted ___ given elevated blood glucose on steroid. Blood
sugars very challenging to control during admission with patient
initially hyperglycemic and then intermittently hypoglycemic.
Patient's sugars well controlled on discharge with ___
educating patient on warning signs. Patient scheduled for ___
follow up in the outpatient setting. On the day after
discharge, pt was instructed to resume Levemir 25units BID with
Humalog 7units before lunch/dinner only. Pt will continue to
monitor his BG four times daily and is comfortable adjusting his
sliding scale with meals if needed.
#ESRD, HD Dependent (___)
Still makes urine. Missed dialysis on ___. Received 2
consecutive days of dialysis following administration of
gadolinium contrast for MRI. Underwent dialysis session on ___
which returned patient to home ___ schedule. Patient should
continue taking Nephrocaps capsule.
#Psoriasis:
Involvement of bilateral upper and lower extremities. Per
patient recent worsening with now lateral aspect of right lower
extremity with numerous new plaques. However, some improvement
over this hospitalization after initiation of corticosteroids.
Patient does not regularly follow with a dermatologist and is
not on any therapies besides home light therapy. Patient is not
a candidate for certain systemic treatments due to renal disease
but could potentially qualify for treatment with a biologic
agent (TNF-a inhibitor) which may be beneficial not only in
terms of psoriasis control but also in terms of controlling
systemic inflammation and risk of additional events. (Ref ___:
___. Dermatology consulted after initiation of
corticosteroids for several days and stating mild involvement at
that time with recommendations for topicals and outpatient
follow up. Of note, patient discharged on high dose
corticosteroids. Cessation of this treatment will be performed
with dermatology closely following as it can lead to acute onset
generalized pustular psoriasis which can be quite serious.
Recommended patient continue light therapy. He will have ___ to
assist with medication application.
#Seborrheic dermatitis/sebopsoriasis of the scalp and face.
Dermatology recommended Ketoconazole shampoo. | 330 | 630 |
10933609-DS-62 | 20,974,196 | Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted with right sided chest and rib
pain. You had multiple tests including EKG and blood tests to
check for heart problems, CT scan to check for PE (pulmonary
embolism), chest xray to check for infection, and rib xrays to
check for fracture. All these tests were normal. Your liver
tests were also normal.
You had an episode of lethargy and low blood pressure. This was
due to too much pain medication, but you were treated for this
and improved immediately.
You were found to have a blood clot in your left arm and were
started on lovenox. You should take this for three months and
follow up with your doctor to determine if you should continue
with your treatment.
We changed your tube feeds to adjust for your slightly elevated
potassium.
Please make sure to call your primary care doctor,
___, and your other specialists to make follow up
appointments on ___. | ___ w/ complicated PMH significant for multiple abdominal
surgeries, bipolar disorder, several past aspiration pneumonias
requiring intubation with recent multifocal pneumonia and L arm
DVT, now presenting with R lateral chest pain for three days.
# Chest pain - Patient with no evidence of cardiac involvement
with normal cardiac enzymes and unchanged EKG. He also had
negative CTA for PE, which is also unlikely given his normal
vital signs. He had no signs/symptoms of infection with no white
count, no cough, no fevers, and no evidence of infection on
chest xray. His CT chest did show some perbronchial changes that
could be consistent with aspiration, which he has had recently
in the past. His initial CT chest and rib xrays did not show any
fracture in the area of his pain. He had some RUQ pain as well
but his LFTs were normal and he has already had a
cholecystectomy. His lipase was normal. Patient had a very
inconsistent physical exam, with complaints of severe pain even
though he appeared comfortable. He also would grimace and writhe
with fingertip touch to his R side, but when the stethoscope
would be placed for auscultation he would have no pain. This
raised concern of possible secondary gain. With his tenderness
to palpation he most likely had a musculoskeletal or
costochondirits. He was continued on his home dose of oral
dilaudid but became somnolent one night and needed narcan for
awakening. Even during this period he complained of excrutiating
pain while appearing lethargic. He stated that no medications
assisted in his pain. He was sent home with recommendation to
continue to try nsaids for pain relief.
# LUE DVT - Patient noted on admission that recently was
diagnosed with a LUE DVT at ___. However, he denied
being sent home on anticoagulation. OSH records were acquired
which showed radial thrombus not DVT. Follow up LUE U/S was
acquired which showed a new clost in his brachial vein. He was
started on Lovenox in hospital and received teaching in
hospital. Confirmation of his insurance coverage for lovenox was
acquired prior to his discharge.
# Hyperkalemia - Patient had elevated potassium this admission.
His max was 5.8. He received kayexalate and had resolution of
potassium. EKG done was unremarkable for hyperacute T waves.
Most likely etiology were nsaids and his tube feeds. He was
continued on nsaids for his pain, but his tube feeds were
changed to Nepro for lower potassium. He ha no evidence of renal
failure.
- He was sent home with nepro tube feeds
# Hemoglobin drop - Patient had a hemoglobin drop from 12.2 to
nadir of 9.9 Unclear etiology, patient with no evidence of
bleeding. He had recent R arm surgery at ___ per his story for
ulnar release. His cast appeared clean dry and intact. He also
appeared slightly dry and was given fluids initially. He did not
have gross GI bleeding. His hemoglobin stabilized near his
baseline and he was discharged in stable condition.
# Thrombocytosis - Patient has a history of elevated platelet
count. The concern initially was for possible infectious cause
but the patient did not have any infectious symptoms, signs, lab
or imaging results. He also had recent surgery on his arm and he
had a splenectomy in the past, which is the likely cause.
Patient's plateletes remained stable but elevated on discharge.
# Nutrition - Nutrition consulted on ___ who recommended
slowing the rate of tube
feeds that he had received as an outpatient. As above they
recommended changing his tube feeds to nepro for lower
potassium.
# Pancreatic insuffuciency: Patient was controlled on home dose
of creon.
# s/p gastric bypass, short gut, cachexia: Patient was continued
on dronabinol
# Chronic pain: Patient's chronic pain was controlled with
lidoderm and gabapentin
# Bipolar: Patient well controlled and pleasant during his
hospital stay on lithium, quetiapine, and venlafaxine.
# Tardive dyskinesia: Patient on tetrabenzine as an outpatient.
This was not acquirable by pharmacy. He attempted to have it
brought in from his hotel, but he was not able to. Pharmacy was
concerned about him being off it for more than five days, but
the patient was able to be medically ready for discharge prior
to this occurring and was recommended to restart his home dose.
# GERD: Asymptomatic during his hospital stay and continued on
home dose of omeprazole. | 166 | 716 |
13788564-DS-16 | 22,661,840 | Dear Mr. ___,
You were admitted to ___
(___) due to back pain and right leg pain.
While here, your pain was controlled with medications including
lyrica, oxycodone, ketorolac, naproxen, flexeril, and Tylenol.
Please take these medications for your pain:
-Tylenol ___ every 6 hours
-Naproxen 500mg twice a day
-omeprazole 20mg (once a day), take this with your naproxen to
prevent GI upset. You can stop this medication as soon as you
are done with naproxen.
-flexeril (also called cyclobenzaprine) 5mg at night - this may
make you sleepy.
-oxycodone ___, every 4 hours as needed.
-lyrica (pregabalin) 75mg in the morning, 150mg at night
Please discontinue taking the omeprazole once you have stopped
taking naproxen.
Please immediately return to the emergency room if you have any
worsening symptoms, especially weakness, loss of sensation
specifically in the groin, or problems urinating or controlling
your bowel movements. If any of these things happen, please go
immediately to the emergency room.
Please follow up with your surgeons in ___ and all your
scheduled appointments. Thank you for allowing us to be involved
in your care.
Sincerely,
Your ___ Care Team | ___ from ___ with hx of known recent herniated disc, now
admitted for pain control due to worsening back pain and right
leg pain.
#Herniated disc: The patient presented to the ED with back pain
in the setting of a known disc herniation. He had pain in his
lower back as well as shooting pain down his right leg. On
admission his vital signs were stable and was afebrile. He was
neurologically intact including ___ bilateral lower extremity
strength, no changes in sensation, including no saddle
anesthesia. No bowel or bladder incontinence. Labs were
unremarkable including a normal WBC, and In the ED, he was given
pain medications to control his pain, though was admitted to
medicine because he was unable to ambulate secondary to pain. On
the floor, he continued to be afebrile though with significant
pain. On hospital day 4 (___) he had an MRI of his thoracic
and lumbar spine, which demonstrated severe spinal canal
narrowing at L4-L5. Spine surgery (orthopedics) was consulted,
and it was determined that he did not require emergent surgery
given that he is neurologically intact. On day of discharge, he
continued to be neurologically intact and was able to ambulate
with manageable pain. He remained afebrile and hemodynamically
stable over the course of his hospitalization.
#Back pain ___ disc protrusion: On admission his vital signs
were stable and was afebrile. He was neurologically intact
including ___ bilateral lower extremity strength, no changes in
sensation, including no saddle anesthesia. No bowel or bladder
incontinence. Intact rectal tone. Labs were unremarkable. In the
ED, he was given pain medications to control his pain, though
was admitted to medicine because he was unable to ambulate
secondary to pain. ___ had cleared for home with home ___. His
pain was initially managed with ibuprofen, ketorolac, and
pregabalin. On the floor, he continued to be afebrile though
with significant pain. On hospital day 4 (___) he had an MRI
of his thoracic and lumbar spine, which demonstrated: "Large
posterior disc protrusion with disc extrusion at L4-L5 level
severely narrows the spinal canal and compresses the cauda
equina nerve roots." Spine surgery was consulted, and it was
determined that he should undergo surgery, which was offered for
___. Patient declined as he felt that the post-op recovery
would interfere with coursework. He was able to vocalize the
risks of not undergoing surgery and was able to vocalize warning
signs of spinal cord impingement and will return to ED if he
experiences any bladder retention, stool incontinence, weakness,
or groin numbness. | 185 | 421 |
15286481-DS-15 | 23,753,712 | Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, yellowing of skin or
eyes, increased abdominal pain, incisional redness, drainage or
bleeding, dizziness or weakness, decreased urine output or dark,
cloudy urine, swelling of abdomen or ankles, or any other
concerning symptoms.
Drain and record the JP drain output twice daily and as needed
so that the drain is never more than ½ full. Call the office if
the drain output increases by more than 100 cc from the previous
day, turns greenish in color, becomes bloody or develops a foul
odor.
Change the drain dressing once daily or after your shower. Do
not allow the drain to hang freely at any time. Inspect the site
for redness, drainage or bleeding. Make sure there is a stitch
at the drain site.
