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18696707-DS-19 | 27,670,479 | Dr. ___,
___ was our pleasure caring for you at ___
___. You were admitted with shortness of breath. You
had a chest xray which showed a moderate pleural effusion.
Clinically you looked as if you had a heart failure
exacerbation. You were given lasix and diuresed well and your
symptoms improved. We discussed with cardiology and
interventional pulmonary who felt comfortable with you going
home. Cardiology recommended increasing your lasix dose to 40MG
twice a day. | #Dyspnea on exertion: Pt's presentation of dyspnea on exertion,
with significantly reduced tolerance to ambulation, S3 on exam,
___ edema and elevated JVP were most consistent with a CHF
exacerbation. Pt's proBNP was elevated at 4285 on admission,
increased from previous admission of 1751. Previous ECHO's have
been consistent with diastolic failure, with last known EF of
40%. Pt's DOE improved from with Lasix diuresis 40MG BID, with
continued improvement in ___ edema. Pt was net negative -1000cc
per day x2 days, with pt being able to ambulate down the
hospital corridor per normal without SOB. Cards was consulted on
this admission due to pt's known CHF history and question of
biopsy findings of amyloidosis and concern for constrictive
pericarditis: pt was noted to not have clinical signs of
constrictive pericarditis, and recommended no R heart
catherization or TEE at this time(due to recent ECHO in Atrius
records <1 month prior to presentation). Pt was further assessed
by IP as an inpt, and decision was made to hold off on
throacentesis on this admission; per IP, the volume of fluid
appreciated on imaging was not consistent with patients severe
symptoms on presentation, and pt was instructed to followup as
planned as an outpt. Following diuresis with Lasix 40MG IV BID,
pt was transitioned to Lasix 40MG PO BID which he tolerated
well. Pt improved clinically, with oxygen saturation in the high
___ and no dyspnea on exertion with ambulation.
# Afib: Patient has known Afib s/p multiple prior ___ s/p PVI
with ___ amputation, and has been rate/rhythm
controlled on a stable dose of Amiodarone 200MG QD. Patient was
anticoagulated on home warfarin 1.25MG, but was reversed in the
ED per ___ with Vitamin K 2MG IV in anticipation of possible
thoracentesis by IP. Following decision to not pursue
thoracentesis as an inpatient, pt was restarted on home Warfarin
with goal of INR ___, with instructions to continue his home
doses and re-check his INR 1 week post discharge.
#CAD: Pt has known coronary Artery Disease (left main and 3
vessel disease) s/p CABG x5 in ___ (left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to diagonal branch, ___ marginal branch, ___ marginal
branch, and posterior descending artery). On this admission, pt
denied Chest pain, with EKG unchanged since previously. Troponin
x3 were stable at 0.02. Pt was continued on home ASpirin 81mg
QD, home Atorvastatin 40MG QD, Lisinopril 2.5MG. Pt's home
Metoprolol XL 12.5MG was held during this admission as pt has
not been taking for >3 month due to low HR
Chronic issues:
Hypothyroidism: Patient has been on a stable home dose of
levothyroxine 88MG daily with TSH within normal limits. Pt was
continued on Levothyroxine 88MG daily. | 76 | 452 |
18240093-DS-18 | 27,378,949 | Dear Ms. ___,
You were admitted to ___ due to shortness of breath. We did
imaging of your lungs and found that you had pneumonia. We
started you on antibiotics for this and your breathing improved.
It is now safe for you to go home. It was a pleasure caring for
you.
Wishing you the best,
Your ___ Team | Ms. ___ is a ___ y/o woman with PMHx asthma, morbid
obesity (last BMI 108.2), OSA/obesity hyperventilation syndrome
on ___ at home and BiPAP at night, HFpEF, and hypercarbic
respiratory failure & PEA arrest requiring intubuation ___,
who presented with likely bacterial PNA. | 56 | 43 |
11604306-DS-19 | 21,296,775 | Dear Mr. ___,
It was a pleasure to care for you at ___. You were admitted
with ongoing pain from the site of lymphoma in your back. We got
an MRI which showed the lymphoma was unchanged in size compared
to the most recent CT scan. The lymphoma was not compressing
your spinal cord, which was excellent news. The increased size
of mass does not meet criteria for disease progression, so you
will not be forced to come off the PD-1 antibody study. Dr.
___ Dr. ___ your imaging together and
agree that it is safe to proceed without radiation therapy at
the current time. Please keep your follow-up appointments as
detailed below.
Due to your history of heart failure, please weigh yourself
every morning, call MD if weight goes up more than 3 lbs. | Mr. ___ is a ___ year old male with a history of transformed
follicular lymphoma who, prior to this hospitalization, had
received 2 cycles of PD-1 antibody, presenting with progressive
pain at the site of the paraspinal mass of lymphoma, recently
shown to be enlarged.
# Paraspinal lymphoma mass: An MRI showed stable appearance
compared to CT scan on ___. No evidence of cord compression.
The patient was continued on MS contin 15mg Q12H, gabapentin
300mg Q8H (increased from QHS on prior discharge), and lidocaine
patches x2. He required minimal additional oxycodone for
breakthrough pain control (one pill per day). The patient had
excellent pain control while hospitalized and was able to sleep
through the nights. He had been unable to pay for the lidocaine
patches after his previous discharge. Since it appeared that his
pain was much improved with lidocaine patches, we switched his
prescription to lidocaine cream, which will be a less expensive
alternative.
Radiation therapy to the mass was considered, but would mean the
patient would have to come off the PD-1 antibody study he is
currently enrolled in. The increased size of the mass at this
time does not meet criteria for disease progression. The patient
was hesitant to proceed with radiation therapy since his pain
was well controlled and RT would mean coming off study. Dr.
___ radiation oncology was consulted and agreed that
it was safe to proceed without RT at this time.
# Right ___ and ___ finger paresthesias: On admission, the
patient reported tingling in his right ___ and ___ fingers. An
MRI of the C-spine did not show any concerning lesions which
would result in upper extremity paresthesias. The paresthesias
resolved on ___ and did not recur.
# Follicular Lymphoma: Pt has been tried on multiple
chemotherapy regimens in the past. Recently diagnosed with high
grade transformation. He was recently started on a PD-1
antibody trial. He opted to stay on this PD-1 antibody trial and
defer radiation therapy, as above. He was continued on acyclovir
and Bactrim for prophylaxis.
# Systolic heart failure: The patient has an ejection fraction
of 35-40% related to prior chemotherapy toxicity. He is followed
by Dr. ___ had been on metoprolol succinate 50 mg daily,
lisinopril 10 mg daily, and spironolactone 25 mg daily prior to
previous admission. Due to hypotension while on narcotics,
lisinopril and spironolactone were stopped during the last
admission (OK'ed by Dr. ___. The patient was continued on
metoprolol succinate 50mg daily during this admission. Consider
restarting lisinopril and spironolactone when patient is weaned
off of narcotics. | 134 | 427 |
16358341-DS-24 | 22,453,750 | ___ were admitted to the hospital after a fall. ___ were found
to have alcohol in your system when ___ arrived. ___ sustained
rib fractures because of the fall. Your pain has been
controlled with oral analgesia. ___ are now preparing for
discharge home with the following instructions:
Please call your doctor or return to the emergency room if ___
have any of the following:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ 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.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ 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 ___.
* Please resume all regular home medications and take any new
meds
as ordered.
Because of your fall, ___ sustained right sided rib fractures.
Please follow these instructions:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause ___ to take shallow breaths
because of the pain.
* ___ should take your pain medication as directed to stay
ahead of the pain otherwise ___ 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 ___ 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.
* ___ will be more comfortable if ___ 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 ___
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 | The patient was admitted to the hospital after a fall. She was
brought to the emergency room and evaluated. She was reported
to have alcohol in her system. On review of her lab work, she
was found to have a urinary tract infection and was started on a
3 day course of ciprofloxcin. She underwent a chest x-ray which
showed right sided ___ rib fractures and a left ___ lobe
nodular density, which could represent atelectasis. She was
also noted to have a manubrium fracture. Her oxygen saturation
was closely monitored and she was encouraged to use the
incentive spirometer. She received oral analgesia for the rib
fractures. During the hospital stay, the patient reported chest
discomfort and was found to have a positive D-dimer. To rule out
a pulmonary embolism, the patient underwent a CTA which showed
right sided pleural effusion, and a left lower lobe density.
Recommendations were made for further imaging with a cat scan in
3 months. Because of her presentation and history of alcohol
abuse, the patient was seen by the social worker who provided
her with support and addressed alcohol cessation programs.
The patient's vital signs have remained stable and she has been
afebrile. She was tolerating a regular diet and voiding without
difficulty. She was discharged home on HD #3 in stable
condition. Appointments for follow-up were made with the
primary care provider and with the acute care service. Call to
primary care provider's office about need for follow-up cat scan
to evaulate lung nodule. The patient was also informed of the
importance of the follow-up appointment as well as findins on
cat scan. Discharge instructions were reviewed and questions
answered. | 465 | 294 |
16838641-DS-11 | 20,635,023 | Dear Ms. ___,
You were hospitalized due to symptoms of vomiting and
lightheadedness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- age
- heart disease
- diabetes
- high blood pressure
We are changing your medications as follows:
- STOP Aspirin
- START Plavix 75 mg daily
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 | Ms. ___ is a ___ F w/ PMH HLD< OA, hypothyroidism, GERD,
T2DM, CAD who presented with lightheadedness, unsteadiness and
vomiting subsequently found to have small ischemic infarct in
the left superior vermis. Her initial neurologic exam was most
notable for unsteadiness with gait that improved with time.
Etiology of stroke is unclear but could be secondary to
intracranial atherosclerosis vs cardioembolic etiology. She
underwent work up for stroke risk factors. Labs were obtained
which showed Hemoglobin A1c 5.7, LDL 54. and TSH 0.52. Echo was
obtained and showed normal EF and no PFO. Patient reports that
she was told that she had one episode of atrial fibrillation
about ___ years ago prior to carpal tunnel surgery. She reports
intermittent palpitations but it has since not been diagnosed
with atrial fibrillation. Here she endorses a few episodes of
palpitations but no arrhythmias were captured on telemetry. She
will be discharged with ___ Monitor to assess for
arrhythmia.
Because patient had stroke while on aspirin, she was
transitioned to Plavix. She will continue on atorvastatin and
her other home medications.
She was evaluated by ___ who recommended discharge home with
services.
======================================================
Transitional Issues:
[ ] ___ of hearts monitor
[ ] monitor blood pressure
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () 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 = 54 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (x) No [reason
()x non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
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 | 288 | 463 |
19609862-DS-12 | 27,311,633 | Dear Mr. ___,
You were admitted to the hospital for reduced kidney function
and elevated potassium levels in the blood. Your medications
were adjusted and you were given IV fluid hydration, and these
levels improved.
It is important that you take all medications as prescribed and
follow up with the appointments listed below.
It was a pleasure taking care of you!
Sincerely, your ___ Team | Mr. ___ is a ___ ___ male with a PMH of
hypertension, hyperlipidemia, chronic kidney disease,
Alzheimer's dementia, pre-diabetes, left carotid stenosis s/p
CEA and asymptomatic interstitial lung disease who was sent to
the ED by his PCP for ___ and hyperkalemia. | 61 | 43 |
14078116-DS-16 | 22,063,050 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having abdominal
pain. When you arrived at the Emergency Department, lab tests
showed that your potassium was very high. You also had an
episode of bloody diarrhea and the following day, your blood
levels were found to be much lower than your normal blood
levels.
What did you receive in the hospital?
- When you arrived, you received several medications and
dialysis to treat your high potassium levels. After your episode
of bloody diarrhea, your blood levels dropped, and we were very
concerned that you might be bleeding anywhere from your
esophagus to your intestines. Your blood pressures were also
low, most likely due to this loss of blood. We gave you a unit
of blood with dialysis, but your blood levels did not rise as
much as expected. We also gave you IV fluids and your blood
pressure improved. We gave you a second unit of blood the
following day to help increase your blood levels. After this, we
performed an endoscopy, which involves using a scope to look
into your esophagus and stomach to look for signs of bleeding.
The endoscopy showed some erosions but no signs of active
bleeding. We recommend starting a new medication called
pantoprazole to help prevent possible bleeding in the future. On
___, you had a large, black stool concerning for ongoing
bleeding since digested blood makes your stool black in color.
We therefore did a colonoscopy on ___ to make sure that we were
not missing any other obvious sources of bleeding, and we did
not see any bleeding or abnormal changes in your colon.
What should you do once you leave the hospital?
- You should follow up with your primary care provider within
one week of discharge from the hospital.
- You should come to the emergency department if you have any
other black or bloody stools
- You should continue a low potassium diet
- You should take your medications as prescribed
- You should continue taking pantoprazole 40mg PO BID for 8
weeks
- You should continue taking stool softeners as prescribed to
help treat your constipation
We wish you the best!
Your ___ Care Team | [ ] Restart labetolol and bumex at discretion of PCP
[ ] Indeterminate 1.5 cm lesion in the interpolar region of the
right kidney, not previously seen on ultrasound from ___ or MR pelvis from ___. Non urgent multiphasic CT
is recommended for further assessment, assuming patient's renal
function is below threshold for contrast enhanced MRI.
[ ] High dose PPI BID for treatment of esophagitis and erosions
for 8 weeks, with plan to then transition to daily PPI therapy
[ ] Repeat EGD in ___ weeks
[ ] Check Stool H. Pylori
[ ] Consider capsule study if concern for ongoing GI bleed
___ is a ___ year old ___ man with PMH of HTN,
hypertensive retinopathy, CAD, ESRD on HD and on transplant
list,
stroke x2 complicated by cognitive impairment now on DAPT with
aspirin and Plavix presented to the ED for abdominal pain. He
was
found to be hyperkalemic to 9.1, received HD in ED, found to
have
signs of GI bleed on ___ with bloody diarrhea, hypotension to
systolics in the ___, and drop in H/H. | 393 | 170 |
15135960-DS-20 | 27,766,525 | Dear Dr. ___,
___ was a pleasure taking care of you on the gynecology service.
You have recovered well from your operation and the team now
feels you are safe to discharge home. You will need a repeat
ultrasound on ___. An order has been placed with radiology
for this. Please call ___ on ___ to schedule a time
prior to your 1pm appointment on ___ with Dr. ___.
Please follow these instructions:
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
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs 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 > 100.4
* 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 ___. | Ms. ___ was taken emergently to the operating room from the
ED for aa exploratory laparotomy, partial right oophorectomy,
and evacuation hemoperitoneum. Please see operative report for
full details. Intra-operatively, she received a blood
transfusion. The intra-operative findings were consistent with a
hemorrhagic cyst and there was no evidence of ectopic pregnancy
noted.
Post-operatively, she had an ultrasound which showed an
intrauterine gestational sac with no yolk sac or fetal pole. Her
HCG was trended from 4640 -> 4421 ___ 4766 (___). She was
started on vaginal progesterone and chose to continue this
regimen as an outpatient as this pregnancy was desired. However,
she was counseled that given the US findings and an abnormally
rising HCG, this was likely not a normally developing pregnancy.
She was counseled on both medical and surgical managment options
and opted for expectant management.
For her post-operative care, her HCT were trended and were
stable. Her urine output was adequate on post-operative day#1
and her foley was removed and she voided spontaneously. She was
discharge home on post-operative day #2 in good condition:
ambulating and urinating without difficulty, tolerating a
regular diet, and with adequate pain control using PO
medication. Bleeding and ectopic precautions were reviewed prior
to discharge. She had close outpatient follow-up arranged for a
repeat US and labs. | 277 | 214 |
19159236-DS-17 | 20,575,000 | Please do not increase your pain medication regimen without
discussing it with Dr. ___. | ___ yo M with h/o OSA, COPD, obesity hypoventilation, and chronic
pain on narcotics, who presented with increasing somnelence and
developed hypercarbic respiratory failure.
Active issues:
# Hypercarbic respiratory failure: Likely multifactorial with
concurrent narcotic/benzo use and obestity hypoventialtion on
top of poor substrate with COPD/OSA. Reportedly responded to
narcan in ED, but became hypercarbic with high FiO2. ___ be due
to decreased respiratory drive from high oxygen. Possible PNA as
pt with cough and CXR wet and so levofloxacin x 5 days was
completed during admission. Pt was brought up to ICU after
intubation in ED. His respiratory status improved and pt was
extubated approximately 16 hrs after admission. He was
transitioned from NC to room air without complication. He was
given albuterol/ipratropium nebs PRN. On general medicine floor
patient's respiratory status remained at his baseline with no
further episodes of hypoxia.
# Somnelence: Almost certainly from hypercarbia. See above. With
improvement in respiratory status, pt became increasingly awake
and alert and returned to baseline normal function.
Chronic issues:
# Chronic pain: Significant chronic hip pain from bilateral
necrosis/replacement. Also with chronic knee pain. On extensive
narcotic regimen including oxycontin 40 po tid with oxycodone
10q6 prn breakthrough. Narcotics were held for entirety of ICU
stay due to concern for sedation and pain was well-controlled
with tylenol. On arrival to general medicine pt was restarted on
prn oxy only. This did not adequately control his pain and so he
was restarted on 40mg BID oxycontin with improved pain control
and without change in respiratory status.
# Psych: Signficant psych history including concern for
schizophrenia. Outpatient med list includes seroquel and
risperdal. Also on buspar and xanax for anxiety. Per mother, is
in process of transitioning from seroquel to risperdal. Buspar,
Xanax and seroquel were held during ICU stay due to concern for
sedation. Risperdal was continued per home regimen. Xanx was
resumed on arrival to gen med at a lower dose and frequency.
Patient will need to address these changes with his
psychiatrist.
# Diabetes: Home meds (metformin, glipizide, novolog 70/30) were
held. Pt was placed on humalog insulin sliding scale. He will
resume home meds on discharge.
# HTN: Contiued home regimen (amlodipine, metoprolol, losartan,
and HCTZ). Patient still hypertensive throughout admission.
Possibly opioid withdrawl? He should follow up with his PCP for
possible medication adjustment.
# HCV: Failed interferon course. Outpatient ___ as directed. | 14 | 394 |
17068892-DS-22 | 21,907,172 | Dear Ms. ___,
It was a pleasure taking care of ___ during your recent
admission to ___. ___ came to us because ___
were having shortness of breath. We found that ___ were
wheezing, and we gave ___ nebulizer treatments to help open your
airways. Please complete your five-day course of prednisone
(last day ___. Please follow up with your pulmonologist and
your regular doctor. We wish ___ a fast recovery.
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with GERD, fibromyalgia,
paradoxical vocal fold dysfunction, tracheobronchomalacia s/p
thoracotomy and tracheoplasty in ___ who presented with
subacute progressive dyspnea, expiratory wheezing, and chest
pain radiating to the right that was exacerbated by palpation on
both the right and left chest wall. EKG was without ST/T
changes, and troponins were negative. Pain was not improved with
nitroglycerin. Wells Score 0, D-Dimer <150, and patient on
apixaban for atrial fibrillation. CT chest showed
stable/improving lung herniation without interval increase in
congestion of the herniated segment. The patient has been
followed for the herniation for more than ___ years. Thoracic
surgery was consulted, and did not think the patient's symptoms
were a result of the stable lung herniation. Interventional
Pulmonology was consulted, and did not think that
tracheobronchomalacia accounted for the patient's dyspnea; no
bronchoscopy was performed. The patient was discussed with ENT;
vocal cord dysfunction was determined to be unlikely as it
causes inspiratory stridor and patient had no changes in
phonation. Ultimately, given the patient's wheezing on exam and
evidence of air trapping on CT, the patient was given nebulizer
treatments and a five-day burst of prednisone with concern for
reactive airway disease.
=============== | 73 | 199 |
14206015-DS-12 | 23,572,605 | Dear Ms. ___,
It was a pleasure taking care of you while you were admitted to
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because your heart rate was too low and you
weren't able to be as active as you normally are.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We found that the conduction system in the heart was abnormal
and that you have something called Third Degree Heart Block
- We gave you medications to lower your blood pressure
- We implanted a permanent pacemaker that will prevent your
heart from going too slow
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Make sure to finish taking the antibiotics that we prescribed
to you
- Take all of your medications when you leave the hospital.
Carefully review the discharge paperwork so you know what
medications to take and for how long.
- Follow all of the activity restrictions that the
electrophysiologists reviewed with you
- Call a doctor or call ___ if you have any new or concerning
symptoms
Sincerely,
___ Cardiology Team | ==================
SUMMARY STATEMENT
==================
Ms. ___ is a ___ year old woman with a history of 2nd degree AV
block (likely ___ II), carotid artery stenosis, dyslipidemia,
hypertension and osteoporosis who presents from her primary care
clinic in the setting of fatigue and exertional shortness of
breath, who was found to be in complete heart block with a
narrow escape rhythm. She was hemodynamically stable and
minimally symptomatic throughout her hospitalization, and
received a dual chamber permanent pacemaker on ___.
==================
ACUTE MEDICAL ISSUES
==================
# Third degree atrioventricular heart block -
Patient was found to have 2nd degree heart block (likely Mobitz
II) on ETT ___. For the month prior to admission, she was
experiencing some exercise intolerance and exertional shortness
of breath. She is very active at baseline. She presented to her
PCP ___ ___ for these symptoms and was found to be in
complete heart block with a narrow escape rhythm around 45 bpm.
She was transferred to the ___ ED for management. She was
found to be asyptomatic at rest and able to tolerate walking the
floor at persistent rates in the 30___ and ______. Etiologies to
consider for AV nodal dysfunction includeconduction disease iso
advanced age vs. infiltrative process (e.g. amyloidosis vs.
sarcoidosis). Patient was not on any nodal blockers. ECG did not
have other concerning ischemic changes. Nothing to suggest acute
infection (e.g. myocarditis vs. endocarditis with valvular
abscess). TSH normal. Troponins negative. No clear reversible
causes.
On ___ she received a dual chamber pacemaker. Post-operative
she was found to have subcutaneous crepitus concerning for
possible pneumothorax. A postoperative CXR did not show any
pneumothorax, and she did not have any dyspnea or hypoxia. She
was prophylactically placed on nasal cannula 6L O2/min overnight
and a subsequent CXR again did not reveal pneumothorax. She
received IV vancomycin on ___ and was discharged on keflex
for a total three day course.
# Hypertension
Hypertensive with SBPs as high as 200's. Previously only on HCTZ
12.5mg daily. Asymptomatic with these blood pressures. Treated
with hydralazine 10mg q8hrs with moderate BP control, which was
continued upon discharge.
# Recent weight gain
# Exertional shortness of breath
# Elevated BNP -
While patient's SOB is more likely a result of her complete
heart block, may consider evolving heart failure given recent
6lbs weight gain and elevated BNP (without any degree of renal
insufficiency). TTE ___ showed LVEF 60-65% with borderline
LVH. JVP mildly elevated with trace lower extremity edema. Not
on maintenance diuretics. Moderate output to 20 IV Lasix, though
difficult to interpret given that multiple urine outputs were
not recorded. Her weight was slightly decreased. Overall she was
not thought to have a florid volume overload.
====================
CHRONIC MEDICAL ISSUES
====================
# Osteoporosis:
By report, patient will receive Zoledronic Acid infusions as an
outpatient once yearly.
=================
TRANSITIONAL ISSUES
=================
- New Meds: hydralazine q8hr
- Stopped/Held Meds: None
- Incidental Findings: None
# CODE: Full code
# CONTACT: ___ (son, ___ ___
[ ] Consider repeat outpatient TTE as patient was found to be
mildly volume overloaded on presentation
[ ] Needs one week follow-up appointment in electrophysiology
[ ] Continued management of hypertension
[ ] Pt will complete a course of kelfex for post-surgical ppx | 174 | 520 |
13153781-DS-18 | 24,749,911 | s/p Lumbar drain placement for a post operative fluid
collection.
Lumbar Drain placement:
You have undergone the following operation: Lumbar Drain
Placementfor post operative seroma.
Immediately after the procedure:
Activity:You should not lift anything greater
than 10 lbs for 1 week. You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:If you have been given a brace
previously, this brace is to be worn when you are walking.You
may take it off when sitting in a chair or lying in bed.
Wound Care: Keep the drain in place for 1 week
until your follow up appointment with Dr. ___. Dressings may
be changed with dry gauze.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound | Patient was admitted to the ___ Spine Surgery Service and
taken to the Ultrasound for a lumbar drain placement for post
operative seroma.Refer to the dictated note for further
details.The procedure was without complication and the patient
was transferred back to the floor in a stable
___ were used for postoperative DVT
prophylaxis.Pain was controlled with oral pain medication.Diet
was advanced as tolerated.Foley was removed and was able to void
independentlyl. Physical therapy and Occupational therapy were
consulted for mobilization OOB to ambulate and ADL's.Hospital
course was otherwise unremarkable.
In summary, ___ is a ___ year-old right-handed woman
who presents
with back pain, weakness, numbness and urinary retention for
whom a code cord was activated by the Emergency room team.
Neurology was asked to help with level of spinal imaging.
History is notable for recent postoperative status with an L5-S1
anterior posterior fusion on ___ by Dr. ___. On exam, she
had bilateral lower extremity weakness which seems to be limited
by pain, decreased sensation to light touch/pinprick extending
from her Lt knee to the dorsum of her foot (L4-L5). Patient went
for surgical procedure on ___ for drainage of fluid
collection and drain was left in place. This drain will remain
in place for 1 week with follow up as outpatient with Dr.
___.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet. | 433 | 238 |
12220797-DS-22 | 21,861,092 | 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, ROMAT RLE
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.
**Since your oncology care is at ___, we were unable to
give you your liposomal doxorubicin here at the ___. From the
orthopaedic surgery standpoint, you are okay to resume your
chemotherapy as usual. Please call your oncologist to reschedule
your appointment upon discharge.**
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Weightbearing as tolerated right lower extremity, ROMAT RLE
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. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right pathologic tibia fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibia intramedullary nail which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
w/home ___ was appropriate. The ___ hospital course was
otherwise unremarkable.
She missed her chemotherapy dose while she was hospitalized.
Since her care is at ___, we were unable to give her
liposomal doxorubicin here at the ___. Instructed to call her
primary oncologist for follow up. She may resume chemo as usual.
XR of her other extremities were obtained and showed diffuse
sclerotic lesions throughout but no definitive fracture.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 671 | 315 |
18764644-DS-32 | 29,829,421 | Dear Mr. ___:
You were admitted to the hospital for difficulty walking, low
blood count (anemia), and low grade fever. You were transfused
two units of blood to help with your low blood count. It was
felt that your difficulty walking may have been from your
fatigue/low blood count. You did not have subsequent fevers, and
infection is not suspected. | Mr. ___ is a ___ with history of central nervous system
lymphoma status post temporal lobe resection in ___, 8 cycles
of high-dose methotrexate, and most recently pemetrexed (C10D1
on ___ who presents to with gait instability.
<< Active Issues:
#Gait instability: Despite presenting symptom of gait
instability, neurologic exam was found to be nonfocal throughout
admission, with subjective instability likely reflecting
generalized fatigue with subjective weakness secondary to
deconditioning and anemia as below. He received supportive
treatment with pRBC transfusion as below, as well as
dexamethasone 2mg bid, which was discontinued at discharge,
given uncertain benefit. Home physical therapy is planned
post-discharge.
#Fever: He remained afebrile without leukocytosis throughout
admission after fever to 101.5 in the ED. Following
vancomycin/cefepime x1 in the ED, antibiotics were held in the
absence of neutropenia or clear bacterial etiology. CXR was
negative for infiltrate, UCx with <10K organisms, and BCx with
no growth to date. Stool was negative for C. difficile,
Salmonella, Shigella, or Campylobacter. Transient fever was
perhaps reflective of self-limited viral infection in the
setting of nausea/vomiting and diarrhea in the ED, without
recurrence throughout admission.
#Normocytic anemia: In the setting of known cold autoimmune
hemolytic anemia, perhaps pemetrexed-induced, hematocrit was
25.7 on admission, down from recent baseline of ___, with
decline to 22.6 on hospital day 2. He received 2 units of warmed
pRBC, with appropriate increase in hematocrit to 28. Although
LDH was elevated and DAT positive, haptoglobin and
total/indirect bilirubin were within normal limits.
<< Inactive Issues:
#Central nervous system lymphoma: He has undergone temporal lobe
resection in ___, 8 cycles of high-dose methotrexate, and most
recently pemetrexed (C10D1 on ___. Close neuro-oncology
follow-up was arranged in the outpatient setting.
#Coronary artery disease status post coronary artery bypass
grafting: Home Imdur, Plavix, ezetimibe, and niacin were
continued throughout admission.
#Chronic kidney disease: Creatinine remained stable at 1.3
throughout admission, consistent with recent baseline.
<< Transitional Issues:
- Close neuro-oncology follow-up is planned in the outpatient
setting.
- In the setting of known cold autoimmune hemolytic anemia,
close monitoring of hematocrit is advised in the outpatient
setting in anticipation of further transfusion requirement.
- Pending studies: BCx x2 (___).
- Code status: DNR/may intubate. | 59 | 356 |
11922103-DS-12 | 21,211,040 | Dear Mr. ___,
You presented to ___ after a paper clip was found in your
esophagus. You had a breathing tube placed to protect your
airway, and you subsequent went a procedure in the operating
room to have the paper clip extracted. You tolerated the
procedure well. Your breathing tube was removed, and you had a
swallow study which showed no concern for perforation of your
esophagus. You were able to tolerate liquids and some food after
the study, so we felt that it was safe to discharge you back to
your facility.
You should follow-up with Dr. ___ surgery, in 2
weeks. See below for the office phone number.
It was a pleasure being a part of your care, and we wish you all
the best.
Sincerely,
Your ___ Surgical Team | Mr. ___ is a ___ year old male who presented with a
paper clip/ foreign object lodged in the esophagus that was not
amenable for endoscopic retrieval by GI or ENT. He was admitted
to the Surgical ICU under the care of Thoracic Surgery and ENT,
and intubated with a fiberoptic scope for airway protection. He
was subsequently taken to the operating room for direct
laryngoscopy, rigid esophagoscopy, and foreign body removal.
A significant amount of manipulation was required to extract the
paper clip during the procedure; post-procedurally, there was
some concern that esophageal perforation may have been present.
He was kept in the ICU for close monitoring, and remained NPO
for the initial 2 days post-operatively. He was placed on
Clindamycin in case of need for source control. He
intermittently spiked fevers (Tmax 101.2) while on Clindamycin,
but infectious workup returned negative. CXR demonstrated that
he may have undergone an aspiration event at some point in the
past (bilateral lower lobe opacities).
POD 3, the patient underwent a swallow study which did not show
evidencde of esophageal perforation, leak, or tear. He was
started on clear liquids and was able to tolerate a regular,
soft diet at the time of discharge. He was safely discharged to
his ___ facility.
