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16956223-DS-3 | 20,437,493 | 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:
-Nonweightbearing left upper extremity, range of motion as
tolerated
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. Okay to use
Ibuprofen instead of oxycodone to avoid opioid use in the
setting of breast feeding. 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 aspirin 325 mg daily 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 resected ___ DAYS OF
REHAB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation of
the left humerus, 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 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
nonweightbearing in the left upper extremity with range of
motion as tolerated, and will be discharged on aspirin 325 mg
daily for 4 weeks 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.
See below for OB recommendations regarding opioid use while
breast feeding. Okay to supplement with Ibuprofen at home to
wean oxycodone. | 527 | 290 |
17661745-DS-10 | 25,574,809 | Dear ___,
___ was a pleasure caring for you at ___
___. You were admitted to our Neurology service for
headaches and dizziness.
During your stay, we have treated your headaches with 3 main
medications: lidocaine patches, valium, and flexeril which you
should continue at home. We feel that you have cervicogenic
headaches related to right sided neck spasms and cervical disc
disease. You should continue to wear your cervical collar as
much as possible.
We performed a number of tests to help diagnose your headaches
and better explain the reason for white blood cells in your
initial spinal tap. Two lumbar punctures were performed on ___
and ___ and you tolerated this well. Your cerebrospinal fluid
continues to have some white blood cells, but the number has
decreased. We are still awaiting the final set of cytology
results and Dr. ___ will call you with these results. We
still do not have a clear reason for this abnormal result in
your spinal fluid and will need to continue to monitor you
closely on an outpatient basis. It is possible that you had a
subacute viral meningitis that is improving.
While you were here, you had a CT scan of your torso which
showed a 4x4cm cystic mass in your mid abdomen. Our oncologists
were involved and discussed your case at our ___ tumor board
conference. They agreed that this is most likely a benign
chylous cyst whicch should be monitored every few months with
ultrasound. There is no need for biopsy at this time. You will
follow up with Dr. ___ and this is listed below.
It is important that you take all medications as prescribed, and
keep all follow up appointments. | Ms. ___ is a ___ right-handed woman with a history of
Hodgkin's lymphoma s/p chemo/XRT, breast CA s/p b/l
mastectomies, recent bronchial carcinoid tumor s/p VATS RLL
segmentectomy (___), Meniere's disease, tension headaches,
and complex migraines - who presented with increasing dizziness
and vomiting.
Her headaches and dizziness were thought to be multifactorial
from cervical spondylosis, muscle spasms stemming from her right
paracervical muscle hypertrophy, and orthostasis. Her symptoms
were somewhat improved with increasing her use of the soft
collar, diazepam, flexeril and a lidocaine patch. Negative
studies include MRI brain with contrast.
Given her prior abnormal LP, she did have 2 subsequent repeat
LPs which redemonstrated leukocytosis: WBC19, RBC4 and later
WBC6, RBC0. Her csf pleocytosis was most likely related to
either low grade viral encephalitis/meningitis vesrus
paraneoplastic process. CT abdomen/plevis showed a cysctic
abdominal mass over 4cm in diameter. Given that carcinoid was
on the differential 5HIAA and chromogranin were tested and were
normal. Oncology was onboard and her case was discussed at GI
tumor board conference. It was felt that this cystic mass
represented a chylous cyst based on its radiographic
characteristics. No biopsy was indicated at that time. An
ultrasound was performed to verify that this is a useful
modality of surveillance in the future. She will follow-up with
her PCP, ___, and physical therapy.
There was no change in management of her chronic outpatient
issues: HLD (atorvastatin), hypothyroidism (levothyroxine), GERD
(omeprazole). | 301 | 244 |
11008298-DS-19 | 25,498,167 | Dear Mr. ___,
You were admitted to ___ with worsening weakness likely due to
recent hospitalization and initiation of dialysis. You were
evaluated by the physical therapy team who recommended rehab and
it was decided with you and your family that rehab would be the
safest place for you to work on your strength.
Please keep your follow-up appointments as below. Please return
to the emergency room if you experience fevers, chills, chest
pain, shortness of breath, worsening weakness, confusion, or any
other new or concerning symptoms.
We wish you the best,
Your ___ team | ___ with PMH HTN, HLD, CKD ___ diabetic nephropathy, CAD s/p
CABG x4, TIA x 2, Afib on coumadin, and CHF who presented to ED
with generalized weakness.
# Generalized weakness: Physical exam did not reveal any focal
deficits. Likely due to deconditioning related to recent
hospitalization and multiple comorbities as well as ? medication
effect. He is being discharged on metoprolol succinate 50 mg
daily and diltiazem 30 mg BID. IV iron was continued with HD
and patient received EPO with HD. Patient was evaluated by ___
who recommended rehab. Family meeting held on ___ to explain
to patient that he needs dialysis and also needs rehab or longer
term care as living at home represents an unsafe situation (his
wife is not able to care for him any longer). Patient has
reluctantly agreed to go to rehab. Upon screening for rehab, the
physician at prior rehab facility advised that patient likely
requires a ___ psych eval. Psychiatry evaluated patient on
___ and advised that patient has dementia and probable
narcissism. They recommended changing his paroxetine to 40 mg
QHS. He appears to have capacity and does not require a ___
psych placement at this time per psychiatry.
#ESRD: Patient did not have symptoms of uremia. He was continued
on dialysis: ___ via tunneled HD line. Patient will need hep
B vaccination. He had less difficulties tolerating dialysis with
low dose lorazepam.
# Pleural effusions: As seen on CXR. Patient was asymptomatic,
though had a new O2 requirement on admission. Patient was
continued on diuresis with bumetanide and continued on dialysis
as above. His oxygen requirement improved and he was weaned to
RA.
# Atrial fibrillation: Patient was continued on decreased dose
of metoprolol and diltiazem as above given his bradycardia on
admission. He was continued on coumadin for goal INR ___.
# Hypertension: Patient was continued on decreased doses of
metoprolol and diltiazem as above.
# DM2: Patient had FSBG checked QID. He was continue on glargine
and a humalog insulin sliding scale as well as a diabetic diet.
# Heart failure with reduced ejection fraction: Infarct-related.
Patient was continued on bumetanide, metorprolol and HD as
above.
# CAD: Patient was continued on home metoprolol.
# Depression: Patient was evaluated by psychiatry who advised
that patient has dementia and features concerning for
narcissistic personality disorder. His paroxetine was changed to
40 mg QHS. He should follow-up with psychiatry as an outpatient.
# BPH: Continued tamsulosin | 92 | 410 |
10366982-DS-12 | 26,452,453 | Dear Ms. ___,
You were admitted to the hospital because you were found to be
in an irregular heart rhythm called atrial fibrillation, with a
fast pulse. You were also found to have significant weight gain,
and found to be in congestive heart failure. Please see below
for more information on your hospitalization. It was a pleasure
participating in your care!
We wish you the ___!
- Your ___ Healthcare Team
What happened while you were in the hospital?
- Your medications were optimized to help lower your heart rate.
- You were started on Apixiban to thin your blood as you are at
risk for stroke with the rhythm of atrial fibrillation
- You had a procedure done called Cardioversion to put your
heart back into a normal rhythm
- You received a medication in your IV (Lasix) to help take
fluid off your body, which was switched to a pill for you to
take at home
- You were improved significantly and were ready to leave the
hospital.
What should you do after leaving the hospital?
- Please take your medications as listed in the discharge papers
and follow up at the listed appointments.
- It is important that you take the Apixiban regularly even
though your heart rate is back in normal rhythm.
- As you are now on another blood thinner, we have stopped your
aspirin
- Your weight at discharge is 224 pounds. Please weigh yourself
today at home and use this as your new baseline weight
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs in a day, or 5
lbs in a week.
- We have stopped your Naproxen medication as it can have
adverse effects for the health of your heart. You can use
Tylenol as needed for pain | Patient Summary:
=======================
Ms. ___ is a ___ woman with PMHx of endometrial
adenocarcinoma, HLD, HTN, LBP, obesity, osteoarthritis, stress
incontinence who was referred from her PCP's office for atrial
fibrillation with RVR. She was found to be volume overloaded
with ~15lb weight gain over the past month and diagnosed with
Acute HFpEF. She underwent TEE cardioversion ___ and started on
apixiban. She was diuresed to dry weight of 224lb and discharged
on Furosemide 40mg daily
-CORONARIES: unknown
-PUMP: LVEF >55% in ___, TTE pending
-RHYTHM: afib s/p cardioversion to NSR | 307 | 89 |
18852313-DS-10 | 28,551,224 | Dear Mr. ___,
You were hospitalized due to symptoms of weakness resulting from
an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
We feel your stroke may be coming from your heart, so we had the
cardiologists come by to place a long term heart monitor.
We are changing your medications as follows:
-STOP PLAVIX
-START APIXIBAN
-START ATORVASTATIN
-STOP SIMVASTATIN
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is an ___ old right-handed man with a history of
cerebrovascular atherosclerosis, occluded L ICA, R V1 and L P2
with recent left thalamo-occipital infarct secondary to
artery-to-artery embolus, who presents with transient aphasia,
found to have bilateral cerebellar infarcts while compliant on
Plavix.
Patient was admitted to the neurology service. He had recurrence
of aphasia in the setting of receiving nitro for atypical chest
pain, which rapidly resolved as his blood pressure increased. On
examination, his aphasia had resolved, with a stable R
hemianopsia and right-sided sensory loss. He had new right upper
and lower extremity mild weakness in an upper motor neuron
pattern distribution. He also had new bilateral ataxia, right
greater than left. CT head demonstrated prior infarct with areas
of chornic and subacute encephalomalacia with a medial
temporo-occipital hyperdensity which appears consistent with
evolution of his known hemorrhagic conversion of his recent
infarct. Patient had follow-up MRI, which showed a new acute
infarct of the left anterior superior cerebellar hemisphere with
likely late acute to subacute punctate infarcts of the left
middle cerebellar hemisphere and right anterior inferior
cerebellar hemisphere. Given these bilateral findings, there was
concern for artery-artery embolism v. cardioembolic source. CTA
of his head and
neck demonstrate stability of his known vessel occlusions.
Aspirin was added to his home Plavix and he was initially
treated with dual-anti-platelet therapy. Simvastatin was
switched to Atorvastatin. However, given high suspicion for
cardiac source, he was switched to Apixaban. Cardiology was also
consulted for placement of a LINQ device to monitor for atrial
fibrillation. LINQ was placed on ___. Stroke risk factors
were deferred given recent check. TTE was deferred given recent
study. He was seen by ___, who recommended home with ___. | 267 | 288 |
18834458-DS-18 | 29,764,943 | Father ___,
It was a pleasure taking care of you at the ___
___. You were admitted with worsening
shortness of breath and blood in your stool. We gave you a
blood transfusion, which made your breathing much better. We
also discussed your breathing problems with Dr. ___
recommended giving you a higher dose of prednisone. Please
continue taking 40 mg prednisone daily until you see him next
week (see below). Your pneumonia is improving, and you
completed your course of antibiotics whilst in hospital.
.