You will have labwork drawn every ___ and ___ as
arranged by the transplant clinic, with results to the
transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT,
Alk Phos, T Bili, Trough Tacro level.
On the days you have your labs drawn, do not take your Tacro
until your labs are drawn. Bring your Tacro with you so you may
take your medication as soon as your labwork has been drawn.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air. Do not
allow the JP drain to hang freely.
The staples are removed approximately 3 weeks following your
transplant.
No tub baths or swimming
No driving if taking narcotic pain medications
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure.
Continue tube feeds using the post pyloric feeding tube in your
nose. Make sure this stays firmly taped to your nose. Do the
flushes as instructed
Check your blood sugars four times daily and record on sheet
provided, and blood pressure daily at home. Report consistently
elevated values to the transplant clinic
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Refer to your transplant binder, and always call the transplant
clinic at ___ if you have any questions or concerns. | Patient remained stable throughout pre transplant admission,
confusion resolved, infectious workup was negative. Patient was
given albumin according to hepatology recommendations and
concern for HRS. Creatinine was closely monitored but remained
elevated. Patient received liver transplant, to be followed by
transplant surgery.
# Acute renal failure: Most likely pre-renal given history of
held TFs and recent large volume para and improvement with TFs
and Albumin/IVFs. Cr improved to ___ yesterday and is 1.5 today.
No evidence of GI bleed and infectious w/u negative to date.
# Ascites: Diuretic refractory ascites requiring large volume
paracentesis. Diagnostic paracentesis was done to rule out SBP.
Ascitic fluid was negative for infection.
# Anemia: patient had decreasing Hct on admission. Two large
bore IVs were placed and H/H was closely monitored and remained
stable throughout pre transplant period.
.
On ___, while patient was admitted, he was offered a liver
transplant from a ___ female, brain-dead donor. The
patient elected to receive the organ, and was taken to the OR
with Dr ___ and Dr ___ for a deceased-donor
liver transplant using piggyback technique and a temporary
portacaval shunt.
Of note, prior to the transplant being performed, the patient
was seen by cardiology. As the patient has a history of atrial
fibrillation, on propafenone and
digoxin as outpatient. transplant surgery requested review as he
will require antifungal prophylaxis post liver transplant.
Recommendations were if using fluconazole, which is a CYP2D6
inhibitor, that it may increase serum levels of
propafenone, as it is a CYP3A4 inhibitor. Recommendations were
to check EKG prior to
restarting propafenone and reduce the propafenone to 150mg PO
BID. As propafenone is a Na channel inhibitor, EKGs were checked
for QRS widening. Daily EKGs were performed post op, the
propafenone was restarted at 150 mg BID per recommendation, and
the QTc remained between 390 and 405. He was kept on telemetry
throughout the stay, and had no cardiac events or arrythmias
noted.
At the time of transplant, once the vascular anastomoses were
completed, the liver reperfused evenly and well. Of note, the
recipient bile duct was large with a large cystic duct stump,
which was oversewn with a ___ PDS stitch. The donor bile
duct was small, approximately half the diameter of the
recipient. It was shortened and dilated. A temporary stent was
made out of an ___ pediatric feeding tube, passing one end
into the duodenum and the other up proximally into the liver.
This tube was not secured.
Two JP drains were placed. The patient received 4 units of
packed RBCs, 1 unit of FFP, 1 albumin and 3000 mL of
crystalloid.
At the completion of the case, the patient remained intubated
and sedated and
was taken to the surgical intensive care unit hemodynamically
stable.
At the time of transplant, he was given 1 gram of mycophenolate
prior to the case. Intra-op he received 500 mg Solu-Medrol.
Tacrolimus was started on the evening of POD 1. The
mycophenolate was continued at 2 grams daily, although on POD 8,
the dose was changed to 500 mg QID for GI complaints. Tacro
levels were checked daily, and the dose adjusted per level.
Steroid taper was per liver pathway protocol, and he is
discharged on 20 mg prednisone and is to follow the standard
steroid taper per post op protocol.
In the post op period, meropenem was given due to concerns for
cholangitis in the pre-op period. He received 6 days of IV
Meropenem.
He initially required Neo, and received a unit of RBCs for low
urine output and low CVPs. He was extubated on POD 1. The JP
drains were non-bilious, but combined output was about 1500 cc.
Initial pathway Doppler ultrasound of the transplant liver
showed patent hepatic vasculature and unremarkable appearance of
the transplant liver.
On the day of transplant, the patients total bilirubin was 23.7.
This decreased daily, and was 2.1 at time of discharge.
AST and ALT did both increase significantly by POD 2 and 3.
(AST: 692 ALT: 1065.) Additionally the patient did seem more
confused. A repeat ultrasound was obtained. This again showed no
substantial change compared to the prior examination. There is
persistent elevated velocity in the main portal vein and similar
waveform in the hepatic artery.
Over the course of the next few days, these values did decrease,
and by day of discharge they were normalizing. He was no longer
icteric. Mental status improved daily. This was likely a
function of both liver and kidney function both improving.
It appeared that the patient was having ATN following the liver
transplant surgery. Urine output was low, and BUN and creatinine
were increasing daily. A renal consult was called. A bilateral
native kidney ultrasound was performed showing normal kidney
size and vasculature.
Patients' mental status was worsening and he seemed more
confused, and with normal liver ultrasound, concern was for
uremia contributing to mental status decline. So on POD 4, a CVL
was exchanged for a temporary dialysis line. Urine output was
only 316 on POD 3, and the patients BUN and creatinine 136 and
4.5. He underwent the one dialysis treatment that he required on
___ (POD5) This was not well tolerated, and no fluid was
removed.
Over the course of the next few days, the urine output began to
increase, and the BUN and creatinine started to decrease on
their own. His weight was coming down and edema was resolving.
On ___ it was noted that the patient had swelling of the
right arm. non-invasive studies confirmed no evidence of deep
vein thrombosis in the right upper extremity but there was an
occlusive thrombus in the cephalic vein. Warm packs and
elevation were prescribed.
Jevity was started on POD 3 at a low rate. He had a feeding tube
in place from pre-transplant. On ___ it pulled back and was
seen coiled in the stomach. Under Fluoro, this was advanced
again to the post-pyloric position. Tube feeds were changed from
Jevity to Nepro when the kidney function was abnormal. This was
continued when he was discharged to home. Outpatient nutrition
assessment will continue, and feeds may be changed, and also
cycled once more stabilized in the outpatient setting.
Patients mental status continued to improve daily. Medication
teaching was instituted, and he did very well with medication
teaching.
Propafenone was kept at 150 BID, QTc intervals stayed stable
around 400, and he did not have any arrythmias or AFib seen on
continuous telemetry monitoring. He will have short term follow
up with his outpatient cardiologist who has been contacted and
will receive a discharge summary.
The medial JP drain was removed, the lateral JP drain has been
left in place and has been draining serous ascitic appearing
fluid. This drain will be left in place at time of discharge.
Flushes have been increased with the tube feeds to help
supplement for losses.
The incision was clean dry and intact.
Patient was evaluated throughout the hospital stay by physical
therapy. By the end of the hospitalization they deemed him safe
for home, but to continue with home ___ and use of a cane for
stability.
Patient did have a fall on ___, and was sent for wrist xrays.
There was no LOC, and he did not hit his head. The xrays showed
bony mineralization within normal limits. There is no evidence
of displaced fracture or dislocation and overlying soft tissues
are within normal limits. There are degenerative changes
involving the wrist, most marked involving the first through
third carpometacarpal and radiocarpal joints. A Volar resting
splint was applied. This was requested to be removed prior to
discharge and he is to follow up with Hand as an outpatient for
further evaluation. The splint was removed due to concern for
loss of mobility. | 453 | 1,263 |
11153842-DS-9 | 22,367,806 | Dear Ms. ___,
You were admitted to ___ for a severe infection of your
pressure ulcer. The infection extended into your bone and your
blood stream. You were started on antibiotics and had
debridement ___ the OR with significant improvement. A foley
catheter was placed to keep your wound dry. Please follow up
with Dr. ___ your urologist at the appointments below. You
will need to continue antibiotics through a PICC line for the
next several weeks and see the infectious disease team ___ clinic
at the appointment below.
You were also found to have a blood clot ___ your left leg, and
you were started on blood thinner Lovenox. This should be
continued at least 6 months | ___ year old female with h/o NF 2 c/b paralysis and a chronic R
trochanteric pressure wound who presents with malaise, fevers,
and osteomyelitis on MRI.
# Sepsis due to
# Osteomyelitis
Patient presented septic with fevers, tachycardia, leukocytosis.
The suspected source of her infection was the decubitus ulcer.
MRI confirmed the presence of osteomyelitis. The ulcer also
probed to bone. ID was consulted, who recommended bone biopsy
and initiation of empiric antibiotic therapy with meropenem and
daptomycin. The patient was extremely resistant to medical
interventions and took several days to agree to biopsy and
antibiotics. She eventually agreed to bone biopsy by the
plastics team, led by her long-time surgeon of ___ years Dr.
___ on ___. After becoming increasingly septic and growing
GNRs ___ her blood, she finally agreed to starting meropenem on
___, refused IV fluids. She was taken to the OR on ___ for
debridement of the wound. ID recommened 6 weeks of meropenem
(ertapenem on d/c) and daptomycin (see page 1). She ultimately
agreed to this. A picc was placed for the same. She should
follow up with ID. She will need weekly monitoring labs.
# Chronic Decubitus ulcer - vacc dressing after debridement by
plastic surgery. Ultimate plan is for ongoing management
including qMWF vacc changes. She should follow up with ___
Plastic Surgery clinic (Dr ___ ___ weeks after discharge.
# Acute blood loss anemia
After bone biopsy mentioned above, the patient experienced
significant bleeding of the wound prompting transfusion of 2
units pRBCs. Her H/H stabilized. The plastics team recommended
foley catheter placement to keep the wound dry. She was seen by
wound care. Nutrition was consulted as well, but the patient
declined their recommendations.
# Neurogenic bladder
Urology was consulted for evaluation for suprapubic catheter. It
was determined that this would likely be unhelpful, as the
patient would continue to leak urine from the urethra. She had a
foley catheter and she declined urology recommendations for
medical management with ditropan. Her Foley catheter continued
to leak but she did not want it to come out permanently. Her
foley catheter was replaced on ___ with a Coude 16 ___
catheter. Patient will discuss with plastic surgery timing of
removal of foley catheter.