Follow-up with Thoracic Surgery is not needed unless further
symptoms develop, but he should follow-up with ENT Surgery in 2
weeks. | 129 | 229 |
13542526-DS-18 | 29,780,033 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | Mrs. ___ was transferred to ___ for emergent surgery on
___ where she underwent an aortic dissection repair. Please
see operative note for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition with an open chest. Later this night she returned to
the operating room for mediastinal exploration due to high chest
tube output. On ___ she returned to the operating room
again for closure of sternum. Following surgery she was again
transferred back to the CVICU for invasive monitoring.
She was transfused blood products for acute blood loss anemia.
She remained intubated due to respiratory failure. She has
remained in shock on multiple pressors and ionotropic support
with milrinone. She has had low grade fevers since her
surgeries. ___ contacted ___ when 1 out
of 4 blood culture bottles returned positive for strep viridans.
ID was consulted and recommend continuing treatment with IV
ceftriaxone given the new Gelweave graft placed and she remained
critically ill in shock. She will remain on CTX for a 4 week
course (Start Date: ___ Projected End Date: ___.
Please obtain weekly CBC with differential, BUN, Cr, AST, ALT,
while on CTX. A head CT revealed left frontal and parietal
infarcts. She was ultimately extubated on ___. She required
aggressive diuresis due to multiple transfusions. She will
require a protracted course of Lasix as an outpatient. She was
readmitted to the ICU on ___ for mucus plugging that resolved
with nebulizers. She remained hemodynamically stable and was
transferred to the telemetry floor for further recovery on ___.
She was restarted on her home dose of Apixaban for atrial
fibrillation and beta blocker was titrated up for better heart
rate and blood pressure control. She was persistently
hypokalemic, requiring aggressive repletion. Vascular was
requesting CTA of torso to evaluate type B dissection. This was
done ___ which showed no change from prior (see reports). She
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD# 18
she was a lift to chair, overall weak and extremely
deconditioned with more pronounced right sided weakness, the
wound was healing, and pain was controlled with oral analgesics.
She was discharged to ___ in good condition
with appropriate follow up instructions. | 123 | 380 |
19185718-DS-15 | 28,904,137 | Medications: Take 1 week course of keflex ___ mg 4 times per ___
for antibiotics. You may also take oxycontin and percocet as
needed for pain, and colace as needed for constipation.
Please keep on your splint until follow up in hand clinic on
___. If you experience severe, unrelenting pain in any part
of your splinted hand, please call the plastic surgeon on call,
or come into the emergency department. Keep hand elevated.
You may resume your normal diet. | Patient was admitted to the plastic surgery service from the ED
with acute pain in her R ___ digit. She was started on IV
cefazolin and pain medication, and was made NPO after midnight
in preparation for surgery in the morning. She went to the OR
on ___ and underwent removal of external fixation, ORIF of R
___ PIP fracture, debridement and joint washout. She tolerated
the procedure well and her R hand was placed in a splint and
elevated. After surgery, she was able to tolerate a regular diet
without nausea, and was voiding appropriately. Patient was
comfortable with good control of pain, and was deemed
appropriate for discharge with scheduled follow up in the hand
clinic on ___. | 80 | 123 |
10382464-DS-21 | 21,171,914 | It was a pleasure to take care of you at ___. You came in with
2 episodes of lightheadedness. Your description of what happened
is very consistent with what we call "vasovagal syncope" - the
same thing that happens to people when they faint. We monitored
your heart rhythm and saw that the pacemaker was functioning
properly. We had the electrophysiologists tweak the pacemaker so
that it does the best job to help the way your heart pumps,
given your heart failure. You should decrease your amiodarone to
1 pill daily.
Your INR was too high. The goal is 2.0-3.0 Don't take your
warfarin until your INR is less than 3.0. When your INR is less
than 3.0, call ___ clinic, tell
them the last time you took warfarin was ___ night, and
ask them how much you should take.
For your rib pain, you can take 1000mg tylenol every 6 hours. | ___ with afib/flutter s/p ablation in ___ and DDD dual chamber
pacemaker ___, on coumadin, presents after 2 short-lived
episodes of presyncope associated with diaphoresis, likely
vasovagal.
# presyncope: lasted minutes and were associated with
diaphoresis but no chest pain, palpitations or dypsnea. Pt was
observed to be atrially paced while on telemetry, and
experienced no further episodes of presyncope. Pacemaker was
interrogated and revealed no malfunction. No medication changes
since pacemaker placement. ACS ruled out with trop neg x 2 and
no ischemic changes on EKG. Presyncope was thought to be
vasovagal. Pt was instructed to follow up with
electrophysiologist Dr. ___ placed her pacemaker.
# Afib / Sick sinus syndrome s/p pacemaker on coumadin: INR
supratherapeutic at 3.8. Warfarin was held during admission. Pt
was instructed to check INR daily at home and call
___ clinic when INR <3.0 for warfarin dosing
instructions. Pt was maintained on metoprolol succinate XL 100
mg PO BID, and was discharged on scheduled reduction in
amiodarone dose to 200mg daily.
# Non-displaced rib fracture: Pt found with subtle nondisplaced
fracture of posterior left 11th rib, after direct impact trauma
to the area during a mechanical fall on ___. Pt discharged on
acetaminophen 1000mg q6h x 7 days for pain control.
# CHF (EF 35%): Pt appeared euvolemic during admission and was
maintained on furosemide 40 mg daily and irbesartan 150 mg
daily.
TRANSITIONAL ISSUE
- Electrophysiologist to consider possible changes in pacemaker
settings by reducing PR interval via RV pacing to optimize
ventricular synchronization, vs. maintaining atrial pacing with
current prolonged PR interval. | 150 | 256 |
16310231-DS-22 | 21,841,956 | Dear ___,
It was a pleasure meeting you in the hospital. You were admitted
for pain in your neck. You were seen by the neurosurgery team,
the orthopedic surgery team, and the radiation oncology team.
The best and safest treatment for your pain is radiation therapy
at this time. You will need to follow up with Dr. ___. | Ms ___ is a ___ w/ metastatic breast cancer to bones
and brain s/p WBRT and multiple courses palliative XRT to spine,
most recently to C7-T4, who is admitted with new neck pain due
to C4 lytic lesion. She had an MRI which did not reveal cord
compression. She was seen by neurosurgery, orthopedic surgery,
radiation oncology, and in discussion with Dr. ___
oncologist, it was felt that the most prudent approach is
through very limited radiation to the C4 area (the only area
that has not been treated). She received her first dose on
___. Her pain was well controlled with intermittent doses of
oxycodone. She has limited has had numbness in L ___
fingertips that is unchanged from baseline and her neurological
exam on discharge was intact.
She will follow up with Dr. ___ her breast cancer next
week to discuss further management. Her CEA, CA125, and ___
were pending at time of discharge. ___ Min spent coordinating
care for discharge. | 57 | 165 |
18619829-DS-18 | 22,311,002 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body | ___ year old male patient who presented with recurrent falls over
the past several weeks, head CT showed a large bilateral acute
on
chronic SDH. Patient was admitted to the neurosurgery service.
Family discussion was had. Will proceed with conservative
managment of SDH at this time.
On ___ Urology consult was placed for renal calculi noted on
outside hosptial L spine CT. Geriatrics was consulted for
failure to thrive at home. Patient was evaluated by ___ was
concerned for hip fracture given hip pain and patient's
positioning in bed. Hip and femur xrays were ordered which
revealed a nonspecific periosteal reaction along the left distal
femoral diametaphyseal is which is nonspecific. An aggressive
process is not excluded.
On ___ a urology appointment was made and geriatrics provided
recommendations. The adjusted his medications to address his
chronic hypotension as well as optimized a pain regemin that was
appropriate for him. A MRI was ordered to evaluate his left
lower leg. Physical therapy ___ rehab.
On ___, patient remained stable on examination. L femur plain
films revealed a distal region of nonspecific periosteal
reaction, MRI L femur is pending. Radiology recommended
obtaining a plain film of the R femur to evaluate for
hyperthrophic osteoarthropathy. On ___, R femur plain films
confirmed hypertrophic osteoarthropathy. Patient was stable on
exam and was informed of requiring further out patient workup of
hypertrophic osteoarthropathy. He was discharged to rehab in
stable condition. | 126 | 232 |
19623697-DS-7 | 22,993,127 | It was a pleasure to participate in your care. You were admitted
to ___ with jaundice (yellow skin), itching, and fatigue. You
were found to have acute liver injury due to hepatitis B
infection. You were started on a medication to treat the
hepatitis B. Your symptoms improved and your were discharged
home. It can take some time (weeks to months) for your liver
function tests to improve and the jaundice to resolve. Please
avoid alcohol.
Continue your home medications with the following changes:
1. START sarna lotion as needed for itching | ___ with acute liver injury due to acute Hepatitis B infection
.
# ACUTE LIVER INJURY: Patient w/ serological evidence of acute
hepatitis B infection at outside hospital. This was presumed to
be due to IV drug use. He was initially admitted to the ICU due
to concern for acute liver failure. However, he never developed
encephalopathy during this hospital course. He was not a
transplant candidate due to recent IV drug use. He was started
on tenofavir in the ICU but this was stopped at discharge. HIV
negative, Hepatitis C viral load negative, acute EBV negative,
CMV negative. Liver function tests were still elevated although
trending down at discharge (AST: 635, ALT: 1446, T-Bili: 19.8).
Tests pending at discharge include smooth muscle antibody,
ALKM-1, and hep delta. His cholestasis induced pruritis was
managed w/ sarna lotion w/ good effect. We discussed the
importance of ETOH avoidance.
.
#HISTORY OF DRUG USE: He was continued on home dose of
methadone. For nausea prior to administration he was given
zofran.
.
CHRONIC ISSUES:
# Depression/anxiety: He was restarted on home seroquel,
clonazepam, neurontin, wellbutrin.
.
TRANSITIONAL ISSUES:
1. will need to f/u smooth muscle antibody, ALKM-1, and hep
delta that are pending at discharge | 94 | 215 |
15988441-DS-22 | 22,948,695 | Discharge Instructions:
Surgery
Your shunt was replaced with a ___ Strata Valve, which
is programmable. This will need to be readjusted after all MRIs
or exposure to large magnets. Your shunt is programmed to 1.5.
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.
Please continue your home regimen of AEDs.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Headache or pain along your incision.
Some neck tenderness along the shunt tubing.
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 | ___ is a ___ year old female with history of obstructive
hydrocephalus who presents after being found down at her group
home with likely seizure activity and VP shunt malfunction.
#Shunt malfunction
On ___, she underwent revision of VP shunt. The procedure was
uncomplicated. A ___ Strata valve was placed and set at
1.5. For further procedure details, please see separately
dictated operative report by Dr. ___. She was extubated in
the operating room and transported to the PACU for recovery.
Once stable, she was transferred to the ___. On day of
discharge, her pain was well controlled. She was tolerating a
diet and ambulating independently. Her vital signs were stable
and she was afebrile. Shunt setting was confirmed at 1.5. She
was discharged to her group home in a stable condition.
#Epilepsy
She was given Ativan 2mg while in the ED. Post-operatively, she
was maintained on her home AED regimen.
#Tachycardia
She was tachycardic to the 120s, sustained and asymptomatic. EKG
showed sinus tachycardia. She was given a fluid bolus with
minimal benefit. She was restarted on her home clonidine patch. | 341 | 176 |
11473993-DS-19 | 26,932,522 | Dear Mr. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you had
pain and swelling in your leg, and were found to have a blood
clot. You were also found to have a blood clot in a part of your
lung. These can both be treated with the same blood-thinner
medicine. Your condition has improved and you can be discharged
to home.
The following changes were made to your medications:
NEW:
-Enoxaparin (blood thinner)
-Warfarin (blood thinner)
-Vitamin B12 shots
-Folate vitamins
-multivitamins
-baby aspirin
CHANGED:
-decreased lisinopril to 5mg daily
STOPPED: none
Please keep your follow-up appointments as scheduled below. | Mr. ___ is a ___ with h/o T2DM, morbid obesity, aortic
stenosis, and HTN who presents with left leg pain for past 2
weeks, found to have a L-leg DVT and admitted for lack of
certainty regarding self-medication administration in the
setting of his PCP moving away.
.
#. L-leg DVT and R pulmonary artery PE: His D-Dimer in the ED
was 3961, INR: 1.1. US found a DVT from left popliteal vein
extending to the proximal superficial femoral vein. He was
started on lovenox ___ SC in the ED. After CT scan was
obtained (initially ordered to ___ on persistent LLL mass on
CXR's to look for malignancy) on ___, pulmonary emboli
beginning in the distal right pulmonary artery with emboli to
all lobes of the right lung were observed. He was satting in the
high 90's on RA, although endorsing subjective SOB.
He had no precipitating factors (immobility, travel, recent
surgery), and this is the first unprovoked DVT. He endorses no
Sx of occult malignancy (no dysphagia, weight loss, BRBPR/melena
or blood in stool), although he has not had a cscopy in about a
decade. His rectal exam was guaiac neg and did not show a
grossly enlarged prostate.
We commenced warfarin 5mg daily and continue lovenox while
in-house, for goal INR 2.0 to 3.0; was increased to 7.5mg daily
on ___.
Regarding duration of anticoagulation, usually pts with first
idiopathic DVT should be treated for 3 months, but indefinite
therapy is considered in patients with a first unprovoked
episode of proximal DVT (his DVT extends to proximal superficial
femoral vein). He may benefit from indefinite anticoagulation,
but this should be decided pending his PCP ___ and ability to
take his medicines consistently.
.
#MCV 107 despite Hct 41.6: this was noticed on admission labs.
___ B12, folate studies revealed very low B12 level in ___, and
B12 was commenced in-house.
Intrinsic factor still pending; PCP ___.
.
# Type 2 DM: hold home metformin and maintain on ISS while
admitted. We restarted ASA 81mg which is on pt's old med list
but he states he's not taking. His HbA1c was 9.3 on ___
indicating lack of glycaemic control, likely in setting of not
taking metformin and glipizide for likely several months. He was
d/c'd on his previous oral diabetes Rx, and will need PCP ___.
.
# Hypertension: Per pharmacy records and the pt's pharmacy
receipts, he was previously on lisinopril 10mg daily. His SBP's
were in the 180's upon admission. His pressures improved to
130-140s after admission and lisinopril administration. Pt was
d/c'd on lisinopril 5mg daily b/c his pressures were
well-controlled on 5mg daily.
. | 99 | 431 |
12329981-DS-17 | 28,342,604 | You will be transferring to ___
Antibiotics will continue via the ___ line until ___
Blood will be drawn twice weekly for lab monitoring
Wound vac will continue with change every 72 hours | ___. M s/p ABO incompatible OLT ___ presented from rehab
with fevers, headache, and increasing perihepatic fluid
collection. He was pan-cultured and continued on previously
ordered antibiotics (Cefepime and Micafungin). Head CT was done
to evaluate headaches. This was negative for intracranial
abnormality. Abdominal CT on ___, demonstrated interval
increase in size of fluid collection with increased rim
enhancement, unchanged fluid collection in the splenectomy bed
with rim enhancement, loculated fluid surrounding the small
bowel, improvement of segment ___ hepatic necrosis with
persistent though improved injury to hepatic segment and
anterior abdominal wall fluid collection.
On ___, he underwent CT-guided percutaneous drainage of large
intra- abdominal fluid collection with placement of two drainage
catheters in the abdomen. A sample of fluid was sent for
microbiological analysis. Fluid isolated 3 strains of E. Coli
sensitive to Meropenum. Cefepime was switched to Meropenem on
___. He remained afebrile. Right upper and right lower drain
outputs were initially high and appeared purulent. Over several
days, drainage decreased and became non-purulent.
On ___, a repeat abd CT was done to reassess collections. This
demonstrated significantly decreased posterior hepatic fluid,
stable fluid collection in splenectomy bed, decreased loculated
fluid surrounding the small bowel with decrease in adjacent
small bowel thickening, stable small focus of segment IVb
hepatic necrosis, more readily apparent hepatic segment VI
necrosis, and stable anterior abdominal wall fluid collection.
Liver US was done on ___ which showed normal vasculature with
normal waveforms and directionality of flow. LFTs remained
stable.
Drain outputs decreased and the patient complained of increased
abdominal pain. On ___, he underwent repeat CT to evaluate. The
prior right lower quadrant catheter was upsized and a new
catheter was placed into a lower left mid abdomen fluid
collection. The inferior catheter in the right lower quadrant
was not up sized. The new left lower ABD catheter did not drain
much with outputs of zero to 20cc/day. The RUQ averaged ___
and the RLQ catheter averaged 50-90cc/day. A liver biopsy was
also performed on ___. This was negative for rejection. Mild
bile ductular proliferation with minimal cholestasis was noted.
Abdominal wound was treated with wound Vac. Wound appeared
mostly granulated measuring ~ 1cm x 2cm x 1cm depth.
Tube feeds continued. He was tolerating small amounts of food.
Appetite was fair. Mood became more depressed over prolonged
stay. Sertaline was increased to 5Omg and Propranolol was
decreased to help improve mood. Propranolol had been started on
previous hospitalization for tremors likely secondary to
Sertraline. TSH was also noted to be slightly increased at 6.6.
Levoxyl was ordered to increase to 37.5 on ___. A repeat TSH
should be check in 6 weeks.
Blood cultures remained negative. Blood cultures from ___ were
negative to date at time of discharge. Micafungin was stopped on
___ as he had received one month course for previous fungal
peritonitis/fungemia. Fluconazole was resumed on ___ as part of
transplant infectious prophylaxis. Meropenum was to continue
until ___ for Ecoli isolated from abdominal abscesses. A picc
line was in place in left arm.
Transplant immunosuppression consisted of Cellcept 500mg bid,
tapering prednisone (due to decrease to 7.5mg on ___
Prograf. Prograf was adjusted per Trough levels. Prograf dosing
will require adjustment by ___ given resumption of
Fluconazole.
Lovenox and Coumadin were given for hepatic artery
stenosis/splenic artery thrombosis (seen on last admission).
Lovenox was discontinued due to nose bleeds and bloody drainage
from JPs. Coumadin was given at 5mg daily then increased to
7.5mg for the last 4 days ___ and ___ as INR
ranged between 1.2 to 1.3 Discharge dose was set at 5mg due to
interaction with Fluc. Labs should be checked on ___. INR was
1.3 on ___.
___ reassessed and recommended rehab. A bed became available at
___. He will transfer there today. | 30 | 632 |
15343139-DS-9 | 28,283,904 | Dear ___,
You were hospitalized due to symptoms of left eye visual
changes, headache and right hand paralysis resulting from an
ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
You had a tear in the lining of one of your arteries that supply
blood to the brain, called a "dissection." We believe this was
caused by an aggressive coughing spell. You were placed on a
blood thinner and will continue to take this medication after
discharge.
We are changing your medications as follows:
-START LOVENOX
-START WARFARIN
The Lovenox is a temporary medication until the level of
Warfarin in your blood becomes therapeutic. You will need blood
levels to check how thin your blood is, called INR. Your goal
INR is ___. Your PCP ___ follow this level and make adjustments
to your medications as needed. You will follow-up with neurology
at the appointment scheduled 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 | Ms. ___ is a ___ woman with medical history of
Lyme's disease with Bell's palsy who presented to the ED with
left eye visual changes, HA, left sided neck pain, and a five
minute episode of right hand paralysis in the setting of a URI,
coughing episode found to have a left ICA dissection and left
frontal ischemic stroke.
Patient's neurologic exam was remarkable for left eye ptosis and
slowed facial activation on the right side. The vision changes
may represent a small embolic event to the retinal artery. Given
the recent history of coughing, left sided neck pain and new
neurologic symptoms, there was concern for ICA dissection with
resulting left sided stroke. Patient had a CTA head and neck
which showed a dissection of the cervical left internal carotid
artery to the level of the proximal left petrous internal
carotid artery. MRA with fat sats confirmed this. MRI did show
an early subacute infarct within the left corona radiata/centrum
semiovale. She was counseled on diet and exercise. Stroke risk
factors were checked, including A1C of 5.6 and LDL 136. Statin
was not started as patient will trial diet and exercise first.
She was started on a heparin drip with Coumadin and transitioned
to Lovenox for an outpatient bridge. Patient will likely
complete a 3 month course of anti-coagulation. Her PCP was
contacted to set up INR checks. She will follow-up with stroke
neurology as an outpatient. | 332 | 239 |
15969355-DS-19 | 24,964,969 | Dear Mr. ___,
You were admitted to the hospital with dizziness. Our
neurologists evaluated you and diagnosed you with benign
paroxysmal positional vertigo (BPPV). Our physical therapists
saw you and did not think it would be safe for you to go home.
We are discharging you to ___ rehab where they will work
on your balance and mobility.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team | ___ year-old male with s/p ACDF ___ who presents with
worsening positional vertigo and persistent unbalanced gait
since his surgery.
#VERTIGO/BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV): Patient's
symptoms have been ongoing since he had his surgery. Apart from
mild cognition issues, his neurological exam and imaging have
been unremarkable. He had no ataxia/visual symptoms to suggest
posterior circulation event. Neurology were consulted in the ED
and felt his diagnosis is most c/w BPPV. His orthostasis could
also be contributing to his symptoms while standing.
Neurosurgery saw the patient and did not want to intervene. The
patient complained of several days of right ear pain but his TM
was clear on exam. This could be related to possible sinusitis
seen on CT. His B12 level was within normal limits.
The patient's symptoms improved somewhat with PRN meclizine.
Neurology continued to follow the patient and they were able to
elicit symptoms of dizziness and nystagmus with ___
maneuver, and findings improved with Epley maneuver, consistent
with BPPV. Physical therapy saw the patient and concluded that
he was not safe to go home, so they recommended discharge to
___ rehab. The patient was discharged to rehab on ___.
Neurology recommended ___ rehab and outpatient follow-up
with neurology.
#ORTHOSTATIC HYPOTENSION: Patient has been orthostatic while in
the ED with systolic dropping from 100s to ___. This could could
be a combination of poor PO intake along with being on his
regular anti-hypertensives. Orthostatics imnproved to 116/70
supine, 104/65 standing on ___. The patient was not
orthostatic on the day of discharge. We stopped the patient's
metoprolol tartrate 25mg once daily during this admission.
#STATUS POST ANTERIOR CERVICAL DISCECTOMY AND FUSION SURGERY:
The patient had his surgery in early ___. Neurosurgery
evaluated the patient in the ED and stated that there was no
surgical intervention indicated. They cleared the patient for
___ and Epley maneuvers by neurology Currently not for
any surgical intervention per neurosurgery. Regular
neurosurgical follow-up is planned as an outpatient. | 67 | 324 |
17259667-DS-5 | 28,527,118 | Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
Your wound was closed with staples.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
You may wear a soft collar for comfort
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit. | Mr. ___ was admitted to the neurosugery service on
___ for a complete metestatic workup and surgical planning.
He was placed on Decadron 4mg Q6H for an epidural mass found in
the posterior cervical spine at the levels of C3-5, concerning
for metastatic disease.
On ___, CT of his torso revealed a right upper lobe lesion and
multiple lesions in his liver in addition to the lesion
posterior to his spinal cord at the cervical lesion.
He was taken to the OR on ___ for a C3-5 laminectomy for tumor
resection. Epidural tissue was sent for permanent and frozen
pathology. Frozen sections confirmed adenocarcinoma. The
operation was otherwise uncomplicated, and the patient was taken
to the PACU for recovery, after which he was transferred to the
floor. The patient was placed in a soft cervical collar for
comfort only after the operation. His Decadron was decreased to
2mg Q8H post-op.
On ___, a post-op MRI of the C-spine was done with and without
contrast. The patient was seen by heme oncology and
neuro-oncology. He will be contacted by them to arrange follow
up. He worked with physical therapy who cleared him to go home
with physical therapy. The patient was discharged home in stable
condition. | 159 | 202 |
13559141-DS-22 | 23,857,898 | Dear ___,
___ were admitted for fever in the setting of a low white count
(neutropenia). ___ were initially thought to have a urinary
tract infection for which ___ were started on IV antibiotics;
however, culture of your urine were negative for bacteria.
___ also had cough and a runny nose, which is suggestive of an
upper respiratory infection (i.e. a cold). These are most often
caused by viruses and are easily transmitted from contact with
others who have a cold. Unfortunately, viral infections can
predispose people--especially those who are
immunocompromised--to pneumonia and it is possible ___ developed
a pneumonia. ___ were treated with broad-spectrum antibiotics
and, at discharge, ___ had been afebrile for several days with
some improvement in your symptoms. ___ should continue the IV
antibiotics as directed.
While ___ were here, ___ also underwent a paracentesis to help
remove some fluid from ___ abdomen. ___ tolerated the procedure
very well and were restarted on your home diuretics.
Prior to discharge, ___ reported a few episodes of loose stools.
A test of your stool was negative for bacterial infection with
C. difficile, so we prescribed ___ loperamide to help decrease
the frequency of your bowel movements. If ___ have worsening
diarrhea or foul-smelling stools, please notify your doctor.
___ will need your labs rechecked on ___ - they
will be drawn by your ___ and the results faxed to Dr. ___
___.
It was a pleasure taking care of ___,
Your ___ Team | ___ cholangiocarcioma s/p FOLFOX x3 cycles who is here with
fever and hypotension thought ___ UTI but cx negative; received
2 doses CTX, then switched to cefepime.
#Neutropenic fever: Thought originally to be UTI, but ___ ucx
negative. Received 2 doses of CTX, then switched to cefepime,
and started on neupogen. Remained afebrile on ___, but spiked
to 103 early ___ at which time patient was broadened to IV
vanc, then azithromycin ___. CXR initially negative despite
cough. Also having mild diarrhea. C. diff and norovirus neg.
Patient noted to have decreased BS over RLL on ___ repeat CXR
suggestive of possible infectious process. Possible that
patient had viral URI initially, then developed superimposed
PNA. Paracentesis fluids were also unremarkable for infection.
Prior to discharge, patient remained afebrile for >48 hours on
IV vanc/cefepime and azithro PO. She was no longer neutropenic
and was discharged on IV vanc/cefepime to be continued until
___ and azithro to be continued until ___ (to complete a
Zpak).
#Neutropenia: Expected post chemotherapy, likely complicated by
bone marrow suppression in setting of infxn and
splenomegaly/sequestration. Neupogen was started ___ and
continued until ___. Home ursodiol was continued. At discharge,
patient was no longer neutropenic.
#anemia: hgb 6.6 at admission on ___. Notably, afternoon of
___ after blood transfusion, had T to 100.4, rigors, lower back
pain; received Tylenol, Benadryl. Labs not c/w hemolysis.
Appropriate bump s/p pRBC ___. Anemic again ___ to hgb 6.8, so
received 1u pRBC--this time without event. Hgb stable at 10.0 at
discharge.
#Cholangiocarcinoma: FOLFOX C3D11 c/b mucositis. AST/ALT
elevated at admission. At discharge, these values were much
improved. Alk phos was largely stable. Continued home
clonazepam, melatonin, dronabinol, simethicone, magic mouthwash,
reglan, Zofran.
#malignant ascites: Hypotensive on admission likely ___
infection and insensible fluid losses through fever. Initially
held home diuretics in the setting of hypotension/fevers.
Provided IVF prn. When BPs remained stable at 85-90s, patient
was restarted on home Lasix and spironolactone; no orthostasis
throughout stay. Likely that patient typically runs BPs in high
___. Notably, underwent ___ guided paracentesis ___ no
evidence of SBP.
#UC: Stable. Continued home azathioprine
#GI prophylaxis: No complaints. Continued home PPI and
famotidine.
#h/o reactive airway disease: Continued home albuterol and
ipratropium.
===================
TRANSITIONAL ISSUES
===================
- Labs ___: CBC with diff, LFTs, chemistries
- New Medications: IV vancomycin (to end ___, IV cefepime (to
end ___, PO azithromycin (end ___
- Medications Changed: None
- Follow-up: Dr. ___ ___
- with continued diarrhea, unclear etiology; negative for c.
diff, may consider loperamide for symptomatic relief
- s/p 2u pRBC during hospitalization; please continue monitoring
anemia
- hypokalemic, possibly in setting of frequent BMs and lasix;
please continue monitoring; K 4.1 at discharge s/p aggressive IV
and PO repletion
- Systolic blood pressure ___ during this admission. Please
continue to monitor and consider decreasing/holding furosemide
if low blood pressure or symptomatic.
CODE: Full
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (husband)
H: ___
C: ___ | 246 | 478 |
18887323-DS-13 | 22,523,920 | You were admitted to ___ after experiencing a stroke.
Unfortunately this was a large stroke and you will require
extensive rehabilitation in order to to regain some of your
previous motor and speech function. In the interim, you should
continue all of your regular home medications. You should
continue your peritoneal dialysis for your end stage renal
disease.
- We have started you on the following medications.
* Plavix 75mg once a day
* Subcutaneous Heparin 5000TID
* Sevelamere 800mg TID with meals
We held your home medications:
- Arimidex 1mg qd
-Lisinopril 40mg qd
-Lasix 40mg BID
Restarting these medications is up to the discretion of your
physicians at ___.
We would like your blood pressure to remain in the 120-110 SBP
range.
We stopped your home dose of aspirin. This is no longer needed
as you are taking
It is essential that your blood pressure stay well controlled,
you eat as healthy as possible, and maintain tight control of
your blood sugar. These changes in addition to taking your
medications will help reduce the risk of having another stroke. | Patient presented to ___ with right sided hemiplegia and
aphasia. TPA was not given because patient was outside the the
time interval for tpa administration. CT brain showed a left MCA
stroke. MRI confirmed left MCA stroke as well as old left
parietal lobe infarction c/w with her pmh of CVA. In the ED,
there was a blood pressure discrepancy between both arms. A CTA
chest was ordered which did not show aortic disection. It was
suggestive of moderate-severe atherosclerotic disease. The
patient was then admitted to ___ for post stroke management
and nephrology management of her peritoneal dialysis. On the
floor, the patient remained on her usual home peritoneal
dialysis schedule. She remained on asa 81 and hsq for dvt ppx.
MRI was performed which confirmed that there was a infarction in
the vascular territory of the left mca. An TTE was performed
which showed no signs of intracardiac thrombus. A TEE showed no
PFO or ASD. While on the floor the patient passed her speech and
swallow on first attempt and her diet was subsequently advanced.
Since she had a stroke on aspirin, the decision was made to
switch her from aspirin to plavix 75mg. Throughout her hospital
stay her antihypertensive medications were held as her blood
pressure ran on the lower side (100/60s). Throughout her course
her blood pressure was allowed to autoregulate. She also
remained on her insulin sliding scale. Her neurologic exam
changed very little throughout her hospital course. She remained
with right hemiplegia and minimal ability to understand
commands. She is aphasic. She is being discharged to ___
for rehab.
-Transitional care issues:
___
*PD management
*Management of antihypertensive medications. We would like her
blood pressure to remain in the 120-100 range.
*Blood glucose management. | 183 | 290 |
11444719-DS-16 | 20,726,588 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY YOU WERE ADMITTED:
- You had bleeding and confusion.
WHAT WE DID WHILE YOU WERE HERE:
- You were evaluated by our liver specialists.