While you were here, we also performed a capsule endoscopy to
look for a source of bleeding in your intestines. At the time
of discharge, the preliminary report of your capsule endoscopy
revealed no source or current bleeding. You should follow up
with your gastroenterologist regarding the final report.
.
Please stop taking warfarin. Given your recent bleeding,
warfarin could be risky for you. We have discussed this with
your primary care practitioner and with Dr. ___ agree
with stopping warfarin.
.
We made the following changes to your home medications:
-STOPPED WARFARIN
-STOPPED LEVOFLOXACIN
-STARTED PANTOPRAZOLE
-INCREASED PREDNISONE to 40mg daily
.
Please continue taking your other medications as usual.
.
Please followup with your doctors, see below. | ___ year old male with a PMH notable for atrial fibrillation on
coumadin, severe emphysema/COPD on ___ at home, OSA, TIA, HTN,
HL, DMII, chronic anemia, recent discharge from the hospital 4
days prior (___) for gastroenteritis and pneumonia, who
presents with dyspnea. Hemodynamically stable and chest
radiograph without acute process.
.
# Dyspnea with exertion: Understandably broad differential, but
patient's presentation likely secondary to anemia, superimposed
on recent pneumonia (last dose of levofloxacin to be given
___ in the setting of poor substrate and end stage
emphysema. Patient is known to desat to the ___ with exertion at
home despite 4L NC. Ischemic heart disease unlikely as ECG
without acute ischemic changes and cardiac biomarkers negative,
volume overload unlikely as patient is euvolemic with wnl bnp.
D-dimer and BNP were within normal limits. Pt completed
treatment for CAP with levofloxacin (last dose ___. He was
transfused him with 1 unit PRBC on ___ and was subsequently
able to successfully ambulate with ___ without desaturation or
dyspnea. We discussed his case with Dr. ___ per his
recommendations started him on 40mg daily prednisone, since he
has responded well to short courses of prednisone in the past,
and dyspnea may represent some degree of COPD exacerbation. He
will followup with Dr. ___ discharge regarding
prednisone course and taper.
.
# Anemia: Patient with guiac positive stools and anemia. Per
PCP note, patient had guaiac positive stools in clinic This is
in the setting of recent gastroenteritis and supratherapeutic
INR. His PCP had held his coumadin and started him on a PPI
pending outpatient capsule endoscopy. His Hct did drop 3 points
overnight, but he remained hemodynamically stable. We
transfused him 1 unit PRBC on ___ with appropriate hct
bump, and improved in his dyspnea. GI was consulted, they noted
no melena, but guaiac positive brown stool in rectum. Note that
stool was coloured secondary to oral iron supplementation. Per
GI recommendations, he underwent a capsule endoscopy inhouse.
Preliminary read of the capsule endoscopy showed some
lymhangiectasias but nothing requiring intervention. Father
___ was instructed to discontinue coumadin (as had been
already recommended by PCP) given his risk of rebleeding in the
future.
.
# Community acquired pneumonia: Completed levofloxacin course
with last doseon ___. No fevers, leukocytosis, or
worsening chest radiograph to suggest treatment failure. CXR
unchanged from prior, but would expect lag time in radiographic
clearance. His dyspnea improved following blood transfusion.
.
# Atrial fibrillation: Coumadin was being held per PCP ___
CHADS2 score of 5 (HTN, age, DM, TIA). Given guaiac positive
stool, capsule endoscopy showing lymhangiectasias and risk of
recurrent bleeding, we held coumadin and instructed the patient
to discontinue coumadin until further discussion with outpt
providers. This was also communicated to his PCP. We continued
his verapamil.
.
# Acute kidney injury: Elevated BUN and creatinine in the
setting of ACE-I and diuretic usage. Will hold home lisinopril
and HCTZ for now. S/p IVF resuscitation in ED, with improvement
in BUN and creatinine. Lisinopril and HCTZ were restarted by
the time of discharge.
. | 201 | 540 |
12317887-DS-19 | 20,147,473 | Mr. ___,
You were admitted to the hospital after fainting at your
inpatient psychiatry facility. We believe the fainting was
likely due to a combination of slow heart rate from the
medications prescribed at the psychiatry facility and straining
to urinate. Your psychiatric medications were stopped. You
will return to the psychiatric facility for further follow up of
your depression. For your urinary symptoms, you should follow
up with urology as scheduled, below. For the laceration on your
nose, sutures need to be removed in ___ days. If you have any
issues, call plastic surgery as below.
MEDCICATIONS CHANGED THIS ADMISSION:
STOP propranolol
STOP prazosin
STOP quetiapine (discuss resuming this medication with your
psychiatric doctors)
START finasteride 5 mg by mouth daily | ___ year old man with a history of depression transferred from
inpatient psychiatric hospitalization following an episode of
syncope; found to have bradycardia with symptomatic pauses.
.
# Syncope: Patient admitted following a syncopal episode
without a significant prodrome, resulting in large nasal
laceration. On admission, patient was found to be bradycardic
with symptoms of lightheadedness and weakness. His propranolol,
quetiapine, and paxil were held, as they may interact to
perpetuate beta blocker effect and prolong QT. Prazosin was
also held as it may cause hypotension. He experienced a 6
second pause, complicated by lightheadedness and hypotension to
SBP in mid-___. The patient was resuscitated with normal
saline. He was seen by electrophysiology who felt that he had
bradycardia secondary to medication interaction (paxil
perpetuating beta blocker effect). Bradycardia was superimposed
on vasovagal symptoms related to micturition, as he urinated
just prior to each symptomatic episode. The patient was
monitored on telemetry throughout admission. With
discontinuation of his beta blocker, bradycardia resolved. He
did not experience symptoms with micturition following
resolution of bradycardia. He was resumed on paxil only prior
to discharge. He was also started on finasteride for his
prostate symptoms, as it does not have blood pressure effects,
and his prazosin was discontinued. The patient should follow up
with his PCP for monitoring of his heart rate as an outpatient.
He should also follow up with urology for poor stream leading to
micturition syncope.
# Depression with suicidal ideation: Patient transferred on
___ for suicidal attempt by celexa overdose. During his
admission, he continued to endorse severe depression with
passive SI. Psychiatric medications were held during admission
for bradycardia. He was discharged on paxil. ___ consider
resuming quetiapine on discharge, as normal QTC. Would NOT
resume propranolol.
# Nose laceration: Patient suffered nose laceration after fall.
He was imaged and did now show any evidence of underlying
fracture. Laceration was sutured in emergency department on
___. The patient should continue routine wound care to his
laceration. Sutures should be removed in ___ days (placed
___.
# CODE: full code
================================================================
Transitional issues:
# At time of discharge, patient medically clear to return to
inpatient psych
# would NOT resume propranolol at discharge
# patient to follow up with PCP and urology upon discharge from
inpatient admission.
# patient should have nasal sutures removed in ___ days (placed
___. If any issues with removing sutures, call plastic
surgery at ___. | 131 | 440 |
19650110-DS-13 | 21,783,576 | WHAT TO EXPECT:
- It is normal to have incisional and leg swelling; Wear loose
fitting pants/clothing (this will be less irritating to
incision) Elevate your legs above the level of your heart with
___ pillows every ___ hours throughout the day and at
night; Avoid prolonged periods of standing or sitting without
your legs elevated
- 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 Take all the medications you were taking before
surgery, unless otherwise directed- Take one enteric coated
aspirin daily, unless otherwise directed
ACTIVITIES:;
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit You may shower (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
CALL THE OFFICE FOR : ___ Redness that extends away
from your incision A sudden increase in pain that is not
controlled with pain medication Temperature greater than 101.5F
for 24 hours Bleeding from incision New or increased drainage
from incision or white, yellow or green drainage from incisions
Warfarin:
- Follow up with your Gi doctor and your PCP regarding when to
restart coumadin after your evaluation for GI is bleed is
complete. They will discuss when it is safe to restart this
medication.
Coccyx Wound care instructions:
Topical Therapy:
CLEANSE WOUND WITH NORMAL SALINE ONLY!
Pat the tissue dry with dry gauze.
Apply thin layer of antifungal criticaid to periwound skin to
protect periwound skin.
Apply nickel thick layer of Santyl gel to the open wound.
Cover with moistened (with normal saline) 2 x 2 gauze.
Then place small softsorb over.
Secure with pink hy tape.
Change daily
IV Antibiotics:
Start Date: ___
Projected End Date WAS PREVIOUSLY ___ --> Extended by at
least 3 weeks through to ___
You will need blood work after you leave the hospital to monitor
the antiobiotics regimen.
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
VANCOMYCIN / PIP-TAZO: WEEKLY: CBC with differential, BUN, Cr,
Vancomycin trough
*PLEASE OBTAIN WEEKLY CRP
FOLLOW UP APPOINTMENTS:
ID/OPAT - to be determined
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
It is important to go to all of your follow up appointments. It
is recommended that you follow up with your PCP ___ ___ weeks as
well. | Due to elevated troponins at presentation, cardiology was
consulted and recommended aspirin 81 mg daily, metop succinate
12.5 mg daily, atorvastatin 80 mg daily, Transthoracic echo to
eval for wall motion abnormality, They also recommend
consideration of warfarin initiation for goal INR ___ if ongoing
stability with bleeding issues and assurance of
close INR monitoring. The patient should also follow up with Dr.
___ at ___ Cardiology on discharge.
In terms of his on-going infection, infectious disease was also
consulted and recommend Vancomycin 1000 mg IV Q 24H and
Piperacillin-Tazobactam 4.5 g IV Q8H. His antibiotic course was
also extended from ___ to ___. OPAT will follow up as an
outpatient and the patient will require weekly blood work that
should be communicated to ___ services at ___. (See patient
instructions).
For on-going aortic graft issues, the patient will follow up in
clinic in 2 weeks with further imaging.
Due to wound on his coccyx, the patient was also seen by the
wound care nurse for recommendations. Staples from the
thoraco-abodominal incision and the groin incisions were also
removed. | 504 | 176 |
10872930-DS-34 | 22,990,996 | Dear ___ was a pleasure caring for you at ___. You were admitted
with abdominal pain which has been going on for the past 6
months but has gotten worse recently. You also had blood in
your ostomy bag. You had a CT scan that showed some
inflammation of your bowel and some blockage of one of the
arteries supplying your bowel. You were followed by the
vascular surgeons who advised that there was no need for a
surgery and recommended that you stay hydrated. You also had a
urinary tract infection which was treated during your
hospitalization.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please keep your follow-up appointments as below.
Please return to the emergency room if you experience fevers,
chills, worsening abdominal pain, inability to eat, blood in
your stools or dark black stools, or any other new or concerning
symptoms.
We wish you the best,
Your ___ team | ___ yo female with CAD s/p CABG, polymorphic VT,
diabetes,ischemic colitis s/p hemicolectomy (___), and small
bowel and colonic AVMs, ILD, PVD, admitted with abdominal pain.
#Abdominal Pain: Differential diagnosis included pain related to
chronic mesenteric ischemia vs SBO vs peptic ulcer disease vs
UTI vs GI infection. CT scan on admission showed no definite
SBO, and patient had good output from ostomy. Hepatobiliary
etiology was unlikely given normal LFTs. Pancreatitis was also
unlikely given normal lipase. Lactate was within normal limits.