# L common iliac vein DVT
A filling defect was seen on MRI consistent with DVT. The
patient was informed of the need for anticoagulation to prevent
migration of the clot. She was informed of the risks of
cardiovascular collapse and respiratory compromise should if a
saddle embolism were to form. Nonetheless, she declined
anticoagulation of any sort. She also declined pharmacologic and
mechanical DVT prophylaxis, as well as IVC filter. Ultimately
she agreed to an u/s of the LLE which proved extensive DVT, she
then agreed to anticoagulation which was begun with enoxaparin,
titrated by levels given low body weight. Ultimately she was
therapeutic on Lovenox 40mg BID based on LMWH level. This
should be checked periodically to ensure this remains
therapeutic. She should have at least 6 months of treatment, if
not indefinite given the nature of her thrombosis. | 118 | 518 |
19066479-DS-18 | 27,731,982 | Dear Mr. ___,
You were hospitalized due to symptoms of difficulty reading. We
believe that this was caused by a TRANSIENT ISCHEMIC ATTACK, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot which then opens up again. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high blood pressure
Your blood pressure and cholesterol are well controlled by the
medications you take. Good job! It is important to continue
taking these medications to reduce your risk of stroke and heart
attack.
We are sending you home with ___ of Hearts monitor to look
for an abnormal heart rhythm. We would like you to wear this
every day for 30 days. This will detect an abnormal rhythm even
if you do not feel it. Your health care aide can help you to
put this monitor on. She should call ___ to get
instructions on how to use it.
We are changing your medications as follows:
- stopping aspirin and starting clopidogrel (Plavix) 75 mg daily
- stop mirtazapine as it may be contributing to your confusion.
We have sent the clopidogrel (plavix) prescription to your ___
pharmacy on ___. You should go with your home
health aide tomorrow to pick up the prescription.
Please take your other medications as prescribed.
We would like for you to see the Stroke Neurologist once and
then continue to follow up with your neurologist Dr. ___. You
should follow up with your psychiatrist and your primary care
physician.
You spoke to your home health provider tonight about coming
tomorrow to see you. If you are feeling anxious you should speak
with her about coming over the weekend or having someone stay
with you the first couple of days. We will also arrange for a
home safety evaluation and will contact you about this tomorrow.
We are giving you a prescription for a driving evaluation given
your recent accident. You should not drive until this evaluation
has taken place.
It has been a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team | ___ is an ___ y/o man with a history of porcine AVR,
prior left parietal centrum semiovale infarct, anxiety and
depression who presented after a transient episode of alexia
while sitting in ___. His examination was notable for anxiety
and impaired memory retrieval but was otherwise normal. MRI
showed no acute infarct. This was thought to be secondary to a
transient ischemic attack and his history of centrum semiovale
stroke in the past raised concern for a second embolic event.
Echocardiogram showed no intracardiac thrombus; a prior study
had evidence of a small PFO but the clinical setting in which
his symptoms occurred was inconsistent with paradoxical embolus.
Telemetry showed sinus rhythm and recent Holter monitor was
negative for atrial fibrillation. He was sent home with ___
of Hearts monitor. Stroke workup was otherwise notable for A1c
5.7% and LDL of 51. His aspirin was changed to clopidogrel
monotherapy and his atorvastatin 20 mg was continued.
Prior to departure he expressed concern about his ability to be
safe at home. He was evaluated by social work and occupational
therapy. He was able to perform all ADLs independently. Although
he was very anxious his function was good. He was able to answer
all safety awareness questions appropriately. We spoke with his
son, psychiatrist and neurologist and the consensus was that he
had significant anxiety and depression which affect his mood but
which have not affected his ability to function. A plan was made
for him to go home with outpatient services for home safety
assessment as well as a prescription for a driving assessment
given his recent accident. In addition, his home health aide
will continue to come five days a week. His home health aide
will assist him with his ___ of Hearts monitor, plavix and
driving assessment in addition to her usual support. | 419 | 304 |
11753916-DS-11 | 20,609,372 | 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 in the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40mg SC daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right intertrochanteric fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 493 | 254 |
14010625-DS-2 | 28,365,422 | Mr. ___,
You were admitted to receive chemotherapy for your acute
leukemia. You developed an infection in the lungs due to immune
system suppression and were treated with antibiotics. You also
developed some twitching and unresponsiveness concerning for
seizures. However, after a prolonged course of chemotherapy, it
was decided that your cancer was not responding and given a lack
of further good options, the priority is to get you home per
your wishes.
We are therefore sending you home with services to help maximize
your comfort and quality of the time you have left.
It was a pleasure taking care of you at ___
___. | Mr. ___ is a ___ male with a PMH of chronic
restrictive lung disease, myeleofibrosis transformed to AML on
decitabine C3D2 w/ long hospitalization c/b extensive M. avium
infection and a-fib/a-flutter, who was transferred to the FICU
after a prolonged hospital course due to AMS and seizure-like
activity with concern for seizure or stroke.
He was initially admitted on ___ with a diagnosis of acute
AML from transformed myelofibrosis. His WBC count was 45,000
with
52% blasts at the time. He was initiated on treatment with
decitabine but has not significantly responded. More recently,
he
was transferred to the FICU on ___ with unresponsiveness and
convulsive movements in both lower extremities. He was also
holding his right arm and leg in flexion. He also became
progressively hypoxic requiring intubation.
Per neurology his AMS was most consistent with seizure activity
but stroke was unable to be ruled out. He was started on keppra
while in the FICU.
In the FICU a goals of care discussion was held with the ___ and
OMEG teams. He has unfortunately had rising blasts counts while
taking decitabine, and per ___ no further treatment options
exist
for his AML given risks would outweigh benefits. The ___ team
recommended transition to comfort focused care. In the FICU he
was continued on current non-chemotherapy medications in order
to
attempt to maximize his chances of discharge and being able to
spend time at home.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care | 103 | 223 |
14295224-DS-30 | 20,685,438 | You were admitted to the hospital with pneumonia that developed
after an episode of reflux. You improved with oxygen and
antibiotics. Your regular reflux medications and precautions
were continued, and you did not have any more problems with
vomiting after admission. You will continue a course of
antibiotics and follow up in clinic next week to ensure you have
fully recovered from the pneumonia.
Please see below for your follow up appointments and
medications. | Mr. ___ is a ___ yo male with a esophageal cancer s/p
esophagectomy/chemoradiation in ___, prostate cancer s/p
brachytherapy in ___, chronic rib pain secondary to thoracotomy
and HTN who presented with fever, found to hypoxic likely ___
aspiration pneumonia.
# Aspiration pneumonia:
He likely aspirated due to altered esophageal anatomy. He was
initially admitted to the ICU due to hypoxia requiring
non-rebreather. He was started on CTX and azithromycin. After
CXR imaging and discussion with pulmonary/critical care
physician, he was changed to IV unasyn. This was later switched
to clindamycin. He will continue clindamycin for at least
another 7 days until PCP follow up. ___ evaluation and
management per PCP. His hypoxemia improved and prior to
discharge he did not desat with ambulation or at rest on room
air. He continued to have some productive cough at the time of
discharge.
# Atrial fibrillation:
He had an episode of atrial fibrillation with RVR in the ICU.
This initially resolved without intervention and then later
recurred. His home metoprolol, which had initially been held in
setting of concern for sepsis, was restarted. He received IV
metoprolol and then IV diltiazem and returned to sinus rhythm.
Throughout these episodes, pt. was asymptomatic with normal BP.
CHADS2 score is 1. Once his hypoxemia and aspiration pneumonia
was better treated he did not have further episodes of atrial
fibrillation. The etiology was likely secondary to stress of
hypoxemia and pulmonary infection. Thus he was not started on
anticoagulation. However, he should discuss this with his PCP.
# Anemia:
He did not have evidence of bleed. The likely cause of the
anemia was due to phlebotomy and marrow suppression secondary to
acute and perhaps chronic illness. He was discharged with a Hct
___. This will need to be followed with further evaluation
and management if not improved or worsened on recheck.
# ___:
Likely pre-renal azotemia from dehydration. Cr quickly
downtrended with administration of IVF.
# GERD:
Continued home omeprazole and ranitidine.
# HTN:
Held metoprolol and amlodipine initially on admission given
acute infection. These were resumed prior to discharge.
# Chronic rib pain s/p thoracotomy:
Continued home gabapentin and oxycodone.
# Hypothyroidism:
Continued home levothyroxine.
# History of esophageal cancer s/p chemo and resection- in
remission, CT in ___ without disease recurrence. Given that
reflux did not continue on the floor, repeat upper endoscopy was
not pursued during this hospitalization.
# Wrist pain:
SEcondary to carpal tunnel surgery. He has a cast on with
continued pain. He was given a small number of pills of morphine
___ for treatment of his pain. He is scheduled to see orthopedics
on ___.
# Transitional issues:
- Communication: Daughter - ___
- Code: Full CODE | 76 | 438 |
14617881-DS-19 | 21,488,363 | You came to the hospital after being assaulted with a baseball
bat. You were found to be intoxicated. You had a head and neck
CT scan that did not show any fracture or bleeding. You had a CT
scan of your chest which showed fractures of the right ___,
___ and 12th ribs with a small amount of fluid near the
lung. You were also noted to have a small enlargement near in
your adrenal gland and you should follow up with your primary
doctor for further evaluation. You were treated with pain
medicine and respiratory therapy to prevent pneumonia. You will
be sent home with more pain medicine. Please do not drink or
drive while taking this medication. Please return to the ED for
worsening chest pain, shortness of breah, lightheadedness or
cough with fevers. | ___ yo male s/p assault brought in by EMS intoxicated. Head and
neck CT negative. CT chest shows acute right ___ rib fractures
and small pleural effusion, no pneumothorax. CT also noted
smooth 2.1 cm nodule in right adrenal gland, patient was advised
he should follow up with PCP as outpatient for further
evaluation. Patient admitted to ACS, pain control, IVF, vitamin
repletion, respiratory therapy, Diazepem, ACW score > 10
initially. Patient did not have withdrawl symptoms on the floor,
his pain was well controlled with PO medications. He was
evaluated by ___ who provided cab voucher and placement at
homeless shelter. Pt was provided with AA resources. Discharged
in good condition on HD #2. | 136 | 115 |
16035396-DS-17 | 21,452,677 | Call ___ to schedule dressing change for ___
call ob office for appt with Dr ___ ___ for dressing
change | Ms. ___ arrived to the ___ ED as a transfer from an
outside hospital to which she presented for drainage from her
cesarean section wound and from her vagina. She received 1 dose
of IV vancomycin before transfer. At ___, she was found to
have a 6cm area of erythema and induration on the right side of
her incision, with WBC 9.1 without left shift. She received a
bedside irrigation and debridement and was started on a course
of Ancef. Ultrasound for vaginal discharge non-concerning for
enlarged endometrial stripe with retained products. Please see
event note for more detail.