- You had two procedures to try to figure out why you were
bleeding. Unfortunately we did not find the cause. Fortunately
your bleeding stopped and your symptoms got better.
- We adjusted your medications and your confusion and kidney
function improved.
INSTRUCTIONS FOR WHEN YOU LEAVE THE HOSPITAL:
- Take your antibiotics (ciprofloxacin) for 2 more days to
prevent infections.
- We did change any of your other medications. Continue taking
them every day as prescribed.
- Avoid eating too much salt (sodium). Limit yourself to ___ mg
each day (read labels on food; avoid canned soups, deli meats,
etc).
- Weigh yourself every day. Call you liver doctor if your weight
increases more than 3 pounds.
- Please return to the hospital right away if you have any more
bleeding, confusion, fever, chills, stomach pain, or any other
symptoms that concern you.
We wish you all the best.
Sincerely,
Your ___ Care Team | ___ with decompensated EtOH cirrhosis listed for transplant,
admitted for hematochezia, encephalopathy, and ___.
ACTIVE ISSUES
==============================
#Lower GIB: Remained hemodynamically stable and did not require
transfusions. EGD found a single non-bleeding gastrix varix,
portal gastropathy and GAVE but no clear source. Sigmoidoscopy
was limited by stool but found no varices, hemorrhoids, fresh or
old blood. Bleeding resolved and H/H remained stable, so held
off on full colonoscopy. Discharged at baseline after stable on
home meds for 24 hours.
#HE: Likely due to GIB and ___. Diagnostic para and infectious
workup was negative. Improved to baseline with treatment of
bleeding and ___, and was discharged on prior lactulose q4h,
rifaximin.
___: Cr peaked at 1.4 and improved to baseline with albumin.
Remained stable after diuretics were restarted.
CHRONIC ISSUES
==============================
# Thrombocytopenia
# Coagulopathy
Chronic, stable, likely due to cirrhosis. No evidence of
additional consumptive process besides bleeding above.
# Leukopenia:
Appears chronic, roughly at baseline. Not neutropenic. Likely
due to marrow suppression from cirrhosis and inadequate
nutrition. Wife reports no ongoing alcohol use and alcohol level
negative. Continued home folate, MVI/minerals.
# Depression:
Continued home Sertraline 25 mg PO DAILY
# DM: Last A1C 4.8%.
Continued home glargine with HISS
TRANSITIONAL ISSUES
==============================
- Discharge weight: 112 kg
- Discharge MELD: 20
- Discharged on cipro ppx to complete 7-day course (last day
___.
- No medications were changed.
- Transplant clinic will arrange f/u labs and appt. Would
recheck CBC, MELD labs.
#CODE: Full (presumed)
#HC PROXY: ___ (wife) | 178 | 234 |
10332792-DS-11 | 28,230,179 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted with abdominal pain, nausea and vomiting. You were
started on intravenous fluids because you were quite dehydrated
on arrival to the hospital. It is still unclear the initial
cause of your nausea/vomiting and abdominal pain but it is
possible that this was caused by an infectious gastroenteritis.
Your liver enzymes were elevated during this admission and the
Gastroenterologists strongly recommend that you follow up with
imaging called an MRCP. The number to schedule this appointment
is listed below. You will be started on an additional
medication which may help with your pain called Nortriptyline
(Pamelor). Please follow up with the appointments as listed
below. We wish you the best. | Mr. ___ is a ___ yo M with hx of eosinophilic gastritis,
iliohypogastric neuralgia who presents with abdominal pain and
N/V x3 days.
# Nausea/Vomiting: Began early ___ morning, on presentation
patient had been unable to take PO for several days and was
significantly dehydrated. Patient was hydrated with IVF and was
initially kept NPO. His nausea and vomiting was treated with
Zofran and Ativan. SBO or partial SBO was considered given
patient's surgical history, but abdominal exam was fairly benign
and KUB showed no signs of obstruction. The nausea and vomiting
eventually resolved and patient's diet was advanced. It was
thought that this presentation may be related to sphincter of
Oddi dysfunction (see below). Patient did persist in asking for
Ativan for anxiety and ultimately this medication was
discontinued as he is not prescribed as outpatient.
# Acute on chronic abdominal pain - predominant in the
periumbilical region and RLQ in the same spot as his known
chronic pain. Per patient the pain was worse than his baseline
since starting the N/V. Patient did have transaminitis on
admission, RUQ u/s relatively unchanged from what was seen on CT
scan from one year prior, but he does not seem to have had any
imaging when he was painfree. With hydration, transaminases
downtrended. Pain service was asked to see the patient and
recommendation was to continue symptomatic pain control, restart
Gabapentin as patient tolerated PO and to add Lidoderm patch
just superior and medial to his right ASIS in the RLQ. Also
recommended starting Nortriptyline 25mg qhs for chronic pain.
The GI service was additionally consulted for concern of
elevated transaminases, acute on chronic abdominal pain. They
were concerned about possible sphincter of oddi dysfunction
contributing to this acute episode with N/V. Plan was to do
MRCP that patient requested be performed as an outpatient.
Initially patient was requiring dilaudid IV for pain control but
this was discontinued as he clinically improved. He did well
without the Dilaudid, using the Gabapentin and Lidoderm patch
for pain control prior to discharge. He continued to take
Dronabinol this admission when tolerating PO. On day of
discharge, his pain was back to his baseline chronic pain. | 132 | 377 |
13329449-DS-5 | 28,688,486 | Dear Mr. ___,
You were hospitalized due to symptoms of vertigo, which is the
false sensation of the world moving around you. You were
evaluated by the Neurology Service. Your neurologic examination
and MRI (Brain imaging) was very reassuring. Your symptoms
spontaneously improved.
Your doctors think ___ had a problem in your left inner ear.
There was no evidence of a stroke.
However, we did find that your blood glucose level was high,
which is a likely sign of diabetes. Diabetes can be a major risk
for stroke as well as other medical complications such as heart
attack.
You should schedule a ___ appointment in our neurology
clinic, as well as establishing care with a primary care
provider to manage your diabetes and evaluate you for any other
health issues.
Thanks,
Your ___ Team | Mr. ___ is a ___ year old male with no known past medical
history who presented with acute onset episodes of vertigo since
the morning of ___. The episode was about ___ minutes long and
happened multiple times throughout the day; symptoms were
worsened by positioning including standing up and turning his
___ to the left. He vomited three times. He had never had these
symptoms prior to current episode.
He did note a mild headache since the morning which was more
___ in distribution. General and neurological review of
systems were otherwise negative.
He presented initially to an OSH where he underwent a CT of the
___, which was unremarkable. He did have ___ glucose
levels in the 300's. At OSH, he received meclizine, Ativan, and
toradol. By the time he was evaluated in the ED, his symptoms
had largely improved.
On transfer to the ___, his exam was consistent with a
___ peripheral vestibulopathy (+left Unterberger and
trace leftward refixation saccades with ___ impulse testing).
The rest of his general and neurological exams were
unremarkable, however he was found to have a blood glucose in
the 300s. He was admitted to the ___ Stroke Neurology Service.
An MRI Brain and CTA ___ and Neck were obtained and both
unremarkable (preliminary reads); no signs of stroke. The next
morning, his neurological exam was entirely within normal
limits. He was started on metformin 500 mg bid and glipizide XL
5 mg prior to discharge based on ___ Recommendations. At
discharge, his lipid profile and glycohemoglobin are pending, as
are final reads on his MRI and CTA.
Transitional Issues
- ___- patient provided information
- Patient to establish PCP. He was provided several numbers for
providers- including free clinics- near by.
- Patient should follow with Neurology in ___ months for his
vestibulopathy.
- Started on Metformin and Glipizine, with planned ___ as
above. | 134 | 311 |
18791678-DS-17 | 20,638,036 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for treatment of your severe
headache, vertigo, and nausea. We used brain and neck imaging to
determine that the cause of your headache is a dissection of the
right vertebral artery with subsequent clot formation. The
vertebral artery is a blood vessel that feeds the brain, and a
dissection is a splitting of the blood vessel wall; this can
lead to blood clotting in the vessel. You were treated with pain
and nausea medications.
You were also started on aspirin to prevent further blood clots.
You should continue this medication at home for 6 months. We
will have you follow-up with an outpatient neurologist in one
month, and have repeat head imaging done in 6 months. You can
take Tylenol as needed for pain.
As we discussed, please avoid the following after you leave the
hospital:
*Do not lift anything over 20 pounds for 6 months
*Do not engage in contact sports for 6 months
*Do not go back to work for two weeks
Additionally, while you were hospitalized you had imaging of
your head and neck to look for causes of headache. This showed
that your thyroid gland is enlarged. Please follow-up with your
outpatient primary care doctor to discuss any additional studies
that may need to be done.
It was a pleasure meeting you!
Your ___ Team | Ms. ___ is a ___ year-old woman with HTN and h/o migraine who
presents with 5 days of headache and neck pain, vertigo, and
nausea concerning for artery dissection. Imaging of her head
and neck confirmed the diagnosis of right vertebral artery
dissection with associated thrombus.
#Headache: On admission, the patient described her headache as
mainly in the right retro-orbital region. She also complained of
pain in her posterior right neck; this area was very tender to
palpation. Ms. ___ described her symptoms beginning 5 days ago
while shoveling snow, first with severe vertigo, and then a
terrible pain starting in her right posterior neck and radiating
all over her head. She had associated nausea and vomiting. By
the time she arrived to the hospital, her symptoms had improved
significantly, however Ms. ___ was concerned because the pain
had persisted for five days. She was also noted to have right
eye ptosis without miosis or anhydrosis. Extraocular movements
were intact. On questioning, it was found that the ptosis had
been present for several months, and thus was not likely
associated with an acute process.
In the ED, an LP was done that showed normal protein and
glucose, but a mildly elevated WBC count and significant RBCs
persisting to the ___ tube; no xanthochromia was noted. Initial
non-con CT head showed no evidence of hemorrhage. CTA head and
neck showed a decrease in caliber of the right vertebral artery.
Ms. ___ was given medications for pain control and nausea,
started on prophylactic acyclovir for possible HSV
meningitis/encephalitis, and received a fluid bolus in the ED.
The next day her headache, neck pain, and nausea persisted to a
lesser degree. She was treated symptomatically with pain
medications, anti-emetics, and IV fluids. Acyclovir was
discontinued due to low concern for HSV infection. Given the
abnormalities in the vertebral artery noted on CTA, the severe
right neck pain, and the onset of symptoms with exertion,
vertebral artery dissection was suspected. Neurosurgery was
consulted about possible angiogram, but the decision was made to
proceed with a less invasive MRI/MRA of head and neck. This
showed right V4 vertebral artery dissection with associated
clot. The stroke team was consulted and determined that the
lesion was stable with no urgent intervention needed. Ms. ___
was started on aspirin for prevention of further thrombus
formation, with a plan to re-image in 6 months to assess for
interval stability. On discharge, her headache had improved to
___ and she was tolerating a regular diet. The patient was
advised not to work for 2 weeks, not to lift objects over 20
pounds for 6 months, and not to engage in contact sports for 6
months. | 230 | 446 |
11234535-DS-22 | 27,595,729 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in because of confusion and your kidney
was not functioning properly. Your confusion resolved with
lactulose and rifaximin. Your kidney function improved with
fluids (albumin). We were concerned because your blood counts
and platelets were low. You received 2U of PRBC. We were
concerned that you were bleeding from your varices. You had an
EGD which did not show an active bleed. It did show varices in
your esophagus and ulcers in your stomach. You will need to take
nadolol for your varices and omeprazole for your ulcers. We
started you back on your water pills.
Please go to the lab on ___ and get your labs
checked. | Mr. ___ is a ___ year old gentleman with Decompensated NASH
cirrhosis c/b esophageal varices, portal gastropathy, HCC, who
presented with hyperkalemia, grade II encephalopathy and ___.
# Encephalopathy - Presented with confusion and asterixis.
Mental status improved on lactulose and rifaximin. Precipitant
of encephalopathy was unclear, however could have been related
to ___ and worsening liver function. Patient was compliant with
lactulose and rifaximin at home. No evidence of portal vein
thrombus on RUQ U/S. Did not have significant ascites and
suspicion for SBP was extremely low. No signs of infection with
negative CXR and UA and lack of fever. Patient was anemic and
there was a concern for a GI bleed. Please read below.
Discharged on lactulose and rifaximin.
# Hyperkalemia - Initially presented to ___ and
was noted to have a K of 7.2. He received kayexelate, insulin,
glucose, calcium gluconate with improvement to 6.1. EKG w/o
peaked T waves. Potassium continued to normalize. Thought that
this was secondary to ___ exacerbated by spironolactone use.
Held losartan and did not restart. Discharged on spironolactone
and Lasix.
# ___: Cr 1.3 on admission from baseline of 0.9. Received
albumin 1g/kg x2 days. Diuretics and nephrotoxins were initially
held. Renal function improved to 0.7 on discharge. Most likely
prerenal azotemia.
# Anemia: Has a history of a chronic macrocytic anemia with
baseline Hct ___. Hct gradually declined and required 2U pRBC
with an appropriate rise in his H/H. Did have hematuria on
admission due to traumatic foley catheter placement. Hematuria
resolved. Concerned that esophageal varices were bleeding and
thus an EGD was performed. EGD showed grade II varices without
evidence of acute hemorrhage. Also concerned about a hemolytic
process such as DIC given INR elevation, thrombocytopenia,
bilirubinemia as well as a low haptoglobin and elevated FDP. It
was difficult to differentiate between DIC v. hematologic
manifestation of liver disease. Did not have evidence of
schistocytes on peripheral smear and it was thought that his
labs abnormalities were related to decompensated cirrhosis. Hct
was 25.2 on discharge.
# Thrombocytopenia: Patient does have a history of ITP s/p IVIG
however also cirrhotic. Admission platelet count was 49K which
was around his baseline. Platelet count decreased to 21K.
Concerned that thrombocytopenia was related to DIC v. ITP,
however ultimately thought to be secondary to decompensated
cirrhosis. Discharge platelet count was 26K. Will need f/u with
hematology as an outpatient.
# Pancytopenia: Thought to be ___ underlying liver disease.
Thrombocytopenia and anemia management above. ANC was 1200.
Patient will need to get labs checked as an outpatient and f/u
with hematology if labs persistently remain low.
# NASH Cirrhosis, HCC: Recently diagnosed with HCC and currently
in the staging process. CT chest was performed in house and did
not show pulmonary nodules or lymphadenopathy. Bone scan was
negative for metastases. Patient is suitable
for RFA and for fuducial placement for cyberknife. Currently on
the transplant list. Discharged on Lasix and spironolactone.
# Grade I-II varices: EGD on ___ with evidence of grade II
varices. The varices were not intervened upon. Continued nadolol
at 40 mg daily.
# Gastric Ulcers: Visualized on EGD. These ulcers were located
in the antrum and were not actively bleeding. Increased
omeprazole to 40 mg daily. H. pylori was negative.
CHRONIC ISSUES
# Hypertension: Blood pressure remained stable. Losartan was
held due to hyperkalemia and ___ on presentation. ___ was not
restarted, however discharged on lasix and spironolactone.
# Insulin-dependent diabetes: Patient uses daily Lantus, plus
metformin and repaglinide at home. Placed on SSI and lantus 34U
qHS. Discharged on metformin and repaglinide. No acute issues.
TRANSITIONAL ISSUES
- continue nadolol 40 mg daily for varices
- omeprazole increased to 40 mg BID
- lactulose TID and rifaximin for encephalopathy
- lasix 20 mg daily, spironolactone 50 mg daily
- stopped losartan due to ___ and hyperkalemia
- has follow up in the liver clinic, needs labs drawn on ___
- needs to schedule an appointment with Dr. ___ in hematology | 123 | 665 |
18338184-DS-12 | 22,028,135 | It was a pleasure taking care of you during your stay at the
___. You were admitted to the
hospital after having slurred speech and were found to have a
stroke. CT head scan was unremarkable and MRI showed some small
strokes on the right side of your brain which are compatible
with blood clots that have travelled from the heart. This stroke
was likely caused by small blood clots from your heart due to
your atrial fibrillation as this irregular beating leads to
irregular blood flow and hence predisposes to clot formation.
You were recently started on warfarin (Coumadin) for this and
although you have had a stroke on this medication, due to your
other health problems and kidney function, there are no other
options regarding blood thinners. You also had an echocardiogram
which showed stable changes regarding your aortic stenosis. Your
symptoms greatly improved during your hospital stay and you were
walking close your baseline however ___ recommended home ___ to
help regarding this. We will also continue your aspirin. You
were found to have low blood pressure during your hospital stay
and in collusion with your cardiologist, we decreased your
carvedilol dose. In addition, we also had wound care see you
regarding your leg ulcers. We have arranged the following stroke
___ as below.
.
Medication changes:
We DECREASED carvedilol to 25mg twice daily
Please continue to take coumadin and have your levels checked.
Your INR was 3.3 today and you should take 4mg tonight and to
take 5mg daily after this.
Please resume your normal home medications.
Also, please take aspirin 81mg once a day as you have been
doing.
If you experience any of the symptoms listed below please go to
your nearest emergency department.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ y/o man with previous bowel ca s/p hemicolectomy in ___,
OSA, new valvular AF on warfarin started 2 months previously,
moderate to severe AS (area 1cm2 with anti-HTN recently reduced
due to significant hypotension) who presented with new
dysarthria and choking to thin liquids. CT scan did not show any
hemorrhage and INR was therapeutic. MRI/MRA brain showed a right
putamen and right occipital subcortical punctate acute infarcts
in keeping with cardiac embolism. His symptoms resolved and he
passed speech and swallow assessment who recommended regular
diet. Given inability to change to a different agent for
anticoagulation given renal function, the patient was continued
on warfarin. Patient had hypotensive episode on walking and his
carvedilol was decreased. The patient was admitted to the
neurology service on ___ and discharged on ___ with
neurology ___.
.
. | 300 | 137 |
10531372-DS-19 | 29,677,890 | Pain medication for comfort, supportive care for sustained
injuries. Resume all home medications. Foley catheter only if
needed for urinary retention. | Ms. ___ was admitted to the ___ following her fall on
___. Neurosurgery, plastic surgery, and spine were
consulted. Her C-spine was cleared by Dr. ___. A thorough
discussion between Dr. ___ the ___ son and
healthcare proxy took place given the ___ baseline
dementia. He noted that the ___ wishes would be to have
conservative care only at this time which would not include
operative intervention or further imaging studies. Plastic
surgery, neurosugery and orthopedic spine surgery initially saw
the patient in the ED and initially evaluated her but did not
continue to follow after her goals of care were made clear.
Ophthalmology saw the patient during her stay and determined
that her globe is intact and that she has some findings
consistent with glaucoma and would benefit from timolol eye
drops twice daily. She was started on a soft solid diet and
transferred to the floor in stable condition. Her foley was
removed on ___, but she failed to void and it was replaced.
She was able to tolerate modest amounts of PO intake, including
her PO medications. She was gently hydrated with IVF during her
stay. Her foley was removed prior to transfer back to rehab. | 21 | 199 |
17467940-DS-10 | 21,550,312 | Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with fatigue and
generalized weakness. Further testing did not cover a cause of
this sensation. You are now being discharged, and will need to
be seen by your PCP and cardiologist for further work-up of
this.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck! | ___ woman with history of atrial fibrillation on
apixaban, hypertension, self-report of rheumatoid arthritis (but
notes documenting polymyalgia
rheumatica), recurrent UTI on Bactrim prophylaxis who presents
for evaluation of generalized weakness and fatigue. | 77 | 32 |
19562787-DS-23 | 28,620,975 | Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted following a fall.
You had Xrays of your knee, hand, chest and a CT scan of your
head which did not show any fractures. In the ED, you were also
found to have unequal blood pressures in your arms, and we
therefore performed a CT scan of your chest. The CT scan did
not show any abnormalities in your blood vessels.
However, the CT scan showed a nodule in your lung, which is
concerning and will require further evaluation. You were seen
by interventional pulmonology. They will call you to arrange
followup including a more detailed CT scan and a bronchoscopy
and biopsy.
You were also found to have a low sodium level in the ED, which
has now returned to normal.
We made no changes to your home medications.
Please followup with your doctors, see below. You will needed
to followup with interventional pulmonology; they will contact
you to arrange an appointment. Please also followup with your
primary care practitioner and with Dr. ___,
to followup regarding your hematuria. You will also need to
have a repeat endoscopy to followup regarding ___
Esophagus. | ___ with PMH of chronic paranoid schizophrenia, temporal lobe
epilepsy, ___ esophagus, hyponatremia, and hematuria s/p
mechanical fall yesterday, with new incidental finding of a
pulmonary nodule.
.
# Lung nodule: 3.8 x 2.7 x 1.8 cm left upper lobe lung mass with
mild nonenlarged lymph nodes; incidental finding on CTA chest.
Patient has a long smoking history, however no cough, dyspnea.
He does endorse possible weight loss, no fevers, night sweats,
chills. Overall concerning for malignancy, likely of lung
epithelial origin. Given PMH of ___ esophagus,
differential diagnosis includes esophageal cancer with possible
lung metastasis, but this is much less likely that a lung
primary in this patient. BOOP might be one other alternative
explanation for the etiology of this lesion. He was seen by
interventional pulmonology, who have discussed the finding with
the patient. They will followup with him to schedule high
resolution imaging of his chest, and a subsequent bronchoscopy
for biopsy of the lesion. LFTs were performed during this
hospitalisation and were unremarkable.
.
# s/p Fall: Fall appears to have been mechanical, patient
tripped on pavement, denies being intoxicated at the time.
patient has multiple bruises on left hand, also right knee.
Hurt his head but denies any loss of consciousness. CT head,
CXR, Xrays of knee and hand all unremarkable for any fractures.
His pain was well controlled with tylenol and ibuprofen.
.
# Hyponatremia: Chronic since at least ___, although has had
periods of normal Na readings intermittently. This has
previously been attributed to carbamazepine. Chronic siADH due
to ephysema is also possible. Head injury likely not causing
acute siADH given chronicity of hyponatremia. Pt appeared
pre-renal by urine lytes and after some gentle IVF in the ED,
his Na returned to normal range on the day of discharge
.
# Asymmetric BP: Noted in the ED. Repeat blood pressure
measurements overnigth were 98/69 in the right arm and 115/63 in
the left arm. CTA did not show any aortic or other vascular
pathology, however, he will need to followup with his PCP for
serial BP measurements
.
# Chronic paranoid schizophrenia: continued quetiapine, ativan,
trazodone.
.
# Temporal lobe epilepsy: Continued carbamazepine, ativan.
.
# ___ esophagus: Due for repeat endoscopy in ___, but
missed appointment. Denies any heartburn, dysphagia. He should
have a repeat EGD as an outpatient.
.
# Hematuria: Microscopic, chronic. The patient has had no
gross hematuria over the past year. He has been followed by Dr.
___ both his hematuria and hyponatremia. His hematuria
was believed to be secondary to IgA nephropathy. He will
followup with Dr. ___ as an outpatient.
.
# BPH: The patient has stable symptoms of BPH. PSAs have been
normal, last PSA ___ was 0.8. We continued doxazosin.
. | 204 | 467 |
12904379-DS-10 | 20,369,494 | You were admitted to the hospital with abdominal pain and
laboratory abnormalities. A gallbladder ultrasound was
performed and revealed stones within the gallbladder. An ERCP
was also performed, but did not indicate presence of stones
outside of the gallbladder, therefore, you underwent a
laparascopic cholecystectomy. You recovered in the hospital and
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 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. | Ms. ___ was transferred to the ___ Emergency Department
from an OSH due to concern for choledocholithiasis as the
patient was experiencing 3 days of right upper quadrant
abdominal pain with increased LFTs. Upon arrival to ___, an
abdominal ultrasound was obtained suggesting cholelithiasis
without definitive evidence of cholecystitis; LFTs were elevated
upon arrival. intravenous ciprofloxacin and metrondiazole was
initiated and the patient was subsequently admitted to the Acute
Care Service for further evaluation and management.
On HD1, the patient underwent an ERCP (unable to have MRCP d/t
previous ear surgery), which was normal. Post-procedure, the
patient was maintained NPO with IV fluids. On HD2, LFTs were
trending downward, the patient's pain was improved and she was
taken to the operating room where she underwent a laparascopic
cholecystectomy; see operative notes for details.
Post-operatively, the patient remained afebrile with stable
vital signs. Pain was managed with oral oxycodone with good
effect. Her diet was advanced to regular, which was well
tolerated; LFTs continued to trend downward. Additionally, she
was voiding adequately and ambulating independently. She will
follow-up with ACS in 2 weeks. | 358 | 188 |
11490051-DS-15 | 26,392,369 | Dear Mr. ___,
You came into the hospital because you were feeling very
depressed, weak and dizzy. You had several tests done to check
for infection or low blood pressure which may have been causing
your symptoms, which showed a urinary tract infection. You were
started on antibiotics to treat this infection. Your symptoms
are likely from your severe depression and you were transferred
to the psychiatric unit to treat your depression to help you
feel better.
It was a pleasure being involved in your care!
Your ___ Care Team | ___ w/ chronic major depressive disorder (1 past psychiatry
hospitalization), CLL in remission, CAD s/p DES, DM, cognitive
decline, who presents with cc of insomnia in setting of
worsening depression, as well as weakness, admitted to medicine
for evaluation prior to consideration of possible psychiatric
admission.
# Weakness/lightheadedness - On presentation, vital signs within
normal limits. Orthostatic measurements normal. Noted on
infectious w/u to have left lung base opacity on CXR and UA with
large leuks but with no fevers, pulmonary symptoms. Endorsed
symptoms of difficulty urinating, urgency found to have urine
culture with greater than 100K coag negative staph, so started
on 5 day course of macrobid for complicated UTI. Thyroid studies
were unremarkable. H/H at baseline. no focal weakness on exam w/
recent ___ showing no acute intracranial process. Pt denied
cardiac symptoms. Pt does have stage I CLL. His WBC count was
only mildly above recent baseline on presentation (52.8 from
47.2), perhaps making CLL progression less likely, per heme/onc
curbside unlikely contributing. B12 and folate were both
recently checked and were within normal limits. Symptoms thought
to be multifactorial, predominantly from underlying severe
depression as well as complicated UTI. Medically cleared for
transferred to ___ for further management.
# Major depressive episode - Lack of precise trigger or clear
organic etiology, recent changes to psychiatric medications may
be contributing. Continue on most recent list of home
psychiatric medications per psychiatry consult in discussion
with ___ home psychiatrist. Of note, QTc on admission elevated
(453/488) so will need to be monitored if continuing to give QTc
prolonging medications. Medically cleared and transferred to
___ for further management and consideration of ECT.
#Complicated UTI: Symptoms of difficulty urinating, urgency but
afebrile and hemodynamically stable. Urine culture with greater
than 100K coag negative staph, so started on 5 day course of
macrobid for complicated UTI (Day ___. Urine culture
sensitivities pending on discharge, but per recent culture
should be sensitive to macrobid.
# Hypothyroidism: Continued on home levothyroxine. TSH and free
t4 levels within normal limits.
# CAD s/p DES: Continued home Plavix.
# DM: Patient was monitored with insulin sliding scale, refused
fingerstick blood glucose checks, but glucose levels were normal
on labs. Does not appear to be on medications for diabetes at
home.
# Glaucoma: Continued home eye drops.
# OSA: continued CPAP while inpatient.
===================
Transitional Issues:
===================
-Complicated UTI: Urine culture with >100K coag negative staph
with urinary symptoms (frequency/retention) c/w complicated UTI.
Started on macrobid ___ Q12h to complete a 5 day course (Day
___. Urine culture sensitivities pending on discharge, but
per recent culture should be sensitive to macrobid.
-Noted on admission ECG to have prolonged QTc 453/488. Please
monitor QTc if going to continue giving QTc prolonging
medications.
-Started on tamsulosin for symptoms of BPH. Unclear if symptoms
from urinary tract infection, underlying depression or BPH.
Could consider discontinuing if urinary symptoms improve.
-For med reconciliation, unclear if taking crestor 10mg at home.
Please address as an outpatient
-Blood cultures and methylmalonic acid pending on transfer
-Lisinopril held on transfer as normotensive, complaints of
dizziness. Consider resuming as appropriate for renoprotective
effect.
-CODE: Full, presumed
-CONTACT: Son, ___ ___ | 90 | 529 |
15930458-DS-25 | 20,912,629 | Dear Mr. ___,
It was a privilege to care for you at the ___
___. You were admitted with a severe skin infection
of your left leg due to extension from a bone infection on your
big toe. You were treated with strong IV antibiotics and had an
operation to remove the infected bone in your toe. You will
need to continue IV penicillin through ___ and then transition
to oral amoxicillin for 4 weeks. Please continue to use the
surgical boot while walking and the waffle boot while in bed.
Take Tylenol and as needed dilaudid judiciously for pain, but
please do not drive or use consume alcohol concurrently with
dilaudid given the risk of respiratory depression. Do not take
Humira until instructed by your dermatologist and infectious
disease doctor.
Your home Lasix and spironolactone are being held on discharge.
Please weigh yourself daily and notify your PCP if your weight
increases by more than 2 lbs in one day or 5 lbs in one week,
which might necessitate resumption of these medications.
We wish you the best!
Sincerely,
Your ___ Team | Providers: ___ with a history of HTN, chronic liver disease,
chronic ETOH use, psoriasis (on humira), chronic venous
insufficiency who presented as transfer from ___ with
complicated cellulitis of LLE and L hallux ulcer that probed to
bone, now s/p L hallux distal phalangectomy ___, with course
c/b hypoxic/hypercarbic respiratory failure. Operative cultures
growing Globicatella species. Discharging home with PCN G with
plan for prolonged PO taper and outpatient podiatry/ID f/u.
# Acute complicated cellulitis of LLE:
# L distal hallux ulcer, operative cultures growing | 181 | 84 |
17569640-DS-20 | 21,072,823 | It was a pleasure participating in your care at ___. You were
admitted to the hospital for confusion. You were evaluated by
the psychiatry and geriatrics team which felt it would be best
if you were under more round-the-clock nursing care.
Please continue to take your normal home medications as
previously with a few small changes.
Medications STARTED that you should continue:
We Started No New Medications.
Medications STOPPED this admission:
-Lorazepam
Medication DOSES CHANGED that you should follow:
-donepezil from 20mg down to 10mg each day
-aspirin 325mg down to 81mg
It is important that you take all of your usual home medications
as directed in your discharge paperwork. | Mr. ___ is a ___ male with dementia,
hypercholesterolemia, and hypertension presenting with acute
onset paranoia in the context of dementia. He was assessed
also by Psychiatry and Geriatric services during this admission.
Active Problems:
1. PARANOIA: The patient presented to ___ with worsening
paranoia. This paranoia was attributed to his advanced dementia.
During his hospitalization, he was worked up for reversible
causes of dementia. The patient was checked for RPR, B12, TSH.
All of the followign were negative. A CT head was also negative
for acute processes. Chest xray as UA were also unremarkable.
Furthermore, the patient has been afebrile without a
leukocytosis for the duration of his hospitalization.