CT abdomen/pelvis showed bowel wall thickening of the transverse
colon leading up to the ostomy consistent with colitis as well
as moderate stenosis of the SMA (which was stable from a prior
CTA in ___. General surgery evaluated patient in the
emergency room and recommended NPO with IVF, admission to
medicine. Cdiff and stool culture were negative making GI
infection unlikely. Vascular surgery was consulted and
recommended a CTA which showed atherosclerotic calcification of
the aorta and its branches as well as moderate stenosis of the
SMA and celiac. Vascular surgery advised that surgery and stent
placemetn was not indicated. They advised that patient's
abdominal pain is most likely related to chronic mesenteric
ischemia caused by a low flow state which was likely
precipitated by dehydration (and possibly UTI as well). Patient
received tylenol for pain control. Her diet was advanced and she
was able to take PO by the time of discharge. Nutrition was
consulted and recommended Scandishake supplements with meals.
# ? GIB: Patient reportedly had 30 mL of bright red blood in
ostomy bag per ___. On presentation to the ED, she
had brown guaiac positive stool in bag. During the course of her
hospitalization, her stools became black and guaiac positive.
She does have significant history of ischemic colitis requiring
hemicolectomy and known colonic and small bowel AVMs. It is most
likely that her ischemic colitis or AVMs are the source. GI was
called and advised that a scope would not be indicated in the
case of mesenteric ischemia. She was initially started on IV
pantoprazole BID and was transitioned back to an oral PPI. Her
hemoglobin/hematocrit were monitored closely and remained
stable.
# UTI: Patient reported a history of increasing urinary
frequency on admission. It is possible that UTI precipitated
exacerbation of chronic mesenteric ischemia. Given age and DM,
treated patient for a complicated UTI with 7 days of ceftriaxone
1 gm IV daily. Her urine culture grew E. coli which was
sensitive to ceftriaxone. Blood cultures were negative.
#Anemia: Patient has history of iron deficiency anemia, ischemic
colitis s/p hemicolectomy (___), and small bowel and colonic
AVMs visualized on enteroscopy which are all potential
etiologies of her anemia. Hct remained around patient's baseline
(29) throughout her hospitalization. She was continued on her
B12 and ferrous sulfate supplements.
# CKD: On review, pt's Cr ___ since ___. Cr remained at
baseline throughout her hospitalization. Her Cr was 1.4 on
admission. Her lisinopril was initially held and she received IV
fluids. Her Cr trended down to 1.1-1.2 with adequate fluid
resuscitation and PO intake.
#h/o Polymorphic VTach: Patient was continued on amiodarone 200
mg every other day.
#Diabetes mellitus: Patient is not on insulin or anti-diabetic
agent at home and blood sugars were well-controlled during
hospitalization on a humalog sliding scale(ranging 100-170s).
#Hypothyroidism: Patient was continued on home levothyroxine.
#CAD and PVD, HTN, HLD: Patient has a significant history of
cardiac disease. S/p CABG many years ago. She denies any chest
pain throughout the course of her hospitalization. Her home
lisinopril 5 mg PO daily was initially held given Cr of 1.4 but
was restarted when Cr trended down to baseline of 1.1-1.2. She
was continued on home simvastatin. She was started on aspirin
81 mg daily as the cardioprotective effects likely outweigh the
risk of GI bleeding.
#Rheumatoid arthritis: Patient was continued on home
prednisone. She received pain control with tylenol. She was
not requiring her home oxycodone 5 mg daily so this was
discontinued during her hospitalization. She was continued on
her home oxycodone 2.5 mg PO Q6H prn.
#GERD: Patient was initially started on pantoprazole IV BID but
was transitioned to omeprazole 40 mg PO daily. She will continue
her home omeprazole 40 mg PO BID after discharge.
#Depression: Patient was continued on home mirtazapine and
venlafaxine.
#Hyperlipidemia: Patient was continued on home statin.
# CONTACT: son ___ ___ cell ___
TRANSITIONAL ISSUES:
-Please ensure patient takes good PO
-Please monitor abdominal pain
-Please continue to address goals of care with patient and her
family (son ___ | 162 | 800 |
11595895-DS-20 | 23,858,599 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were transferred to ___ for management of an epidural
abscess.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent a surgical drainage of the abscess and
stabilization of the affected area by laminectomy and spinal
fusion. Cultures grew Methicillin-sensitive Staph. aureus, and
you were treated with IV antibiotics (cefazolin). You also
underwent drainage of a left shoulder hematoma, but cultures
subsequently did not grow bacteria. You were treated with
medications for pain control.
- You had severe constipation and were treated with medications
and enemas to help facilitate bowel movements.
- You developed vomiting in the setting of severe constipation,
leading to aspiration pneumonitis. Further work-up was not
suggestive of progression to pneumonia, and you were continued
on IV cefazolin without fevers or other signs of infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ yo F, with a PMH of Left breast carcinoma
(s/p complete resection in ___ w/ axillary node dissection, XRT
and Tamoxifen therapy ___, eczema on chronic
prednisone therapy (5 mg daily for ___ yrs), COPD, who presented
to ___ on ___ with acute onset unsteady gait and
urinary incontinence, found to have supraclavicular and epidural
abscesses for which she was transferred to ___. S/p surgical
drainage of the epidural abscess and spinal
stabilization, and on Cefazolin for MSSA+ spinal cultures.
TRANSITIONAL ISSUES
[] Follow-up with Dr. ___ in orthopedic surgery 2 weeks
post-discharge (call ___ to schedule)
[] Cefazolin and rifampin course to complete ___
[] Follow-up with OPAT for management of outpatient antibiotics
[] Remove PICC after IV cefazolin completed
[] Soft C-collar when out of bed or ambulating
[] Aspiration event early morning ___, initially on
vancomycin/cefepime/metronidazole. Patient afebrile with
downtrending leukocytosis for >24 hours prior to discharge after
de-escalating antibiotics from broad-spectrum back to cefazolin;
likely aspiration pneumonitis. If febrile or developing
worsening pulmonary symptoms, would be concerning for aspiration
pneumonia.
[] Pain control with standing Tylenol, ibuprofen, gabapentin,
lidocaine patches, oxycodone for breakthrough. Continue to wean
oxycodone and other analgesics
[] Course complicated by severe constipation in setting of
opioids and immobility. Discharging on aggressive standing bowel
regimen based on inpatient course, wean as able as oxycodone is
weaned off
[] On long-standing prednisone for eczema, potentially
contributing to skin breakdown and infections. Consider
dermatology referral, alternative regimens for eczema management
[] Home simvastatin switched to rosuvastatin due to medication
interaction
[] Home quinapril held on discharge with pressures ranging
___ in days prior to discharge. Consider resuming if
hypertensive at follow-up
[] Home metoprolol held on discharge, consider discontinuing or
switching to alternative agent if only indication is
hypertension
[] Noted to have new normocytic anemia on admission. Ferritin
726, transferrin saturation 17.7%. Hemolysis labs negative.
Retics 3.3%. Re-check hemoglobin at follow-up, consider further
work-up.
[] Started on thiamine and folic acid while inpatient given
history of frequent alcohol use. No evidence of withdrawal
symptoms or seizures while inpatient. Consider further
discussion/evaluation for possible alcohol use disorder
[] Urinary retention noted in setting of severe constipation.
Monitor post-void residuals | 183 | 353 |
18096803-DS-13 | 27,968,087 | Mr. ___,
You were admitted to the hospital with abdominal pain and
distention. You underwent a cat scan of the abdomen and you
were reported to have a small bowel obstruction. You had a tube
placed in your stomach for bowel decompression. After return of
bowel function, the tube was removed and you resumed your diet.
You are now preparing for discharge 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. | The patient presented to ___ Emergency Department on ___
for evaluation and management of abdominal pain. Pt was
evaluated by the Emergency department and the Acute Care Surgery
Team. CT abdomen showed there are multiple dilated, fluid-filled
loops of small bowel, with a transition point seen in the right
lower quadrant, consistent with small bowel obstruction. There
is no fluid or stranding seen within the mesentery, and the
small bowel wall demonstrates normal enhancement. Some proximal
small bowel appears decompressed, which may be seen in the
setting of vomiting. Based on the patients clinical findings and
the aforementioned imaging findings, the patient was
conservatively treated by placing an NG tube, made NPO and given
IV fluids for resuscitation. The NG tube provided some relief
after placement. Anti-nausea medication, zofran & scopolamine
patch for secretions/post nasal and retching was administered.
IV tylenol was given for pain control with good effect.
On HD 2, the patient was passing flatus. The NGT was clamped,
and the residuals were 50ml. The NGT was removed and the patient
was started on sips with no nausea or vomiting. The patient was
out of bed ambulating and his abdomen remained soft, nontender.
On HD 3, the patient was started on a clear liquid diet and
continued to pass flatus.
HD 4, ___, patient was given a dulculax suppository which
resulted in a BM. Patient was tolerating a regular diet without
n/v or significant abdominal distention.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV tylenol
with good effect and then transitioned to oral pain medications
once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On HD 2, the NGT
was removed; subsequently, the diet was advanced to clears on
HD3 and sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge on ___, 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. | 333 | 461 |
10614625-DS-25 | 29,597,160 | Dear Ms. ___,
You were admitted to the hospital with a small bowel
obstruction. You were managed non-operatively and had a tube
placed in your nose into your stomach to help decompress your
abdomen. Your obstruction resolved on its own and the tube was
removed. You are now having bowel function, tolerating a
regular diet, and your pain is better controlled.
You were also diagnosed with acute sinusitis, an infection of
your sinuses which can cause facial pain and fevers. You were
started on an antibiotic called Azithromycin and will be
discharged with a prescription.
You are now medically cleared to be discharged home to continue
your recovery. Please note the following discharge
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Ms. ___ is a ___ year-old female with a history of multiple
previous abdominal surgeries who presented this admission with
abdominal pain and emesis. CT abd/pelvis revealed a small bowel
obstruction with a transition point in the right lower quadrant
adjacent to ventral hernia repair mesh. She was made NPO, had a
NGT placed to low continuous wall suction and started on IVF.
On HD1, the patient passed flatus and had minimal NGT output, so
her NGT was removed. Her admission EKG showed new ST depressions
in the anterior, left axis and troponins were sent which were
negative. CXR was unremarkable.
On HD2, the patient was advanced to a regular diet which was
well-tolerated. The patient was ordered oxycodone for a
migraine. The patient was later febrile to 103, urinalysis,
urine culture and blood culture were ordered. There was no
leukocytosis. CXR was unremarkable.
On HD3, the patient reported facial and ear pain and she was
diagnosed with acute sinusitis. Given her allergy to
penicillin, she was started on Azithromycin. The patient has a
history of migraines and PO fioricet prn was started. A social
work consult was placed to address her current housing and
coping issues.