After her procedure, she reported improvement of pain at wound
site, though also with complaint of headache that has come and
gone since delivery. She was treated with oral pain medications.
By hospital day 2, she reported resolution of concerning
symptoms and desire to be discharged home to attend to
childcare. Her vital signs were stable, she was voiding and
tolerating a regular diet. Plan made for close follow-up of
wound and patient educated on daily dressing changes. | 19 | 175 |
13105954-DS-31 | 20,166,207 | Dear Mr. ___,
You were admitted to the hospital with worsening of chronic pain
in your neck, chest, back and leg. This pain is due to severe
arthritis. The best way to manage this pain is with pain
medications (as you are already taking, prescribed by Dr. ___
and physical therapy. Since you are already taking high doses
of pain medications, it is not safe to increase the dose.
However, we hope that you will have improved pain control after
working with the physical therapist in your home.
We have continued all of your medications, except for one:
Seroquel. You should STOP taking seroquel, because this
medication could cause a serious problem with your heart. You
can continue taking all of your other medications as previously
prescribed.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your ___ Team | ___ yo M w/ hx of Afib on warfarin, CAD, rectal Ca s/p colectomy,
prostate Ca, severe, chronic pain attributed to arthritis
(opiate dependent) who presented ___ w/ worsening of chronic
R-sided musculoskeletal pain.
He was treated with his home pain regimen, which includes high
doses of opiates (fentanyl 75mcg) with improvement of his
symptoms to his baseline level of chronic pain. His primary
care doctor confirmed that his pain control has historically
been challenging and voiced concern for opiate dependence after
a prolonged treatment course with opiate pain medications.
While he has a remarkable functional status (walks easily with a
cane despite chronic arthritis pain), he lives alone with only
home-___ services. His son and daughter, both of whom live
45 minutes away, have been investigating possibilities for
long-term care where he would have additional social and
healthcare support.
The remainder of his chronic medical conditions (Afib, HTN) were
stable. | 149 | 155 |
17716945-DS-14 | 21,646,552 | Dear Ms. ___,
You were admitted to the hospital with shortness of breath,
likely from a flare of your COPD. You were treated with
steroids, antibiotics, and nebulizers with some improvement. You
are being discharged on levofloxacin, which you should continue
through ___, and prednisone, which you should take as follows:
40mg through ___ through ___ through ___ through ___, then stop.
In addition, you are being discharged on a new inhaler, Spiriva,
which you should take until you see your pulmonologist.
Please schedule follow up appointments with your pulmonologist
and PCP within the next week or two.
With best wishes,
___ Medicine | ___ with hx COPD (not on home O2), depression, HTN, HLD, CKD
stage III, lymphocytic colitis, eosinophilic esophagitis
presenting with dyspnea on exertion, pleuritic chest pain, and
hypoxia, likely secondary to COPD exacerbation and now
improving.
# Dyspnea on exertion:
# Cough:
# Pleuritic chest pain:
# Hypoxia:
# COPD:
Ms. ___ presented with ___ days of shortness of breath,
dyspnea on exertion, and R-sided pleuritic chest pain. She was
treated with lovenox empirically on admission for PE,
discontinued on ___ after CTA chest showed no evidence of PE,
PNA, or pulmonary edema. ACS was thought unlikely given negative
cardiac biomarkers and a non-ischemic EKG. Her presentation was
attributed to a COPD exacerbation in the setting of known
emphysema (quit smoking in ___, possibly with a viral URI
trigger. She received solumedrol 125mg x 1 in the ED and was
continued on prednisone 40mg daily, levofloxacin 750mg daily
(allergy to azithromycin), and standing nebs. B/l rib pain was
attributed to muscle sprains from coughing and was treated with
cough suppressants, lidocaine patch, and low-dose oxycodone and
Tylenol PRN. Her hypoxia resolved (97% on RA with ambulation on
discharge) and her dyspnea on exertion improved dramatically
(but
had not fully resolved) by the time of discharge. CXR on the day
of discharge showed likely mild R basilar atelectasis with no
e/o
edema or PNA. She was discharged to complete a 5d course of
levofloxacin (through ___, QTC 410 on admission) and a short
prednisone taper (40mg through ___, then 30mg through ___, then
20mg through ___, then 10mg through ___. Home albuterol was
continued on discharge, and Spiriva was initiated. She will ___
with her primary pulmonologist (Dr. ___ in ___ after
discharge and would benefit from full PFTs and titration of her
COPD regimen. Of note, CTA chest did show an enlarged main
pulmonary artery, possibly from pHTN, and Ms. ___ would
likely benefit from a TTE and further pHTN w/u as an outpatient.
# AG metabolic acidosis:
# Respiratory alkalosis:
# Elevated lactate:
Presented with AG of 20, HCO3 16, and lactate to 3. Likely
secondary to mild hypovolemia in the setting of decreased PO
intake. Elevated lactate resolved with IVFs and HCO3 improved to
21 at the time of discharge, thought to be compensatory in
setting of mild respiratory alkalosis (VBG 7.45/33 on
discharge).
Would recommend repeat labs at PCP ___.
# Migraines:
Developed headache similar to chronic migraines on admission,
treated with Tylenol and IVFs. Home Topamax was continued. No
evidence for CNS infection.
# CKD stage III:
B/l Cr unclear. Cr 1.1 on admission. Received ___ IVFs
for CIN ppx in setting of CTA chest. Cr remained stable and was
1.1 on discharge.
# HTN:
Continued home losartan, HCTZ (held briefly for hydration in
setting of CIN ppx), and clonidine BID PRN. She would benefit
from further PCP ___ for BP management.
# Hyperlipidemia:
Continued home statin.
# Low back pain with sciatica:
Pain was controlled as above with Tylenol and low-dose
oxycodone.
Home Tylenol #3 was continued on discharge.
# L thyroid nodule:
Incidentally seen 2 cm heterogeneous left thyroid nodule on CTA
chest. Warrants non urgent thyroid ultrasound as outpatient.
** TRANSITIONAL **
[ ] ___ for presumed COPD exacerbation (would benefit from PFTs,
discharged newly on Spiriva)
[ ] continue prednisone taper through ___
[ ] continue levofloxacin through ___
[ ] consider TTE as outpatient and further w/u for possible pHTN
[ ] ___ with PCP for BP management and repeat labs
[ ] thyroid U/S for L thyroid nodule as outpatient
# Code Status/ACP: FULL (presumed)
# Disposition: home without services on ___ PCP is ___
in
___, ___ ___ and pulmonologist is Dr. ___
in ___, ___ ___ | 98 | 544 |
19573671-DS-7 | 25,670,414 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had abdominal pain and
fatigue
What happened while I was admitted to the hospital?
-You were found to have liver cirrhosis
-You were also found to have a blood clot in your liver vein
-You had an ultrasound of your heart that showed it was
healthier than before
-You had a CT scan of your abdomen that did not show any
abnormalities other than your liver cirrhosis
-Your lab numbers were closely monitored and you were given
medications
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
We wish you the very best!
Your ___ Care Team | Mr. ___ is a ___ yo man with complicated cardiac history
notable for HFrEF EF 20% to 30% previously and now improved to
50%, paroxysmal atrial fibrillation on Coumadin, and ventricular
tachycardia(s/p ICD), who presented with three months of
worsening fatigue, epigastric pain, belching/flatulence and
abnormal liver tests, with new evidence of cirrhosis and portal
vein thrombosis. | 178 | 57 |
12806204-DS-16 | 28,871,451 | Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with lower
extremity swelling, consistent with volume overload from your
congestive heart failure. Your diuretic medication was changed
from furosemide (Lasix) to torsemide. You did very well with
this medication.
Please see attached for an updated list of your medications, and
below for your follow-up appointments.
Wishing you all the best!
Please weigh yourself every morning, and call your doctor if
your weight increases more than three pounds. | Patient is an ___ yo man with history of ischemic sCHF
(EF30-35%), CAD s/p 3vCABG, post-operative atrial fibrillation
and sick sinus syndrome s/p ___ permanent pacemaker
placement, with recent admission from ___ for acute on
chronic sCHF exacerbation, who is returning from ___
___ concern of increased peripheral edema over the last
week. | 83 | 53 |
16695286-DS-20 | 29,147,310 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non-weight bearing to the left upper extremity in sling,
elevation
- protected weight bearing to the right lower extremity
- RLE with ROMAT
- LUE with ROMAT to wrist and digits, No ROM at shoulder and
elbow
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 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
********** For follow up of perisplenic hematoma and left
posterior ___ and 12th rib fx***************
Please follow-up with ___, Dr. ___, 2 weeks
after your discharge. Please ___ to schedule this
appointment.
Physical Therapy:
- non-weight bearing to the left upper extremity in sling,
elevation; protected weight bearing to the right lower extremity
- RLE with ROMAT
- LUE with ROMAT to wrist and digits, No ROM at shoulder and
elbow
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team as well as the ACS
service. The patient was found to have left midshaft humerus fx,
left distal both bone forearm fracture, right LC1 pelvis
injury,L2-L5 transverse process fx, left posterior ___ and ___
rib fx, as well as small perisplenic hematoma; and she was
initially admitted to the ___ service. Her R LC1 pelvis fracture
was treated non-operatively, as were her L2-L5 TP, and left
posterior ___ and 12th rib fxs. Her small perisplenic hematoma
was deemed stable by the ___ team - and therefore did not
require surgical intervention.
For her left hemurus and forearm fractures, the patient was
taken to the operating room with orthopaedic surgery for Open
Reduction Internal Fixation of Left both bone forearm fracture
on ___, 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.
On ___ the patient's humerus of the Left upper extremity was
placed in ___ brace to remain in place until follow up.
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing to the left upper extremity in sling,
elevation; protected weight bearing to the right lower
extremity, and will be discharged on lovenox 40mg daily for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. She will also follow-up with ___ outpatient clinic
within 2 weeks of discharge as well. 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. | 527 | 393 |
14847712-DS-5 | 22,572,547 | Dear Mr. ___,
You were admitted for a severe headache and rash. We evaluated
you for this and felt this was likely due to your lumbar
puncture procedure that occurred on ___. In the emergency
department, you received fluids, ketorolac, caffeine, and
Tylenol. Upon coming to the floor, your headache improved. We
gave you Fioricet and ibuprofen while you were here, which
further improved your headache. Because of this, we decided
after a lengthy discussion with you that we won't pursue a blood
patch. Please stop the Fioricet and ibuprofen when you no
longer need it. While you do need it, please stagger these two
medications so that you get full coverage of your pain.