Neurological exam is not revealing for focal neurological
deficits suggesting that this was not attributable to a CVA or
TIA. From a medical standpoint, the patient is clear for long
term placement as he has no acute issues. During his
hospitalization, the patient was pleasant towards the staff and
very cordial. Of note, during this hospitalization patient has
infrequently required low dose seroquel for agitation. He has
not required any seroquel in the past 72 hours.
-Low dose seroquel PRN agitation.
Chronic Problems:
2. DEMENTIA: Long standing issue which has been progressing
insidiously over the past several years. Patient is currently
being treated with donepezil.
3. HYPERTENSION: Patient's blood pressure runs in the 150's.
Patient is not actively being with antihypertensives prior to
admission. He was not started on anti-hypertensives. Of note,
beta blockers were not started during this admission secondary
asymptomatic sinus bradycardia.
Transitional Issues:
1. Code Status: DNR/DNI
2. Patient Contact and HCP: Son ___.
___ ___
3. Please schedule a follow up appointment with Patients PCP
upon discharge. | 104 | 284 |
15591198-DS-23 | 24,446,364 | Ms ___,
It was a pleasure taking care of you while you were
hospitalized. As you know, you were admitted for an infected
cancerous lesion near your vagina. You were given antibiotics
and improved. You should continue the antibiotics as directed
for the next 8 days and followup with Dr ___. She will assess
your response to treatment and decide if further antibiotics are
needed. She will also decide when it is safe to resume your
etoposide. | ___ PMH of OSA, CVA, Metastatic Ovarian Cancer (on PO
Etoposide), presented with abdominal pain, found to have
metastatic lesion at vaginal cuff which was secondarily
infected, but improved on antibiotics, so was discharged on
cipro/flagyl with outpatient followup in 1 week
# Sepsis
# LLQ abdominal pain
# Secondarily Infected Metastatic Lesion
Presented with fever to 103 and abdominal pain, found to have
lesion abutting vagina c/f abscess. TVUS ___ clarified that
lesion was thick walled, mostly cystic/solid with thick internal
septations demonstrating flow on doppler. As per discussion
between GYN/Radiology, it was felt to be more consistent with
necrotic malignancy. GYN did exam in ED and felt vagina had no
tears or mucosal defects that would have caused abscess or
secondary infection of this mass. Regardless, it seems to have
been secondarily infected as Tmax in ED was 103, and treatment
with cefepime/flagyl initially caused fever to break, WBC to
decline from 13->7, and LLQ pain to improve from 8->2.
While patient improved symptomatically with IV antibiotics, ___
consulted regarding aspiration for further source control to
help hasten recovery, and to determine causative bacteria. They
noted that mucinous malignant lesions are difficult to aspirate,
and transvaginal approach would be difficult procedure that
would be painful for patient to tolerate. Given such
constraints, and fact that patient had been improving on
cipro/flagyl, decision made to continue such antibiotics for an
additional 7 days, then follow-up in clinic with Dr ___. If
continues to be symptomatic at that time, Dr ___ either
extend abx therapy, re-image, or consider attempt at aspiration.
# Migraines:
Continued propranolol and nortriptyline for prophylaxis
# Constipation:
Continued home regimen with Metamucil, Colace etc...
# Metastatic Ovarian Cancer
Recent progression, started oral Etoposide ___. CT from
admission with new liver met + adrenal lesion. Not necessarily
unexpected in that she just started etoposide. Oral Etoposide
held as patient actively infected. Patient has f/u appt with Dr
___ in 1 week, when she will re-assess whether or not it is safe
to restart.
# Hyponatremia
Likely ___ hypovolemia from poor po intake as resolved with IVF
#Presumed Malignant Pleural Effusion
Known finding, patient asymptomatic, will be followed in
outpatient setting
# Anemia:
Likely ___ malignancy + chemotherapy, stable during stay, will
need to be trended in outpatient setting. | 76 | 372 |
19777866-DS-14 | 26,641,186 | You came to the hospital for low blood pressure and signs of
infection while preparing for colonoscopy at home.
You were treated in the intensive care unit with fluids through
the vein, antibiotics and special medicines to keep your blood
pressure in a safe range.
You had a sigmoidoscopy on ___ and biopsies were done of the
mass. You will get the results either from us or from Dr ___
___ you see her in followup.
Your potassium levels remains quite low - please take the higher
dose of potassium that we are prescribing to you and have your
potassium level rechecked. Your vitamin D levels are also low,
please take the vitamin D tablet once a week. I was unable to
send your prescriptions to ___ Electronically so
our RN is giving you prescriptions. | HOSPITAL COURSE
================
___ with hx recurrent prostate cancer and HTN, who presents
with vomiting and diarrhea in the setting of colonoscopy prep,
found to be hypotensive with elevated lactate and fever
concerning for shock secondary to hypovolemia and sepsis.
___ w/ CAD (noted on PET scan), and prostate cancer s/p radical
prostatectomy with recurrence and known large pelvic mass with
possible colonic extension, currently receiving Lupron and
abiraterone who was admitted to the ICU with septic shock with
probable GI source, now improved and transferred to the floor.
ACUTE ISSUES
=======================
# Shock, hypovolemic vs. septic
# Fever
# Leukocytosis
# Vomiting/diarrhea
# Lactic acidosis - RESOLVED
Pt presents with acute on subacute diarrhea and vomiting as well
as fevers/chills and found to be in shock, responsive to fluids
but still requiring pressors in the ED. Likely etiology is both
hypovolemia in the setting of ongoing diarrhea and acute
vomiting due to prep, as well as possible sepsis given fever,
chills, leukocytosis, with possible GI source given invasion of
prostate cancer into bowel, but other less likely possible
sources include urine and lung. He was admitted to the ICU for
NE pressor support. He was given significant IVF and weaned off
pressors on ___ and transferred to the floor and completed a
week of IV antibiotics. All blood cultures remained negative.
He was hemodynamically stable throughout his stay on the general
medical floor.
#Prostate Cancer
#Pelvic Mass - malignant
Per e-mail exchange with outpatient oncology team at ___,
initially considered inpatient prep + inpatient colonoscopy
given difficulties preparing for it as outpatient, however in
discussion with GI and outpatient team, percutaneous ___ biopsy
was initially pursued, but it was very difficult to properly
position the patient. He ultimately had a sigmoidoscopy and
pathology shows adenocarcinoma and high grade villous adenoma.
His outpatient oncologist and PCP were emailed of these results,
and patient has f/u with them this week.
# ___
Baseline Cr 0.6 in ___. High of 1.3. Likely pre-renal from
hypovolemia and hypotension. He received IVF and his Cr improved
back to baseline.
# Subacute diarrhea - resolved
Pt endorses 2 weeks of nonbloody diarrhea (several loose stools
daily), with acute worsening in the setting of taking prep.
Infectious work up negative for C diff, campy, salmonella,
shigella.
# Hypokalemia
Seems to be chronic, possibly ___ HCTZ although this was
discontinued months ago. ___ be contribution of GI losses from
weeks of diarrhea. Unlikely to be nutritional component as pt
endorses good diet, although also has hypophosphatemia and low
albumin so may be malnutrition component. Takes daily potassium
supplementation outpatient. He was ultimately discharged on
supplemental potassium 60 mEQ and his outpatient providers were
emailed and asked to recheck this as an outpatient. Given
improvement in his diarrhea, and the fact that this is long
standing, it is suggestive of K wasting in the urine.
Outpatient providers can ___ further.
# Malnutrition
# Hypophosphatemia
Pt cachectic with hypoalbuminemia and electrolyte abnormalities
which may be ___ diarrhea/prep but also possible nutritional
component. His po intake improved substantially over the
course of his hospital stay.
CHRONIC ISSUES
=======================
# Prostate cancer
Continued home abiraterone. His outpatient oncologist was
notified and involved with inpatient management as above
Greater than ___ hour spent on care on day of discharge. | 139 | 559 |
16779219-DS-15 | 23,706,438 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
You were admitted to the hospital for increased right knee
swelling, pain, and fevers up to 102 at home. Because you
recently had an incision and drainage of that knee for a
bacterial infection in the joint space on ___, we
suspected that you may have an incompletely treated chronic
infection in that joint and/or further bleeding into the joint
that can be irritating.
A sample of fluid in your right knee joint was analyzed and
showed inflammatory cells without evidence of bacterial
organisms. Because you have hardware in your joint, it is hard
to completely eradicate infection because the organism can
"stick" to the hardware. Therefore for this serious infection,
we continued your IV antibiotic therapy and placed a "PICC" line
for you to getinfusions of the antibiotic ("Daptomycin") until
___ at ___. You will also be taking the oral
antibiotic "Rifampin" until ___.
On ___, you developed fevers and blood cultures were
obtained that grew out bacteria in your bloodstream. For this,
we treated you with another antibiotic ("IV Ceftriaxone"), which
you will also continue until ___. The cause of this
blood infection is unknown, but we believe it may have been due
to fecal contamination of your PICC line.
IMPORTANT: You will need to take oral antibiotic suppression
therapy after your course of IV antibiotic therapy is done to
suppress infection from re-occurring. To decide what this will
be, please make sure to follow-up with infectious disease at
___ after completing IV antibiotics at
___.
Please make sure to:
- Continue getting IV Daptomycin, IV Ceftriaxone, and taking
oral Rifampin until ___ for your right knee
infection
- Attend all of your follow-up appointments
Warmly,
Your ___ medical team | ___ is a ___ with Hemophilia A (+inhibitor) from ___
___ s/p I&D for septic arthritis of right knee with hardware
(total knee replacement) on ___ at ___, on IV Daptomycin,
who was admitted for fevers at home to ___ and increased right
knee pain and swelling most likely from an under-treated joint
infection vs. hemarthrosis.
#Chronically infected right knee joint: ___ had missed ___
daily infusions of Daptomycin at ___ since his
prior discharge from ___ on ___. On admission, Heme and
Ortho were consulted. After an infusion of Factor VIIa, patient
underwent ___ guided right knee aspiration to evaluate for septic
arthritis. R joint fluid gram stain had no organisms, +1PMNs.
Joint fluid WBC count was 13,550 with 89% Polys and ___ RBC
count. Final joint fluid culture NGTD; blood cultures also NGTD.
CRP 5.1 and peripheral WBC 9.1 and HCT 33.1 (at baseline) on
admission. Per ortho: because CRP was normal, and though the
aspirate was suggestive of ongoing infection, there was no plan
for OR at this point because there was no drainage, and patient
was systemically well with stable joint size and no evidence of
active bleeding or sepsis. If he did not have hemophilia they
could do a two stage reimplantation but it was determined that
this was not a good strategy in him because his re-implant will
likely get re-infected due to hemarthrosis. Therefore, patient
received a PICC and was discharged to a skilled nursing facility
to continue to get infusions of IV Daptomycin 400mg QD along
with oral Rifampin 600mg PO QD per infectious disease recs until
___ (for a total of 6 wks of antibiotics with day 1
= ___. ___ agreed to follow up with a new PCP, his hematology
team, and infectious disease at ___. He will most likely be on
lifelong oral suppression antibiotic therapy, likely with
Bactrim per ___ ID.
#GNR Bacteremia: On ___, a day prior to his anticipated
discharge, the patient developed fevers to 102-103 w/blood
cultures positive for K. Pneumoniae bacteremia ___ drawn from
PICC line and peripheral). For this, he was given IV Cefepime x
1, then continued on IV Ceftriaxone with some IVF and was
thereafter afebrile and VSS. Patient othterwise asymptomatic (no
GI/urinary sx) and the presumed etiology was contamination of
his PICC line (patient reports he went to help his roommate and
got roomate's fecal matter on his hands and may have touched his
PICC line; he does have a history of injecting crushed diluadid
into his IVs at ___, caught on video camera, and several known
IV line contamination episodes). ID was consulted and we agreed
on a 2-week treatment of IV Ceftriaxone to conclude on ___ for what was presumed to be transient and low-grade
bacteremia from a known fecal source; the surveillance blood
cultures were NGTD on discharge.
#Pain management: On this admission, the patient was also
agreeable to weaning down on oral dilaudid, which he reports
needing to control his knee pain. He has a long and complicated
history of pain medication use. On this admission his admission
dose was ___ PO Q4H PRN and on discharge, his dose was 6 mg
PO Q4H PRN with standing Acetaminophen ___ PO Q8H.
#Asthma: Continued nebs PRN. | 296 | 539 |
18126119-DS-17 | 20,947,501 | No Surgery done. Some cervical compression at C5-6. Advise for
ACDF C5-6.
Treatments Frequency:
None | Patient was admitted to hospital for possible surgery for
cervical stenosis and neurological symptoms.
Neurology team evaluated patient: Ms. ___ is a ___ year old
woman with metastatic breast cancer
(to bone) who presents with subacute decline in gait, with
multiple falls, as well as concurrent sensory loss in the ___
and
___ digits bilaterally. She has been found to have severe
cervical spine compression due to a disc protrusion, as well as
L4/5 spinal and foraminal stenosis due to a subacute spinal
compression fracture. These findings do explain her symptoms and
are most likely the etiology for her worsening gait.
However, with her history of metastatic breast cancer, the
severity of EMG findings, and the invasive nature of spinal
surgery which requires a potentially long rehab period, we would
like to ensure that this is the best option for her. A
neoplastic
or paraneoplastic process affecting the nerve roots is a
possibility which should be ruled out before going to surgery.
To
this end, she needs a lumbar puncture. We attempted lumbar
puncture at the bedside today with subcutaneous lidocaine (5cc),
however the attempt was unsuccessful and the spinal canal was
not
reached, likely due to severe degenerative disease in the lumbar
spine and body habitus.
We recommend LP in ___, which will be scheduled for tomorrow
morning. The following CSF studies should be sent:
- Routine studies (cell count, protein, glucose)
- Gram stain and culture
- Cytology and flow cytometry
- Paraneoplastic panel
If the routine studies are normal, she can be discharged to
rehab. Case (risks and benefits of surgery) will be discussed
with her oncologist and she will likely be scheduled for spinal
decompression surgery in the next ___ weeks, if cytology and
paraneoplastic panel return and are negative.
If the routine studies are abnormal, we will consider
transferring her to the neurology service for any further
required workup and treatment. | 14 | 284 |
15702566-DS-18 | 22,997,915 | Dear Mr. ___,
You were admitted to ___ and
underwent laparoscopic appendectomy. You are recovering well and
are now ready for discharge. Please follow the instructions
below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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 steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the ___ Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT revealed acute appendicitis (please see
radiology for report). The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears liquids , on IV fluids, and PO Oxycodone for
pain control. The patient was hemodynamically stable.
Patient was transitioned to PO Dilaudid for better pain control.
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
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 311 | 201 |
10726866-DS-9 | 27,814,015 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to ___ with an asthma
exacerbation. This improved with nebulizer treaments and
steroids. It is now safe to be discharge. You should follow up
with Dr. ___ ongoing care. We wish you all the best.
Sincerely,
Your care team at ___ | Ms. ___ is a ___ ___ and lifelong
non-smoker with a PMH pertinent for asthma, hypertension,
hypothyroidism, and glaucoma who is admitted with an asthma
exacerbation.
# Asthma exacerbation: She presented to urgent care with dyspnea
consistent with prior asthma exacerbations. She received duonebs
and steroids but given her hypoxia was to the ED. Her D-dimer
was negative so PE unlikely, and her exam and CXR without
concern for pneumonia. She was continued on steroids,
nebulizers, and her home inhalers. She slowly improved over
several days. Patient discharged on prednisone taper and home
asthma regimen, including home nebulizer therapy. She should
eventually follow up with her Pulmonologist, Dr. ___.
# Hypertension: continued home nifedipine
# Hypothyroidism: continued home levothyroxine
# Glaucoma: continued home dorzolamide eye drops. Latanoprost
was recently removed due to concern that it was promoting
bronchospasm. | 56 | 135 |
18260420-DS-13 | 29,383,832 | ================================================
Discharge Worksheet
================================================
Dear Ms. ___,
WHY WERE YOU ADMITTED?
-You came to ___ because you were having shortness of breath
and were found to have low oxygen levels.
- You had shaking while having a CT scan.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You had an ultrasound of your heart which showed normal heart
function.
- You were on a heart monitor which showed no abnormal rhythms.
- You had a CT scan of your lungs which showed a small area of
inflammation in your right lower lung.
- You received supplemental oxygen. You were able to wean off of
the oxygen while in the hospital.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please be sure to attend your follow up appointments (see
below).
- Please take all of your medications as prescribed (see below).
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | BRIEF SUMMARY:
==============
Ms ___ is a ___ yo F with T1DM, CAD s/p CABG (___),
hypothyroidism s/p thyroidectomy for Graves (___), HTN, HLD,
OSA (not on CPAP), asthma, gastroparesis, depression,
fibromyalgia admitted for seizure-like episode and found to have
hypoxemia and ground-glass opacities on CT scan. | 165 | 45 |
18792843-DS-20 | 23,732,116 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Touch down weight bearing left lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left acetabulum fracture. The patient was taken to
the OR and underwent an uncomplicated ORIF. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: touch down weight bearing left lower
extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 181 | 174 |
17556105-DS-18 | 26,784,133 | you were hospitalized for skin infection and abscess that was
drained. you still have skin infection, cellulitis, so take
antibiotics as prescribed. change gauze every day and your pcp
___ remove ___ from your wound, but you can pull it out a tiny
amount each day. report any spreading redness, pain, swelling or
increase in pus or fever to your doctor right away.
since the area is on your back be sure to have someone look at
your back every day | ___ year old female without significant medical history,
presented with sepsis due to an abscess on her back with
surrounding cellulitis (originally to ___ but
transferred to ___ from their ED). Now status post I&D in our ED,
on vancomycin. Denies IVDU, but has areas all over skin that
look like she's been skin popping, she has no veins, she has
meth teeth, and she had an episode today of acute
disorientation, chest pain, shortly after leaving the floor,
found to have markedly dilated pupils. Also with positive
opiates on tox screen at ___ and now here. She then told
the nurse that one of her friends "gave her something" and she
didn't know what. Suspect use of methamphetamine. Positive tox
screen.. Given her tachycardia and complaint of pleuritic chest
pain (EKG with sinus tach, normal troponin) getting a CTA which
on prelim showed negative PE.
1) Sepsis secondary to back abscess/cellulitis: Her leukocytosis
is normalizing and her BP likely runs low as she is presently
90/58 after 3L NS. Unfortunately a culture wasn't sent from the
ED, but this is likely CA-MRSA.
Will discharge on Bactrim and Keflex, and will leave her wick in
until she f/u with PCP
2) Pleuritic chest pain, tachycardia:
4) Hypothyroidism: Never followed up with PCP for med
initiation. Encouraged her to see her PCP after discharge.
5) Smoking: Provided nicotine patch.
6) IBS: Reports periods of diarrhea intermittently, stable.
she provided current phone number ___ and I told her
that prelim cta chest showed no acute abnormalities but that if
on final read I needed to contact her I would. | 80 | 263 |
11437634-DS-13 | 23,730,655 | It was a pleasure taking care of you at ___
___. You were admitted with cough and abdominal
pain. This was a result of a viral infection causing a
worsening of your COPD. You were treated with steroids and
antibiotics and you improved. You were able to tolerate a
normal diet and walk with a normal oxygenation. | Mr ___ is a ___ with complex medical history including s/p
whipple, cholecystectomy, chronic pancreatitis, prior h/o
alcoholism, COPD who presents with shortness of breath and
abdominal pain.
# Shortness of breath - Likely ___ COPD exacerbation. No
evidence of PNA on CXR. Normal WBC, Afebrile. Started on
prednisone 60, NEBS, Azithromycin. Sent home with Rx for
prednisone and azithromycin for a total of 5 days. Able to
ambulate without shortness of breath.
# Abd pain/diarrhea - Likely pancreatitis flare. Diarrhea had
resolved. By morning the patient wished to eat, passed a PO
challenge and wished to be discharged.
#H/o Alcoholism: Denies active ETOH abuse. No h/o w/drawal
seizures per pt. Pt was monitored and showed no signs of
withdraw.
#Celiac disease:
Pt w/ history of celiac disease diagnosed by TTG. on nomral diet
now, unclear if could contribute to sx.
#Depression: Sertraline, Mirtazapine were continued
# Tobacco abuse - Pt was counseled on smoking cessation, and
given a nicotine patch. | 61 | 177 |
11084025-DS-19 | 28,630,129 | Dear Ms. ___,
You were admitted with ongoing seizures concerning for status
epilepticus. You were treated with medications, and required
intubation with mechanical ventilation to protect your airway.
You were successfully extubated the following day.
Please avoid driving for the next 6 months (following your last
seizure). Please avoid operating heavy machinery. You are
strongly advised to take all of your medications as directed and
do not miss doses. Follow up with Neurology as below. | ___ was admitted to the Neuro-ICU after being intubated in
the ED for airway protection. EEG did not show ongoing seizures.
She was treated initially with propofol and keppra. She was
subsequently extubated on day 2 of admissioin without
complications. Although patient had leukocytosis of 17 on
admission with low grade temperature, this was felt to be due to
her seizures and she was not treated with antibiotics. She did
not have any more fevers; leukocytosis resolved without
intervention. Infectious work up was negative. No clear trigger
for her seizures were identified, and it appeared that she had
been adherent to her medication regimen. Therefore, we decided
to add on a second agent (levetiracetam was discontinued after
load in ICU). She was started on trileptal which was titrated to
600mg BID without issues. On discharge, she was set up with a
Neurology follow up. For AED, she was discharged with home
lamictal and trileptal.
Transitional Issues
#Neurology
[ ] Continue lamictal, trileptal
[ ] Follow up with Dr. ___ | 74 | 166 |
16439649-DS-22 | 25,443,700 | Dear ___,
___ were hospitalized due to symptoms of DEPRESSED LEVEL OF
CONSCIOUSNESS and LETHARGY resulting from ENCEPHALOPATHY.
We are changing your medications as follows:
1. Restarted Coumadin. ___ will be on IV heparin with a goal
PTT 50-70 until this is therapeutic (INR ___
2. Increased Keppra to 750mg bid
3. Stopped Trazodone
4. Stopped Tolterodine
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek medical
attention.
It was a pleasure providing ___ with care during this
hospitalization. | ___ h/o prior IPH/SAH c/b seizures p/w three episodes of
generalized convulsions from her SNF in the setting of an ESBL
Klebsiella UTI and diarrhea. Noted to have bilateral pulmonary
emboli, possibly melena, and encephalopathy. Her mental status
continues to improve gradually.
.
[] Stupor and Encephalopathy - The patient's predominant
presenting issue was waxing-waning mental status. At times, she
was somnolent and poorly responsive, whereas at other times she
was arousable but would not be verbal and appear confused. She
was evaluated for a variety of etiologies of encephalopathy as
well as depressed LOC. She notably has significant
periventricular white matter disease which could result in
underlying cognitive impairment and susceptibility for
encephalopathy/delirium. Her electrolytes and glycemic status
remained stable. She was evaluated with NCHCTs and a repeat MRI
which showed no new evidence of hemorrhage or cerebral
infarction. She was monitored on EEG and was thought to have a
clinical seizure on ___, but our Epilepsy specialists felt that
this did not clearly demonstrate electrographic evidence of
seizure. Her fluctuations in mental status otherwise did not
have any EEG correlate, and were not thought to represent
seizures. She was treated for aspiration pneumonia with
Vancomycin and Cefepime for 7 days in the setting of bibasilar
crackles and a left lower lobe basilar opacity. Her urine had
cleared from her previous ESBL Klebsiella UTI. C.difficile tests
were sent which were negative. She had an LP which was bland and
showed no evidence of meningitis; an HSV PCR was negative. We
held her amantadine and tolterodine as they might have
psychoactive effects. We initially increased her LEV to 1000 BID
but reduced this to 750 BID without any recurrence of seizure
activity. The amantadine was restarted on ___, and she was also
placed on CPAP while sleeping, both of which did seem to improve
her mental status. Her mental status gradually improved to the
point of her being easily arousable, awake, alert, oriented and
appropriate in response to questions and simple command
following.
.
[] Pulmonary Embolism - She was found to have bilateral
subsegmental PEs for which she was restarted on Heparin GTT. In
the setting of guaiac positive stools, the goal was reduced from
___ to 40-60, but when no evidence of bleeding was found, this
was increased back to a middle ground of 50-70. Warfarin was
restarted on the last day of hospitalization. Heparin drip
should be continued, with a goal PTT of 50-70 until INR is in
the goal of ___.
.
[] Atrial Fibrillation - She had one episode of Afib/flutter
with RVR which resolved and was controlled with Metoprolol 125
BID.
.
[] Gastrointestinal Hemorrhage - She had at least five positive
fecal occult blood tests with a downtrending Hgb/Hct; she
received a transfusion of 2 units of crossmatched pRBCs. GI was
consulted and performed endoscopy which revealed only focal
gastritis without any other major lesions. She was kept on BID
IV pantoprazole. This was changed to Famotidine 20 BID due to
concerns of possible association with her waxing-waning mental
status and she had no further signs of GIB or dropping
hemoglobin/hematocrit.
.
.
PENDING STUDIES: EEG final reports
. | 90 | 517 |
15068665-DS-21 | 22,196,738 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You may 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.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs. | Mr. ___ is a ___ M with Hx EtOH +withdrawal seizures,
transfer from OSH s/p fall with right temporal tip EDH, left
temporal IPH.
Neuro: Had nausea/vomiting with reported seizure, loaded with
keppra 1g in ED. Admitted to ICU ___, repeat NCHCT showed
blossoming of L temporal contusion. Bilateral temporal
contusions continued to blossom, concern for EtOH withdrawal and
started on phenobarb taper. Transferred to stepdown.
GI: elevated liver enzymes on admission, liver u/s showed
steatosis
ID: Blood cultures obtained on ___ grew coagulase negative GPCs
in one bottle. Re-cultured blood to determine if contaminant
versus legitimate infection. He had no leukocytosis or fevers
during this time.
On ___, the patient was evaluated by Physical Therapy. Due to
lack of insurance, the patient does not qualify for outpatient
benefits, i.e. rehab, and will likely rehabilitate while
inpatient.
On ___ Neurologically stable. Remained afebrile. Blood cultures
were still pending.
On ___ Neurologically stable. Evaluated by ___ who noted patient
to be very cognitively impaired and will either need 24 hour
supervision or discharge to rehab.
On ___ Patient remained neurologically stable. Continued to
work with ___ and OT. Police department was contacted to check
patient's home for any information about relatives.
From ___, the patient continued to be confused without
focal neurologic deficits. He was re-evaluated by ___ who
continued to recommend rehabilitation. Blood & urine cultures
sent in the days prior were negative for infection. He continued
to be afebrile.
On ___ the patient continued to be confused oriented to
person, and when asked location the patient responded with
"Hospital". The patient was stable and following commands, and
moving all og his extremities spontaneously ___.
On ___ the patient was alert and oriented to self and date,
and was able to state that he was in a "hospital", although
thought he was in ___. The patient otherwise remained
neurologically intact, followed complex commands and was moving
all of his extremities with full strength. The patient continued
to complain of a headache which was being treated as needed with
oxycodone and fioricet. Social work and case management continue
to work on contacting family for dispo planning. The patient
will need rehab ___ cognitive deficits.
On ___, the patient's neurologic examination remained stable.
Social work and Case management met with the patient and family
to discuss dispo planning with an interpreter present.
During the days ___, the patient remained neurologically
and hemodynamically stable. He remained in house, rehabing here.
However, the patient is A&Ox3 and improving from a cognitive
standpoint.
On ___, the patient remained neurologically and
thermodynamically intact. Case management met with the pt and a
interpreter and the patient expressed readiness to be discharged
home. All discharge instructions and follow up were given prior
to discharge. | 243 | 455 |
13972513-DS-32 | 28,625,259 | You were admitted for a 6 week worsening of your shortness of
breath. It appears your cancer is the main reason for your
shortness of breath. However, you did have about a half liter of
fluid that was removed by our lung specialists and you now feel
a bit improved.
You met with your oncologist and our palliative care specialists
and you have decided to go home with hospice services. | TRANSITIONAL ISSUES:
- will f/u in ___ clinic to assess need for
repeat thoracentesis for comfort; has gone 1.5 months between
taps and has not been accumulating quickly
HOSPITAL COURSE:
#Acute on chronic respiratory failure
Known pulm HTN ___ intrathoracic carcinomatosis and chest
radiation, anemia ___ malignancy, afib (rate controlled), PEs on
Lovenox, breast cancer with mets to the lung, pleura, and
subcutaneous tissue, lymphangitis carcinomatosis with recurrent
right malignant pleural effusion s/p PleurX removal ___,
prior malignancy-related pericardial effusion s/p drainage
without window, and pneumonitis ___ pembrolizumab p/w 2 weeks of
progressive DOE. TTE was done and it showed known
severepulmonary hypertension, no recurrent pericardial effusion.
CT scan did show moderate right sided pleural effusion, which
was drained by the IP service (550 cc of serosanguinous fluid)
and she had some improvement in her dyspnea. CT scan also showed
scant improvement in severe carcinomatosis affecting both lungs.
A team meeting was held on ___ with multiple family
members to discuss her condition and wishes on how to proceed,
the fact that at this point that the use of chemotherapy or
immune mediated therapy would likely shorten her life instead of
extend it. She will not receive any additional chemotherapy or
immune mediated therapy at this time, and will be discharged
with home hospice. She was started on oral morphine for help
with her symptoms of dyspnea though she was requiring minimal
dosage. She will f/u in ___ clinic to trend her pleural
effusion reaccummulation and consider repeat tap, as this is
palliative. Final O2 needs 4L. DC weight of 200.6lb (standing)
on day of DC.
# Metastatic breast cancer
Known mets to the lung, lymphangitic carcinomatosis, malignant
effusion. Oncologist ___ involved in discussion of
GOC and saw pt in hospital. No further chemo/immunotherapy to be
offered at present, though per Dr ___ discussion w
pt at bedside, he will see them in clinic to discuss her course
and treatment. To be arranged for ___ days post-DC. Pt is
DNR/DNI on DC with a MOLST filled out; of note, there is still
resistance to this on part of husband, ___, and her daughters
though pt is firm in expressing she thinks it would not help.
# H/o PEs: C/w home lovenox.
#Thrombocytopenia, likely ___ marrow suppression from
immunotherapy/chemo. C/w Lovenox until Plt < 10, <20 if febrile,
<50 if bleeding.
# Atrial fibrillation: Rhythm controlled
- C/w home amiodarine
- C/w home lovenox
# Neuropathy: ___ chemotherapy. C/w home gabapentin 300 mg PO
TID.
# Constipation: Treat with miralax BID, docusate BID, senna BID.
Monitor for BMs.