On HD4, the patient was again febrile to 103 at night time and
she received acetaminophen with good effect. On HD5, the
patient reported her facial pain had greatly improved, was
afebrile and reported no abdominal pain. She had a bowel
movement and was passing flatus.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with po oxycodone and acetaminophen.
Oxycodone was discontinued as she reported her pain had
improved. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. The patient
remained stable from a pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
The patient's intake and output were closely monitored. The
patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge with the aid of
___ interpreter services. Teaching and follow-up
instructions were discussed with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
scheduled with the patient's Primary Care Provider. | 338 | 439 |
17732432-DS-4 | 25,214,249 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute uncomplicated
appendicitis. The patient underwent laparoscopic appendectomy,
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 liquids,
on IV fluids, and oral analgesia for pain control. The patient
was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
.. | 729 | 189 |
13069558-DS-14 | 24,910,206 | You were admitted to ___ after a fall while intoxicated. You
were found to have a very small intracranial bleed. Neurosurgery
was consulted and they recommended a repeat head CT scan, which
showed a slight increase in the hematoma however your exam
remained stable and there was no intervention needed. The blood
will be reabsorbed on its own. You were also treated for alcohol
withdrawal. You are now stable and medically cleared for
discharge home. Please note the following discharge
instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms | Mr. ___ is a ___ year old male with history of alcohol abuse
s/p a mechanical fall with CT demonstrating SDH/SAH.
Neurosurgery consulted for left frontal lobe
contusion/SAH. Patient received 2 units of platelets while in
the ED. Patient was admitted to the TSICU under the ACS service
for continued care and management of ETOH withdrawal. Patient
had a repeat CT Scan that showed evolution of the left frontal
SAH/contusion however his neurological exam remained stable and
unchanged. The patient was started on the phenobarb taper for
withdrawal. He was transferred out of the TSICU in stable
condition.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, had a stable
neurological exam, and denied pain. 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. | 220 | 215 |
19567431-DS-16 | 28,414,700 | You were admitted with severe abdominal pain, nausea, inability
to take food or liquids. You were treated with IV fluids, bowel
rest, and anti-nausea medicatons. You also responded well to IV
tylenol. The GI team recommended a colonscopy. This showed a
normal appearing colon and terminal Ileum (this is the area
where ___ tends to show up.) You were started on Levsin
before meals and your diet was advanced slowly. You can
continue to work with your physicians on the Irritable Bowel
Syndrome.
You were noted to have white plaques on the inside of the mouth
that are painful. You can continue the nystatin and the
lidocaine for comfort. Please follow up with dermatology to
evaluate further next week. | ASSESSMENT AND PLAN: ___ with IBS presenting with RLQ pain and
possible colitis on CT scan
pt was given IVF, pain medication, and anti-emetics. She was
evaluated by the GI consult team. Due to 2 months of RLQ pain,
poor po intake, weight loss, and hx of being treated empirically
for IBD the GI service recommended a colonscopy. The pt
underwent ___ prep and colonscopy. It was determined that she
had a normal scope. Her symptoms are most consistent with
severe irritable bowel syndrome. She was started on levsin TID.
She was seen by nutrition for help with following a low residue
diet and recommended to have daily ensure supplement. She was
able to take much better PO and was discharged to home in stable
condition.
Pt will f/u with pcp, ___.
In addition, pt was noted to have mouth pain and B white plaques
on the buccal surfaces. The etiology of this was unclear. Pt
has been taking nystatin. She will continue to do so and is set
up to see dermatology next week for further evaluation for these
lesions.
Pt was otherise continued on her home medications for
--anxiety
--HTN
--chronic knee pain | 126 | 202 |
14177696-DS-7 | 23,167,691 | Dear Mr. ___,
You were admitted to the hospital because you had constant
abdominal pain that required high doses of pain medications. You
had a CT scan and ultrasound of your abdomen which did not show
anything abnormal in the location of your pain other than the
dissection of an artery that was previously known to be there.
The CT did show a large dilated loop of bowel. You underwent a
barium enema which did not show any obstruction in the colon and
again showed the dilated loop of bowel. You were seen by
gastroenterology and general surgery. Since you were able to eat
and have bowel movements, they did not think that the dilated
loop of bowel was significant.
Although we do not think your bleeding is related to the pain,
it is very important you follow up with Dr. ___ so that
you can have a colonoscopy to evaluate your bleeding with bowel
movements.
It was a pleasure taking care of you during your stay in the
hospital.
Very best wishes for the new year.
Your ___ Team | ___ yo man with history of bipolar disorder, known R iliac
dissection, volvulized hiatal hernia s/p gastrectomy,
splenectomy, cholecystectomy in ___, who presents with RLQ
abdominal pain.
# Abdominal pain: Patient reported abdominal pain intermittently
for 6 months prior to admission but typically lasting only 15
minutes, unlike the episode that brought him into the hospital.
In house he initially required high doses of opiates but pain
then remitted, but did occur again intermittently. Pain was very
specifically localized to RLQ, close to McBurney's point, with
rebound tenderness. CT abdomen/pelvis showed no pathology in
that area but did show distended loop of bowel in LUQ. Given
severity of pain and concern for peritoneal signs, imaging was
discussed extensively with radiology and patient was evaluated
multiple times by general surgery. Per surgery recommendations
he underwent barium enema which did not successfully opacify
this dilated loop; final radiology read was concerning for cecal
volvulus. General surgery again evaluated the patient. As pain
had resolved, and he had good signs of normal bowel function
(tolerating PO, passing gas/stool), the dilated loop was felt
not to be clinically significant. Furthermore its location in
LUQ was far removed from where he reported the pain. He was seen
by GI who suggested consideration of median arcuate ligament
syndrome given significant recent weight loss, and recommended
outpatinet colonoscopy for follow up of his BRBPR (see below).
Patient improved clinically and was discharged home with strict
return precautions for return of his pain.
# Bright red blood per rectum: Patient reported intermittent
episodes of painless small volume BRBPR approximately once per
week for past 6 months. In house his hemoglobin remained stable
and he did not have any active bleeding. He was seen by GI who
did not think this was related to his abdominal pain. He is
recommended to have outpatient colonoscopy to further evaluate
as soon as possible.
# Pyuria: Patient was found to have pyuria on admission. He has
had prior UTI as well as culture-negative pyuria in the past. He
denied urinary symptoms and urine culture was negative. He was
treated with cipro/flagyl as above for abdominal pain.
# Transaminitis: On admission patient had mild transaminitis.
This resolved after one day. Hepatitis serologies showed Hep B
immune, Hep A and C negative.
# Benign prostatic hyperplasia: Patient missed one dose of
Flomax on admission and had foley placed for urinary retention.
Flomax was restarted and foley removed uneventfully.
# Right iliac dissection: Per chart review patient has known
dissection of right iliac artery which has been present since
___. He was seen by vascular surgery who felt this was unlikely
to be related to his pain. He is recommended to follow up with
vascular surgery as an outpatient for possible elective repair.
# Bipolar disorder: Patient appeared euthymic with no evidence
of mania in house. Continue lamotrigine and fluoxetine.
# HLD: Continued home statin, ASA.
# S/p gastrectomy: Continued home vitamin B12 and vitamin D3.
Patient refused cholestyramine.
# Social: Patient is recently divorced and currently living in a
tent. Intermittently he stays at ___ house or showers
there. SW discussed this extensively with patient and confirmed
details with ___. He has extensive winter camping experience
and appropriate winterized gear. He declined shelter resources
as it is his preference to stay in his tent. Patient and family
were comfortable with plan to discharge to his tent.
# CODE: Full
# CONTACT: ___ ___ | 175 | 560 |
13496926-DS-15 | 26,764,844 | Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted for treatment of Influenza, Pneumonia, and Urinary
Tract Infection. In the course of your hospitalization, you
finished the appropriate courses of antibiotics for each
infection.
Since this infection has led to decreased strength and mobility,
we recommend that you be transferred to rehab for further
physical therapy.
We wish you a speedy recovery!! | BRIEF HOSPITAL COURSE:
====================================
___ w/ PMH of Afib, Parkinsons, HLD who presents with 1 week of
worsening dyspnea and cough, found to have influenza A (s/p5days
tamiflu) c/b RUL infiltrate concerning for concomittant
bacterial pneumonia (s/p 7days levaquin) as well as UTI (s/p 3
days cefepime) who is now w/ improved respiratory status off
oxygen supplementation and is being discharged to rehab for
continued ___ given deconditioning. | 73 | 66 |
15184449-DS-6 | 28,702,365 | You were admitted to ___ for a trauma. You were taken to the
operating room to place a chest tube and wash out a wound which
was closed with 2 vac wound black sponges.
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 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. Do not showere with
your wound vac dressing, when the sponge is off, you may let
water run over the open wound. | The patient presented to Emergency Department on ___ after a
fall off of a ladder. Given findings upon evaluation, the
patient was taken to the operating room for Right flank wound
wash out in and placement of chest drain and wound VAC.
There were no adverse events in the operating room; please see
the operative note for details. Patient was extubated, taken to
the PACU until stable, then transferred to the ward for
observation. On ___ the patient had good oral intake with good
urine output and was transfered to the floor with chest drain
under waterseal. On ___ the patient had a wound vac dressing
change in the operating room with Dr. ___ was tolerated
well without complications and no issues postoperatively.
On ___ the Chest tube was removed and follow up with a chest
XRAY which showed no pneumothorax. The PCA was also dicontinued
and an oral analgesia regimen was started. On ___ the
patient was doing well and his wound vac for home was ordered.
On ___, the patient tolerated a wound vac dressing change on
the floor. Patient tolerating a regular diet, ambulating
independently and voiding on his own. Pain well controlled.
Patient has no complaints and is comfortable for discharge home
with services.
Throughout the patient's hospitalization the patient was alert
and oriented;
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. The patient's fever curves
were closely watched for signs of infection, of which there were
none. The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 305 | 333 |
18354956-DS-4 | 21,752,251 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted because of an area of bleeding
in your liver after your recent biopsy. We gave you blood
transfusions and our interventional radiology team was able to
locate the bleeding blood vessel and embolize it. Please follow
up with your oncology team as planned for your port placement
and cancer treatment.
Sincerely,
Your ___ Care Team | PRINCIPLE REASON FOR ADMISSION:
___ is a ___ yo man with newly diagnosed metastatic
esophageal SCC to the liver, who presented as a transfer from
___ with subcapsular hepatic hematoma and acute on
chronic anemia (hgb 6 from baseline 7) after ___ liver biopsy
___. He received 2 units pRBC and underwent ___ guided
angiogram and embolization on ___. He tolerated treatment well
with stable HCT after the procedure.
# Subcapsular hepatic hematoma in s/o liver biopsy ___
# Acute on chronic anemia
# Sinus tachycardia
- Patient received 1 unit at ___ prior to transfer where
CT scan confirmed "new mild to moderate subcapsular
hemoperitoneum likely
secondary to a small 5 mm pseudoaneurysm in the posterior
branch of the right hepatic artery". He received add'l 2 units
pRBC on admission and HCT remained stable. He underwent
angiogram with gelfoam embolization on ___ and was monitored
overnight with stable HCT.