Regarding your rash, since starting on the prednisone it has
significantly improved. We obtained a dermatology consultation
who recommended that this was non-specific and the rash has
changed after starting the prednisone. It is hard to determine
the specific cause now. They also recommended we go down your
steroids a little slower. We decided to go down on your steroids
as follows: 40mg for 1 more day, 20mg for 3 days, and 10mg for 3
days, then stop. For itch, you can use topical triamcinolone
0.1% for up to 2 weeks (not to exceed, and only use if itchy).
They recommended you follow up with them in outpatient clinic in
2 weeks on ___ at 11am with Dr. ___ (___).
Dr. ___ you while you were hospitalized and was aware
of all the planning, and recommended he follow-up with you in 2
weeks in his clinic.
It was a pleasure to care for you during this hospitalization.
Good Luck!
Sincerely,
Your ___ Care Team | ___ y/o right-handed male with history of prostate cancer not on
treatment, hypothyroidism, conus and cauda equina mass
suspicious to be a schwannoma who presents to the emergency
department for a new rash and persistent headache in the setting
of a recent lumbar puncture on ___.
#Rash: Patient endorsed a new rash on ___ on R arm and L
abdomen. It was itchy and was unrelieved by Benadryl. He was
started on prednisone by a family friend on ___ and since has
had near full resolution of the rash. He denied any recent URI
symptoms, recent travel or new medications. This was initially
thought to be a viral exanthema vs. unlikely an acute infectious
process. Meningococcemia and lyme were considered given his
headache, but absence of fever, benign physical exam, and
morphology of the rash makes these less likely. The distribution
is not characteristic of RMSF, ___ or syphillis. The
clinical morphology of the rash did not appear to be a
vasculitic or connective tissue process. Extensive testing by
the outside provider, including CSF analysis for lyme, crypto,
AFB, VDRL, were negative.
We obtained a dermatology consultation who recommended that this
was non-specific and the rash it was difficult to evaluate at
this time since the morphology changed after starting the
prednisone. They also recommended we initiate a slightly slower
steroid taper. We decided to go down on the steroids as follows:
40mg for 3 days, 20mg for 3 days, and 10mg for 3 days, then stop
(last dose ___. For itch, he was prescribed topical
triamcinolone 0.1% for up to 2 weeks PRN (not to exceed). He
will follow-up with dermatology in 2 weeks on ___ at 11am with
Dr. ___ (___).
#Post-lumbar puncture headache: Patient underwent an LP on ___
to evaluate for the etiology of his rash, and had post-LP HA
that was mild. His symptoms worsened on ___ that prompted him
to visit the ED. The HA is positional and improves with lying
down. Now s/p IVF, toradol, caffeine, Tylenol with significant
improvement. Likely post-LP headache. CT neg for acute
intracranial process. No change in mental status, afebrile, and
clinical exam not suggestive of an acute infectious etiology
such as meningococcemia, lyme, or other processes. We started
him on fioricet and his symptoms improved significantly the next
day. However, towards the afternoon he reported another episode
of HA and we added Ibuprofen with good relief. He was discharged
with Fioricet and Ibuprofen, and was instructed to stagger these
two medications in order to get coverage of your pain. He is
aware that he can stop these medications when no longer needed.
#Leukocytosis: At the time of admission, he had a new
leukocytosis to 15.1. Infectious etiologies were considered as
above, and numerous diagnostic tests sent by the outside
provider have been negative. He remains afebrile and clinically
appears very energetic and robust, hence an infectious process
appears less likely at this time. His leukocytosis downtrended
to 10.6 the next day. Given that he was on prednisone, it was
thought it was ___ steroid use. We monitored him closely, and
share this result with him. He was well-appearing at the time of
discharge.
#Cona and cauda equine mass: Patient has a history of conus and
cauda equina mass (likely schwannoma) and is followed by Dr.
___. A recent MRI on ___ demonstrated a stable 4 mm
intradural extramedullary T1 hyperintense, T2 hypointense nodule
at the proximal cauda equina/ conus medullaris tip which does
not demonstrate definitive postcontrast enhancement and is
unchanged comparison to ___. During this
hospitalization, Mr. ___ denied any back or lower extremity
neurological symptoms, denied bowel or bladder incontinence. Dr.
___ the patient during this hospitalization and
recommended an outpatient follow-up in 2 weeks.
#Hypothyroidism: We continued him on his home synthroid.
=
=
=
================================================================
Transitional Issues:
1. Please follow-up regarding patient's headache and ensure that
it has fully resolved.
2. Please follow-up regarding patient's R arm/L abdominal rash
and coordinate care based on dermatology recommendations
3. Please follow-up regarding his cona/caudal tumor.
Code: Full
Contact: Wife ___ | 280 | 666 |
12804871-DS-3 | 24,687,089 | You were admitted with viral meningitis. You had a lumbar
puncture which ruled out bacterial and treatable viral
infections. The viral infection that you have will resolve over
time. You were treated with pain control as needed. You should
not breast feed until 48 hours after your last tramadol or
acyclovir dosing. An MRI of your brain was normal.
Please see below for your follow up appointments and
medications. | ___ y.o. ___ s/p C-section for breech presentation on ___ on
lovenox s/p ORIF of R ankle fracture in ___ who now
presents with headache, fevers, elevated LFTs found to have
leukocytosis of CSF.
# Meningitis:
# Headache:
# Fevers:
She presented with nuchal rigidity/pain, photophobia, headache,
fevers and myalgias. She had an LP, and along with her symptoms,
were very suggestive of viral meningitis. ID was consulted.
Vanc, CTX and acyclovir were initially started. After results of
LP returned Vanc and CTX were discontinued. Acyclovir was
continued until HSV PCR returned negative. Neurology was
concerned about possible papilledema on exam, at the time
patient was improving clinically. Given post-partum state,
obtained MRV/MR head to eval for venous sinus thrombosis, which
returned normal. Discharge fundoscopic exam showed no evidence
of papilledema. Patient was counseled on symptoms of increasing
intracranial pressure, and will seek medical attention if this
occurs. Would repeat fundoscopic exam in follow up in clinic.
Her pain was treated with tramadol (she had nausea and emesis
with stronger narcotics including dilaudid and codeine).
She is breast feeding. She should not use breast milk for at
least 48 hours after acyclovir or tramadol dosing.
# Transaminitis:
This was likely related to viral syndrome. It resolved to normal
during the course of the hospitalization.
# Hyperthyroidism:
Her TSH was suppressed. Her levothyroxine dose was decreased
from 100mcg daily to 50mcg daily. This should be followed
closely by her outpatient providers. Free T4 was normal. Needs
repeat TFTs in about 4 weeks.
# Ankle pain:
She is s/p ORIF for ankle fracture. She was evaluated by
orthopedics. The ankle is normal for post operative time period.
Full code | 68 | 270 |
11188695-DS-35 | 29,612,490 | It was a pleasure to care for you during your admission. As you
know, you were admitted for abdominal pain and nausea limiting
your ability to eat and drink. You required IV fluids and nausea
medication. RUQ ultrasound and MRCP revealed no detectable
abnormality.
You are prescribed antibiotic for presumed small intestinal
bacterial overgrowth. Please complete this treatment for 7
days. Please continue with your home medications.
You had an MRI of your abdomen to evaluate a tiny stone in your
como=mon bile duct seen on an ultrasound which showed no bile
duct stones and possible IPMN in your pancreas which are cysts
that have a very low possibility of becoming cancerous
thus you need another mrcp in ___ years time to look at your
pancreas
Please be sure not to drive or operate heavy machinery while
taking your pain medications. | ___ is a ___ year old woman with known extensive
abdominal surgeries and history of procedures and evaluations
who presents with RUQ abdominal pain and bloating associated
with her typical diarrhea and abdominal symptoms otherwise. She
reports that the pain appears slightly different than her
typical, but otherwise her 'flare' is per her usual. Her LFTs
were normal but a CBD stone was seen on ruq u/s and then MRCP
obtained with guidance of ERCP service did not show CBD stone
but very small side branch likely IPMN that she will need repeat
mrcp in ___ years time. she does not need any interventional
procedures. We spoke with her GI physician regarding this
finding and he thinks perhaps she passed a stone and recommends
starting ursodiol.
We reconciled her pain meds with her ___ pain clinic and she
gets 4mg dilaudid that she uses with variably frequency and
despite long w/u for pain both at BI and ___ there is no
definite cause for her pain and diarrhea. She was treated for
presumed SIBO - given her risk factors of s/p gastric bypass,
use of PPI, slow motility, and significant opiate use. She was
given rifaximin 550 TID for a total 7 days. (Fax for approval
by ___ was sent and an emergency 3 day prescription was
provided along with another 4 days in the event it gets
approved). Her diet was advanced to regular foods which she
chooses based on known tolerance from her gastric bypass.
She will follow up with her GI doctor and with the pain
clinic. | 144 | 275 |
16741986-DS-2 | 24,760,940 | Dear ___,
___ was a pleasure taking care of you at ___
___.
Why were you admitted to the hospital?
You were admitted after you presented with nightly fevers of
unknown cause.
What was done for you while you were here?
We sent a bunch of tests for infection, everything came back
normal so far. We also tested for other autoimmune conditions,
especially lupus, and all those tests have also been negative so
far. There are still some infection and autoimmune tests that
haven't come back yet, and your outpatient doctors ___
those and let you know if there was anything concerning found.
We stopped your immunosuppressive medication azathioprine and
put you on another immunosuppressive medication called Cellcept
(MMF). We did this because azathioprine is known to cause
fevers as a side effect. After we made this change, you no
longer had any fevers.
What should you do once you leave the hospital?
Please follow up with your appointments with your PCP, liver
doctor, and infectious disease doctor. They will review any of
the labs that had not come back before you were discharged. If
you continue to have fevers at home, please be seen by a doctor
right away.
We wish you the best of health,
Your ___ Care Team | ___ yo F with autoimmune hepatitis c/b cirrhosis and portal
hypertension (Child A) on azathioprine, CREST who presents with
fever of unclear etiology since ___, transitioned from
azathioprine to cellcept with thought that fevers likely
azathioprine induced.