# Hypothyroidism: C/w home levothyroxine
>30 minutes spent on care on day of discharge including extended
discussion of hospice and code discussion; >1 hour total, with
30 mintes+ spent at bedside. | 70 | 443 |
12655574-DS-8 | 27,224,339 | It was a pleasure taking care of you in the hospital. You were
admitted with chest pain. Your blood tests and EKG did not show
that you were having a heart attack. Your chest x-ray showed a
pneumonia and you were treated with antibiotics. Please
continue to take this antibiotic for three more days. There was
also some more fluid around your lungs which could be because of
the infection. Please follow up with your doctor regarding an
outpatient echocardiogram to look for any underlying heart
failure that can lead to fluid accumulation in the lungs.
You had some confusion during your hospital stay which is likely
delirium. It was recommended that you stay in the hospital
until your mental status was more clear. However, you and your
family requested discharge from the hospital with the
understanding that leaving the hospital while confused was not
safe. You will need close supervision until your mental status
clears. You were offered nursing services at home but your
family declined.
The following changes were made to your medications:
1) START levofloxacin 750mg daily for three more days (stop on
___ | ___ year-old woman who presented from her assisted living
facility with chest pain. Chest radiograph showed some bibasilar
opacities that could be consistent with
infection as well as findings of pulmonary edema with associated
small pleural effusions. Cardiac enzymes were negative. She
was started on levofloxacin treatment for pneumonia. Her chest
pain and mild hypoxia resolved by hospital day 2.
On the day of discharge, the patient was found to have mild
confusion and agitation early in the morning. This improved
later in the morning. She was quite insistent about going home.
The patient's daughter said that she would work together with
the ___ staff to make sure someone would
look in on her with increased frequency. The patient and
daughter both understood that we preferred that the patient stay
for one more day of observation to ensure improvement in her
mild delirium, but they remained insistent about being
discharged and understood that it was not the most preferred
course of action and that it would put the patient at increased
risk of harming herself.
PROBLEM LIST
# Chest pain. Pt was admitted with chest pain that she reported
began under left breast and then migrated to under right breast,
relieved with tylenol. EKG did not show ischemic ST changes.
Cardiac enzymes were negative x 3. She had another episode of
chest pain during hospital stay that also resolved with tylenol;
EKG was unchanged. CXR showed bibasilar opacities likely
representing atelectasis vs infection. She was treated for CAP
with levofloxacin for a planned course of 5 days. She was not
febrile throughout hospital stay; WBC peaked at 11. Urine
legionella was negative. Blood cultures showed NGTD but final
results were pending by time of discharge.
# Pulmonary edema: CXR also showed mild to moderate interstitial
pulmonary edema with small pleural effusions. She received 10mg
iv lasix during night of admission. It was difficult to
determine how much urine output she had from this because she
was incontinent. She was initially on ___ oxygen by NC but was
weaned off it by time of discharge, satting mid ___ on room air.
She should follow up with her PCP regarding possible ___ upon
resolution of her pneumonia.
# Dementia: On admission, pt was A & O x 3 and appropriate and
agreeable to medical plan. Per nursing, pt was unable to sleep
and exhibited signs of delirium. On hospital day 2, she became
agitated and demanded to leave the hospital. She continued to
be A & O x 3 and was able to recite months of year backwards but
was confused about recent hospital events and was talking
somewhat nonsensically (e.g. claiming sharps box was her bag and
claiming she had sardines in the closet). She did not cooperate
with a full neurologic exam but was moving all extremities,
ambulating without difficulty, and had no frank neurologic
deficits. Her daughter came to the hospital and stated that pt
had previously had similar episodes of confusion periodically.
It was recommended that the patient stay in the hospital until
mental status cleared. However, patient and her daughter
requested to leave. The risks of leaving the hospital in a
delirious state were discussed with the daughter. Her daughter
stated full understanding. Her assisted living facility was
contacted who stated that they could not provide close
supervision and would only be able to check in on the pt twice a
day. This information was communicated to the daugther who
again requested discharge. It was recommended that if
discharged, the daughter should stay with the patient throughout
the day at home or obtain other services. She was offered home
visiting nurse which she declined. Her PCP was contacted and
made aware of the ___ hospital course by telephone. Of
note, urine culture did not show UTI.
# Hyponatremia. Na was 129 on admission and resolved to 134-135
by time of discharge. She was diuresed with 10mg iv lasix per
above. Urine legionella was negative.
# Normocytic Anemnia. HCT was at baseline at high ___ during
hospital stay.
# Hypertension. She was continued on her home BP meds,
amlodipine, atenolol, and isosorbide mononitrate.
# Hyperlipidemia. She was continued on her home statin | 197 | 731 |
12120702-DS-26 | 23,951,377 | You were admitted to the hospital for abdominal pain. A CT of
your abdomen showed inflammation in your stomach. It is possible
that the stress from your recent surgery caused your marginal
ulcers to become inflammed and are causing your pain.
Additionally, our nutrition labs showed that you have low iron
in your blood. You should take iron supplements, and ___
with your PCP for monitoring of your blood counts.
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, or any other symptoms which
are concerning to you.
Diet: Stay on Stage 4 diet: soft and pureed solids.
Resume your home medications as outlined in these instructions.
You will be starting some new medications:
1. You were started on omeprazole, an anti-acid medication to
help your ulcers to heal. You should continue to take 40mg twice
a day and ___ with Dr. ___.
2. You are also being sent home with sucralfate, another
anti-acid medication that your should continue taking 4 times a
day.
3. You are being discharged on medications to treat the pain.
These medications will make you drowsy and impair your ability
to drive a motor vehicle or operate machinery safely. You MUST
refrain from such activities while taking these medications.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
Please follow the activity guidelines as outlined by your
orthopedic surgeon and physical therapist.
Please call the doctor if you have increased pain, nausea,
vomting, bloody bowel movements, or dark tarry bowel movements. | The patient presented to ED on ___ with epigastric pain. He
was found to have an inflammatory changes around the anastomotic
junction of his previous surgery.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV medication.
Pain was very well controlled.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Systolic blood
pressure remained 150-180. These levels are consistent with his
outside records. He was instructed to followup with his PCP for
outpatient monitoring, along with his found iron deficiency.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: The patient was initially kept NPO. When pain
improved, he was advance to clears and then stage 4 diet which
the patient was tolerating on day of discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received Lovenox and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate.
Of note, patient was seen by orthopedic team for staple removal
and physical therapy to continue his rehabilitation.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a
bariatric stage 4 diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and ___ instructions with understanding
verbalized and agreement with the discharge plan. | 326 | 262 |
15193875-DS-18 | 24,888,311 | Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
admitted because of increasing weakness and confusion as well as
fever and foot pain. During you admission you underwent blood
tests which excluded that you have an infection in your blood
stream. To further evaluate your fever and foot pain we
performed an x-ray and an MRI of your loeft foot to exclude an
infection in the bone. Your confusion and weakenss improved
significantly with starting you on a seizure medication called
phenytoin. Your blood pressure was elevated during this
admission. Therefore, we changed your midodrine dosing so that
you will get it only if your blood pressure is low when you are
sitting up.
Please continue to take your medication as prescribed and follow
up with your appointment as listed below.
We wish you all the best.
Your ___ team. | ___ is a ___ gentleman with a PMH
significant for GBM with left hemiplegia and DVT on apixaban who
presents with weakness. The patient was found to have
subclinical seizures which improved with empiric therapy with
phenytoin.
1. Non-Convulsive Seizures: The patient presented with
intermittent confusion and drozzyness as well as stool and urine
incontinence. A head CT did not show acute changes or signs of
increased intracranial pressure. An LP was performed on
___ which was significant for high viscosity and high
protein content with elevation in WBC. Likely these changes
represent his GBM. Of note no elevation in opening pressure was
noted. The patient underwent EEG which did not show evidence of
seizures. The cause of the patient CNS manifestation was thought
to be non-convulsing seizures that were not detected by the EEG
on admission. The patient was started on fosphenytoin which
caused resolution of his symptoms and increase alertness. The
patient improved to his baseline cognitive function being A&Ox3
and interactive. His fosphenytoin was switched to phenytoin.
2. Liable Blood Pressure: Concerning for autonomic instability
with rapidly fluctuating blood pressures. The patient developed
an episode of hypotension to ___ while in hospital in the
setting of stopping his midodrine after his blood pressure was >
180 systolic, asymptomatic at both pressures. His hypotension
quickly resolves with IVF. He was restarted on his home regimen
with medodrine switched to PRN if blood pressure is < 120 on
sitting.
3. Left Foot Pressure Ulcer: The patient presented with one
episopde of low grade fever to 100.5F. A Grade 1 pressure foot
ulcer was found on the lateral aspect of the foot over a bony
prominence. Since his foot x-ray was limited study, an MRI was
performed and excluded osteomyelitis. His pressure ulcer was
evaluated and treated by the wound care team. no antibiotics
were given since the ulcer did not look infected and the fever
did not persist we did not start antibiotics.
4. Glioblastoma: The patient has history of GBM s/p craniotomy
for gross total resection of the right temporal lobe on
___. on this admission his disease is stable and his CT
head was showed no acute change.
5. History of DVT: His apixaban was stopped because of
interaction with phenytoin. Patient should remain on
subcutaneous lovenox life-long.
6. Narcolepsy: We continued his home Modafinil
7. Hypokalemia: Patent suffered from transient hypokalemia
likely from poor nutritional K in addition to diarrhea. this was
corrected with PO KCl
8. Muscle spasms: we cont his home pramipexole and baclofen | 145 | 419 |
13988663-DS-21 | 26,881,073 | Dear Ms. ___, it was a pleasure taking care of you while you
were in the hospital. You were admitted because you were having
difficulty walking. There were no findings on the scan of your
head to explain these symptoms. However, you were found to have
bacteria in your urine and a fever. We were concerned for a
urinary tract infection and started you on antibiotics for this
infection. We are sending you home with a prescription for this
medication so that you can complete the treatment. You worked
with physical therapy and they determined that it will be best
for you to be discharged to a rehabilitation facility to make
you stronger. | ___ yo F with advanced Alzheimer's dementia, CAD, HTN, HLD,
recurrent UTI's in setting of bladder cystocele, presents after
a fall.
.
# UTI, bacterial: Ms. ___ was admitted to the hospital for
gait instability and urinary incontinence. According to her PCP
she is incontinent at baseline given a grade 3 pelvic prolapse
and cystocele, though is typically ambulatory independently. On
arrival to the ED her UA was positive, though patient has
asymptomatic bacteruria at baseline. However, given that she
presented with a fever, the decision was made to treat her UTI
emperically with ceftriaxone. Her culture came back positive for
pansensitive E.coli and she was narrowed to Bactrim DS, with
plans for discharge with Bactrim to complete 7 day course of
treatment through ___ given complicated UTI given
cystocele.
.
# ? Pneumonia: Patient presented with fever and a probable RLL
consolidation. Given that she did not have an elevated white
count, was not presenting with symptoms of shortness of breath,
and did not have a cough the likelihood that the cause of her
fever was pneumonia was very low. She was initially started on
Azithromycin (and Ceftriaxone as noted above) for empiric
treatment, though ultimately treatment for pneumonia was
discontinued as the suspicion for this was very low for the
reasons noted.
.
# Imbalance: Per PCP the patient is able to walk independently
at baseline, +/- occasional handholding. Her imbalance is likely
secondary to severe underlying dementia exacerbated by acute
infection. She does have a history of imbalance with her
recurrent UTIs according to her son's report. She worked with
physical therapy during the hospital admission, who evaluated
her and determined that she will require participation in a
rehabilitation program.
# GUARDIANSHIP - pt has ___, ___ | 113 | 283 |
12726148-DS-22 | 27,910,673 | You were seen in the hospital for bloody output from your ostomy
and abdominal pain. You were found to have an infection from
clostridium difficile and were treated with antibiotics for this
with good repsonse. You did require a short stay in the
intensive care unit as you were given appropriate intravenous
fluids. You were brought back to the floor feeling well and your
diet was advanced back to regular diet.
You should continue taking all of your home medications.
Be sure to complete your antibiotic course for treating your
infection.
For your heart failure please weigh yourself every morning, call
MD if weight goes up more than 3 lbs. | On admission patient was brought to the general floor, made NPO
and started on IVF. She initially denied a Foley for urine
output monitoring. On HD 1 she was given gentle resuscitation
due to her heart failure. She did endorse liquid ostomy output
prior to bloody output starting. A C. Diff was sent and came
back positive. On HD 2 she was noted to become hypotensive on
the floor to SBP of ___. Her WBC count also rose and her urine
output was not adequate after Foley placement. She was therefore
transferred to the unit for appropriate resuscitation. | 107 | 98 |
14615695-DS-6 | 27,459,710 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had R leg pain, urinary
retention, and night sweats.
What happened while I was in the hospital?
- You had an MRI and blood tests which suggest that you do not
have a new ___ infection.
- You also had a renal ultrasound which was normal. Your urinary
retention is likely related to your pain medications and
constipation. We started you on Flomax and stool softeners to
help with this.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | SUMMARY:
=========
Patient is a ___ with past medical history of alcohol use
disorder, erosive gastritis, fatty liver/alcoholic hepatitis,
OSA, epidural abscess with MSSA bacteremia, and LLE
radiculopathy s/p spinal decompression surgery with placement of
hardware at L5 (___) who presents as a transfer from OSH with
fevers/chills, urinary retention, and new RLE radiculopathy.
ACUTE ISSUES:
=============
# Bilateral ___ radiculopathy
# Spondylolithesis s/p
# Hx of epidural abscess with MSSA bacteremia
Patient presenting with basline LLE radiculopathy and new pain
in his right foot, most notable over his last 3 toes, consistent
with L5-S1 dermatome c/w area of recent spinal surgery. Also
with subjective fevers/chills and urinary retention, raising
concern for cord compression +/- progression of epidural
abscess. He was admitted for further monitoring and infectious
workup. Workup was notable for repeat MRI which was negative for
new osteomyelitis, discitis, or epidural abscess. Additionally,
his CRP on admission was within normal limits and ESR was 48
(down-trending from prior). He had no leukocytosis or fevers
during admission. Blood cultures NGTD. Given no evidence for new
or active infection, his outpatient Ciprofloxacin Q12H was
continued. We spoke with his outpatient ID team, Dr. ___
___, who agrees with plan and will follow up as
outpatient. It is more likely that his radiculopathy symptoms
are related to narrowing of the L5-S1 neural foramen, as evident
on MRI. He also has 7mm bone fragment in that area on past CT
___ which may be contributing. He is scheduled to follow up
with his neurosurgeon, Dr. ___, with plan for further spinal
decompression surgery as an outpatient for his ongoing symptoms.
Otherwise, will continue his home gabapentin and tizanidine PRN.
He is set up with physical therapy and ___ services at home.
# Subjective fevers, chills, night sweats
Unclear etiology. Afebrile during admission. No leukocytosis,
CRP 4.3, ESR down-trending. Negative MRI C, T, L ___ as above,
without evidence of recurrent epidural abscess. CT abd/pelvis
also negative. UA bland, urine cultures negative. Blood cultures
NGTD.
# Urinary retention
No evidence of cord compression on MRI. Appears to be chronic
issue, likely related to opioid use and constipation. Renal U/S
without hydronephrosis, and no post void residual. UA bland,
urine cultures negative. Started on tamsulosin, and treated with
bowel regimen. Also able to wean opiates. Pain currently well
controlled with gabapentin, Tylenol, Ibuprofen, and tizanidine
PRN.
# Hx Alcohol use disorder
Last drink ___. Denies any recent alcohol use. No signs of
alcohol withdrawal during admission.
# Normocytic anemia
Likely ___ chronic disease, recent surgeries, phlebotomy. Would
consider iron studies as an outpatient for further workup.
# Hyperphosphatemia
Phosphate 6.2 on admission, no evidence of acute kidney
injury/renal failure. Likely related to diet. Please recheck in
1 week as an outpatient.
TRANSITIONAL ISSUES:
=====================
[] Likely that his radiculopathy symptoms are related to
narrowing of the L5-S1 neural foramen, as evident on MRI. He
also has 7mm bone fragment in that area on past CT ___ which
may be contributing. He is scheduled to follow up with his
neurosurgeon, Dr. ___, with plan for further spinal
decompression surgery as an outpatient given his ongoing
symptoms.
[] Given no evidence for new or active infection, his outpatient
PO Ciprofloxacin BID was continued. More likely that
radiculopathy symptoms are related to spondylolithesis as above.
We spoke with his outpatient ID team, Dr. ___, who
agrees with plan and will follow up as outpatient.
[] Continue to monitor for symptoms of urinary retention.
Started on tamsulosin this admission and bowel regimen (miralax,
senna). Will continue at discharge. However, now that he has
been weaned off opiate medications, may be able to trial
discontinuing tamsulosin as an outpatient.
[] Found to have normocytic anemia on admission. Likely ___
chronic disease, recent surgeries, phlebotomy. Would consider
iron studies as an outpatient for further workup.
[] Phosphate 6.2 on admission, no evidence of acute kidney
injury/renal failure. Possibly related to diet. Please recheck
chemistry panel in 1 week as an outpatient.
[] Continue physical therapy services at home.
[] Pain regimen: Discharged on gabapentin, tylenol, ibuprofen,
and tizanidine PRN.
#CODE: Full (presumed)
#CONTACT: ___ Phone: ___
>30 minutes spent coordinating discharge home | 148 | 677 |
19788237-DS-6 | 25,989,336 | You were admitted to the hospital due to abdominal pain. Based
on the imaging, we are concerned about a possible disruption of
the pancreatic duct, resulting in an ongoing peripancreatic
collection. You were seen by the gastroenterology and surgical
teams, who will follow-up with you closely as an outpatient. You
may need an advanced endoscopic procedure to address this issue
and also will likely need your gallbladder removed. We have
prescribed you a brief course of oxycodone for pain and Ativan
for sleep. Please follow the important safety precautions we
discussed while taking these medications, including no driving,
working, or other potentially dangerous activities while taking
them. | #Necrotizing gallstone pancreatitis
#Suspected pancreatic duct disruption
#Peripancreatic collection
___ is a ___ year old man who recently developed severe
necrotizing pancreatitis and has been awaiting outpatient
cholecystectomy, who presented within two weeks of discharge due
to worsening epigastric pain. The initial concern was for
recurrent acute pancreatitis. however his LFTs were normal and
after reviewing MRCP images and his clinical course, the
pancreatology team felt that duct disruption and ongoing related
peripancreatic collection might better explain his symptoms.
Neither the surgery nor the pancreatology team recommended any
further inpatient procedures. He was able to tolerate a diet
prior to discharge. He will follow-up closely with both teams
for likely advanced endoscopic intervention and ultimately
cholecystectomy. He was discharged with one week of PRN
oxycodone and low dose ativan for anxiety and sleep. He was
counseled on safe use of these medications.
# Neuropathy
- continue home pregabalin
============================ | 107 | 146 |
19014146-DS-20 | 24,721,434 | Discharge Instructions
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers. You can also contact the ___ Emergency
Services Team (BEST) at ___.
*It was a pleasure to have worked with you, and we wish you the
best of health.* | PSYCHIATRIC
#) Schizophrenia:
Mr. ___ initially presented with suicidal ideation for
several days in the setting of feeling out of touch with
reality. He described a plan to buy a gun off the ___ and
shoot himself and expressed a desire to be admitted and started
on medications. He was started on Olanzapine for control of his
symptoms and initially refused injectable medications (offered
Risperidone consta). Possible ide effects were discussed with
him, including dizziness, stomach pain, dry mouth, constipation,
weight gain, and drowsiness. A few days into his
hospitalization, a few odd behaviors were noted--he carried
around a clove of garlic, lined coins in front of his bathroom,
and put coins inside of his bellybutton. During the first family
meeting, his parents brought pictures of his apartment showing
rice and salt distributed in front of windows and doorways,
holes drilled in the walls and filled with incense, boarded up
windows, a frying pan on top of a wooden board which was on top
of the toilet, trash in the sink, and a makeshift bed in the
bathtub. His ___ worker noted that his apartment looked normal
and clean just a week prior to admission. He became angry during
that meeting and needed to be asked to leave the room twice,
which he did voluntarily both times. Later, he described getting
paranoid during that meeting. That week he began being more open
about his paranoid delusions.
On the recommendation of his team, he eventually agreed to
switch from olanzapine po to Risperidone consta, and so the
decision was made to also switch him to Risperidone po (m-tabs
were selected given his history of cheeking medications during
prior hospitalizations). Potential side effects were discussed,
including EPS and dystonia. Mr. ___ is very driven to keep
his own apartment, and we explained that injectable medications
have been shown to decrease the chances of hospitalizations and
therefore were in line with that goal. He received his first
dose of Risperidone consta 25mg IM on ___. He continued to
attend group meetings and expressed a desire to get better. On
the weekend of ___, he endorsed paranoid delusions but
recognized that he was feeling paranoid, talked to his nurse,
and asked for a standing dose of po Risperidone qAM in addition
to his standing pm dose. He also asked to start psychotherapy on
___ during which he talked more about the sexual, physical,
and emotional abuse that he had suffered--he said he found
talking very helpful. He received his second injection of
Risperidone Consta 37.5mg IM on ___.
On the evenings of ___ and ___, Mr. ___ had two more
episodes of anxiety, psychomotor agitation, and paranoid
thinking. He appeared to be responding to internal stimuli.
During both of those episodes he approached staff members and
asked for medications. Though he admitted to feeling suspicious
of the staff and thinking that people might actually be evil
spirits, he demonstrated good insight into needing additional
help. During the second episode on ___, he asked for
injectable medications because he felt that his PO Risperidone
and Ativan were not helping enought, so he received 5mg Haldol,
2mg Cogentin, and 1 mg Ativan IM. The following morning, he
reported that he felt so much better after receiving the Haldol
that he requested to be switched from Risperidone to Haldol as
his primary antipsychotic medication. He stated, "For the first
time, I woke up and did not feel afraid to get out of bed." His
PO and PRN Risperidone were transitioned to Haldol PO BID, which
was uptitrated over several days. He had a few more episodes of
anxiety and paranoia on ___ and ___, which he was able
to recognize and request medications for again. He received 5mg
Haldol, 2mg Cogentin, and 1 mg Ativan IM during those episodes
and reported feeling much better afterwards. On ___, he
received Haldol decanoate 75mg IM. Potential side effects were
discussed, including EPS and dystonia.
#) Anxiety: The patient reported episodes of anxiety,
particularly when he became increasingly paranoid and psychotic.
We started Ativan 1mg BID PRN and hydroxyzine 50mg PO tid prn
anxiety and discussed ___ side effects, including
sleepines. He responded well to ativan, and at one point asked
for it to be changed to a scheduled medication, but we discussed
the risk for increasing tolerance and rebound anxiety upon
discontinuation, so we kept this as a prn med.
On discharge, mood was "good," MSE was pertinent for bright
affect, no report or evidence of paranoia or delusions, no AVH.
Safety: The patient remained in good behavioral control
throughout this hospitalization and did not require physical
restraint. He at times requested IM Haldol/benztropine/ativan
for chemical restraint when he felt triggered.
GENERAL MEDICAL CONDITIONS
#)Viral URI: On ___, the pt reported symptoms of chills,
some difficulty breathing, nasal congestion, right ear pain,
nausea with dry heaving, nasal congestion, sore throat,
feverishness, and a headache in the context of 2 elevated
temperatures of 103 and 100.4, an elevated WBC with neutrophilic
predominance, and microhematuria and few bacteria on U/A (repeat
UA was unremarkable). CXR was negative. Flu panel negative. CK &
ALT were found to be elevated, but downtrended to WNL.
Blood/urine cultures and rapid strep were negative. The pt
improved with symptomatic management. Antibiotics were not
indicated or necessary.
#) Tachycardia: Heart rate ranged from ___ for several
days. Pt remained asymptomatic throughout this time. DDx
included anxiety, viral syndrome, poor po intake, medication
side effect. We encouraged po fluids, treated his anxiety as
above, and treated his viral URI symptomatically.
PSYCHOSOCIAL
#) MILIEU/GROUPS
The patient was participatory in the milieu, but at times only
superficially so. At times, staff reported that he was self
dialoging and appeared suspicious of others. The patient was
visible on the unit and had conversations with select peers. He
attended some groups. He never engaged in any unsafe behaviors.
The pt ate all meals in the milieu, slept well, and cooperated
with unit rules.
#) FAMILY CONTACTS
Family meeting was held with the patient's parents and they also
testified during his court hearing. They were very concerned
about the pt's recent paranoid behaviors and the destruction
that he had caused in his apartment. They report that he
frequently calls them in distress and shouts/swears/growls at
them like an animal. The pt's parents are very triggering for
him, and he had to leave the room twice during our initial
family meeting with them. He also became upset with them and
swore at his mother during his court hearing. They understand
and are in agreement with the current treatment and discharge
plan.
#) COLLATERAL
We requested records from some of Mr. ___ prior
hospitalizations, including ___ and
___. See records for details.
#) OTHER INTERVENTIONS
The pt. had already been receiving ___ services and was in
weekly contact with a ___ worker, ___, before
admission. He did not have an outpatient psychiatrist or
therapist and last saw outpatient providers at ___
___ ___) four prior to
admission.
LEGAL STATUS
The pt intially signed in on a CV, but then signed a 3-day
notice. We filed a Section ___, which was accepted on
___.
RISK ASSESSMENT:
This patient is currently sober, is no longer suicidal or
homicidal, is feeling well and is euthymic, and is participatory
in the milieu, all of which indicate a low immediate risk of
harm. He is accepting of treatment, motivated to remain sober by
attending AA meetings and motivated to remain out of the
hospital by accepting injectable antipsychotics. Also, he is
future oriented with plans to transition back to his apartment
and go back to school.
Despite his history of HI and assaultive behaviors (towards
staff members during prior hospitalizations, thus requiring
chemical and physical restraints) and recent episodes of
agitation, his current risk of harm to others is low given that
he was able to ask for additional antipsychotics when he felt
triggered and when he felt that he may get out of control. While
he did have verbal altercations with another patient while on
the unit, he was able to ask staff members for help and remain
under good behavioral control, which is a marked improvement
compared to his prior hospitalizations. | 109 | 1,350 |
17754635-DS-21 | 26,609,117 | Dear Ms. ___,
You were admitted to the neurology service at ___ for
confusion and difficulty speaking. We monitored your brain
activity, and it was normal.. A chest X-ray and EKG was normal.
An X-ray of your hip joint and knee joint showed no signs of
infection or fracture. The following day, you returned to your
baseline and felt comfortable going home.
Your blood culture grew bacteria, most likely due to
contamination. However, if you get a fever (>100.4), please
return to the ED.
Please follow up with a PCP ___ ___ weeks. If you need a new
PCP, feel free to call ___ to make an appointment with
a PCP at ___.
Thank you for the opportunity to participate in your care.
Your ___ Neurology Service Team | Ms. ___ presented to the ED at ___ for chest pain and R hip
and knee joint pain. Neurology was consulted and she was
admitted to the neurology service for altered mental status and
aphasia. Work up included toxic-metabolic panel, EKG, CXR, CTH
without contrast, 24-hour EEG, and R knee and hip X-ray. All
results came back within normal limits. A thorough social
history was taken, including screening for history of sexual
abuse and domestic violence, but all were unremarkable. Ms.
___ returned to her baseline mental status without
intervention but waxes and wanes, most likely due to an
underlying behavioral problem. .
# chest pain
- EKG and troponin levels were WNL
- CXR WNL
- bHCG negative
# AMS and dysarthria
- EEG and CTH WNL
- no signs of acute process
# R hip and knee pain
- x-ray of hip and knee WNL
transitional issues
Ms. ___ presentation most likely has a functional component
to it. We recommend that she follows up with a PCP ___ ___
weeks of discharge.
[ ] follow up on likely contaminated blood culture data (GPC in
pairs/clusters in ___ bottles) | 128 | 186 |
11715648-DS-22 | 20,051,527 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
When you come to the hospital?
- You came to the hospital because of worsening abdominal pain
What happened during your hospitalization?
- You were admitted with a recurrence of your abdominal pain.
This may have been caused by inflammation of your pancreas. You
were also found to have a lot of fluid in your body. You
required a water pill to decrease this fluid. You will need to
continue to take a water pill every day to prevent the fluid
from returning.
- You were also seen by the diabetes nurse ___
- ___ insulin regimen was changed so that you were started on a
new medication called glipizide 5 mg twice daily in addition to
degludec 10 units daily
Which should be doing leave the hospital?
- Please have your labs drawn on ___ with the lab slip that
was provided as part of your discharge paperwork. This will be
followed up by your primary care physician who will receive the
results
- Continue to take all of your medications as prescribed
- Start your losartan at a lower dose 12.5mg daily starting
___
- Please keep your appointments as listed below
- Closely monitor your blood sugars with assistance from her
daughter and from the visiting nurse, which can be measured
twice daily first thing in the morning and before bedtime
- Weigh yourself daily, call your PCP if your weight increases
by more than 1 pound in 1 day or 3 pounds within 7 days
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ female history of CKD stage III,
type 2 diabetes, hypertension, recent admission for pancreatitis
who presented with recurrent abdominal pain, nausea, vomiting,
and diarrhea. She was found to have likely recurrent
pancreatitis and gut wall edema on imaging. It was not entirely
clear the etiology for this, her edema was possibly secondary to
volume overload from nephrotic syndrome causing inflammation of
the pancreas versus possibly drug-induced pancreatitis from her
losartan. Her losartan was initially discontinued due to concern
this could be causing pancreatitis, ultimate decision made to
start after discharge. She underwent intermittent IV diuresis
with improvement of her symptoms, however hospital course was
complicated by ___. She was ultimately transitioned to p.o.
torsemide 40 mg daily. There was also concerns regarding her
ability to self administer insulin, however through extensive
diabetes nurse education, she was ultimately transitioned to
long-acting 10 units daily in addition to glipizide 5 mg twice
daily in order to limit use of sliding scale.
ACUTE ISSUES
===============
# Abdominal pain/Nausea/Vomiting
# Possible acute pancreatitis
# Colitis - Patient was admitted with persistent abdominal pain,
nausea and vomiting. This followed a recent admission for the
same found to have possible pancreatitis. She underwent a CT
scan with contrast at ___, the read of which
showed persistent edema around her pancreas as well as some
inflammation consistent with either colitis or gastroenteritis.
She was initially placed on a clear liquid diet with IV fluids,
however she improved with supportive care and was transitioned
to an oral diet.
She was seen by the pancreas team who thought that her symptoms
were possibly related more to pancreatic edema as opposed to
frank pancreatitis, particularly given that she never had an
elevated lipase. They did recommend Reglan for motility given
her long-standing diabetes and possibly her nausea was related
to gastroparesis from diabetes. She was also treated for
constipation and with diuresis (as below) with improvement in
her symptoms. She will follow up with the pancreas service for
further evaluation including possible MRCP once her renal
function returns to baseline given her family history of
pancreatic cancer. She will need to call in order to have this
appointment scheduled.
# Possible colitis and gastroenteritis - On admission she had a
history of vomiting as well as diarrhea. This stopped for
several days but then restarted on hospital day 3. C. difficile
was negative and stool cultures were negative as well.