# Newly diagnosed metastatic esophageal SCC
Established care earlier this week with Dr ___. He is
scheduled for outpatient POC scheduled ___ and med onc follow
up on ___.
# Thrombocythemia, stable- suspect in s/o malignancy. ___
consider further hematologic workup on nonurgent basis.
# HTN: Fractionated home metop succinate 25 daily to metop
tartrate
12.5. Resumed home dose on discharge.
# Low back pain: Ran out of gabapentin ___ days ago. Declined to
continue as
inpatient. ___ resume as outpatient non-urgently.
# Billing: >30 minutes spent coordinating this discharge plan | 69 | 226 |
14795148-DS-17 | 27,642,525 | Dear Mr. ___,
Thank you for choosing us for your care. You were admitted for
shortness of breath. We did a chest X-ray and found some fluid
surrounding your right lung. We gave you IV doses of the
diuretic Lasix to help you urinate out excess fluid. You
reported feeling better.
Going forward, you should have your care facility do a standing
weight at least once a week and you should call your doctor if
your weight goes up more than 3 lbs. This likely means that you
are retaining fluid, which can again cause you to become short
of breath. You should also have the doctor at your facility do a
lung exam weekly to check for fluid accumulation in the lungs.
We have made the following changes to your medications:
Please CHANGE your dosing of Lasix from 20 mg daily to:
Lasix 20 mg daily except on ___ and ___ to take 40 mg
daily
Otherwise there have been no changes to your medications. | ___ y/o gentleman with h/o diastolic heart failure (diagnosed in
___ who presents with 2 weeks of worsening shortness of breath
diagnosed as CHF exacerbation. Diuresed with IV Lasix several
doses with improvement of SOB. Discharged on furosemide 20 mg PO
DAILY 40 mg daily on ___ and ___ only, otherwise 20 mg
daily.
ACTIVE ISSUES
# Dyspnea: He has known diastolic heart failure and had a recent
CHF exacerbation in ___ of this year in the setting of a
pneumonia. There were no clinical or radiographic signs of
pneumonia. He had no chest pain and the EKG was not suggestive
of acute MI; however, we ruled out MI to be cautious (his
troponin was elevated at 0.5 but this is baseline for him).
There were no signs of acute renal failure (creatinine stable at
1.0). He Recieved IV furosemide in ED and serial diuresis with
same on floors. At discharge, changed home furosemide regimen to
Furosemide 20 mg PO DAILY 40 mg daily on ___ and ___
only, otherwise 20 mg daily.
# Pleural Effusion: Recurrent right-sided pleural effusion, most
likely from CHF. Thoracentesis in ___ of this year during last
CHF exacerbation; 1L of transudative fluid was removed. It was
decided not to perform thoracentesis because he was saturating
well on RA and symptomatically improving with diuresis.
INACTIVE ISSUES
# BPH: stable, continued finasteride and tamsulosin.
# Hypothyroidism: stable, continued levothyroxine.
# GERD: stable, continued omeprazole.
# Osteoporosis: stable, continued calcium, vitamin D, weekly
aledronate.
TRANSITIONAL ISSUES
# Change furosemide regimen to ___ cycle | 160 | 248 |
12520179-DS-14 | 21,824,662 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had anemia (low blood counts),
and we were concerned that you had a bleed somewhere
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We stopped your rivaroxaban, which puts you at a higher risk
for bleeding
- The GI specialists did a scope procedure to look at your
stomach and small intestines (enteroscopy) and your large
intestines/colon (colonoscopy). they did not find a clear
bleeding source to explain your anemia, but they did find some
abnormalities that they took care of.
- We watched your blood counts to make sure they didn't drop
further, and they remained around the same level while
hospitalized, which was reassuring.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It's especially important to not take your rivaroxaban
(Xarelto) until you talk to your cardiologist or primary care
doctor.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
====================
[] Rivaroxaban held in setting of likely GI bleed. Given her
CHADSVASc score of 5, consider restarting after a discussion of
the risks and benefits of AC if her H/H remains stable. If she
is amenable, she may be a good candidate for a Watchman device.
[] Would recommend a follow-up CBC in office to monitor for
continued stability of H/H within 1 week of discharge | 192 | 67 |
14381451-DS-20 | 26,865,646 | Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital due to bloody vomit
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received three blood transfusions and underwent an
endoscopy to try and locate the source of your bleeding. An EGD
on ___ did not show any evidence of bleeding but did show small
esophageal varices and portal hypertensive gastropathy.
- You had 3 separate paracenteses, draining ~14 L of fluid.
- You received antibiotics to prevent against any infection.
- You received medications to help you have regular bowel
movements.
- You received lab work to monitor your blood counts.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- We have given you five doses of oxycodone for pain and
promethazine for your nausea.
- It is important for you to have regular bowel movements
(ideally at least ___. You can take over-the-counter
medications like senna and miralax, or you should take Miralax.
You can also try drinking prune juice.
- Please follow up with all the appointments scheduled with
your doctor. It is especially important for you to follow up
with your liver doctor as scheduled, as they will tell you when
to restart your very important diuretics (water pills).
- Your discharge weight is: 65.68kg (144.8lb)
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | TRANSITIONAL ISSUES
===================
[ ] The patient has not had a colonoscopy in the past. Consider
outpatient colonoscopy for patient for continued workup of
possible slower LGIB.
[ ] The patient has an outpatient GI follow-up appointment with
Dr. ___ on ___. She can restart her torsemide and
spironolactone after this appointment if Dr. ___ make
any changes to these medications. | 284 | 59 |
14659650-DS-6 | 22,616,544 | It was a pleasure providing care for ___ during your
hospitalization. ___ were admitted to the hospital for an
arrhythmia called Atrial Fibrillation. ___ were seen by the
heart doctors. ___ were given a heart rate medicine called
Metoprolol and a blood thinning medicine called Coumadin. ___
also had a cardioversion procedure performed to restore your
heart rhythm to normal sinus rhythm, which ___ tolerated well.
Please be sure to follow up with your cardiologist as an
outpatient.
Your red blood cell counts were found to be elevated. It is
possible that ___ have sleep apnea, a condition where people
snore while sleeping and have breathing pauses while sleeping.
We recommend that ___ see a pulmonologist as an outpatient and
obtain a sleep study to determine this. If ___ have the
condition, it can be managed with a nighttime breathing machine.
___ were found to have a lung nodule in your lung. This might
just be from your sarcoidosis but it will be important to
consult a pulmonologist for further evaluation.
Medication Changes: ___ already have the Coumadin medication at
the pharmacy.
STOP: amlodipine- instead we are starting ___ on Metoprolol that
will both help your blood pressure and heart rate
START: Metoprolol 50mg XL - this is important for controlling
your heart rate and blood pressure | ___ with hx of sarcoidosis & HTN presents with new onset atrial
fibrillation and incidental lung nodule on CT workup.
# Atrial Fibrillation: The patient was admitted for evaluation
of her new diagnosis of atrial fibrillation. The results of
lower extremity ultrasound was negative for DVT and CTA did not
demonstrate PE despite elevated D-dimer to 1187. She had two
serial troponins that were <0.01. TTE ECHO demonstrated mild
LVH, LEVF 45%, moderate mitral regurgitation, mild LV
hypokinesis. Recent TSH was within normal limits. She was
started on Warfarin therapy for a CHADVASC Score of 4 (female,
age >___, CHF, hx of HTN) as an inpatient. Atrius cardiology
followed her throughout her hospital course. She was initially
managed with metoprolol titrated to 50 mg daily, however she
continued to have episodes of tachycardia to the 150s with
ambulation. She was then switched to diltiazem 60 mg TID. After
failure of rate control via diltiazem, a conversation was
started regarding the option of TEE cardioversion. She underwent
successful TEE cardioversion on ___ and was continued on
Coumadin therapy without heparin bridge per Cardiology recs (as
there was no evidence of thrombus on TEE). It was felt that
patient's atrial fibrillation and polycythemia may be secondary
to undiagnosed obstructive sleep apnea, especially given her
body habitus. It was recommended that she obtain a sleep study
as an outpatient.
#New onset cardiomyopathy: Pt had TTE on this admission
demonstrating new heart failure: EF 45% with mod mitral
regurgitation and mild LV hypokinesis. It was felt that this
might be a tachycardia induced cardiomyopathy that might
resolved with control restoration of sinus rhythm. She was
discharged on metoprolol XL.
--> Consider starting ACE-I if BP tolerates as outpatient
--> Repeat TTE in 3 months to assess for resolution of LVEF
# Pulmonary Nodule: She had an incidental finding of a pulmonary
nodule on CT evaluation in the right upper lobe. Unclear
etiology presently, possibly result of sarcoid vs. malignancy
(hx of smoking) vs. benign nodule. Pt denies current symptoms of
cough, hemoptysis, no evidence of effusion/PTX on imaging. She
has been advised to follow-up with her pulmonologist for further
evaluation as an outpatient.
# Polycythemia: A review of previous labs reveal a steady upward
trend in HCT. On admission, her HCT was 51, followed by 49 on
___ and 50.4 on discharge (___). This is likely secondary
polycythemia, possibly from undiagnosed OSA. While pt does have
sarcoid, she has no known involvement of lung other then hilar
LAD. Etiology of polycythemia unclear at this time and will
likely require ___ work-up to differentiate between
polycythemia ___ vs. secondary causes.
#Hypertension: The patient has a history of mild hypertension on
Amlopidine. After Cardiology input, her amlodipine was stopped
and she was switched to Metoprolol 50 mg for both rate control
and blood pressure control.
# Sarcoidosis: she has a known history of sarcoidosis with
mediastinal LAD. Actively followed by pulmonology and PCP as
___. Not an active issue presently. | 213 | 490 |
17918651-DS-7 | 29,522,582 | Dear Ms. ___,
You were admitted to the hospital with severe back pain. We
found that this was due to fractures in your spine and tailbone.
We did some additional imaging and testing to determine the
cause of the fractures which was pending at the time of your
discharge. Please follow up with your primary care doctor and
hematologist for additional testing and treatment. Please set up
a followup appointment with an endocrine doctor for your
osteoporosis.
It was a pleasure taking care of you, best of luck.
Your ___ medical team | Summary:
___ w/COPD, osteoporosis (reportedly s/p bisphosphonate
treatment several years ago) s/p lumbosacral bone cement ___
years ago who presents with one month of worsening low back pain
found to have bilateral sacral insufficiency fractures and
bilateral L5 transverse process fractures. | 89 | 41 |
15904363-DS-16 | 22,940,705 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time. Your last dose of Keppra will be on ___ at 8pm.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
You had a facial laceration that was repaired at an outside
hospital before being transferred to ___
___. Most of the sutures were removed but a few were
left behind. You will need to have the remaining sutures
removed, which can be done at your rehab facility. | # TBI
Mr. ___ is a ___ year old male with history of glaucoma who had
an unwitnessed fall with LOC on ___. He was transferred to
___ ED from an OSH with facial fractures, left tSAH that had
expanded on OSH repeat CT. OSH CTA was negative for vascular
abnormality. He was admitted to Neurosurgery and started on
Keppra 1000mg BID for one week. His goal serum sodium was above
140 with plans to start hypertonic saline as needed. On ___,
he was taken for diagnostic cerebral angiogram, which was
negative. His right radial artery was used for access. Following
the procedure, he boarded in the PACU as he was ICU status and
there was no ICU bed availability. His neurologic exam remained
stable with continued receptive and expressive aphasia. On ___,
he was transferred to the ___ where he remained stable
overnight with slightly improving aphasia the next day. On ___,
he was made floor status and his sodium checks were liberalized
as his serum sodium was consistently >140 without medical
intervention. His sodium goal was liberalized to normal on
___. Last dose of Keppra is ___. Patient remained stable and
was discharged to rehab on ___.