# Fever: Patient presented with persistent fever for past 3
weeks, ever since recent d/c of prednisone, without leukocytosis
or true localizing signs of infection. She had diffuse
maculopapular rash and b/l symmetric polyarthritis that began at
time of fevers, but rash and joint pains have since resolved.
She was reportedly being treated for anaplasma at ___
___, although likely empirically. Review of records reveals
negative babesia smear, negative lyme EIA, negative ehrlichia
antibody titer. Differential diagnosis of her fever included
rheumatological cause vs side effect of azathioprine vs
infection (bacterial, viral, parasitic), or septic
pyelephlebitis. CT torso with IV contrast ___ unremarkable for
malignancy, abscess, or other infectious etiology. Portal vein
and SMV thrombosis nonocclusive and stable since last imaging.
unchanged 14 mm cyst in head of pancreas (previously evaluated
w/ MR), no evidence of necrotizing pancreatitis.
Infectious/autoimmune w/u results so far: ferritin 419, lipids
nl, dsDNA neg, C3/C4 nl, CMV VL neg, monospot neg, RPR neg,
urine cx neg, rubeola and rubella IgG positive, ESR 38, CRP
112.3. Blood cultures negative to date at time of d/c.
Azathioprine d/c'd on ___ and changed to cellcept 750mg BID.
Patient has not spiked fever since the change, Tmax since has
been 99. Please follow up on pending rheumatological/infectious
workup to ensure nothing concerning (specific tests that are
pending are highlighted in transitional issues below). Patient
continued on cellcept 750mg BID on d/c.
# Cirrhosis
Secondary to autoimmune ___ female with Child
A compensated cirrhotic and signs of portal hypertension on
endoscopy, currently on nadolol. No history of SBP, and bedside
ultrasound in the ED without significant ascetic pocket amenable
to drainage. No hx of HE. Per patient, had recent EGD in ___,
found nonbleeding varices, but none banded. Likely that
azathioprine is contributing to fevers described above, so
switched to cellcept 750mg BID. Otherwise, continued home meds
nadolol 20 mg tablet daily, spironolactone 50 mg daily,
furosemide 20 mg daily, Pantoprazole 40 mg PO Q24H.
# Portal vein thrombosis:
CT abdomen significant for nonocclusive chronic thrombus within
the main portal vein and SMV but unchanged since ___.
Persistent fevers raise the possibility of septic
pyelephlebitis, however, the patient lacks abdominal pain or
worsening LFTS, which are common features of pylephlebitis.
Therefore, no abx started. No systemic anticoagulation started
given nonocclusive chronic nature of thrombus that has not
progressed since last imaging.
# Connective tissue disease:
Patient with a diagnosis of CREST syndrome, not currently
followed by rheumatology. Labs from ___ significant for
positive ___ at 1:1280 titer, and positive anti centromere
antibody. Given history of autoimmune disorder, her fevers could
represent inflammatory disease, especially with a flare up of
her symptoms following a short course of steroids. Her history
is suggestive of possible diagnosis of lupus as she reports
facial erythema and swelling (possible malar rash), cutaneous
eruption, arthralgias and arthritis. However, DsDNA neg,
___ still pending.
# Anemia:
Admission H/H of 10.6/33.9, trended down to 9s, down from a
baseline Hb of ___. No signs or symptoms of active bleeding.
Possible due to bone marrow suppression from recent illness,
medication effect, or consumptive process given known thrombosis
(less likely given imaging results described above). Hemolysis
labs negative. Ferritin slightly elevated at 419, TIBC slightly
down at 228, and serum iron slightly low at 21 indicating
possible mixed ACD and iron deficiency. Continued on Ferrous
Gluconate 324 mg PO daily, Hgb on discharge was 9.1, was stable
at time of d/c.
# Recent diagnosis of pancreatitis:
No clear etiology of pancreatitis, however, reportedly
developed epigastric pain after starting doxy. She endorses
chronic history of epigastric pain radiating to the right side
and toward the back, however has had pain before her episode of
pancreatitis, and CT abdomen did not demonstrate any e/o of
chronic or complicated pancreatitis.
# Vaginitis: Pt reported vaginal irritation and burning. UA
negative, Ucx no growth at time of d/c. Given one dose of
fluconazole, and started on miconazole topical cream BID (last
day ___.
================
CHRONIC ISSUES
================
# Hypothyroidism: Continued levothyroxine 25 mcg daily
# HLD: Continued home atorvastatin 20 mg qhs.
TRANSITIONAL ISSUES
===================
GENERAL
[ ] Creatinine at time of discharge 0.7
[ ] Weight at time of discharge 69.13kg
FEVER
[ ] please f/u with patient re: any further fevers since
azathioprine was stopped
[ ] please f/u with the following labs that were pending at time
of d/c: ___ Ab, Quant-Gold, EBV VL, parvovirus B19,
Ehrlichia IgG/IgM, Babesia (IgG/IgM), Borrelia, lyme IgG/IgM,
EBV, Mumps IgG, ANCA
[ ] f/u LFTs s/p change from azathioprine to cellcept to ensure
no decompensation or worsening of autoimmune hepatitis after
changing immunosuppression regimen
PORTAL VEIN THROMBOSIS
[ ] patient will need repeat imaging in future to ensure no
progression of thrombosis in venous system
[ ] consider anticoagulation therapy if there are signs of
thrombus enlargement
ANEMIA
[ ] Hgb lower than baseline, repeat H/H as outpatient to ensure
Hgb remains stable
#CODE: Full Code (confirmed during this admission but needs to
be readdressed with each subsequent admission)
#CONTACT: Patient's daughter ___ ___ | 214 | 860 |
18336565-DS-22 | 27,068,310 | Dear Mr. ___,
You were transferred from ___ for further
management of your severe abdominal pain and infection. You were
extremely ill, so you were sent to the intensive care unit and
put on medications to help support your blood pressure. You were
started on multiple antibiotics because your blood grew
bacteria. Fortunately, you showed marked improvement, so we were
able to transfer you from the intensive care unit to the medical
floor. We consulted infectious disease, who recommend
vancomycin, ciprofloxacin and metronidazole treatment to take
through ___.
In terms of pain, we consulted the chronic pain service given
your significant pain and your previous exposure to pain
medications. Their recommendations for pain management at rehab
include fentanyl patch 125 mcg, PO hydromorphone 4 mg Q3H as
needed, and gabapentin (liquid)1200 mg TID. Given that your
venting G tube is very important for your comfort, we consulted
interventional radiology who replaced the G-tube on ___.
Thank you for letting us be a part of your care,
Your ___ care team | ___ with a history of Crohn's disease c/b multiple SBOs
requiring multiple surgeries resulting in frozen abdomen and
short gut syndrome (totally TPN dependent) who was transferred
from ___ after presenting with abdominal pain and
septic shock and having gastric/duodenal pneumatosis and portal
venous gas on CT.
SICU COURSE
============
Patient was admitted to surgical ICU on ___ for management
of pneumatosis of stomach and proximal small bowel with portal
venous gas, the etiology of which was unclear on imaging (CT and
abdominal US). At time of admission, pt was hypotensive with
pressor requirement, metabolic acidosis, and ___. Initial labs
were notable for a WBC of 50, lactate of 4.5, bicarb of 12, and
creatinine of 2.1.
He was started on aggressive IVF resuscitation with LR, blood
pressure support with levophed and later vasopressin, broad
spectrum antibiotic coverage (vancomycin, ciprofloxacin, flagyl,
and fluconazole), and GI decompression via NGT. His pain was
controlled initially with dilaudid PCA and methadone which was
transitioned by APS to a ketamine drip, methadone, and prn IV
dilaudid breakthrough to good effect.
On HD#1 patient was noted to have some brief ST elevations on
telemetry and a slight bump in troponins to 0.11 which
down-trended to 0.07 with normalized CK-MB by ___. He was
given PR Aspirin 300mg on HD#1 and 2. Given the briefness of
this episode, his overall clinical picture, and resolution of
EKG changes cardiology was not consulted and this was not
further worked-up.
Between ___ patient's hemodynamics, urine output, and labs
(WBC, lactate, creatinine) improved markedly. He was able to be
successfully weaned off of all pressor support overnight HD#2
and he remained stable with SBPs ~120-150, normal heart rate,
and excellent UOP (___).
Given that he has had multiple prior abdominal surgeries with a
resulting frozen abdomen he is aware that he is not a surgical
candidate and that this diagnosis of pneumatosis is
life-threatening. After multiple family meetings pt and his wife
decided to proceed with maximal medical therapy although he is
now DNR/DNI. To date, he has responded very well and is now
stable for call-out to the medical floor.
At the time of transfer his ongoing issue remain abdominal pain
with significant narcotic requirement above his baseline,
pneumatosis of stomach and proximal small bowel with portal
venous gas of unclear etiology but perhaps an SMV thrombus, and
continued management of his TPN-dependent intestinal failure.
HOSPITAL MEDICINE COURSE
==============================
#Septic shock: He presented in septic shock with CT showing
gastric/duodenal pneumatosis and portal venous gas. Sepsis was
thought to be secondary to gut translocation. He was initially
in the SICU on norepinephrine and vasopressin. He was started on
vancomycin, ciprofloxacin, flagyl, and fluconazole. Given
reports of feculent emesis, an NGT was placed for decompression
given that his venting G tube was not functioning. He was
thought to be unlikely to survive but within 48 hours had
markedly improved and was able to come off pressors and move to
the floor. Blood cultures from ___ grew Klebsiella pneumoniae.
ID was consulted and recommended Infectious disease was
consulted with recommendations to continued his vancomycin,
ciprofloxacin, metronidazole, and discontinue fluconazole. Final
sensitivities for Klebsiella and Kluyvera from ___
showed sensitivity to ciprofloxacin. He was discharged on
vancomycin, ciprofloxacin and metronidazole for ___fter first negative culture (___).
#Pain: Chronic pain and palliative care were consulted. He was
initially managed on hydromorphone, fentanyl, methadone, and a
ketamine drip. Once he was transferred to the medicine floor,
his ketamine drip and methadone were discontinued, and he was
placed on a PCA of 0.24 mg hydromorphone Q6m, with 0.5-1mg IV
hydromorphone Q2 PRN available in addition to home fentanyl.