# CKD III
# Diabetic nephrosclerosis with nephrotic syndrome and anasarca:
# ___
# Likely CIN - She was admitted with significant edema and her
renal function worsened throughout her hospitalization. She was
seen by the nephrologist who thought that her worsening renal
function was related to contrast-induced nephropathy from the CT
scan for her abdominal pain. She was eventually started on a
diuretic including Lasix 40 mg IV twice daily, increased to 60mg
BID which appeared to be keeping her even and further efforts
limited by hyperkalemia. She was transitioned to Torsemide 60mg
with resultant ___ so she was transitioned to torsemide 40mg
daily at discharge. EDW 177 pounds on day of discharge. She was
re-started on home dose of losartan 50mg daily however
experienced hypotension and some worsening renal function on
this, therefore was discontinued. In consultation with renal,
plan will be for her to be discharged on losartan 12.5mg daily
and to closely monitor electrolytes and renal function after
discharge to be followed up by PCP and for her losartan to be
titrated as indicated by her nephrologist. Losartan will be
indicated for her given her diabetic nephropathy with nephrotic
syndrome. Discharge Cr 2.0.
# DMII poorly controlled with retinopathy - Exchanged Tresiba
for Lantus while hospitalized plus hISS. During hospitalization,
she was evaluated by ___, there was also concern regarding
patient's ability to administer insulin and check fingersticks.
On further evaluation by diabetic nurse educator, daughter
demonstrated capability of being able to administer insulin and
check fingersticks. In order to help simplify her regimen, plan
will for her to continue on home Tresiba 10 units daily with
fingerstick checks in the morning and QHS and she was started on
glipizide 5 mg twice daily. She was also provided glucometer and
supplies. Of note given her renal dysfunction and history of
pancreatitis she is a poor candidate for metformin or likely
other alternative oral agents such as GLP-1 agonist.
# Unstable housing - She was recently evicted from her home but
is in stable transitional housing although it is in ___ which
is very inconvenient for her in terms of reaching her doctors as
___ as for her daughter's schooling. Letter was written to
support her moving to a first floor apartment as well as to
something closer to her doctors and ___ school. She
was also seen by social work. | 251 | 792 |
13806328-DS-17 | 27,487,085 | Dear Mr. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having chest pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We found that you were having a small heart attack and treated
you with medications.
- We looked in the vessels of the heart (coronary angiography)
and found a blockage in one of the major arteries. This may or
may not have been causing your symptoms, but is not an easy
vessel to open up. If you continue to have symptoms, we will
plan on having you come back as an outpatient for a special
procedure to try to open this vessel up.
- We started you on some new medications to help protect your
heart.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Carefully review the attached medication list as we may have
made changes to your medications.
- We will contact you to set up an appointment with your
cardiologist
Sincerely,
Your ___ Care Team | =================
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year old man with an intracranial
oligoastrocytoma, CAD with a BMS to the LAD in ___,
seizure disorder, and a history of a DVT who presented to ___
___ with chest pain and was found to have an NSTEMI. He was
treated with a heparin gtt initially and then had a coronary
angiography that demonstrated 100% lesion of the RCA with some
acute features on IVUS. Therefore a POBA was attempted but no
stent was placed given concern this was too high risk. His
medication regimen was optimized and he will follow up with his
cardiologist. If he has persistent symptoms, a complex PCI to
his RCA can be attempted in the future.
===================
TRANSITIONAL ISSUES
===================
[ ] Needs close outpatient cardiologist for monitoring of chest
pain given known RCA lesion. If recurrent pain, may consider
complex PCI.
[ ] Should have close blood pressure monitoring given addition
of multiple agents during this hospitalization.
[ ] Patient endorses myopathy to statin in the past, unknown
which medication. Discharged on rosuvastatin 20mg daily. Patient
should be assessed for evidence of myopathy and compliance.
- New Meds: Plavix 75mg, isosorbide mononitrate 30mg daily,
lisinopril 5mg, rosuvastatin 20mg
- Stopped/Held Meds: None
- Changed Meds: None
- Discharge weight: 82.2kg (181.22lb)
====================
ACUTE MEDICAL ISSUES
====================
# NSTEMI
# CAD s/p BMS LAD ___
Presented with chest pain and found to have NSTEMI with peak
trop-T 0.19. He had a coronary angiography on ___ that
demonstrated a 100% RCA lesion with some acute features based on
IVUS. Therefore a POBA was attempted but the lesion was felt to
be too high risk for stent at that time. We planned to optimize
his medication regimen and if he has persistent symptoms a
complex PCI can be planned.
Of note, we did speak with his neuro-oncolgoist Dr. ___
felt that his tumor type has low risk for bleed, and when there
is an indication for DAPT or anticoagulation it is recommended
that these patients proceed with the required therapy, even in
patients who have had radiation therapy [CT ___ can serve as
a baseline prior to DAPT].
A TTE on ___ demonstrated normal LVEF and no regional wall
motion abnormality. He was discharged on rosuvastatin 20mg,
aspirin 81mg, Plavix 75mg, isosorbide mononitrate 30mg, and
lisinopril 5mg daily.
======================
CHRONIC MEDICAL ISSUES
======================
# Oligoastrocytoma
Last therapy ___. Stable on imaging two months ago. Spoke
to outpatient Neuro-oncologist as above.
# Seizure disorder
?familial as his brother has similar. Continued home Keppra | 173 | 399 |
18917324-DS-7 | 29,555,476 | Ms. ___
___ presented to the hospital with confusion and left sided
numbness and were found to have a bleed in your brain that
likely occurred in the setting of high blood pressure. We will
discharge ___ to rehabilitation where they will work with ___ to
regain your strength.
___ need to make sure that your blood pressure is well
controlled at all times and should always be below 160 systolic.
Please follow up with your primary care physician within one to
two weeks of discharge from hospital to follow up on this
hospitalization and to ensure that ___ are on appropriate
medications to adequately manage your blood pressure.
___ were previously taking aspirin 81 mg daily, please hold on
taking this medication until 7 days after your brain bleed which
would mean that ___ should restart this medication on ___.
Thank ___ for allowing us to care for ___,
___ Neurology Team | Patient is a ___ year old right-handed woman with past medical
history of traumatic intraparenchymal ___,
difficult to control hypertension and diabetes mellitus type II
and hyperlipidemia whom presented with chief complaint of
altered mental status and left sided weakness. Patient was
found to have a left pontine intraparenchymal hemorrhage likely
in the setting of elevated blood pressure.
Patient was initially admitted to the neuro intensive care unit
given concern for respiratory decompensation and also requiring
nicardapine drip for elevated blood pressures (up to 220
systolic).
Patient's neurologic examination improved during hospitalization
and at discharge had mild right facial weakness with only mild
weakness at the right iliopsoas muscle (___). Patient also with
complaints of reduced sensation throughout the left side of her
body.
Patient's blood pressure management is her key issue and goal
should be less than 160 systolic. Patient was discharged on
amlodipine 10 mg daily, metoprolol tartrate 200 mg daily, and
lisinopril 20 mg daily. If blood pressure remains elevated would
increase lisinopril (was previously taking 40 mg daily) or
restart her on hydrochlorothiazide (was previously taking 25 mg
daily).
Patient should hold aspirin until one week after bleeding event
so should resume it on ___.
Patient has scheduled follow up with stroke and we recommended
that she follow up with her primary care physician one to two
weeks after hospitalization.
Patient was discharged from hospital to acute rehabilitation for
maximization of recovery. | 154 | 251 |
19308449-DS-18 | 29,940,190 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___nd found to have a fracture in your skull near
your left ear (temporal bone). You were seen by the head and
neck specialist who recommend non-operative management of your
fracture. You were also found to have a concussion/bleeding in
your brain on CT scan. You were seen by the neurosurgery team
for this injury who recommended a medication to prevent seizures
and follow up in the concussion clinic as needed.
============================================
Temporal Bone Fracture Instructions:
Please continue to follow "CSF leak precautions" including:
elevated head of bed at all time, avoid straining to have bowel
movements, sneeze with your mouth open, and avoid nose blowing.
You may need to take stool softener and/or laxatives to avoid
straining. Continue to place antibiotic ear drops in your left
ear as prescribed. Keep your left ear dry until follow up. You
can do this by placing a cotton ball in the ear, then smear
Vaseline over the ear and cotton ball when showering. Remove
cotton ball and do not place anything in the ear at all other
times. Having blood in your ear can cause loss of hearing and/or
difficulty hearing; this ususually resolves on its own over ___
weeks. You will have your hearing tested in outpatient follow
up.
=============================================
Traumatic Brain Injury Instructions/Concussion Instructions:
Do's and dont's:
-Ask a friend or family member to stay with you for a few days.
You should not be alone until you know how the injury has
affected you.
-Tell your caregiver to wake you every 2 to 3 hours during the
first night. Your caregiver should call ___ if he or she cant
wake you, or if you are confused.
-___ take any medicinenot even aspirinunless your healthcare
provider says it's OK. If you have a headache, try placing a
cold, damp cloth on your forehead. You may take
Tylenol/Acetaminophen for headache.
-Don't drink alcohol or use any recreational drugs.
-Don't return to sports or any activity that could cause you to
hit your head until all symptoms are gone and you have been
cleared by your doctor. A second head injury before full
recovery from the first one can lead to serious brain injury.
-Avoid activities that require a lot of concentration or
attention. This will allow your brain to rest and heal more
quickly.
What are the symptoms of postconcussion syndrome?
The symptoms include:
-Headache
-Dizziness
-Feeling very tired
-Feeling irritable or anxious
-;Memory problems or problems paying attention
-Problems with sleep
-Being easily bothered by noise
Some of these symptoms can be stressful or scary. It might help
to keep in mind that they are real problems caused by your
concussion, and they will get better with time.
If you have postconcussion syndrome, your symptoms will probably
start to go away after about a week. Most people start to feel
better in a week or 2, and are back to normal in 3 months. But a
few people have symptoms that last longer. In these cases, your
doctor might suggest medicines or other treatments. You can
follow up in the concussion clinic if you have ongoing symptoms.
==========================================================
General 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.
*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. | Mr. ___ is a ___ yo M transferred from outside hospital after
being found down. Outside hospital CT scan concerning for left
temporal bone fracture. Trauma surgery and otolaryngology were
consulted for further management. The patient was examined and
Otoscopy demonstrated bloody otorrhea AS, TM unable to be
visualized, face
grossly symmetric, unable to test tuning forks. Imaging
demonstrates likely longitudinal temporal bone fracture on the
left and second fracture through squamous portion of temporal
bone with sparing of the otic capsule, facial canal, and
ossicles. The patient was admitted to the trauma surgery service
for further mental status work up, repeat head CT with fine
cuts, and tertiary survey.
On HD2 the patient was awake, alert, and oriented to person,
place, but had no recollection of event or events surrounding
trauma. Tertiary survery done and showed no new acute injuries.
Repeat CT of temporal bone consistent with outside hospital
findings. A small right hemorrhagic contusion was noted and
neurosurgery was consulted. They recommended keppra for 7 days
and outpatient follow up in the traumatic brain injury clinic as
needed.
The patient was seen and evaluated by the physical and
occupational therapy who cleared patient for discharge to home.
The patient was seen and evaluated by social work for lack of
resources as he is homeless with minimal family support. He was
given a list of shelters and transportation for discharge was
arranged.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient had medications
filled on site at ___ and an appointment to
establish primary care arranged. | 703 | 294 |
15544188-DS-5 | 24,686,924 | Dear Dr. ___,
___ were admitted and treated for a urinary tract infection as
well right hip pain and low sodium levels. ___ were given IV
antibiotics then switched to oral antibiotics to treat your
infection. Your sodium level has remained stable. ___ will be
discharged back to the rehab facility for further therapy.
___ should follow up with your primary care doctor and
neurologist to discuss your labile pressures and your neurologic
symptoms. | ___ male with recurrent falls, possible early
parkinsonism, cognitive impairment, PAF, hypertension,
hypothyroidism, depression, recently diagnosed urinary retention
status post Foley, recent right hip fracture, admitted on ___
with altered mental status | 73 | 28 |
18943661-DS-11 | 26,911,598 | Dear Ms. ___,
You were admitted to the hospital for vaginal bleeding, which
was being caused by your ___. During this hospital stay, you
started chemotherapy and radiation for the ___. Before
starting these, you had a surgery to move your ___ so it would
not be damaged by the radiation.
You also had a short transfer to the intensive care unit because
you could not breath well on your own. This might was likely
caused by a pneumonia, and we treated you with antibiotics. You
were put on a machine to help you breath for a short period of
time, but you improved and were transferred back to the oncology
floor.
Please take all of your medications as prescribed and follow up
with your appointments as below. You will continue your
radiation treatment at ___. You have an appointment there
tomorrow at 1:30 ___. If you experience any of the danger signs
listed below, please call your primary oncologist or come to the
emergency department immediately.
Best Wishes,
Your ___ Oncology Team | Ms. ___ is a ___ year old woman with recent diagnosis of
metastatic rectal ___ c/b recto-vaginal fistula initially
admitted with vaginal bleeding, now s/p diverting colostomy ___
and initiation of radiation ___ (interrupted by complications
below) + ___ ___. Hospital course was
complicated by acute hypoxic respiratory failure requiring ICU
transfer and intubation, as well as hypotension prompting
initiation of midodrine, likely secondary to aspiration
pneumonitis v. hospital acquired pneumonia. She completed a
course of zosyn for hospital acquired pneumonia. After stopping
zosyn she developed a new fever of unclear source. Infectious
disease was consulted. CXR, UA/UCx, and TTE revealed no clear
infectious source. Antibiotics were stopped on ___ and patient
had no subsequent fevers.
# Metastatic Rectal ___ complicated by recto-vaginal fistula:
Patient was admitted with vaginal bleeding. She was kept on her
home aspirin during admission significant cardiac history,
although her Plavix was held. Patient had CT abdomen/pelvis this
admission, which showed lesions most likely consistent with
sacral mets and gluteal met. Per radiology, these were present
on prior imaging at ___ earlier ___ ___. Both sacral and
gluteal lesions are slightly larger on ___ scans than on those
___ early ___. She underwent port placement on ___ and
diverting colostomy on ___. She then began concurrent radiation
___ and chemotherapy ___ ___, with radiation
interrupted by ICU transfer as below. Repeat CT A/P on ___
showed new soft tissue mass along the left serratus anterior
muscle/lateral chest wall concerning for metastatic disease. Per
radiation oncology, the serratus anterior muscle will not be
treated now given it is assymptomatic currently.
#Anemia: Following intiation of chemotherapy, patient developed
downtrending hemoglobin requiring transfusion. This was most
likely secondary to myelosuppression ___ the setting of
chemotherapy, given all cell lines were downtrending.
Haptoglobin and indirect bilirubin were not concerning for
hemolysis. She had no blood ___ ostomy output and no other
evidence of active bleeding and denied hemoptysis, hematemesis,
hematuria, hematochezia, and vaginal bleeding. Hemoglobin at
discharge was stable at 8.0.
# ___ associated pain: Patient had significant pain primarily
over left gluteal region ___ the area of the likely gluteal met
seen on CT. On ___, she had brief pain over her left chest that
self-resolved, EKG was without evidence of ACS. This may have
been secondary to likely serratus anterior met seen on CT, but
this pain did not occur again during admission. She was
maintained on MS ___ 30mg po q12 hours and oxycodone ___
po q4 hours with good pain control. | 170 | 416 |
18515750-DS-18 | 20,446,695 | It was a pleasure taking care of you at ___.
You were admitted with a rapid heart rhythm called aflutter and
low blood pressure. You also had trouble breathing and needed
bipap to help your oxygen level. You converted to a regular
rhythm and your blood pressure improved. Because of the fluid
that you received when your blood pressure was low, you needed
to have intravenous lasix to remove the fluid and will now
continue on your home dose. Because of the atrial flutter, and
the risk of stroke that this entails, you were started on
Warfarin. Warfarin dosing requires close follow up and
monitoring. The medical team at the rehab facility will monitor
your Warfarin while you are there. When you go home, Dr.
___ monitor your Warfarin dosing.
You are also being discharged on an antibiotic for 3 days to
treat a urinary tract infection. Your urinary urgency may
improve after treatment.
After your initial low blood pressure, your blood pressure was
elevated, and you were started on Imdur and Hydralazine. Your
Trandolopril was stopped because of your kdiney function.
Weigh yourself every morning, call Dr. ___ weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at
discharge is 63.7 kgs
Your kidney function is slightly worse since you have been
hospitalized and this is likely due to your low blood pressure
and the diuretics. We will make an appt for you to see a kidney
doctor in the near future.
Your resuscitation status was discussed and reviewed with you on
the day of discharge. You would like to remain a full code at
this time. | This is a ___ year old woman with CAD, ICM, HTN and old LBBB who
presented to an OSH with dyspnea and tongue fullness, found to
have a wide-complex tachycarida, most consistent with a. fluter
vs. a. tachycardia, and developed hypotension after receiving
metoprolol for rate control. Upon arrival to ___, her clincial
exam was consistent with fluid overload. Diuresis was attempted
with 40 mg IV Lasix in the ___, without significant UOP. She
became increasingly tachypneic, requiring BiPAP. She was
transferred to the CCU for further diuresis and respiratory
management.
# Acute on chronic systolic heart failure:
TTE was repeated and revealed LVEF 30% (akinesis of
inferior/posterior wall of LV), 2+MR and ASD. BNP peak was
18759. She received Lasix 120mg IV for diuresis. She underwent
diuresis to dry weight of 63.7kg. She was transferred to the
general Cardiology floor on ___.
# CAD:
Pt had intermittent episodes of nausea. There were no
significant EKG changes. TnT max was 1.52.
# ___ on CKD.
Creat peak 3.3. 2.6 on discharge. Pt's ACE was held.
# AFlutter/AV block:
Pt revered to SR with AVCD. Good rate control. She was
transitioned to warfarin with INR 2.2 on discharge.
# UTI:
Pt found to have e. coli uti and was discharged on abx (please
see medication list) | 277 | 218 |
15775440-DS-21 | 24,364,891 | Dear Ms. ___,
You were hospitalized at ___ due to inflammation of your arm.
You were initially treated with IV antibiotics. However, after
reviewing your skin biopsy, it seems that the inflammation of
your arm is not due to a bacterial infection, but rather may be
inflammation caused by your immune system. You were seen by
dermatology who recommended a topical steroid cream to use as
needed for itching.
We checked some blood tests to figure out why your biopsy and
blood has a high percentage of a certain type of white blood
cell called eosinophils. Many of these tests were pending by the
time you were discharged.
You should follow up with your dermatologist and your primary
care doctor after discharge.
We wish you all the best!
Sincerely,
Your ___ Team | ___ female with history of asthma, headache, active C.
difficile infection, presenting for recurrent skin welts
initially believed to be cellulitis; however, skin biopsies from
___ consistent with eosinophilic hypersensitivity reaction. She
had initially been started on IV vancomycin, which was promptly
discontinued morning after admission, and she remained afebrile
and without leukocytosis or worsening of skin findings. She was
evaluated by dermatology who thought her presentation is more
consistent with eosinophilic cellulitis, less likely a
rheumatologic condition such as eosinophilic granulomatosis with
polyangiitis, given that she did not meet all clinical criteria.
ANCA was ordered and pending at time of discharge. As part of
her eosinophilia workup, she had IgE, Aspergillus Ab,
Strongyloides Ab, and Toxocara Ab, which were pending at time of
discharge. She was discharged with a two-week course of
Diprolene PRN for symptoms, and should follow up with
dermatology and her PCP upon discharge.
============= | 128 | 148 |
18707455-DS-2 | 29,776,613 | Dear Ms. ___,
It was a pleasure caring for you during your recent admission.
You came to the hospital with dehydration after your recent
colonoscopy. The dehydration caused your kidneys to be
temporarily injured, and because your kidneys weren't working
properly your body couldn't clear your insulin so you also came
in with very low blood sugars. We gave you IV fluids which
improved your kidney function. We also had the ___ Diabetes
Doctors adjust your ___ medications, and the ___ nurse
educators worked with you to make sure you take them correctly.
We stopped your metformin, lisinopril, and hydrochlorthiazide
and your blood pressure was normal here. Please discuss with
your doctor whether to restart these medications.
**Please check your fingersticks 3 times daily. If finger stick
blood sugars are greater than 400, wait 1 hour and recheck. If
greater than 400 for two readings 1 hour apart, call: ___ which is a bilingual ___ Diabetes Line**
Please take your medications as directed and ___ with your
doctors as ___ below.
Sincerely,
Your ___ Care Team | ___ with IDDM, HTN, anemia and GERD who initially presented with
nausea/vomiting/diarrhea in the setting of 2 recent
colonoscopies and was found to be in acute renal failure with
severe hypoglycemia.
# IDDM: FSBG was in the 30's on admission, likely due to
full-dose insulin administration at home in the setting of
decreased PO intake and poor renal clearance with ___. Patient
reported not regularly checking FSBG and not administering
standard SSI. Out of concern for med non-compliance and poor
education on DM2, the ___ Diabetes service was consulted.
Their nurse educator worked with the patient and her daughter to
ensure safe administration of insulin on discharge. She was
started on 10 mg BID of glipizide and Lantus was uptitrated to
achieve goal FSBG <250 in order to avoid hypoglycemic episodes
at home. Lantus dose at discharge was 42 units. No SSI was given
at discharge in setting of non-compliance with checking FSBG.
Metformin held at discharge. She was discharged home with ___
services, close PCP ___, and ___.
# ___: Her Cr was 10 on admission. Renal was consulted and
thought it was secondary to ATN/prerenal azotemia from
hypovolemia in the setting of 2 recent colonoscopies requiring
bowel prep and worsened by nausea/vomiting likely from uremia
and continued diuretic/ACEi use. She received isotonic bicarb
initially. Muddy brown casts were seen on urinalysis. Creatinine
rapidly improved with IVF, and was 1.2 on discharge.
# Suicidality: Per family, patient has been having suicidal
thoughts with initial concern for intentional ingestion. ___ completed in the ED. However, Psych evaluation noted no
imminent danger to self. She was given information on
establishing psychiatric care as an outpatient. No SI/HI or
feelings of depression on discharge.
# HTN : normotensive throughout admission. Her lisnopril and
HCTZ were initially held in setting of ___, and were
subsequently held because she remained normotensive throughout
stay. ___ need to be restarted by PCP in the future.
# Asthma: Continued on home inhalers
# GERD: Continued on home omeprazole
TRANSITIONAL ISSUES:
==========================
-Patient will check FSBG at least BID and call ___ Latino
line if FSBG >400 on 2 checks.
-SSI d/c'ed as patient not checking FSBG at home, and concern
for iatrogenic hypoglycemia if she adminsters SSI without FSBG
- Discharged on 42 units of ___ Lantus and glipizide 10 mg 30
minutes before breakfast and 10 mg 30 minutes before dinner. She
should test blood glucose before each meal and at bed time.
- Metformin held during admission and at discharge
- HCTZ and lisionopril held during admission in setting of ___.
She remained normotensive during admission, and they were
therefore held on discharge to be restarted by ___ in the future
once renal function has stabilized
- Creatanine to next be checked at ___ ___ appointment
- Has ___ in place with ___
- Psychiatry recommends a referal to ___
program at ___
Psychiatrist: ___
Patient referral line: ___ or ___ | 173 | 480 |
10577647-DS-67 | 23,170,006 | Dear ___,
___ were admitted to the hospital for kidney injury. This was
likely from dehydration. ___ were given IV fluids and with this
your kidney function improved back to normal. it is extremely
important that ___ attend your follow up appointments with your
primary care doctor.
It was a pleasure taking care of ___. We wish ___ the best!
Sincerely,
Your ___ Medicine Team | Ms. ___ is a ___ woman with GERD, HTN, depression,
poorly-controlled T2DM, delayed gastric emptying, anxiety,
chronic abdominal pain, recurrent UTIs, chronic leukocytosis,
and multiple hospitalizations for abdominal pain/UTIs p/w
recurrent abdominal pain, back pain, dysuria, and n/v who
presents with ___ resolved with fluids.
___
# DSYURIA
# LEUKOCYTOSIS
___ likely from dehydration. Her UA only has 7 wbc which is
remarkably less than usual. Her leukocytosis is chronic and
stable. In the past her UTIs have all been resistant to
ceftriaxone, so it was stopped. Got x1 ceftriaxone in the
emergency room. Her final culture was contaminated. Her
lisinoipril was initially held but restarted after her renal
function normalized. She should have her Cr rechecked in 1 week.
# N/V/ABDOMINAL PAIN
# CHRONIC GASTROPARESIS
-- Continue supportive care with home tramadol, zofran
-- Continue home amitriptyline, lyrica
-- Continue PPI, sucralfate
#HTN: Bp's elevated on admission in the 190's
-- Continuing NIFEdipine/propranolol/isosorbide/lisinoipril
-- Monitor for worsening orthostasis after restarting home
anti-hypertensives
#DEPRESSION ANXIETY:
-- Continue sertraline/amitryptiline/lorazepam
#DIABETES MELLITUS: Poorly controlled, last HgbA1C = 10.3 in
___. BG's now very elevated possible iso infection per
above.
-- Continue home lantus of 54U + 10 U humalog coverage with
meals
#ASTHMA:
- continue fluticasone/albuterol | 63 | 188 |
14053278-DS-11 | 24,038,831 | 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:
- TDWB RLE in unlocked ___, ROMAT
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks post-operatively.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
TDWB RLE in unlocked ___ brace, ROMAT
Treatments Frequency:
dressing changes as needed with dry sterile dressing and ACE
wrap OR tape | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R Schatzker IV tibial plateau fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of the fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in an unlocked ___ 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. | 205 | 260 |
11677149-DS-4 | 22,876,626 | Dear Mr. ___,
You were admitted after being found down. You were found to be
in respiratory failure and were transferred to ___ for
further management. The cause of your respiratory symptoms was
likely a combination of pneumonia, COPD exacerbation, and fluid
in your lungs. You were treated for all of these causes and your
respiratory symptoms improved.
You were seen by our social worker who provided you with mental
health resources.
It will be very important for you to follow up with your primary
care physician. It will also be important for you to avoid
ongoing drug use. To be safe, we are discharging you with a
prescription for naloxone. Please fill this at your local
pharmacy. | Mr. ___ is a ___ year old gentleman with a history of COPD,
polysubstance abuse, DMII, hypertension, hyperlipidemia who was
transferred from an OSH for acute hypoxemic respiratory failure.
He was found to have diffuse ground glass opacities on CTA
concerning for multifocal pneumonia vs. aspiration vs.
inhalational injury from intranasal heroin use.
# Hypoxemic respiratory failure
# Community acquired pneumonia
# Volume overload
# COPD exacerbation
# ?Inhalational injury
Transferred from ___ with hypoxemia. Mr. ___ initially
requiring BiPAP in the ED, but was able to be rapidly weaned to
high flow nasal cannula upon arrival to the ___. His OSH CTA
demonstrated diffuse ground glass opacities without septal
thickening, concerning for possible inhalational injury from
intranasal heroin use vs. multifocal pneumonia vs. aspiration.
While in the FICU, he was treated for multiple processes,
including COPD exacerbation (prednisone 40 mg ___,
standing duonebs q6H, albuterol neb q6H PRN), possible
multifocal pneumonia (initially with vanc + pip/tazo +
azithromycin ___, narrowed to CAP coverage with ceftriaxone
+ azithromycin for ___nding ___, as well as volume
overload with lasix with improvement in O2 requirement. At time
of transfer to floor he was stable on ___ NC with SpO2 92-94%.
He continued to require IV diuresis but was ultimately weaned
off oxygen, saturating 96% on room air on day of discharge.
# Syncope: Patient presented with reported syncope. EKG was not
concerning for acute infarct and troponins negative. Telemetry
without e/o arrhythmias. CTA without evidence of PE. TTE without
valvular disease. Patient has been functionally independent in
the FICU. Unclear precipitant, though may have been found down
in the setting of drug use/ ETOH intoxication.
# Rhabdomyolysis: Patient presented with elevated CK after being
found down with peak ___. CK downtrended with IVF to < 5000 at
time of transfer to floor and subsequently to ___. No evidence
of renal failure throughout his hospital stay.
# Normocytic anemia: Baseline reportedly ___. No active
bleeding on exam. Differential includes acute blood loss, iron
deficiency, anemia of chronic disease. Laboratory workup
consistent with iron deficiency. Would advise outpatient
colonoscopy screening, if not already performed.
# Suicidal ideation
# Illicit drug use: Patient endorses passive SI on meeting with
social work. On further discussion he endorsed a long standing
history of depression, though stated that he would never act on
any thoughts of self harm. Patient's roommates use illict
drugs/heroin and patient used heroin himself prior to hospital
admission. He was seen by social work throughout his admission.
He is discharged with naloxone script. Per SW note, referrals
made to:
___
Discover Program at ___
This is a dual diagnosis partial hospitalization program
consisting of full and half day groups M-F for a total of 10
days.
___
referral forms found on ___ website under
Services and outpatient and medication control programs.
WAITLIST is until early ___.
___ Hospitalization Program PHP.
This is more psychiatric based and consists of full day groups
M-F for 10 days total.
Same referral form.
WAITLIST 2+ weeks. Spoke with Director who suggested that Pt
call
to confirm he wishes to remain on the waitlist on ___. The
waitlist may go faster. Patient aware and has phone number to
call.
Telephone call to ___ and received
no calls back. Did not pursue aggressively as it may not be the
best fit as pt no longer has heroin in his system and states he
wishes to use the MMTP for pain rather than recovery.
# Left foot pain
# Right leg pain: Patient has history of chronic pain in the
right leg and per the medical record, non-compliance with
narcotics contracts. He endorsed LEFT foot pain while in the
hospital. No evidence of fracture. No obvious source of pain on
exam. Full ROM of left ankle, no point tenderness throughout.
Patient repeatedly stated that he could "not explain the pain."
He was able to ambulate without difficulty. His pain was treated
with acetaminophen.
# Chronic back pain:
- Continued gabapentin
- Continued diclofenac
- Continued methocarbamol
# DM II: Patient was continued on home lantus, 18U mealtime
Humalog TID as well as SSI. Home metformin was held during stay.
# HTN: Continued home clonidine given concern for rebound
hypertension
# Hyperlipidemia: Continue atorvastatin | 115 | 667 |
15652168-DS-9 | 29,303,605 | You were hospitalized with abdominal pain from your cancer, and
infection of your bladder. A Foley catheter successfully
improved your urination. Your pain medications were changed to
Methadone primarily with improvement in your pain, in addition
to Oxycodone. Your gabapentin was also increased slightly.
You will be going home to continue your Cyclophosphamide as well
as your home medications. You also have a urinary tract
infection and will need to complete a short course of
Amoxacillin.
We spoke with the kidney doctor, and there is no need to see
them in clinic. Please discuss with Dr. ___ you
should follow up with the radiologists regarding your
nephrostomy tube. | This is a ___ y/o woman with a history of IPF on prednisone and
sildenafil, who unfortunately was discovered to have an
abdominal mass adjacent to the duodenum during work up for lung
transplant ___. She had biopsy showing carcinoma, unknown
primary. She has since been under the care of Dr. ___
___, being treated with chemotherapy (see below); in ___ of
this year she was found to have rt. hydronephrosis believed due
to RP LAD and ureteral compression and had a percutaneous
nephrostomy tube placed.