#Facial fractures
Patient presented to the OSH with a facial laceration that
required suturing. He presented to ___ with sutures in place.
Most of the sutures were removed while inpatient, but two were
left in place that will need to be removed either by rehab or
PCP. While in the ED he was evaluated by trauma surgery and
plastic surgery for facial fractures. Plastic surgery did not
feel the patient required surgical intervention, and recommended
conservative management with sinus precautions x two weeks and
follow-up as needed. ACS performed a tertiary survey during his
admission - and did not feel he required further ACS
interventions. While in the ED, the patient became increasingly
aphasic. Repeat NCHCT was stable.
#Syncopal workup
Patient was given a syncopal workup while inpatient for cause of
unwitnessed fall. Workup included an ECHO, which cardiology felt
there was no structural reason for a syncopal episode but
recommended following up outpatient for a cardiac MRI. Patient
was instructed to follow up with his PCP to order this MRI (PCP
is ___.
#Discharge
___ and OT evaluated the patient and recommended discharge to
rehab. SLP was also consulted and recommended continuation of
therapy at next level of care. | 468 | 397 |
18540662-DS-14 | 28,812,805 | You were admitted with for a urinary tract infection which
caused your blood pressure to drop. You improved with IV fluids
and antiobiotics. A urine culture was positive for the bacteria
Pseudomonas. You are currently being treated with the
intravenous antibiotic cefepime. Final drug sensitivity results
will not be available until ___. We will contact your
facility to notify them of the results - you may be able to take
oral antibiotics thereafter. You should continue to take
antibiotics through ___ to complete a 10 day course. | ___ male with PMH of multiple sclerosis and left hemispheric
stroke presenting from nursing faciltity with fevers, and AMS,
found to have UTI on UA.
.
# UTI/Sepsis: Pt with history of VRE UTI in ___ which was
treated with linezolid. Pt at increased risk of UTI given his
neurologic deficits, and condom-cath use. UA showed 104 WBC,
nitrate positive, large leuks, few bacteria. Patient was
empirically started on linezolid in the ED. Transferred to the
FICU for elevated lactate and possible hypotension. In the FICU,
patient was continued on linezolid and started on cefepime for
gram negative coverage. Urine culture grew Pseudomonas. Patient
rapidly improved and was transferred to the general medical ward
on ___ ___. Linezolid was stopped. Cefepime was continued.
Final sensitivity results are pending at the time of discharge.
A midline was placed on ___. He should continue antibiotics
through ___ to complete a 10 day course. Once final
sensitivity results are available, these will be communicated to
SNF (may be able to switch to oral antibiotics).
.
# Fever/AMS: Most likely explanation is from UTI. Pt at
increased risk of UTI given his neurologic deficits, and
condom-cath use. CXR unremarkable for pneumonia. No obvious
skin/soft tissue source. Meningitis may be considered given
fever/AMS, but no meningeal signs. No focal signs of infection.
Linezolid was given to cover for MRSA UTI, given history, and
Cefepime was started to cover for gram negative bacteria.
Patient remained afebrile throughout his stay in the ICU and
general medical ward. His mental status returned to baseline
(alert and oriented x3).
.
#Borderline hypotension: Patient with SBP in the low 100s, down
to 80, but responsive to fluids. Bolused 3L IVF in the FICU.
Lactate decreased steadily from 3.1->2.6->1.2. Cause presumably
the UTI, which is being treated with linezolid and cefepime.
SBPs reportedly in the 110s to 120s as an outpatient. On
transfer to the floor, patient was with a blood pressure of
110/69.
.
# MS: Seen in neurology clinic in ___ at which point it was
recommended that he continue Betaseron injections without any
changes in management. Betaseron was held injections in setting
of acute infection. Outpatient neurologist Dr. ___ was
contacted by phone, and agreed with holding interferon during
this admission.
.
# History of Left sided stroke: Pt with residual right sided
hemiparesis and spasticity. Continued baclofen.
.
# Atrial fibrillation:: Pt found to be hypotensive and in A.fib
w/ RVR requiring MICU transfer during hospitalization in ___.
He was started on amio and coumadin, though the coumadin was
d/c'd in ___ and he remains on amio. Here in NSR. Held amio
in the setting of hypotension, but then restarted.
.
# Hypokalemia: repleted K here. Recommend following potassium
levels and repleting as needed.
# Depression: Continued abilify and fluoxetine. Monitored for
Seratonin syndrome in setting of linezolid.
.
# Hx of seizure: continued home keppra.
.
# Code: Pt would like chest compressions/shocks, but does not
want to be intubated
TRANISITIONAL ISSUES
1. Will f/u urine culture final sensitivities on ___ and
will communicate results to his facility. ___ be able to switch
to oral antibiotics.
2. Should complete a 10 day course of antibiotics (through
___.
3. Follow potassium level and replete as needed. | 87 | 528 |
10628620-DS-8 | 28,959,959 | Dear Mr ___,
You were admitted to the hospital because you had an infection
along your jaw and eye. The infection was drained and you were
treated with antibiotics. With treatment, your condition
improved and you will now be discharged home to continue a
course of oral antibiotics.
Medication Changes:
- Antibiotic: ciprofloxacin and clindamycin
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team | ___ is a ___ year old man with a history of
well-controlled HIV and recurrent complicated MRSA abscess and
SSTI who was admitted with facial abscesses.
# Right Mandibular Abscess/Cellulitis
# Right Periorbital Abscess: Patient has a history of
complicated MRSA SSTIs. Presents with similar right periorbital
abscess and right mandibular abscess after picking at his skin.
In the emergency department started on IV clinda and underwent
I&D. Wound cultures were not obtained at that time. He did not
improve while in ED obs, and so was admitted and subsequently
started on vancomycin and augmentin, and then vancomycin,
ceftriaxone and metronidazole. ENT was consulted for further
wound assistance, and recommended BID wick dressing changes.
Wound swab demonstrated MRSA and pan-sensitive Enterobacter. CT
scans of the neck and face demonstrated right mandibular abscess
and right periorbital abscess. With treatment, his condition
improved and he was eventually transitioned to ciprofloxacin and
clindamycin on discharge, for a total 14-day course. By day of
discharge patient had improving clinical exam, was afebrile and
tolerating regular diet. He will do dressing changes at home.
He was referred to follow up with his PCP and allergy/immunology
for possible innate immunodeficiency.
# HIV: Patient was continued on his home ARV regimen.
# Depression: continued home citalopram
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will be on ciprofloxacin and clindamycin on
discharge, for a total 14-day course. By day of discharge
patient had improving clinical exam, was afebrile and tolerating
regular diet. He will do dressing changes at home. He was
referred to follow up with his PCP and allergy/immunology for
possible innate immunodeficiency. Please consider outpatient
staphylococcal decontamination for recurrent MRSA abscesses.
Time spent coordinating discharge > 30 minutes. | 111 | 282 |
19346354-DS-11 | 21,971,504 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
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
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.
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
Physical Therapy:
WBAT LLE
Daily ___
Treatments Frequency:
___ daily | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hemiarthroplasty, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The hospital course was also notable for the
development of urinary burning and incontinence; UA showed a
UTI, for which the pt was started on a 3 dose q48h course of
fosfomycin. She also required 2u PRBCs but Hct was stable by the
time of discharge 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
WBAT 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. | 261 | 298 |
15310448-DS-9 | 22,968,265 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you were unsteady while walking. We evaluated you, along
with psychiatrists and neurologists, and did not find an
explanation for your unsteadiness. You are medically stable to
continue to get psychiatric care. Please continue to eat and
drink well and work with your psychiatric doctors towards
___.
Best wishes,
Your ___ Medicine Team | HOSPITAL COURSE: Ms. ___ is a ___ with PMH signficant for
catatonia, bipolar disorder, schizoaffective disorder per
records, who presents from ___ inpatient psych for
medical evaluation of unsteady gait, thought likely functional
by neurology after examination and reassuring CT and MRI head,
who was found to be medically stable for inpatient psychiatric
treatment. | 68 | 55 |
17083786-DS-5 | 26,379,375 | Dear ___,
___ was a pleasure caring for you at ___. You were admitted for
coughing and a new blood clots in your lung.
To treat your blood clot, you will be treated with a blood
thinner called "Rivaroxaban" twice daily for 3 weeks (then your
cardiologist will change the dose).
For your coughing, you were evaluated with swallowing studies,
which did not show any serious problems.
Please take all of your medications as prescribed. Please
followup with all your physician ___. | ___ year old female with past medical history of HLD, HTN,
hypothyrodisim s/p thyroidectomy presented to physician's office
with complaints of paroxysmal coughing following ingestion of
solids and dysphagia. CTA done and showed multiple pulmonary
emboli and patient was referred to ___ ED. Patient was started
on heparin drip for the pulmonary emboli. She underwent barium
and swallow study for complaints of paroxysmal coughing
following ingestion of solids. Tests failed to show evidence of
aspiration or obstruction. Patient was discharged home on
rivoraxaban anticoagulation for the pulmonary emboli. Her
hospital course is summarized by problems below:
# Pulmonary embolism: Patient found to have RLL subsegmental
pulmonary arterial pulmonary emboli on CTA scan with
questionable PE in R pulmonary artery. On presentation to
hospital patient was hemodynamically stable, saturating well on
room air, with no complaints of SOB. Etiology of the pulmonary
emboli were unclear. Patient denied recent travel, hormone
therapy, and had a negative mammogram earlier this year and
negative colonoscopy in the past. Patient was started on heparin
drip on admission. She was discharged home on rivoraxaban.
# Dysphagia: CTA of thorax showed evidence of patulous esophagus
raising concern for an underlying connective tissue disorder.
Patient denies ophynophagia.Patient previously had barium
swallow in ___ which showed small hiatal hernia and tertiary
esophageal contractions. Video oropharyngeal swallow was normal.
Barium swallow showed small hiatal hernia below tortuous,
dilated esophagus without evidence of
obstruction. Patient tolerated po intake during this admission.
# UA with leukocytosis: Patient was asymptomatic. UA with large
leukocytes, negative nitrites, and no bacteria. Patient received
ceftriaxone in the ED. Final urine culture contaminated with
mixed skin flora.
# HTN: Systolic blood pressure ranged from 115-150. Home dose of
valsartan and metoprolol was continued. Patient is taking 2 mg
of metoprolol BID, unclear why patient is on such a low dose.