Prior to this admission, his home pain regimen was PO
hydromorphone 4mg Q3h:PRN, fentanyl patch 125 mcg Q72h,
gabapentin 1200 TID. Chronic Pain Service was consulted with
initial recommendation to continue fentanyl patch 125mcg/hr,
Dilaudid 0.5 - 1 mg IV q2hr PRN, and gabapentin 1200 mg TID/
Because of his esophageal spasm/NPO status, regimen switched to
IV methadone, dilaudid PCA and discontinued fentanyl patch. PCA
was titrated off as his ability to take PO improved. He
tolerated his advanced diet to clear liquids. He was discharged
with fentanyl patch 125 mcg, gabapentin (liquid) 1200 mg TID and
hydromorphone PO 4 mg Q3H for pain.
#Pneumatosis and portal venous gas: Due to his multiple (over
10) previous surgeries, he was not a surgical candidate. As
above, an NGT was placed given feculent emesis. He tolerated
clamping on ___ and the NGT was removed on ___. His venting G
tube has not been functioning since beginning of ___, so ___
was consulted given concern for recurrent SBO without proper
venting. This was replaced on ___. The G-tube should be used
for venting ONLY. There is no surgical contraindication to
taking PO, although his ability to take PO has been complicated
by esophageal spasm in the past. He was advancing his diet to
soft foods at discharge without issues with nausea, vomiting or
abdominal pain.
#Leukopenia: On ___, he was noted to have WBC count 3.4
(without neutropenia). He did not have any evidence of recurrent
infection, and no focal signs or symptoms on exam. This was
trended with a daily differential, and nadired at 2.9, later
improving to 3.5 at discharge. Of note, ID consult did not feel
that his antibiotics were a likely culprit. This can be trended
as an outpatient.
#Nutrition: Patient was TPN-dependent at home (NPO except for
meds). TPN was restarted ___. This can be addressed if his PO
intake improves.
#Diabetes mellitus: his glucose was controlled using insulin in
his TPN. As he started to take more PO, he was started on a
gentle sliding scale insulin to be given with meals.
#GOC: He was also seen by palliative care for goals of care
discussions with goal of being discharged to rehab. He completed
a MOLST form indicating that his code status is DNR/DNI, but
later revoked this, saying that his primary motivation to pursue
full treatment should he become ill again was his wife, his
children and his grandkids. Code status and GOC should be
readdressed with Palliative Care and PCP.
#HTN: home labetolol was held. This can be restarted upon
discharge.
#Anemia: stable at baseline. He received 1u pRBC on ___ but did
not require additional transfusions. | 168 | 1,039 |
19891107-DS-20 | 26,303,115 | Dear Mr. ___,
It was a pleasure to take care of you here at ___. You were
initially transferred here for concern that you had an aortic
dissection. We found that you did not have this on repeat
imaging. We found that you had a bacteria in the blood which we
treated with antibiotics. You will continue these antibiotics
and be seen again by infectious disease clinic. You were found
to have fluid collections in your spine due to bacteria in the
blood- the spine surgeons did surgery to remove these pockets of
fluid. You will have the staples removed at the ___ this week.
We also found that you had another clot in your left leg. You
have had a history of this in the past. We started you on a
blood thinner that you should continue to take. Other testing
showed that you have a virus called Hepatitis C which can affect
the liver. We are waiting on more testing to determine what next
steps we can take. Your primary care doctor ___ discuss this
more with you. You should continue to work with physical therapy
and build up your strength. We were very impressed with the
amount of progress you made while you were here. It was a
pleasure to take care of you and we wish you all the best and a
speedy recovery. | ___ morbidly obese male with history of HTN and chronic lower
back pain who presented with acute on chronic hypertension and
admitted to MICU for possible thoracic aortic dissection, found
to have GPC bacteremia and epidural abscesses for which he
underwent L2-S1 laminectomy with hospital course complicated by
difficult intubation/extubation and DVT.
# Epidural abscesses s/p L2-S1 laminectomy: Transferred from OSH
given concern for aortic dissection on imaging. Vascular surgery
reviewed films and did not think there was a dissection,
however, recommended admission to ICU for esmolol drip (SBP goal
of 90-130). A repeat CTA was negative for dissection and the
Esmolol drip was discontinued. As a result, thought to be acute
flare of his chronic pain, unrevealing neuro exam, however, pt
did refuse DRE and a full neuro exam on ICU admission. After
admission, blood cxs returned + for GPCs (eventually speciated
into staph aureus). Given bacteremia, there was concern for
epidural abcess/osteomyelitis. MRI of L/T/C spine without
contrast did not show evidence of diskitis/osteomyelitis or
epidural abscess - however recommended MRI w/contrast. Patient
refused x2 to undergo MRI w/ contrast until pain better
controlled. Patient was transferred to medical floor on ___
after esmolol drip was discontinued in ICU. On ___ due to
continued severe back pain, patient was given narcotics, became
obtunded, requiring non-rebreather. Was transferred back to ICU
on ___ for continued pain management and possible intubation
to undergo MRI w/ contrast and TEE to r/o endocarditis. In the
ICU the patient was intubated and underment an MRI that was
notable for epidural collection in the L2-L4 region and
underwent laminectomy ___ with orthopaedics with drainagle
of purlant materail that was a MSSA collection. He will require
6 weeks of nafcillin with day 1 of treatment the drainage on
___. Stop Date: ___ (min 6 weeks)
- Patient should have staples removed on ___ by physician at
___.
# DVT: Patient states that he had DVT a few months ago treated
at ___ with coumadin. Patient has had prolonged
sedentary course given morbid obesity and complicated hospital
course. He reports he became noncompliant with coumadin when his
uncle passed away. Imaging indicates dvt of left popliteal- and
it is unsure if this is old or new. Patient was started on
heparin drip ___ for treatment of DVT and transitioned to
coumadin 4mg daily. Goal INR ___.
- INR on discharge was 2.9 ___ yesterday)
- daily INR should be collected and medications should be
titrated up/down as indicated to reach goal INR
# Hypertension, controlled on multiple antihypertensives: 24
hour blood pressures within normal limits. At home, patient was
on 100mg atenolol daily, 40mg lasix po BID, lisinopril 40mg
daily, nefidipine Cr90mg daily. Patient has had CTA done during
hospital stay and radiologist has confirmed that there is no
evidence of renal artery stenosis. Patient is currently on
atenolol 100mg po daily, clonidine patch ___, lasix
40mg IV daily, lisinopril 40mg qdaily, nefidipine cr 90mg
qdaily. Systolics were elevated to 200s in the MICU but have
been <180 on the wards. Hydralazine po was added upon transfer
to the wards but discontinued on ___. Dry weight is 186.8
(upon admit) and patient is currently at 173kg. Pain needs to be
controlled to decrease risk of elevated blood pressures.
- continue home dose of 40mg lasix po BID, obtain ___ lytes and
replete as indicated
- oupatient workup for refractory hypertension
- daily weights
# Fever, resolved: T of 101.8 in the ED. Patient afebrile 72
hours prior to discharge. Likely secondary to epidural abscesses
s/p laminectomy. Patient continued to intermittently spike
fevers during his hospitalization. Initial exam was remarkable
for back pain raising possibility of epidural abcess/OM; no
other infectious symptoms. Infectious work-up done in ED
returned with blood cxs + GPC (eventually speciated to staph
aureus). Started on Vancomycin. ID was consulted who recommended
a MRI w/ contrast of spine, TEE and a knee xray (which was
negative - given h/o TKR). Portal of entry for bacteremia was
thought to be IVDU versus skin (given findings of dry skin in
___. TTE done on ___ - did not show any significant
vegetations or significant valvular regurgitation, however exam
was limited due to patient's large body habitus. CXR on ___
did not show any focal consolidation. MRI of L/T/C spine
without contrast did not show evidence of diskitis/osteomyelitis
or epidural abscess - however recommended MRI w/contrast.
Patient refused x2 to undergo procedure until pain better
controlled. TEE showed: No evidence of endocarditis. Normal
left ventricular systolic function. MRI w/ contrast showed
epidural abscess seen which extends from L2-L4 level anterior to
the thecal sac. He underwent laminectomy ___ with
orthopaedics with drainage of purlant materail that was a MSSA
collection. He was transitioned to nafcillin and will require 6
weeks of nafcillin with day 1 of treatment, the drainage on
___. See possible PNA below.
# Klebsiella in the sputum: No evidence of ventilator associated
pneumonia on CXR ___. Patient was started on empiric tx cipro
500BID for 7 day course (started on ___ in MICU but cipro was
discontinued on ___ in order to monitor fever curve. Patient
does not have clinical signs of pneumonia such as new cough but
he did have baseline shortness of breath.
- continue to monitor fever curve and order chest CT for better
eval of lungs if patient fevers again
# Hepatitis C, newly diagnosed: Patient has history of IVDU and
his diagnosis was explained to him prior to discharge but he
showed little insight. Hep B vaccine was administered. Patient
had normal LFTs. Per primary care doctor, right upper quadrant
ultrasound was performed earlier this year and found to be
negative for fibrosis. RUQ u/s was not performed during this
hospital visit given recent normal imaging per PCP. AFP is 1.4.
- Hepatitis C viral load is pending
- Hepatitis C genotyping is pending
- RUQ u/s to assess for liver fibrosis
- Referral to ___ clinic should be done if patient has
elevated Hepatitis C viral burden - see below for contact
information
# Hx of opiate use: Pt denies recent drug use, although has IVDU
(last use ___ ago). Pt reported that he was on methadone,
prescribed by Habit ___ clinic at ___ that
follows pts with opiate abuse - He was started on Methadone 3
months ago at a non chronic back pain dose - 85mg PO QD. Given
bacteremia, there was a concern for current IVDU. It was
confirmed with a friend that the patient last used IV drugs on
the morning of admission. He was difficult to extubate in the
setting of the IVDU as his mental status declined and he was
placed on methadone with improvement in his mental status.
# Pain management s/p laminectomy on methadone. Patient states
he has not used drugs in years. Records indicate that patient
was on 85mg methadone daily administered by ___ clinic.
Must monitor breathing closely since patient has had severe
difficulty with breathing when overdosed on narcotic medications
for pain.
- continued methadone 80mg daily in the hospital
- consider referral to pain clinic outpatient
- continue high dose lidocaine patch to be applied to back and
bengay cream
- continue tramadol and oxycodone PRN- transition to long acting
pain medication based on the amount of use of short-acting
oxycodone
# Hypertension, controlled on multiple antihypertensives: 24
hour blood pressures within normal limits. At home, patient was
on 100mg atenolol daily, 40mg lasix po BID, lisinopril 40mg
daily, nefidipine Cr90mg daily. Patient has had CTA done during
hospital stay and radiologist has confirmed that there is no
evidence of renal artery stenosis. Patient is currently on
atenolol 100mg po daily, clonidine patch ___, lasix
40mg IV daily, lisinopril 40mg qdaily, nefidipine cr 90mg
qdaily. Systolics were elevated to 200s in the MICU but have
been <180 here. Hydralazine po was added upon transfer to the
wards but discontinued on ___. Dry weight is 186.8 (upon
admit) and patient is currently at 173kg. Pain needs to be
controlled to decrease risk of elevated blood pressures.