She came to the ED here describing the onset of lower
abdominal/suprapubic pain since ___ of this week (5 days
pta) with mild associated nausea and anorexia. She also
endorsed urinary frequency of small amts of urine. She states
that the pain has progressively become worse, and that it is not
modified by any activity, position, or medication. It does not
radiate from the lower abdomen. The pain is constant, ___,
down to ___ at best with her prn oxycodone, 10 mg. She
continues on 280 mg of oxycontin daily in three divided doses
(100, 80, 100).
In the ED she had a CT of the abdomen and pelvis without acute
changes - has known perc nephrostomy, and known LAD with IVC
obstruction. She was given morphine, ondansetron, and IV
ciprofloxacin and admitted.
On evaluation on the ward, she was felt to have cystitis (due to
cyclophosphamide and or a urinary tract infection) with urinary
retention. A foley catheter was placed for urinary retention
with draining of clear, non - bloody urine, and near instant and
near complete resolution of her abdominal pain. She was started
on IV CTX pending urine culture findings. Her cyclophosphamide
was held, and her hematologist/oncologists were alerted of her
admission and asked to see her on ___.
Pain and palliative care were consulted. She was transitioned
from Oxycontin to Methadone 10mg BID equivalent with Oxycodone.
Her gabapentin was increased slightly, and her Tylenol was
continued. This will be continued at discharge.
Her Foley catheter was successfully discontinued. Her urine
culture grew pan sensitive Enterococci. She was transitioned to
Amoxacillin to complete a ___fter discussions with her oncologists and family, her
Cyclophosphamide was restarted on discharge, and she will pursue
home hospice care. | 111 | 387 |
19230307-DS-4 | 27,140,348 | Dear Ms. ___,
You were hospitalized due to symptoms of difficulty speaking
resulting from an ACUTE HEMORRHAGIC STROKE, a condition where a
blood vessel in the brain bleeds. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain 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:
<>
We are changing your medications as follows:
Increased your lisinopril to 40 mg daily
Added Bactrim for three days for UTI
Other medications unchanged from prior home doses
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is an ___ old right-handed woman with a past
medical history of HTN, hypothyroidism who presented with acute
onset dysarthria, found to have a right thalamic bleed. Etiology
of the bleed is most consistent with hypertensive. Exam is
improving with only mild dysarthria. She was admitted to the ICU
and nicardipine gtt was discontinued shortly after. Repeat NCHCT
was stable so she was transferred to the floor.
Patient's right thalamic hemorrhage was felt to be most likely a
hypertensive bleed. She was briefly in the ICU on admission and
then transferred to the floor for further management. Her blood
pressure medications were titrated to goal normotension, and she
was given PRN medications for any SBP>160. Her home lisinopril
was increased to 40 mg daily. Her stroke risk factor labs were
notable for LDL of 94, HbA1c of 6.2, and a TSH of 0.94. She was
otherwise continued on her other home medications.
Her urine culture from admission grew more than 100k CFU of E
Coli, so she was started on three days of Bactrim to complete a
total of a ___t home.
Daughter reported grey, sticky stools at home. Stools in the
hospital were normal brown color. LFTs including total bilirubin
were within normal limits, which was reassuring against acute
biliary or hepatic process.
She was discharged with plan to follow up with Neurology,
primary care physician. She will have home ___ and OT services.
1. Increase lisinopril to 40 mg daily. Goal normotension
2. Complete Bactrim 3 day course for UTI (___)
3. Follow up with primary care in ___ weeks and neurology as
scheduled
========================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No | 258 | 363 |
16580997-DS-5 | 26,422,862 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___!
WHY WERE YOU IN THE HOSPITAL?
- You were in the hospital for expedited workup of B-cell
lymphoma.
WHAT HAPPENED IN THE HOSPITAL?
- You met with the oncology team, including Dr. ___
will take care of you in the outpatient setting.
- You had an echocardiogram of your heart.
- You had a PET scan to help stage your lymphoma.
- You had a port placed in order to make it easier to give you
chemotherapy and draw labs in the future.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- Take all of your medications as prescribed, including the
steroids (prednisone) over the weekend.
- Follow up with your doctors, including Dr. ___, as
scheduled below.
- Call your doctor if you experience new fevers, night sweats,
chills, or other symptoms that concern you. Go to the nearest
emergency room right away if you experience weakness in your
legs or bowel/bladder incontinence.
We wish you the best,
Your ___ Care Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ male with history of CAD
s/p CABG, hypertension, hyperlipidemia, psoriasis, and new
diagnosis of large B-cell lymphoma based on biopsy of L4
vertebral mass admitted for further workup and expedited
treatment including TTE, PET, and port placement prior to
beginning chemotherapy next week. | 166 | 49 |
19668518-DS-4 | 26,190,774 | 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 left lower extremity next field
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add codeine as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
See OMR for physical therapy plan and disposition.
Treatments Frequency:
Physical therapy: Weightbearing as tolerated
Daily wound checks.
Assistance with ADLs | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic hip fracture And was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of left hip periprosthetic
fracture., which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. ___ hospital course was
complicated by delirium. Geriatrics was consulted for delirium
management. Patient was placed on atypical antipsychotics for
the treatment of delirium. Medications were optimized to reduce
delirium. The patient required 2 units PRBCs of transfusion.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. Geriatric
consultation was obtained during this hospitalization, who made
recommendations to help with agitation and delirium.
Additionally neurology was consulted, and after discussion with
the patient no changes were made to the patient's medications as
the patient was stable on her medication regimen prior, and it
seemed that she had returned to baseline. The patient worked
with ___ who determined that discharge to extended care facility
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left 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. | 522 | 360 |
12619846-DS-14 | 20,015,407 | Mr ___,
You were admitted to the hospital with shortness of breath and
concern for infection in your jaw. You were treated with IV
antibiotics. You were found to have a clot in your leg and were
treated with a blood thinner. On discharge you will be treated
with lovenox (an injection 2x/day) for your blood clot, and you
will take an antibiotic for your jaw infection. | ___ with hx of castration resistant prostate cancer recently
started on docetaxel 2 weeks prior to presentation, chronic
anemia initially presenting with progressive DOE x 3 months and
jaw pain x1 week found to have anemia, thrombocytopenia and CT
concerning for osteomyelitis of the L maxilla.
# Anemia:
# Thrombocytopenia: Most likely etiology of myelosuppression is
docetaxel vs infiltration of bone marrow in the setting of
advanced prostate cancer. He denies evidence of overt blood loss
aside from occasional hematuria, has no abdominal or flank pain
to suggest occult RP blood loss. Hemolysis less likely as
haptoglobin is normal and no schistocytes reported on smear and
elevated LDH most likely related to metastatic cancer. His Hb
improved from 6.0->8.3 after 2u PRBCs. He did not need any more
units of blood. Counts stabilized even while on a heparin drip,
with discharge hemoglobin 8.5, discharge platelets 58.
# Progressive DOE x3 months: Most likely etiology is marked
anemia, with Hb as low as 6.0 on ___. He had a recent cardiac
evaluation including cardiac catheterization and stress test
were both unrevealing within the past 2 months. He also had a
CT-PA without PE. TTE recently was also notable for a normal EF.
His dyspnea on exertion resolved after blood transfusion.
# Acute DVT: Patient with acute DVT of the gastroc vein.
Discussed with radiology and with the patient. Given malignancy
options are trial of anticoagulation vs IVC filter which were
discussed with the patient and opted for a trial medication
treatment with IV heparin with close monitoring. Patient
tolerated the IV heparin trial, and after discussion with his
oncologist Dr. ___ was discharged on sq lovenox.
# L jaw pain, trismus: Facial CT at ___ raised
concern for L maxillary osteomyelitis with odontogenic maxillary
sinusitis. Evaluated by ___ in ED who suspect
medication-related osteonecrosis of the jaw (MRONJ) in the
setting of poor
dentition. ___ ___ read of facial CT does not clearly suggest
bony infection. He received denosumab per the records obtained
in the setting of malignancy and bony metastases, which would
represent his most significant risk factor for MRONJ. He was
treated with IV unasyn and transitioned to PO augmentin upon
discharge.
# Hyperlipidemia: Continued home atorvastatin.
# Chronic steroids:
- Continued prednisone 5 mg PO BID
# Positive UA: Difficult to interpret in setting of prostate
cancer and intermittent hematuria, pt denies dysuria. He was
treated with IV unasyn as above. Urine Cx did not grow anything.
# Metastatic prostate cancer: As above, followed at ___
___, with known diffuse metastatic disease. He will follow
up with his outpatient oncologist on discharge.
# EtOH use: Pt endorses ___ beers per day 4 nights per week.
Denies hx of withdrawal symptoms. He was monitored on CIWA with
no withdrawal.
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge. | 67 | 473 |
14372694-DS-16 | 26,430,766 | You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; you will not require blood work
monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
*** You have recently had a seizure. Please do not operate a
vehicle for 6 months. *** | The patient was admitted to the floor from the emergency
departement and obtained a non-contrast MRI. The patient was
ordered for a contrast MRI, however, she refused as her mother
in law had an averse reaction to a contrasted MRI. The patient
was counseled about the indications for her MRI and why we were
requesting constrast to better visualize the cerebral edema seen
on CT. Due to more than one lesion seen on her initial
non-contrast MRI, a CT torso and an abdominal CT was obtained to
rule out metastatic disease, both of which were negative for
suspicious lesions. A functinal MRI was obtained in preparation
for a biopsy of her lesion which showed areas of activation in
the left temporal lesion during the tongue movement and language
paradigm. The small right frontal lesion is discrete from any
area of activation. The results were of the scans were discussed
with the patient. The need for a biopsy of her lesion was
discussed at length with her as well as her husband.
___ as well as neuro oncology were consulted on the
patient and were involved in her care. A biopsy was initially
scheduled for the following hospital day, however, the patient
declinced care. She wanted to be discharged home on Keppra and
a Dexamethasone taper so that she could seek a second opinion
regarding her brain lesions. She was discharged home
neurologically intact with seizure prophylaxis. | 92 | 245 |
15031793-DS-18 | 28,185,985 | Dear Ms ___,
On behalf of the ___ team, it was a
pleasure taking care of you. You were admitted to the hospital
because you were lightheaded and dizzy at dialysis. We believe
that this was because you had not received dialysis for several
days. When you do not get dialysis, your potassium and other lab
values become abnormal. These abnormalities can make you
lightheaded and confused. Once you arrived to the hospital, you
got dialysis in the emergency room. Your potassium was still too
high after this, and you received a second half session of
dialysis on ___. On ___, you received your normal
dialysis session. Please weigh yourself every morning, call MD
if weight goes up more than 3 lbs.
The wound care team helped to take care of the burns on your
left arm. You will need to change this bandage and apply
clindamycin to it daily.
Lastly, because of your elbow pain, we got an xray of your elbow
which did not show signs of any broken bones. It did show some
inflammation from overuse, which is most probably causing your
pain. Please contact your PCP if it continues to bother you. | Brief Hospital Course: This is a ___ with history of DM, CAD,
bilateral ___ amputation, and ESRD on HD (MWF) who was referred
to the ED after episode of dizziness/lightheadedness in the
setting of missing dialysis for 5 days.
# Lightheadedness: The patient reportedly had an episode of
dizziness/lightheadness at dialysis, although she denied this.
No report of LOC, hypotension, alterned mental status at the
time. Most likely secondary to hyperkalemia/uremia secondary to
missed dialysis. Her weight was up 8 kg and she had pulmonary
vascular congestion on CXR. Cardiogenic etiology is less likely
given that she had no LOC and EKG relatively unchanged from
prior. Troponins were positive, however, decreased after
dialysis, and are thought to be secondary to decreased clearance
from renal failure. She has had positive troponins in the past.
Infectious etiology also less likely as she had no
fevers/chills, nausea/vomiting, or leukocytosis. Blood cultures
were drawn on admission, however, had no growth at time of
discharge. She had no further episodes of lightheadedness during
the admission. Electrolyte abnormalities resolved with
hemodialysis during admission.
# Decreased alertness: Pt was intermittently drowsy, but easily
arousable, during admission. Daughter-in-law reported that this
has been a chronic, progressive issue. Her home oxycontin was
initially held, then restarted at a lower dose, as it was
suspected to be contributing. VBG also had a slightly elevated
pCO2 of 54. Due to large tongue and frequently hunched over
posture, she may benefit from a sleep study to evaluate for OSA.
# ESRD on HD: Secondary to diabetes and htn, on ___ HD.
Currently undergoing eval for transplant. Given hyperK and
missed HD sessions, underwent dialysis in ED on ___, received a
half session on ___, and a full session on ___. She continued
her home nephrocaps, sevelemer, calcitriol.
# Hyperkalemia: Most likely due to missed HD and resolved with
HD (was 4.2 on discharge).
# Second degree Burn: The patient has a burn on left forearm
reportedly from one weeks ago that she reported was from hot
water while washing her dishes. Wound care was consulted and
recommended topical clindamycin with daily dressing changes.
# Elbow pain: Patient reported elbow pain, however, xray did not
show fracture. It did show signs of medial epicondylitis. Her
joint was not warm, erythematous or edematous. It did have some
tenderness with active flexion/extension. OT was consulted for
an elbow cushion for her scooter, however, did not see patient
before discharge.
# Diarrhea: She reportedly had diarrhea prior to dialysis on
___, however, had no episodes while inpatient.
=================== | 194 | 417 |
14260736-DS-14 | 25,499,872 | You came to the emergency room secondary to a sudden onset of
right foot pain associated with decreased sensation and the
inability to walk. You were seen by the vascular surgery tean
who emergently took you to the operating room for an
embolectomy (clot removal) from one of your major leg arteries.
The clot was felt to be secondary your irregular heart rate or
atrial fibrillation. We started you on a blood thinner called
coumadin.
While you were in the hospital, your heart rate was very fast
(120s). We consulted your home cardiologist and the cradiology
team here and they increased your metoprolol dose.
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed | Ms. ___ was admitted ___ after acute change in
temperature, sensation, and pain in her right foot. She was
started on heparin drip and underwent emergent right femoral
embolectomy. At the time of cut down, no pulse could be felt in
the femoral artery. Clot was immediately found and extracted.
Clot was also extracted from the profunda with vigorous
backflow. However, the ___ catheter could not be passed
through the SFA, indicating likely chronic occlusion. As she
could walk at baseline withis SFA occlusion and the profunda had
great flow, no intervention was performed on the SFA. She
tolerated the procedure well and was trnasferred to the PACU in
stable condition. Post-operatively, she was started on a heparin
gtt and coumadin was held. She had a right dopplerable ___, and
no DP. She had significant right groin pain. The site was oozing
overnight and into POD1. There was a small skin bleeder that we
elected to stitch. However, the patient would not allow this and
we instead put surgicel over the area of bleeding, which stopped
it successfully. She was also hypotensive to ___ systolic
and tachycardic to 100s-120s, in afib. She received multiple
boluses and one unit of blood. Hct did not bump significantly,
from 29.5 to 30.7, likely due to simultaneous bleeding into her
groin. No change in mental status or other symptoms during this
time. Her hypotension improved with blood and fluids. She had
increased pain in her right foot and the right popliteal and ___
signals were lost. After her blood pressure was stabilized, she
underwent an CTA, which showed a moderate sized right inguinal
region hematoma. No evidence of pseudoaneurysm or AV fistula.
Short segment right CFA dissection. A 3 cm length of right mid
SFA shows no flow. Recanalization of the distal right SFA. Lack
of flow beyond the ankles in both lower extremities, which may
be due to delay in transit. Right adrenal adenoma. Extensive
aortic atherosclerosis with focal dissection just proximal to
the bifurcation. No further bypass or angio options were thought
to be possible at this point. Echo showed EF 55% with severe
aortic stenosis (valve area 0.8). She was continued on heparin
and started on coumadin. Later the same day, her right ___ was
again dopplerable. POD #2 Heart rate was decreased to 100-110s
with IV and PO metoprolol. Therefore, we consulted cardiology on
POD #3, who recommended a PO metoprolol regimen only, with IV
metoprolol prn, as it was permissive to allow her to be
tachycardic up to 110s. She was maintained on metoprolol 75mg
tid. Gabapentin was added to her pain regimen. She was
discharged on POD #4 in stable condition to rehab. | 441 | 445 |
14774769-DS-16 | 23,145,546 | Ms. ___, You were admitted to ___ with increasing weakness,
falls and urinary retention. This was felt to be due to problems
with your cervical spine. Plans were made to have surgery on
your spine on ___. In the mean time you will be discharged to
the ___ facility and will return next week for
surgery. | ___ yo W w/ spinal stenosis, progressive tremor and severe
orthostasis, presenting with orthostatic lightheadedness and
presyncope, unlike prior vertigo. Patient was admitted to the
neurology service for further work-up. She was evaluated for
orthostatic hypotension which was normal. She was given
compression stockings and received an ECHO in case a decision
was made to begin florinef or similar medication.
Given the patient's history of cervical spine disease and the
her upper motor neuron pattern of weakness a repeat c-spine MRI
was done. The official read was unchanged from prior, however
given the worsening weakness, falls, and urinary retention much
of this symptomotology was attributed to the c-spine. She had
previously been seen by Dr. ___ Ortho/Spine and their
team was consulted. A plan was made to have surgery next week.
She was placed in a soft collar.
Her seizure medications were maintained through her
hospitalization. There was some question whether these
medications contributed episodes of confusion and lightheadness.
This did not seem to correlate clearly, however consideration
will be made to titrating down her medications following her
surgery and recovery.
The patient is being discharged to a skilled nursing facility
for the weekend where she will receive appropriate support and
can return for surgery next week when this is coordinated. | 56 | 211 |
11457450-DS-22 | 25,005,226 | Dear Mr. ___,
You were admitted to ___
because of shortness of breath. We think you had an exacerbation
of your COPD and a pneumonia. We do not think you had an
exacerbation of your congestive heart failure (CHF). You were
given a medication called prednisone, which you will need to
take for 1 more day. You were also given an antibiotic called
azithromycin, which you will need to take for 2 more days.
For your COPD, you are being discharged with a new inhaler
called Advair (fluticasone-salmeterol). You should take this
twice each day, even if you are feeling well. Please rinse your
mouth after using this inhaler, as in can increase your risk of
mouth infections if you do not. You should follow up with a
pulmonologist (lung doctor) to manage your COPD. We are working
on getting an appointment for you.
You should STOP taking your warfarin after discharge until you
follow up with your primary care physician on ___. Your INR
was too high, and this could increase your chances of bleeding.
You should try to follow up with Dr. ___ Dr. ___ on
___.
It was a pleasure to help care for you during this
hospitalization, and we wish you all the best in the future.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with a history of COPD, dCHF,
CAD s/p MI, chronic pain, and AF s/p cardioversion presenting
with dyspnea.
#Dyspnea - Likely ___ COPD exacerbation and/or PNA. CXR showed
possible LLL opacity, and pt was empirically treated with
azithromycin for 5 days (d1 = ___ and prednisone 40mg PO for 5
days (d1 = ___. Pt otherwise had no e/o volume overload or
cardiac ischemia. For his COPD, pt was started on Advair after
discussion with his PCP. He was discharged with a plan to f/u
with a new pulmonologist as an outpatient.
#Elevated INR - INR on admission was 3.9; went as high as 6.5
during this hospitalization. The patient's warfarin was held and
he showed no evidence of bleeding. He was discharged with a plan
to hold warfarin and have INR rechecked by PCP, ideally on ___.
This was communicated over the phone to pt's PCP.
#Anemia - Hb remained stable at ~12 in setting of
supratherapeutic INR. No obvious source of bleed. Stool was
guaiac negative. Patient was given B12 and folate supplements.
___ - Pt had ___ w/Cr 1.7 (baseline 1.1). He notably had
been taking torsemide 60mg PO QDay prior to arrival, and FeNa
was consistent with prerenal azotemia. Cr was 1.7 at the time of
discharge. He was kept on torsemide 10mg PO QDay (home dose).
#Chronic Diastolic CHF: Pt's admission weight was slightly above
dry weight by 4 lbs. Mild pulm edema on CXR, low proBNP. As
above, no e/o volume overload on exam. The patient's home dose
of torsemide was continued throughout his hospitalization.
#Chronic pain: For his chronic pain, he was maintained on his
home regimen of methadone, donnatal, hydromorphone. | 208 | 300 |
18206930-DS-23 | 28,169,296 | Dear Ms. ___,
It was a pleasure taking care of you. Please read the following
instructions carefully:
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted from your nursing facility because you had
several falls and were noted to be confused
- We found that you had a urinary tract infection that likely
caused the confusion.
WHAT WAS DONE FOR ME WHILE I WAS HERE?
- We gave you antibiotics to treat your infection
- We aggressively searched for a new facility that could better
take care of you.
WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL?
- Please keep your appointments as listed below and take your
medications as prescribed
We wish you the best with your health!
- Your ___ care team | SUMMARY STATEMENT:
===================
___ yo F with PMH of non-ischemic cardiomyopathy, R MCA
cardioembolic stroke (___), R temporal solitary fibrous tumor
s/p resection (___) and radiation tx and depression, with
recent hospitalization for diverticulitis now s/p sigmoid
colectomy, with course c/b refractory nonconvulsive status
epilepticus ___ PRES syndrome, who presents to the ED from
nursing home with altered mental status and behavioral concerns,
found to have UTI s/p abx course. She was discharged to short
term rehab with estimated rehab stay less than 30 days.
TRANSITIONAL ISSUES
====================
[ ] Lisinopril dose decreased from 10mg to 5mg while inpatient.
Please closely monitor her blood pressures given prior history
of PRES and uptitrate lisinopril as needed for goal SBP 110-130
ACUTE ISSUES
============
# Altered mental status, resolved
Initial precipitant at this point likely UTI noticed on arrival,
however on poor substrate given medication effect from AEDs.
#UTI: citrobacter > 100,000 CFU sensitive to macrobid. s/p 5d
macrobid course.
# neck pain: Suffered a ground-level fall overnight because she
was startled by the bed alarm while getting up to use the
restroom. Resultant neck pain likely musculoskeletal as CT
c-spine and CT head without fx or other abnormality. She was
treated with acetaminophen and lidocaine patches.
#Self-harm behaviors, resolved
#Fall risk
Exhibited self-harm behaviors while at ___,
including intentional falls, however this appears to be due to
desire for attention. She was placed on 1:1 sitter on arrival,
however psychiatry did not have a psychiatric indication for
continuation and so this was since discontinued. She denied
thoughts of self-harm while inpatient.
#Hypertension
#h/o PRES
On arrival, SBPs ___, so home lisinopril was held. Since
then, blood pressure was slowly trending upwards, and at
discharge SBPs in the 120-130 range. Note history of PRES at
recent hospitalization. She was re-initiated on her home dose of
lisinopril at discharge.
CHRONIC ISSUES:
===============
# History of nonconvulsive status epilepticus
Pt with recent very complicated hospital course due to
nonconvulsive status. Evaluated upon arrival to the ED for this
admission, felt by neuro not to be in ___. Home meds as listed
below continued
--Phenobarbital 35/40mg
--Clobazam ___ mg
--Phenytoin 100-25-100
--Lacosamide 150/250 mg
--Levetiracetam 1250/2750 mg
# Depression
- home sertraline 75mg QD was continued
# Nonischemic cardiomyopathy
# Hx of cardioembolic stroke
- Home ASA and lisinopril continued, lisinopril dose decreased
to 5mg daily
# Chronic normocytic anemia
Per chart review, patient has chronic anemia with baseline ~8
during last admission, previously ___, unclear etiology. On
initial ED presentation Hb 10.7, repeat 13.0 without
transfusion,
possibly suggestive of hemoconcentration. This was stable during
hospitalization. | 121 | 394 |
10344189-DS-3 | 28,214,279 | Dear Mr. ___,
You were admitted to the hospital with an infected ulcer of the
right heel. This was debrided by the podiatry service and the
blood flow to the heel was improved with an angioplasty of one
of the arteries ___ your leg. Unfortunately the heel did not
appear to be heeling and the infection persisted and so the leg
was amputated below the knee. Surgery went well and you have
been recovering well. You worked with physical therapy who
recommended you be discharged to rehabilitation facility to
continue your recovery.
A follow up appointment has been made for you with Dr. ___
___ staple removal. A lower extremity ultrasound has also been
scheduled prior to this visit.
Upon discharge you will resume your home dialysis schedule.
Please follow up with your primary care physician after
discharge from the hospital for appropriate follow up care.
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
An appointment will be made for you to return for staple
removal.
Monitor wound for signs of infection - expanding redness,
swelling, purulent drainage
MEDICATION:
Continue all other medications you were taking before surgery,
unless otherwise directed
You will be discharged on coumadin which will require close
monitoring. This will be managed by the physicians at your
rehabilitation ___, and upon discharge will be managed by
your PCP, ___.
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist ___ wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which ___ turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site. | Mr. ___ was admitted from rehab with an infected non-healing
ulcer of the right foot. The patient was treated with
antibiotics and was debrided twice by podiatry. He underwent
angioplasty of the right posterior tibial artery to improve the
blood flow to the ulcer. However, the ulcer remained clinically
infected and did not appear to be healing. Thus he underwent
guillotine amputation with subsequent below knee amputation. His
hospital course by system is summarized below.
Neuro: The patient was started on his home citalopram upon
admission. Pain control remained an issue. He was treated with
opiate narcotics. However, the dose was initially tapered due to
concern for sedation. Following the completion amputation, his
pain was treated oral oxycodone and IV dilaudid for breakthrough
pain.
CV: The patient was hemodynamically stable at the time of
admission. His home amlodipine was started upon admission. The
patient had known atrial fibrillation that remained rate
controlled. His Coumadin was restarted following his right
guillotine amputation on ___, held for the completion
amputation, and subsequently resumed.
Resp: There were no acute issues during this hospitalization.
Following the podiatric debridements, the white count remained
elevated and a chest x-ray was performed to rule out pneumonia
which was negative.
GI: The patient remained on a renal diet. Unfortunately he was
found to have relatively low PO intake that was insufficienct to
meet his caloric needs. PO nutrition was encouraged and
supplements were started. He was subsequently put on Megace for
appetite improvement. The patient was incidentally found to have
thickening of the stomach wall on RUQ US to rule out acute
cholecystitis. On official radiology reading, there was question
of a neoplastic process. However, there was not high clinical
suspicion for malignancy.
Renal: The patient underwent dialysis on his usual MWF schedule
under the care of our Nephrology service.
Endo: There were no acute issues.
Heme: The patient's coumadin had been held ___ anticipation for
the angiogram. Following the second debridement of the heel his
coumadin was restarted but was held when supratherapeutic. He
was given vitmain K prior to the guillotine amputation and then
placed on a heparin drip to bridge until the completion BKA,
after which Coumadin was resumed and dosed based on INR.
ID: The patient was initially placed on IV vancomycin (dosed at
dialysis) and zosyn. This was switched to vancomyocin and
ceftazidime both dosed at dialysis. Metronidazole was added for
anaerobic coverage when cultures revealed mixed flora. CXR
showed no evidence of pneumonia. RUQ US was done and ruled out
acute cholecystitis. On POD 7 from BKA revision, a small amount
of serosanguinous fluid was expressed and cultured from the
stump and there was no growth. Infectious Disease and Hematology
were consulted ___ regards to the patient's persistent
leukocytosis despite medical and surgical treatment and an
improved clinical picture. A peripheral blood smear and workup
suggested that the persistent leukocytosis was due to an acute
reactive infectious process. There was minimal suspicion for
malignancy. His WBC count continued to decrease slowly and at
the time of discharge was 20. His antibiotics were stopped on
day of discharge.
The patient was discharged to a rehabilitation ___
continued recovery with an anticipated less than 30 day stay. A
follow up appointment has been provided for Mr. ___ with Dr.
___. He will also follow up with his PCP for continued
monitoring of his white blood cell count and coumadin
management. If indicated, the incidental finding of gastric wall
thickening on RUQ US can be followed up with outpatient
endoscopy. | 518 | 584 |
19454919-DS-11 | 26,703,284 | It was a pleasure participating in your care at ___. You were
admitted to the hospital for abdominal pain and nausea. You were
found to have high potassium levels which were treated. It is
evident that your pancreatitis is improving but please follow
the diet instructions below and also make sure to follow low
potassium diet.
REGARDING YOUR MEDICATIONS...
No medication changes were made.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork. | ___ year old with ESRD on HD, HTN and chronic pancreatitis
presents with recurrent abdominal pain after recent pancreatitis
flare, course complicated by hyperkalemia with EKG changes.
# Abdominal pain: history is consistent with recurrent
pancreatitis, diet was likely advanced too rapidly. Note is made
of downtrending lipase from prior admission however trending
lipase is less useful than clinical examination and history in
monitoring resolution of pancreatitis. GI service was consulted
who recommended outpatient followup with pancreatologist and
advancing diet as tolerated. He was treated with his outpatient
pain regimen after several doses of IV dilaudid when he was NPO
and he self advanced his diet to clears to be further gradually
advanced at home to low fat, diebetic, low potassium diet.
# Hyperkalemia: admission labs remarkable for potassium 6.8, EKG
with peaked T waves, and thus he received insulin, glucose,
calcium and albuterol as well as overnight dialysis. Potassium
on discharge was 4.7
# Hypertension: ___ has been vomiting and unable to take
oral medications. His blood pressure has been in the 160-200
range on admission. Chart review shows that his blood pressure
is often 160-220. Home medications were continued of amlodipine,
lisinopril and labetolol and his measurements improved.
# ESRD: ___ on dialysis MWF. Received ___ night dialyis
as well as ___ AM diaylsis.
# Diabetes: diet controlled.
# GERD: home PPI.
# CODE: FULL
# CONTACT: ___ | 81 | 230 |
17776930-DS-14 | 26,830,393 | Dear Ms. ___,
You were admitted to the hospital with abdominal pain after
undergoing colonoscopy. You had a CT scan which revealed a small
injury to your spleen, but no obvious bowel perforation. Your
blood levels were monitored and have remained stable. You
received antibiotics and were restricted from eating. Your diet
was gradually advanced and you are now tolerating a regular
diet. You do not require more antibiotics after hospital
discharge. You are now medically cleared to be discharged home
to continue your recovery. You will receive no new medications
following this discharge. Please take all of your previous
medications that were on before this admission. Please follow up
with your PCP as discussed or with the GI team that performed
your colonoscopy. You may take Tylenol for abdominal discomfort
and OTC stool softeners for any constipation. Please do not
over-exert yourself; you may resume your usual activities but do
not lift anything greater than 10 pounds before discussing this
further with your PCP on follow up.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable. | Ms. ___ is a pleasant ___ year old female who presented with
abdominal pain after receiving an outpatient colonoscopy.