# Hypothyroidism: Continued levothyroxine.
# Reflux: Continued omeprazole
Patient was full code during this admission. | 84 | 321 |
15662316-DS-3 | 22,582,725 | Dear ___
___ was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came in after having a fall and were found to have a
bleed.
What did you receive in the hospital?
- You were admitted to the intensive care unit and required one
blood transfusion. You did not require surgery
- You became confused and were managed with medications. We
placed a feeding tube, which was removed when your mental status
improved.
- You required oxygen to assist with your breathing. You were
found to have fluid in your lungs, which we treated by giving
you medications to help remove the water.
- You had an episode where your heart was beating slow, so we
changed around medications to help control your blood pressure.
- We placed a Foley catheter since you were not able to urinate
on your own. You will continue this going forward.
What should you do once you leave the hospital?
- Make sure to weigh yourself every day. If your weight goes up
by 3 lb, please call your doctor.
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the best!
- Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[ ] Replaced Foley prior to discharge given urinary retention.
Consider urology referral
[ ] Ongoing hematuria, likely traumatic in setting of frequent
straight caths. CBC stable. Performed bladder irrigation prior
to DC. Please perform bladder irrigation BID until hematuria
resolves
[ ] Adjust insulin as needed. Consider starting Metformin
[ ] Cerumen disimpaction performed. Consider audiology
testing/referral
[ ] Discharged on soft, thin liquid diet. Recommend 1:1
supervision while eating
[ ] Ensure patient has f/u in ___ clinic in ___ weeks for
mesenteric hematoma (Call Trauma at ___
[ ] Consider endocrinology referral and/or reimaging for adrenal
mass/hematoma. "Per review of imaging, pt's adrenal mass has
been progressively increasing in size approximately half
centimeter to centimeter every 6 months to year. The current
size is most likely normal progression of disease."
[ ] Patient was actively diuresed with IV Lasix transitioned to
Torsemide 40mg ___. Given mild ___ and euvolemic, transitioned
to Torsemide 20mg po daily on discharge. Monitor weights and
urine output. Adjust as tolerated
[ ] Restarted on Quinapril initially 10mg po BID, uptitrated to
home 20mg po BID on ___. Please monitor BPs
[ ] Recheck CBC, CHEM10 on ___
[ ] Continue to wean Clonidine: 0.05mg BID (___) -->
0.05mg daily (___), then can stop
[ ] Stopped Erythryomycin eye drops and started on artificial
tears on day of discharge as conjunctivitis improved and did not
appear bacterial. Monitor for recurrence of conjunctivitis
[ ] Was on higher dose of Levothyroxine, though will transition
to home Levothyroxine on discharge.
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___ with a history of hypertension, anxiety/depression, colon
cancer s/p colectomy, DMII, adrenal mass, and spinal stenosis
with gait disorder who presented on ___ after a fall. He
was found to have a mesenteric hematoma and
hemorrhagic-appearing
right adrenal mass that were managed conservatively in the
T-SICU with course complicated by acute hypoxemic respiratory
failure secondary to pulmonary edema and pleural effusions,
delirium, hypernatremia, and ___ on CKD.
#Mesenteric Hematoma
The patient presented to Emergency Department on ___ as a
transfer from an OSH. His chief complaint was fall with positive
head strike, blunt abdominal trauma who was found to have a
mesenteric hematoma and hemorrhagic appearing right adrenal
mass. Upon arrival to ___ he was admitted to the ___ for
further management. The pt's mesenteric hematoma was managed
non-operatively with serial HCT monitoring. No further
intervention was indicated. He received 1U PRBCs in ICU. He
denied any further abdominal pain/distension. CBC remained
stable. He will f/u with ___ clinic ___ weeks post-discharge.
#Right Adrenal Mass/Hematoma
Followed since it was revealed on an MRI lumbar spine performed
in ___. Previously followed at ___ by ___, MD
and at ___ by ___, MD. ___ studies and 24 hour urine
collection did not show evidence of metanephrines for
pheochromocytoma or hypercortisolism. The patient/family have
opted for conservative management. Can consider endocrinology
referral as outpatient.
# Acute hypoxemic respiratory failure
# Pulmonary edema
# Pleural effusions
# Acute on chronic HFpEF
Likely in setting of home furosemide being held and blood
administration. TTE with EF 55%. Negative >2L prior to transfer
from ICU. Patient required IV diuresis. CXR without focal
consolidations and noted improvement in pulmonary vascular
congestion, though with persistent pleural effusions. Concern
for possible aspiration and diet cautiously advanced with 1:1
supervision. LENIs negative for DVT. He was actively diuresed,
transitioned to Torsemide 40mg po daily on ___. Given
improvement, he was discharged on maintenance diuretic Torsemide
20mg po daily. Discharge weight: 115.94 kg (bed weight)
#Toxic Metabolic Encephalopathy
Most likely ___ ICU delirium with altered sleep wake cycle,
though also with degree of hypernatremia as below. Geriatrics
was consulted and recommended pain control and standard delirium
precautions. Was weaned off Olanzapine. Stopped Gabapentin due
to concern for contribution to delirium. Somnolence ultimately
improved, back to baseline. Will continue Ramelteon to assist
with sleep-wake cycle.
#Hypernatremia
Patient hypernatremic, likely secondary to poor po intake in
setting of delirium. Received D5 to correct free water deficit.
Discharge sodium 144
___ on CKD III
Cr elevated to 1.7 on admission, likely pre-renal in setting of
blood loss. Improved with good UOP though again rose in setting
of volume overload and ACEI, which was held. Subsequently
improved with diuresis suggesting cardiorenal component.
Quinapril added back on to home 20mg po BID prior to discharge.
Discharge Creatinine 1.2.
#Hypertension
#Bradycardia
Patient was hypertensive, also with bradycardia that
subsequently resolved. Bradycardia possibly ___ aspiration
event. Felt that Clonidine may have been contributor so weaned
down from home 0.2mg BID to 0.05mg BID on discharge. Plan to
continue Clonidine 0.05 BID through ___ --> 0.05mg daily
___. Continued home Amlodipine. Restarted home Quinapril
at same dose. Also started Tamsulosin prior to discharge given
urinary retention.
#Urinary Retention
#Hematuria
Patient initially had Foley catheter that was d/c'd. Continued
to retain on bladder scan requiring frequent straight cath with
subsequent hematuria likely ___ catheterization. Given ongoing
retention, had Foley replaced prior to discharge. Started
Tamsulosin prior to discharge. Still with persistent hematuria,
though CBC stable and performed bladder irrigation prior to DC.
Can consider urology referral for chronic Foley placement
#Anemia
Likely ___ blood loss in setting of mesenteric hematoma as
above. Nadir HgB 6.6, for which he was transfused 1U PRBC. In
setting of hematuria, HgB remained stable with discharge HgB
10.1 (<--10.5, 10.8).
#Conjunctivitis
Was on Erythryomycin eye drops, though did not appear bacterial
in nature. Planned to start artificial tears day of discharge.
#Advanced Care Planning
Patient was transitioned to DNR/Ok to intubate this
hospitalization and was changed in MOLST. Had HCP invoked (wife)
though this was ultimately changed to his daughter, ___. As
patient's mental status improved on discharge, patient is now
able to make decisions on his own and can choose his own HCP.
#T2DM:
Followed by ___. Modified regimen to NPH 18U qAM, 12U QPM | 204 | 936 |
18486197-DS-14 | 20,819,317 | It was a pleasure to participate in your care Ms. ___. You
were admitted to the hospital with an infection, which caused
you to have fever and low blood pressure. We did not find a
source of the infection - you did not have pneumonia, an
infection in your blood or urine, or an infection in your spine.
We stopped the antibiotics and you remained stable. Please
call your doctor or return to the hospital should you develop
fevers, chills, or any of the symptoms that brought you to the
hospital the first time.
You met with the social worker who provided you with information
regarding addiction resources. It is very important that you do
not inject IV drugs as this puts you at high risk for serious
infections.
Please see below for your follow-up appointments. | ___ year old homeless male with HIV/AIDS not on HAART (last CD4 6
on ___, HCV, IVDU, and history of MSSA epidural abscess
(C4/C5 and L4/L5, admission ___ to ___, treated with 8
wks of nafcillin) who presents with fevers, chills, cough
productive of greenish sputum, headache, vomiting, and diarrhea
for the past week. He was found to be lymphopenic and developed
sepsis prompting transfer to ICU with resolution of hypotension
after 3L IVF.
ACTIVE ISSUES
#Sepsis, unknown source: The patient developed hypotension to
high ___ in the setting of fever to 103 and hypotension to SBP
___ on the medicine floor. Pt was broadened antibiotics
coverage to vancomycin, cefepime and levofloxacin. Blood,
urine, sputum cultures, stool studies, C diff assay, beta glucan
assay, and cryptococcal & legionella antigen assays were sent,
all of which were negative. Pt was found to be alert and
oriented while in the medical ICU. His condition was felt
secondary to narcotics withdrawal. He was called out of the MICU
after remaining afebrile with stable hemodynamics on the second
day.
After coming back to the ward floor a TTE was found to be
negative and a whole spine MRI to r/o epidural abscess was
negative. He remained afebrile and hemodynamically stable and
antibiotics were withdrawn on ___ with no source identified. He
began dapsone 100mg daily for PJP prophylaxis on ___. He began
azithromycin 1200mg weekly for ___ prophylaxis on ___.
Upon discharge he had >36 hours off of antibiotics with
observation to make sure he did not become febrile or
hypotensive again.
#Opiate withdrawal: Patient's last use was 1 day prior to
admission. He began having withdrawal symptoms after transfer
out of the ICU characterized by yawning, dilated pupils,
abdominal cramps, diaphoresis, and occasionally goose-flesh. He
was followed with the ___ scoring system to objectively
identify his symptoms. He received 5mg of methadone on ___ and
again on ___ ___s symptomatic mgmt with antiemetics. On
the day of discharge he was tolerating PO and without objective
findings of opiate withdrawal.
He spoke with ___ RN about his outpatient options
for homeless shelters, methadone clinics. Upon discharge there
was a plan in place for him to go to a shelter. | 141 | 374 |
10868733-DS-5 | 21,576,889 | Dear Mr. ___,
You were admitted to the hospital because you were having
difficulty breathing. This was due to an exacerbation of your
COPD. We treated you with medications to help you through this
exacerbation, including antibiotics. Your symptoms resolved and
we feel that you are safe for discharge from the hospital. You
will go to a rehabilitation facility, where you will work to get
stronger before going home.
It was a pleasure to be a part of your care!
Your ___ treatment team. | Mr. ___ is an ___ year old gentleman with a history of HLP,
CAD, BPH, COPD, and dementia who presents with respiratory
distress and elevated troponins from an outside hospital.
# COPD exacerbation: Mr. ___ has a history of COPD and
presented in respiratory distress, initially requiring ICU
admission and BiPAP. BNP was 200, CXR was not consistent with
volume overload. CTA at OSH was negative for PE with limited
scan. Further corroboration with his wife reveals that he did
have symptoms of an upper respiratory tract infection in the
___ leading up to his admission, the likely the precipitant of
his acute exacerbation. He received iptratropium nebulizer
treatments, albuterol inhalers, was started on prednisone. His
symptoms improved and he was transferred to the medicine floor
where he was also started on azithromycin for added
anti-inflammatory effect. His symptoms resolved and he is
discharged to rehab on tiotropium as well as albuterol and
ipratropium nebs as needed.