- continue home dose of 40mg lasix po BID
- daily weights
- outpatient workup for refractory hypertension
# Abdominal pain: patient had persistent abdominal pain during
admission with no evidence of rebound, guarding, or other
concerning symptoms. Likely secondary to gas and symptoms had
improved by discharge
- Patient was discharged on simethicone and maalox
# Shortness of breath: DDX includes Pickwickian syndrome, PE,
OSA. Symptoms improved with head of bed elevated so pickwickian
syndrome is likely contributing given morbid obesity. PE is also
probable given findings of DVT and hx of prior DVT
- patient should remain therapeutic on coumadin INR ___
# Diarrhea, resolved: most likely secondary to antibiotics.
Patient reports symptoms immediately afterwards. C diff
negative. | 227 | 1,460 |
17405743-DS-18 | 27,020,050 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | Patient presented to ___ after a fall while intoxicated. She
was evalauted in the emergency department and admitted to the
step down unit. Repeat CT scan of the brain showed expected
blossoming of her contusions with stable extra axial hemorrhage.
On ___ she underwent repeat CT head that should continued
expected evolution of her contusions and again stable
extra-axial hemorrhage. She clinically remained stable as well
but was deferring full neurologic exam as she had been prior. On
___ the patient was transferred to the floor from the Step down
unit and ___ continued to see the patient. She was cleared for
home after ___ more visits.
On ___, patient was cleared by ___ to be discharged home. On
examination, patient neurologically intact, but reports
headaches. Head CT was done and showed stable L frontal
contusion with surrounding vasogenic edema. Stable R SDH. She
was started on oxycodone and was discharged home in stable
condition. | 427 | 156 |
17827425-DS-21 | 26,034,530 | You were admitted to the hospital for pain in your back and hips
due to recurrent metastatic cancer shown on CT scan. Your other
studies from ___ and ___ showed cancer
in your liver, lymph nodes in your abdomen, and in both lungs.
You developed pneumonia and a COPD (chronic obstructive
pulmonary disease, emphysema) exacerbation causing shortness of
breath and hypoxia (low oxygen levels). These were treated with
antibiotics, steroids, nebulizers, and oxygen. The Pulmonary
doctors also saw ___ and a CT scan of your chest did not show a
blood clot or other cause. You will need oxygen at home. You
also had a yeast infection in your mouth; this was treated with
fluconazole. An MRI of your brain did not show cancer but
showed a small recent stroke that has not caused any symptoms.
You had difficulty passing urine and were started on a new
medication called tamulosin (Flomax) for an enlarged prostate.
This might cause dizziness if you sit up or stand up too
rapidly. You should sit up slowly and wait a few minutes before
standing up slowly to avoid falls. You were constipated for
your pain medications and should keep taking stool softeners
when you go home. Your blood pressure medication was stopped
and does NOT need to be restarted. Your cholesterol medicine
was stopped and does not need to be restarted.
.
The following changes have been made to your medications:
1. Prednisone taper.
2. STOP lisinopril/hydrochlorothiazide (HCTZ).
3. STOP simvastatin (Zocor).
4. Albuleterol nebs-scheduled four times daily x5 days and then
as needed.
___ 0.4 mg po at night.
___ 10 mg po q8hrs
7.oxycodone ___ mg po q 3hrs as needed for pain
8.gabapentin 300 mg po TID
9.pantoprazole 40 mg po daily
10.prochlorperazine 10 mg q 8hrs as needed for nausea
11.zofran ODT 8mg q8hrs as needed for nausea
12.tiotropium bromide capsule daily. | ___ man with ___ s/p chemo/XRT ___ followed by resection
of residual disease admitted for right hip and lower back pain
with new lytic lesions in pelvis and L-spine. Also new
retroperitoneal adenopathy and bilateral pulmonary nodules.
.
# Pneumonia & COPD exacerbation: Completed course of antibiotics
cefepime and levofloxacin ___ for hospital-acquired
pneumonia. Sputum culture grew Strep pneumoniae sensitive to
penicillins. Pt developed ne wO2 requirement and increased
wheezing. Peak flow ___ was ~150 (best of 4). Repeat CXR
stable. Pulmonary consulted. CTA chest was negative for PE,
but showed extensive mets. Started prednisone taper for COPD
exacerbation. Changed to IV methylprednisolone because of N/V
and poor response to PO. Changed albuterol nebs to scheduled
and PRN. Started tiotropium. Continued outpatient
budesonide-formoterol.Prior to discharge wheezing did improve
and pt to continuea slow oral prednisone taper.
.
# Back and Hip pain: Due to new metastatic disease most likely
from known primary. No evidence of cord compression on MRI.
Ortho recommended weight bearing as tolerated. XRT x1 fraction
given ___. Palliative Care consulted. Started methadone
___ --> decreased by ___ due to fluconazole, then increased
to ___ on ___. Increased to 10mg q8HR ___ given his
continued need for oxycodone ___ q4HR + additional PRN.
Oxycodone ___ mg PRN. Bowel regimen for narcotic-induced
constipation.
.
# Incidental lacunar infarct: Neurology consulted.Not checking
lipid panel given his metastatic cancer. HgbA1c 5.9%. Echo
with bubble study without source of embolism. Telemetry
negative for intermittant afib.
.
# Metabolic encephalopathy and acute delirium: Improved after
stopping lorazepam. Consider haloperidol if it recurs.
.
# Nausea/vomiting: Unclear cause - due to constipation vs. meds.
Improved after changing hydromorphone to oxycodone.
Anti-emetics PRN.
.
# Oral candidiasis: Resolved on fluconazole, stopped after six
days. Methadone halved while on fluconazole for drug
interaction.
.
# Leukocytosis: Resolved. Due to pneumonia.
.
# Anemia: Stable. Low retic index and iron studies support
anemia of inflammation.
.
# Gross hematuria: Unknown cause - concerning for renal mets vs.
nephrolithiasis. Urine culture was negative. No further
work-up given Mr. ___ does not want any more
interventions.H/H remained stable adn as below symtoms of
urinary hesitancy improved..
.
# Urinary hesitancy and retention: Improved. Started tamsulosin
for BPH.Bladder scan prior to d/c showed a post void residual of
300cc. Crea remained wnl. If pt to develop worsening symptoms
may need a foley cath placed.
.
# Lung CA with new lung, liver, bone, and retroperitoneal
metastases: MRI ___ ___ showed no cord
compression. CT ___ showed liver mets. After he discussed
it with his primary oncologist Dr. ___, Mr. ___ decided to
hold off on the liver biopsy or any further interventions.
Social Work consulted and followed . Anti-emetics PRN. Pain
control as above. Palliative Care consulted. Mr. ___ and
his family decided to continue supportive care with home
hospice services.
.
# Constipation: Due to narcotics. Bowel regimen.
.
# Hypertension: Lisinopril held on admission due to hypovolemia.
Remained normotensive off BP meds.
.
# DVT PPx: Heparin SQ.
.
# CODE: DNR/DNI | 312 | 513 |
11301702-DS-20 | 26,803,001 | Dear Mr. ___,
You presented to the hospital with abdominal pain, nausea and
abdominal distention due to a recurrent small bowel obstruction.
You managed conservatively with bowel rest, gastric
decompression and intravenous fluids. You have had signs that
your obstruction has resovled and you are now preparing for
discharge to home with the following 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 experiencing severe abdominal bloating, severe,
nausea, vomiting and cannot keep down fluids or your
medications, abdominal pain.
*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. | Mr. ___ is a ___ s/p sigmoid colectomy ___ with multiple small
bowel obstructions. He presented to the Emergency Department on
___ with abrupt onset of abdominal pain, distention
and nausea. An abdominal CT scan was obtained and confirmed
recurrence of a small bowel obstructions. Therefore, the
patient was admitted to the Acute Care Surgery service for
attempted conservative management with bowel rest, intravenous
fluids and ___ decompression.
On HD2, the patient had return of bowel function with positive
flatus and bowel movement. He tolerated a regular diet on HD3
without abdominal pain, nausea, vomiting or abdominal
distention. Therefore, he was discharged to home. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 243 | 126 |
19456024-DS-19 | 24,216,186 | Dear ___ were admitted to the hospital with abdominal pain and
diarrhea. ___ had a CT scan of your abdomen that did not show a
source of your symptoms. ___ had an upper endoscopy and
colonoscopy that also did not explain your symptoms, but
biopsies were taken. The GI doctors ___ with the
results of those biopsies within the next ___ weeks.
___ should continue to avoid foods that cause your symptoms. ___
have been prescribed some supportive medications for symptoms
that are not controlled by dietary changes alone. ___ may
benefit from trialing the "Low-FODMAPS Diet" - more information
is available online at
___
___ may benefit from seeing a nutritionist as an outpatient as
this diet can be difficult to do on your own.
If ___ have severe abdominal pain, ___ should come to an
emergency department.
Best wishes for your continued healing!
Take care,
Your ___ Care Team | SUMMARY/ASSESSMENT:
Mrs. ___ is a ___ y/o woman with a history of cerebral palsy,
epilepsy, GERD, and asthma who presented with 1 month of
worsening abdominal pain and watery diarrhea. | 147 | 33 |
10913302-DS-38 | 21,527,374 | Dear Mr ___,
It was a pleasure being involved in your care.
Why you were here:
-You came in because you were having shortness of breath
What we did while you were here:
-Your were transferred to the ICU and found to have RSV
pneumonia. You were given a medication to treat the RSV
pneumonia (palivizumab). -Because of your chronic GVHD affecting
your heart and lungs, your lung infection resulted in
accumulation of fluid in your lungs. You required intubation to
get you through the infection.
-We also treated you with antibiotics in case you had a
superimposed bacterial infection.
-You were transferred to the regular ___ floors where your
respiratory status and infection continued to improve.
Your next steps:
-Please keep all your appointments
-Please take all your medications as prescribed
We wish you well,
Your ___ Care Team | ___ y/o man with complicated PMH notable for AML s/p multiple
chemotherapy regimens and MUD-pSCT in ___ c/b recurrent skin
and pulmonary infections and pulmonary/restrictive GVHD,
admitted with acute respiratory distress found to have RSV
pneumonia | 130 | 36 |
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