Imaging from OSH demonstrated a small amount of hemoperitoneum
with minor splenic injury during the colonoscopy as the
underlying etiology. Ms. ___ was hemodynamically stable
throughout her admission. She was originally kept NPO with IVF
hydration while her pain was initially managed with IV followed
by PO pain medications as tolerated. Over the ensuing days, we
monitored her labs and hematocrit. She received a short duration
of empiric antibiotics that were discontinued upon discharge.
Following an original, minor downtrend of her hematocrit, her
blood levels remained stable. We discussed the likely causal
factors for her current admission and advanced her diet slowly.
She tolerated a diet well, only noticing some minor abdominal
discomfort after eating her first meal. She was amenable to
discharge. At the time of discharge, she was independently
ambulatory, tolerating a regular diet, pain was controlled with
minimal PO medications and she was well appearing. She was
instructed to follow up with her PCP and her GI physician as
needed. She has no need to follow up with us in the ___ clinic. | 250 | 196 |
16662264-DS-33 | 26,390,489 | Dear Ms. ___,
It was a pleasure taking care of you at the ___. You
were admitted to the hospital for pneumonia. We gave you
antibiotics and you improved. There was also a concern for
narcotics overdose which required you to get intubated and your
dose was lowered. You spent over a week ___ the ICU for this
reason. We would have like you to have home ___ and ___ however
you declined, as you wanted to return to ___.
There have been several changes to your medication list and
these will be reviewed with your nurse prior to leaving.
You will need your labs checked ___ one week.
Please follow up with the appointments as outlined below. Your
Nephrologist may want you to be followed by a Transplant
infectious disease doctor ___ the future. He will discuss this
with you ___ your next appointment.
Thank you, | MICU COURSE:
============
Ms. ___ is a ___ year old woman with type I DM, ESRD s/p
living-related-donor kidney transplant ___ ___ on chronic
immunosuppression, IgG deficiency on weekly replacement, and
recurrent pneumonia here with bilateral LL PNAs, hospital course
c/b altered mental status and hypotension requiring transfer to
the ICU on ___.
# Respiratory failure: Ms. ___ had frequent admissions for
recurrent multifocal pneumonia, often affecting the lingula and
RML. ___ the past she has been treated with broad spectrum
antibiotics and subQ IgG due to her hypogammaglobulinemia. Her
last admission for multifocal pneumonia was ___ ___- she was
treated with levofloxacin for a 10d course and her radiograph
showed resolution of the infiltrates by early ___. Patient was
admitted for respiratory distress. CT chest showed increased
multifocal opacities compared to ___ with predominance ___ RML
and lingula. Significant R sided pleural effusion tapped,
cytology negative. Treated w/ vancomycin, azithromycin and
ceftriaxone, transferred to the MICU for concern for airway
protection and soft pressures (90s). Noted to be quite somnolent
with RR ___ with progressive acidosis on ABG. Narcan
administered, pt awoke uncomfortable but with improved MS and
respiratory drive and pH. On ___ ___ setting of IVIG
administration, awoke very SOB, hypoxic into mid ___, got 20mg
IV lasix, IVIg stopped, pt placed nonrebreather, given 1 mg
ativan w/ some improvement. However, pt continued to have
increased work of breathing w/ desaturations into ___,
electively intubated and sedated. Coverate broadened to
meropenem 500 Q8 for empiric HCAP per ID recs. Underwent bedside
bronchoscopy, purulent material from lingula which showed no
growth, sputum cx also negative. Pt became agitated on vent,
self-extubated, was difficult to re-intubate ___ airway edema,
airway obtained w/ glidoscope. Given solumedrol to resolve
airway edema. Diuresed to improve overload component to her
respiratory failure. On ___ extubated successfully after
spontaneous breathing trial. Breathing continued to improve, pt
weaned to nasal cannula, afebrile X >48 hours, called out the
floor. On the floor she remained afebrile and maintained
adequate saturations on room air. Her lung exam, cough, and
energy continued to improve and she completed her antibiotic
course on ___ for multifocal pneumonia.
# DIABETES MELLITUS TYPE 1: Pt initially maintained on insulin
pump w/ basal rate and ISS, discontinued prior to transfer to
the ICU, insulin was adjusted per ___ recommendations.
Difficult to control given intermittently NPO, intubated, given
steroids. Pt maintained on basal rate to avoid DKA, had one
episode of hypoglycemia to ___ overnight, given D5W (inadequate
access for D50) and glucose recovered. Pt called out to floor w/
stable BGs ___ 100-200s. ___ adjusted insulin pump one final
prior to discharge and patient maintained euglycemia prior to
discharge.
# ALTERED MENTAL STATUS: Likely related to narcotics overdose as
mental status improved with narcan and cessation of pain
medications. Initially there was concern for meningitis as she
was complaining of some neck stiffness. However, given that she
was afebrile and mental status improved significantly, LP was
deferred. Blood and urine cultures did not reveal a causative
organism.
# TOXIC METABOLIC ENCEPHALOPATHY ___ TO NARCOTICS OVERDOSE:
Likely ___ narcotic overdose as resolved with narcan.
Hypoventilation from narcotics on top of pneumonia causative of
somnolence, dramatic response to narcan. Mental status returned
to baseline s/p narcan. Subsequently became paranoid, anxious,
given ativan PRN. Sedating medications limited. Gave small doses
oxycontin to prevent withdrawal, mental status improved over
course of MICU stay. On the floor she was placed on oxycodone
prn and narcotics dose was calculated and patient was
transitioned to
# ANION GAP METABOLIC ACIDOSIS: Likely secondary to renal
injury, DKA less likely given modest hyperglycemia, but ketones
present ___ urine. Corrected gap was 14.5, possibly a
combination of mild DKA, non-gap metabolic acidosis from renal
failure. Gap closed w/ treatment of PNA and management of blood
sugar, pH normalized.
# HYPOTENSION Had BPs ___ ___ ___ ED. No history of CAD, last ECHO
shows normal EF. Pt diabetic, risk for ACS, but trops neg and
EKG w/ no changes. Thought likely narcotics or sepsis. Patient
received 3L of fluid for resuscitation. A left EJ was placed for
access pending PICC insertion and serial VBGs were trended. BPs
stabilized on MICU floor after fluids.
# LABILE BPs: Pt had a few episodes of BPs ___ 200s systolic,
mostly ___ setting of pain/nausea, thought possibly a component
of narcotics withdrawal. Treated to good effect w/ low doses of
ativan and oxycontin.
# ___: Baseline Cr 1.2-1.4, up to 1.6 likely ___ the setting of
hypotension. The patient was treated with aggressive fluid
repletion. Pt's creatinine peaked at 2.0, thought likely ___
transient hypoperfusion from sepsis. Downtrended, and had
normalized by callout to floor. Remained stable for remainder of
hospital course with discharge creatinine of 1.1.
# S/P RENAL TRANSPLANT: The patient was continued on
mycophenolate and tacrolimus. Tacrolimus dose on admission was
13.6. MM and tacro both monitored and dosed by nephrology during
hospital stay. Patient was discharged on home dose of tacrolimus
and mycophenolate was decreased to 250mg daily as there was
concern it was contributing to diarrhea. She will follow up with
transplant nephrology ___ one week. Furosemide was discontinued.
# COMMON VARIABLE IMMUNE DEFICIENCY: IgG SC dependent, has not
missed any doses. IVIG was held on ___ due to hypotension. Pt
hypoxic during next adminstration and dose once again held. Pt
stabilized, extubated, and received next dose successfully. She
received one final dose prior to discharge. She will have
follow-up with immunologist as outpatient.
#DIARRHEA: although patient is only moving bowels ___ day on
admission, with increase ___ number of loose BM over hospital
course. Stool studies and c. difficile assays were negative ___
house. Patient was started on lomotil with improvment ___
diarrhea. There was concern that immunosupressives were
contributing and dosing has been adjusted.
# CHRONIC PAIN: Home dose of narcotics were held. Maintained on
PRN low doses of narcotics; required less than home dose. On
the floor she was transitioned to oxycontin 20mg q12 hours and
she was discharged on this dose with percocet for breakthrough
pain. PCP was notified about narcotics overdose and possible
diversion and narcotics contract will be reviewed during next
PCP ___.
# ASTHMA: Continued albuterol, advair, singulair.
# DEPRESSION: Continued paroxetine and mirtazepine.
# EUSTACHIAN TUBE DYSFUNCTION: Patient with notable right ear
bulge. Improved with fluiticasone and nasal saline.
# ODYNOPHAGIA: believed to be due to yeast and was placed on
nystatin. | 145 | 1,065 |
18650549-DS-25 | 29,119,393 | Dear Mr. ___,
You were admitted with urinary retention and acute kidney
injury, likely secondary to an enlarged prostate. A foley
catheter was placed with significant improvement in your kidney
function.
You will need to keep the Foley catheter in place for 1 week, at
which point you should be evaluated by your outpatient
urologist, Dr. ___. Please call on ___ to schedule an
appointment with Dr. ___ this coming week.
With best wishes for a speedy recovery,
___ Medicine | ___ male with hx CKD and obstructive uropathy who
presents with ___ and urinary obstruction improving s/p Foley
placement. | 76 | 19 |
19133985-DS-3 | 24,160,573 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted because you noticed some
weight loss and your skin was turning yellow. We found that you
most likely have acute alcoholic hepatitis, which is when
alcohol use has damaged your liver.
It is very important that you refrain from drinking again.
Please let us know if you need any assistance in this venture,
as we understand it can be very difficult.
We also noted that you have a large right inguinal hernia that
contains your appendix. Please see the general surgeons as
listed below to fix it.
There are a lot of new medications for you that are important to
help manage your liver damange:
- prednisone 40mg daily
- Lasix (furosemide) 20mg daily
- Aldactone (spironolactone) 25mg daily
- omeprazole 20mg daily
Please ___ with your new primary care physician, liver
specialist, and the general surgeons as directed below.
Thank you for allowing us to participate in your care. | Impression: Mr. ___ is a ___ gentleman with no past medical
history p/w jaundice and weight loss, found to have cirrhosis,
most likely ___ alcohol abuse.
# Acute alcoholic hepatitis with evidence of cirrhosis: Patient
presented with jaundice and laboratory analysis c/w severe
hepatitis given bilirubin of 14.4 and synthetic function
abnormalities with elevated INR of 1.8. Infectious workup was
unremarkable. RUQ u/s showed findings c/w cirrhosis with patent
portal vasculature. CT abd/pelvis r/o further pancreatic or
other ___ pathology. Patient has significant history
of alcohol abuse, please see below. Hepatitis ___ was
negative for HBV, HAV, and HCV. Iron studies consistent with
iron overload with a transferrin saturation >90% and a high
ferritin of 4621. HFE gene analysis pending at discharge.
___ discriminant function was 46 on admission and patient
initiated on 40mg prednisone daily on ___. Lille score on
day 7 was 0.126 and thus, prednisone was continued at discharge
to complete a 28 day course (final day: ___.
# Esophageal varices: EGD performed on ___ revealed ___ 1
varices. Although patient was ___ Class B on admission,
this was in the setting of acute hepatitis and thus, nadolol was
not started. Would recommend ___ as an outpatient.
# Ascites: Perihepatic ascites noted on RUQ u/s and as patient's
abdomen became increasingly distended during hospitalization, he
likely had ascitic fluid accumulation. He was started on
furosemide 20mg and spironolactone 25mg daily at discharge.
Would recommend electrolytes check at next clinic visit.
# Alcohol abuse: Patient reports significant alcohol use in the
recent history, up to ___ shots of vodka daily for the past ___
years. He has little family support and lives alone. His
occupation is also often a hazard as he works in a ___.
Patient appeared to understand and desire alcohol abstinence
moving forward. Social work provided patient with additional
resources to aid in abstinence at discharge.
# Hyponatremia: Sodium on admission was 131, likely dilutional
hyponatremia from liver process. Patient was maintained on
___ diet and ___ to 2L during
hospitalization.
# Inguinal hernia: CT abd/pelvis noted large right inguinal
hernia containing the patient's appendix. Patient had no
complaints during hospitalization and will ___ with
surgery as outpatient for hernia repair.
# Gastritis: Patient noted to have antral gastritis on EGD. He
was started on omeprazole 20mg daily.
# Nutrition: Patient reports having irregular eating habits with
significantly decreased PO intake over the past few weeks
resulting in a 20 pound weight loss. Albumin on admission was
3.3. Nutrition recommended Ensure supplementation and patient
educated regarding ___ diet. At discharge, patient's
appetite was much improved.
**TRANSITIONAL ISSUES**
- Patient received first dose of Hep A and Hep B vaccine on
___. Will need remaining doses as an outpatient.
- lasix 20mg and spironolactone 25mg daily were initiated prior
to d/c, will need labs to monitor electrolytes at PCP visit
- ___ 1 varices seen on EGD, patient ___ Class B based
on admission labs but in the setting of acute alcoholic
hepatitis, may not be accurate classification. Thus, nadolol was
not started. Please consider starting as outpatient.
- HFE gene mutation analysis pending at discharge
- large right inguinal hernia containing appendix noted
indicentially on CT abd/pelvis, will need repair | 158 | 525 |
16833478-DS-32 | 20,006,989 | Dear Mr. ___,
You were admitted to the hospital with fevers/shakes. Blood
cultures did not grow a culprit organism. Echocardiogram of your
heart showed no evidence of valvular disease, and CT scan of
your belly showed no infection there either. You were initially
treated with antibiotics, which were discontinued in the absence
of clear evidence for infection. You did well with a period of
observation and are being discharge home on your prior
medication regimen
Please be vigilant for recurrent fevers and notify your doctors
about ___ immediately.
With best wishes,
___ Medicine | ___ with ___ polyposis/HHT cross-over
syndrome, duodenal adenoCA s/p Whipple ___ c/b chronic TPN
requirement, DVT/PE (s/p IVC, on apixaban), multiple recent
admissions for bacteremia ___ for S.___ w/chest port
removal and ___ for Klebsiella, source unclear) p/w fevers and
rigors of unclear etiology.
# Fevers/rigors:
# Recurrent bacteremia:
Pt with hx of recurrent bacteremia (S.lug___ in ___,
thought due to line infection and s/p Nafcillin and chest port
removal and then Klebsiella ___ of unclear source, treated
with ethanol locks and CTX. Now presenting with fevers/rigors
concerning for recurrent bacteremia. No clear localizing source
by symptoms or exam. BCx on ___, and ___ -- along
with UCx -- were all negative at the time of discharge. CT A/P
with no clear source; stable pneumobilia likely secondary to
prior Whipple. TTE without vegetations (obtained for new murmur
on exam). Afebrile since admission. Initially got Vanc/Cefepime
in ED on ___, switched to CTX ___. Antibiotics were
stopped on ___ and he was observed for 24h without recurrence
of his symptoms. He is discharged off antibiotics and will f/u
with his PCP and hematologist on ___.
Of note, patient has been getting intrmittent fevers of unclear
source on and off for a year with several PCP visits and
admissions for fever and hematemesis ___ and ___ with
no clear source of fever identified. He is s/p whipple for
ampullary carcinoma which was completely resected; he also has
chronic cytopenias for which he is followed by hemeonc as an
outpatient. Hypogammaglobulinemia recently ruled out by Ig
eletrophoresis.. Currently no evidence of active malignancy.
Also no associated clinical features suggesting a
connective-tissue disease. His occasional fevers could be caused
by intermittent bacterial translocation from the gut iso
underlying polyposis. He will be followed up for this in the out
patient setting by ID.
# Chronic moderate malnutrition:
# Protein-losing enteropathy s/p hemicholectomy:
TPN was initially held on admission, resumed on the night of
___. He was discharged to continue his home TPN
formulation.
# Chronic anemia:
Thought secondary to chronic GI blood loss, followed by
hematology (Dr. ___ and on monthly IV iron infusions, next
due ___.
# Leukopenia:
# Thrombocytopenia:
Chronic and generally stable since at least ___. Haematologist
did not think there is concern for blood malignancy. likely
secondary to marrow suppression in setting of infection given
significant fluctuation over last few years. Has f/u apt
w/outpatient hematologist next week.
# ? pleural thickening: per subtle residual opacity along
the periphery of the left lower lung on CXR. Will require
repeat CXR for interval change in outpatient setting.
# HFpEF: Appears euvolemic currently. Continued on home Lasix
40mg.
# DVT: continue apixaban
# Depression/anxiety: continue citalopram
# Seizure disorder, brain AVM: continue keppra
# Chronic pain: continue oxycodone
# Asthma: continue albuterol PRN
# h/o adenocarcinoma of duodenum/ampulla and high grade
dysplasia of pancreatic tail s/p Whipple; stable
** TRANSITIONAL **
[]f/u pending BCx ___ , UCx
[] IV iron scheduled ___
[] will f/u as outpatient with ID to consider further workup if
fevers recur.
[] PCP to repeat CXR in 4 weeks for interval change given ?
pleural thickening.
[] f/u with hematology
[] resume previous TPN orders | 90 | 508 |
10287475-DS-12 | 22,730,947 | Dear Mr. ___,
You were hospitalized due to symptoms of right sided weakness
and slurred speech resulting from an ACUTE HEMORRHAGIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is impaired due to bleeding. 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
We are changing your medications as follows:
Started Lisinopril, a new blood pressure medication
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 | SUMMARY:
Mr. ___ is a ___ man with a history of hypertension,
not compliant with his outpatient treatment regimen, who
presented with acute onset slurred speech and right-sided
weakness. CT at an outside hospital showed left thalamic
intraparenchymal hemorrhage with intraventricular extension. He
had not been taking his home chlorthalidone prior to admission.
He was hypertensive to SBP 170-200 on presentation. He was given
labetalol, transferred to ___, and admitted to the ICU via
the ED. A nicardipine drip was started, bringing his SBP to
130-140s. He subsequently was weaned off of the cardene drip
and blood pressures were well controlled after restarting his
home regimen of chlorthalidone and lisinopril.
HOSPITAL COURSE BY PROBLEM:
# LEFT THALAMIC INTRAPARENCHYMAL HEMORRHAGE WITH
INTRAVENTRICULAR EXTENSION
His initial exam on ___ in the ED was significant for mild
aphasia (slowed speech, occasional paraphasic errors, difficulty
understanding complex commands), and mild right-sided weakness
most prominent in the deltoids (4), wrist/fingers (~4), IP (4-),
hamstrings (4-), and TA (3). Upon transfer to the ICU, his exam
worsened with his deltoids and wrist/fingers becoming barely
anti-gravity (3). Do to this change, he was sent for a repeat CT
which was grossly stable, showing only mildly increased
surrounding edema. He was not started on hyperosmolar therapy.
This weakness improved somewhat the following day. His blood
pressures were well controlled after being restarted on his home
regimen of chlorthalidone 25mg daily and adding lisinopril 10mg
daily. At the time of discharge, his exam was notable for
dysarthria, mild weakness of right instrinsic muscles of hand
(interossei, finger extensors), and unsteady gait requiring a
walker to ambulate. He was evaluate by ___ and recommended for
rehab given his significant decompensation from his functional
baseline.
The etiology of his bleed was likely hypertensive in the setting
of not being compliant with his outpatient regimen. He had not
been taking his home chlorthalidone prior to admission.
# HYPERTENSION
His SBP on presentation to OSH was 170-200, so he was given
labetalol prior to transfer. Upon transfer here, his SBP was
~180 so he was admitted to the ICU for a nicardipine drip with a
goal SBP <150. He was on this drip at a rate of 2mcg/kg/min for
~4 hours until 9PM on ___, whereafter his SBP stablized to the
120s without nicardipine. He was monitored in the ICU for the
next ~18 hours and did not require any antihypertensives. Before
transfer to the floor, his SBP began to climb to 150s, so he was
restarted on his home chlorthalidone 25mg and we added
lisinopril 10mg.
He was transferred to the floor ~9PM on ___. After this
transfer, patient's blood pressures remained stable, SBP<150.
*******************
TRANSITIONAL ISSUES
-Continue Chlorthalidone 25mg daily and Lisinopril 10mg daily
-Once you have obtained insurance, please follow up with a
Neurologist from the Stroke Neurology division at ___. The
number for the office is ___
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes
2. DVT Prophylaxis administered? (x) Yes
3. Smoking cessation counseling given? (x) No [reason (x)
non-smoker
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes | 243 | 545 |
18641234-DS-17 | 27,325,562 | You were admitted to the hospital with lower abdominal pain and
right upper quadrant pain. You were reported to have gallstones.
You were taken to the operating room to have your gallbladder
removed. Your vital signs have been stable and you are
preparing for discharge with the following instructions:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
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
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | ___ year old female who was admitted to the hospital with lower
abdominal and right upper quadrant pain. Upon admission, the
patient was made NPO, given intravenous fluids and underwent
ultrasound imaging which showed gallbladder sludge and a large
gallstone completely filling the gallbladder. She was taken to
the operating room on ___ where she underwent laparoscopic
cholecystectomy. The operative course was stable. The patient
was extubated after the procedure and monitored in the recovery
room.
The post-operative course was stable. The patient resumed a
regular diet and was voiding without difficulty. Her incisional
pain was controlled with oral analgesia. She was ambulatory and
had return of bowel function. On POD # 1 the patient was
discharged home. An appointment for follow-up was made with the
acute care clinic. Discharge instructions were reviewed and
questions answered. | 758 | 147 |
12453404-DS-38 | 26,088,925 | Dear ,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were coughing
blood and had abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were found to have urinary tract infection as the result
of kidney stone. You were treated with antibiotics for two
weeks.
- You were given blood products as your blood levels were low
from the bleeding.
- You underwent upper endoscope, where a tube with a camera at
its end is used to examine the lining of the esophagus
(swallowing tube), stomach, and upper part of the small
intestine (duodenum).
- It was thought that the source of bleeding was your nose as a
result of recent cocaine use.
- You developed another infection in your urinary tract and we
treated you for that
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please remember to continue taking your lactulose to have
atleast 3 bowel movements per day.
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds
- Please maintain a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
or you develop
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY
=========
Ms. ___ is ___ year-old female with a history of HCV cirrhosis
(complicated by ascites, variceal bleeding, hepatic
encephalopathy), chronically infected retained left kidney
stones c/b recurrent MDR UTI for which she is not a surgical
candidate, panhypopituitarism, history of heroin IVDU, cocaine
use disorder, and type II DM, who presented with abdominal/flank
pain, fevers, hematemesis and melena. She was found to have
pyelonephritis ___ infected nephrolithiasis and with an MDR
E.coli. Her UGIB workup was unrevealing, and it was felt that
her hematemesis was ___ nose bleed ___ recent cocaine use. She
completed a course of meropenem and was started on fosfomycin
suppressive therapy, as surgical intervention was not considered
an option, discussed below. Hospital course was also notable for
the discovery of a L-femoral stress fracture and a second UTI
despite suppressive therapy.
Transitional Issues
[] Patient is often non compliant with lactulose and is high
risk for worsening HE if not having adequate BMs. Encourage
compliance.
[] Recommend following up chemistry panel within ___ days of
discharge to evaluate for ___ and electrolyte abnormalities.
Consider adjusting diuretic dosing. Discharge Cr 1.1
[] Discharged on furosemide 20mg daily for management of
ascites, did not restart spironolactone given that the patient
is taking Bactrim for a ___onsider restarting
spironolactone s/p completion of Bactrim. Would consider
decreasing Lasix from 20 to 10 when restarting spironolactone.
Would consider increasing Lasix from 20 to 40 if patient is
gaining weight or has e/o worsening ascites. Discharge weight
242.5 lbs. Discharge Cr: 1.1
[] Patient reported vaginal bleeding during hospitalization,
consider pelvic ultrasound
[] Patient will require follow up with ortho within two weeks of
discharge
[] Patient will need to be provided a medical alert bracelet
that she has adrenal insufficiency at the time of discharge from
rehab
[] Patient requires HLA matched platelets and it can take up to
days for her platelets to be obtained. Significant consideration
should be given to this if any future intervention/procedure is
planned.
[]Needs follow up MR liver to follow up AFP and AFP-L3
elevations
[]Endocrine reccs:
- will need bracelet saying she has adrenal insufficiency
- will also be discharged with a dose of stress dosed steroids
- Ensure pt gets Solu-cortef 100mg 1 vial IM prescription
(ACT-O-VIAL)at discharge with rx for BD ___ Syringe 3ml 23
gauge.
- Will require stress dose steroids under periods of increased
stress (eg infection, surgery).
==================== | 273 | 383 |
10154271-DS-15 | 25,314,369 | Dear Ms. ___,
You were recently admitted to ___
___.
Why I was here?
- You had right sided chest, back, and belly pain.
- You were also found to have high blood pressures.
What happened while I was here?
- You had a CT of your torso which showed an enlarged thyroid
but was otherwise normal.
- You were monitored on the heart monitor, which showed some
episodes of slow heart rate. Your metoprolol was decreased to
help prevent this.
- You were started on a new medication, amlodipine, to help
control your blood pressure.
- You were given a medication by IV, Lasix, to help remove extra
fluid.
What I should do at home?
- Please continue to take all of your medications as directed.
- Follow up with your primary care doctor and with the
cardiologist.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
Thank you for allowing us to care for you,
Your ___ Care Team | Ms. ___ is a ___ year old woman with history of atrial
fibrillation (on warfarin), HFpEF (EF 50-55% on ___, poorly
controlled HTN, and HLD who presented with atypical R-sided,
pleuritic chest pain, back pain, and abdominal pain.
#Atypical chest pain:
Upon presentation, patient with vaguely characterized chest pain
with associated right-sided abdominal and back pain. Troponin
was negative x2 and EKG without any changes. CTA torso was
notable for no evidence of PE or aortic dissection or any acute
abdominal processes. She also underwent a RUQ US without any
evidence of cholelithiasis or cholecystisis. Patient continued
to have intermittent R-sided pleuritic pain during admission,
mostly with movement and deep breathing, that improved with GI
cocktail.
#HTN crisis:
#Acute HFpEF (EF 50-55%)
Patient noted to have difficult to control pressures as an
outpatient despite frequent medication titrations. She had
pressures in the 190s/100s on admission. She also endorsed
dietary indiscretions prior to admission. She was also noted to
be fluid overloaded on exam. She was diuresed with 40mg IV Lasix
with some improvement in her pressures. Amlodipine 5mg daily was
added to her anti-hypertensive regimen when her metoprolol was
decreased (as below). She was then restarted on her home
torse___.
#Bradycardia:
Patient had several, brief episodes of bradycardia on telemetry.
Episodes of bradycardia reportedly correlated with brief
episodes of R-sided chest pressure. Her metoprolol succinates
was decreased from 150mg BID to ___ BID.
#Bilirubinemia:
Patient found to have elevated bilirubin upon admission. RUQ US
negative for cholelithiasis/cholecystitis and CT abd showed
signs of possible congestive hepatophaty. Patient was diuresed
(as above) and her bilirubin normalized.
TRANSITIONAL ISSUES:
=====================
#Medication Changes:
- decreased metoprolol succinate from 150mg BID to ___ BID
- started on amlodipine 5mg daily
[] Nodular thyroid enlargement seen on CT. Please work up as
outpatient.
[] Will need outpatient TTE to evaluate LVEF and valvular
function
[] Started on amlodipine 5mg daily for HTN. Please uptitrate as
needed for better BP control.
[] Pt with brief episodes of bradycardia to ___ on telemetry.
Metop succinate decreased to 100mg BID. Please monitor HR as
outpatient and consider further downtitrating metoprolol as
clinically indicated.
# CODE: DNR/DNI (confirmed)
# CONTACT: HCP: ___, ___ | 166 | 360 |
15915799-DS-3 | 23,379,432 | You were admitted to the ___ Service at ___
___ with complaints of abdominal pain and
fever. During your stay, you were given antibiotics and your
abdominal drain was replaced with a larger tube.
Drain care: Your percutaneous abdominal drain will stay in
place until its output decreases significantly. At the ___
nursing facility, your nurse should mobilize ("strip") the fluid
in the clear plastic drain tubing every few hours by holding the
proximal portion securely and using peristalsis. The drain
should always be to bulb suction. Keep the drain close to your
body and secured, so it does not fall out. Flush the drain
every 8 hours with 10 cc of normal saline. The drain should be
emptied periodically, at least daily, and its output volume and
appearance recorded. Keep a log of the output to communicate to
Dr. ___. If you see a change in the quantity or
quality of the drainage, please call the office.
Incision care: Your incision is now well-healed. You can get
water on the incision, but continue to avoid baths or swimming
until otherwise directed by Dr. ___.
Antibiotics: You should continue on the antibiotics vancomycin
and fluconazole as prescribed as long as the drain is in place.
We will re-evaluate this treatment at your office visit with Dr.
___. | The patient was admitted to the ___ Surgical Service under
attending Dr. ___ on ___. She was kept NPO
with IVF for hydration and TPN for nutrition. She was started
on vancomycin, ciprofloxacin, and flagyl for empiric coverage of
infection. Cultures were sent from her urine, blood
(venipuncture), and PICC line, which later returned as no growth
for five days.
On ___ the patient was febrile to 102.4, so blood
cultures were repeated. She had some tachycardia to 117 bpm
associated with her fever, but was otherwise hemodynamically
stable. She was started on 5 mg metoprolol IV Q6hr for
tachycardia, which was subsequently increased to 7.5 mg IV Q6hr
given persistent tachycardia, with good response. The drain was
discontinued from bag drainage and put to bulb suction and
stripped, with consequent drainage of about 100 cc of bilious
purulent fluid, from which culture was sent. Her gram stain
from her intra-abdominal fluid showed GPCs, GPRs, and yeast.
Cultures grew out coagulase-negative staphlycoccus sensitive to
vancomycin, and ___ albicans. Fluconazole was thus added to
her antibiotic regimen, and flagyl was discontinued given
empiric coverage by ciprofloxacin, which was later discontinued
after speciation.
On ___, the patient was taken to Radiology where her
percutaneous drain was exchanged for a larger tube. She
tolerated the procedure well, and the tube subsequently drained
better than previously. The output was generally bilious and
intermittently purulent. She was kept NPO (with TPN for
nutrition) and started on octreotide to decrease drain output
with the intention of resolving her leak. She had some low
grade temperatures to 101.1. She was subsequently afebrile.
On ___, she was started on sips for comfort along with
continued TPN, octreotide, and antibiotics. Medications were
switched to PO where tolerated, including metoprolol. Drain
output was around ___ cc/day, still mostly bilious and
somewhat purulent. She was given clear liquids on ___, which
she tolerated well. A vancomycin trough was noted to be in good
therapeutic ranger at 15.6.
On ___, she was started on a regular diet (which she
tolerated well) and octreotide was discontinued. Her TPN was
cycled at night from 6 pm to 6 am. She was seen by ___, and was
found to be able to stand and ambulate with contact guarding.
On ___, the patient was felt to be stable for discharge
to a rehabilitation facility for continued drain management, IV
antibiotics, and physical therapy. She was ambulating with
assistance/contact guarding, tolerating a regular diet,
urinating without difficulty, afebrile, and with minimal
abdominal tenderness. She is to followup with Dr. ___. She
understood and was in agreement with her plan of care. | 225 | 452 |
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