# Elevated troponin: Mr. ___ presented with elevated
troponin to 0.4 and was started on a heparin drip for presumed
NSTEMI at the outside hospital prior to transfer to ___.
Troponins downtrended at ___. MB remained flat. The patient
remained chest pain free. EKG was notable for ST depressions in
the lateral leads. Cardiology was consulted and determined that
the etiology was most likely secondary to demand ischemia. His
heparin drip was discontinued. He was continued on aspirin and
was switched to atorvastatin. He was not started on metoprolol
due to a note in ___ noting he was unable to tolerate secondary
to his COPD.
# ___: Creatinine was elevated to 1.8. Per PCP, his baseline is
around 1.5. His FeNa was consistent with pre-renal etiology,
though contrast induced nephropathy from outside hospital CTA
could not be excluded. He received IVF at ___. Foley placed to
rule out obstruction with good urine output. His creatinine was
trended and was 1.6 at discharge.
# Dementia and Delirium: Mr. ___ has a history of
Alzheimer's Dementia per his family, though is not on any
medications currently. He had waxing and waning mental status
consistent with superimposed delirium. He was managed
conservatively with frequent reorientation, scheduled trazodone,
and olanzapine as needed for agitation. On day of discharge,
the patient's mental status was improved.
# Hyperglycemia: Patient noted to be hyperglycemic in-house,
though no history of diabetes. Likely precipitated by prednisone
for COPD exacerbation. He was maintained on an insulin sliding
scale in-house.
# Hypertension: Patient noted to be hypertensive in-house,
likely again secondary to steroids. He was started amlodipine 5
mg. | 82 | 426 |
12468016-DS-21 | 22,813,532 | Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on CC7 regarding management of
your abdominal pain and loose stools, attributed to your Crohn
disease. You also were noted to have poor oxygen levels when
resting and while ambulating, which is likely related to your
sleep apnea and chronic smoking issues. You will be setup with
supplemental home oxygen. A chest imaging study prior to
discharge did not show any evidence of a pulmonary blood clot.
You were also treated with antibiotics for your right groin
infection. You were feeling improved at the time of discharge.
.
** IT IS ABSOLUTELY CRITICAL THAT YOU QUIT SMOKING! Please
discuss support measures with your primary care physician. **
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* You have pain that is not improving within 12 hours or is not
under control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Bactrim DS 1 tablet by mouth twice daily for 7-days
(started ___, ending ___
START: Dilaudid 2 mg ___ tablets) by mouth every ___ hours as
needed for pain. AVOID taking this medication if you anticipate
driving or if you are consuming alcohol.
START: Hydrocortisone enema (1 enema) per rectum twice daily for
14-days (started ___, ending ___
START: Advair diskus 250/50 mcg (1 puff) inhaled twice daily;
only use your rescue inhaler for acute shortness of breath.
START: Home supplemental oxygen use (as instructed).
START: Nicotine patch 21 mg applied transdermally daily.
.
* This admission, we CHANGED: NONE
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Vicodin
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above. | IMPRESSION: ___ with a PMH significant for Crohn colitis (s/p
total abdominal colectomy and splenectomy for colonic-splenic
fistula in ___, having failed multiple immunemodulators and
biologics), HTN, HLD, OSA, current smoker and chronic back pain
who presents with 1-week of RLQ abdominal pain, increased stool
frequency and CT imaging noting distal ileal thickening
concerning for active Crohn colitis with superimposed concern
for possible acute COPD exacerbation and draining groin abscess.
.
# ABDOMINAL PAIN, LOOSE STOOLS (PRESUMED ACUTE CROHN ILEITIS) -
Strong history of Crohn disease diagnosed in ___ (followed by
Dr. ___. Primarily colonic involvement previously;
attempted immunemodulators and biologics ___, Remicade,
Humira). Status-post ex-lap, total abdominal colectomy and
splenectomy for spleno-colonic fistula in ___ - also had
abdominal abscess drainage in ___. Presents with active Crohn
ileitis ___ times yearly (last flare in ___. Seen by
GI in ___, encouraged to stop smoking, con't Cimzia
(Certolizumab) and start Canasa suppositories, as his flares now
involve the ileum and rectum. Now presenting with 1-week of RLQ
abdominal pain, increased stool frequency without fevers. CT
imaging demonstrates wall thickening in the ileum and rectum,
but his pain did not correlate with these findings (primarily
his pain was in the RLQ and his CT imaging was notable in the
left lower quadrant). Overall these findings were concerning for
possible active Crohn ileitis with rectal involvement vs.
infectious colitis given immune suppression. No evidence of
fistulation, abscess or obstruction on imaging. Gastroenterology
consulted and felt hydrocortisone PR suppositories would be
beneficial (for 2-weeks), opting to avoid systemic steroids
given his prior fistula concerns. We also continued his
Mesalamine PR 1000 mg QHS. While he was initally antibiosed with
Levofloxacin and Flagyl in the ED, we felt he did not require
antibiotics for his abdominal concerns. Rather, we opted to
treat with Bactrim DS for his soft tissue infection and lung
concerns (see below). We strongly encouraged smoking cessation
and provided support tools and a nicotine patch this admission.
We maintained him on a clear liquid diet and oral pain
medication while his symptoms improved.
.
# ACUTE HYPOXEMIA - Patient had some active wheezing on exam
with O2 sats < 90% on RA. Has required Albuterol inhaler several
times daily prior to admission. No symptomatic dsypnea. He
required 2 liters of supplemental oxygen via nasal cannula on
admission with improvement. A work-up revealed minimal evidence
of an active COPD flare (chronic smoker without known
diagnosis). Patient was only on home albuterol as needed.
Pulmonary embolism seemed less likely, and a CTA prior to
discharge was reassuring. He has no CHF history and his most
recent Echo in ___ noted an LVEF of 55% with no significant
valvular disease or other concerning features. We attributed his
oxygen needs to either chronic COPD vs. his known OSA for which
he has declined CPAP use. We therefore sent him on home oxygen.
His CXR was without consolidation or effusions. We dosed him
with Bactrim DS for his soft tissue infection, but this also
provides pulmonary coverage for COPD-related organisms. We sent
him on an Advair inhaler twice daily for a suspected chronic
component of COPD. We scheduled him follow-up with
Pulmonary-Sleep medicine and strongly encourage smoking
cessation.
.
# SOFT TISSUE INTERTRIGINOUS GROIN ABSCESS - Right groin with
evolving erythema and groin pustule that ruptured days prior to
admission. Now draining purulent material. Risk factors include
chronic immune suppressive agents and steroid needs
periodically. Prior draining folliculitis noted by the patient.
Concern for CA-MRSA given his risk factors (immune compromise
vs. chronic medical issues). No evidence of enterocutaneuous
fistula on exam or imaging. Dosed Bactrim DS for 7-day course.
He remained afebrile.
.
# HYPERTENSION - Currently normotensive this admission. Home
regimen includes: Lasix and Lisinopril. We resumed these
medications on discharge.
.
# HYPERCHOLESTEROLEMIA - He was continued statin medication.
.
# DEPRESSION - No active concerning features. Mood appears
stable. We continued his home dosing of Cymbalta 60 mg PO daily
and Risperdone 1 mg PO QHS.
. | 394 | 655 |
10892316-DS-20 | 22,599,503 | 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 blood in your urine.
What happened while I was in the hospital?
==========================================
- We completed imaging and laboratory tests and did not find an
obvious cause for your bleeding. It is possible that this was
related to the apixaban you were taking. However, it also raises
the concern that you could have a cancer in your bladder,
urinary system, or prostate, and it is important that you follow
up with your urologist.
- Your kidney numbers were noted to have worsened compared to
your prior numbers, and we believe this led to electrolyte
abnormalities. We adjusted your medications to attempt to
improve these numbers and to bring your electrolyte levels
closer to normal. These numbers did not improve, so you will
need a follow up with a kidney doctor
___ should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | Transitional Issues:
[] Initiated warfarin, ensure follow up with ___
___.
[] Please repeat BMP to evaluate renal function on lower
torsemide dose and electrolytes
[] Juxtarenal AAA measures 6 x 5 cm, unchanged since ___. 2.6 cm left internal iliac artery aneurysm also stable
since ___ consider what follow-up would be necessary
for these findings.
[] On home Aspirin 81 mg PO 3X/WEEK ___ unclear why on
this dose and would recommend daily.
[] Held home spironolactone and Sacubitril-Valsartan iso
___, could consider when/if to restart.
[] Due to hematuria, should get outpatient cystoscopy and have
discussion with urology regarding prostate MRI.
[] Initiated sodium bicarbonate and sevelemer given worsening
renal function (d/c Cr 4.4), hyperkalemia, and elevated phos
================== | 226 | 113 |
17508484-DS-8 | 20,188,092 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were short of breath
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We found that the mass in your lungs has gotten larger
- We gave you antibiotics to treat an infection in your lungs
- Your heart rates were high, and we gave you a medication to
treat this
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is an ___ y/o woman with history of SVT, HNT and
recently diagnosed EGFR exon 21 mutation L858R adenocarcinoma of
the lung who presented with progressive dyspnea and was found to
have supraventricular tachycardia.
=================
ACTIVE ISSUES
=================
# Supraventricular tachycardia, Likley MAT with ectopy: Patient
with history of SVT. Patient developed hemodynamically unstable
tachycardia with rates in the high 100s to 200s. Likely
secondary to anatomical compression related to lung mass and
increased catecholamines related to acute illness. The patient
received intravenous metoprolol and esmolol and converted to
normal sinus rhythm. The patient was transferred to the
intensive care unit for ongoing management of her
tachyarrythmia. She improved and was called out and was stable
on Metoprolol 37.5mg PO Q6 hours for >24 hours. She was
converted to metoporol succinate 150mg PO daily on discharge.
# Acute hypoxic respiratory failure: Patient presented with
increased dyspnea, found to have new hypoxia. CT of the chest
showed enlargement of known lung adenocarcinoma. Patient also
with possible pneumonia, for which she was treated with
levofloxacin. Tachycardia, as above, may have also contributed
to dyspnea. She was on room air with stable sats prior to
discharge.
# Lung adenocarcinoma, EGFR mutated with likely leptomeningeal
spread: Initiated treatment with first-line gefitinib in ___,
which she has continued. Per son and clinic notes, largest mass
noted in ___ was 8x6, on CT today now involving entire span of
right mid and lower lung with mediastinal extension. Thus likely
progressing, with vessel encasement and bronchial obstruction,
unclear if also has endobronchial involvement. IP contacted, did
not feel that stent indicated at this time. Goals of care
discussed with family and patient and no invasive procedures are
within goals of care. She will resume gefitinib on discharge.
Oncology is planning ___ as an outpatient and working on
obtaining Osimertinib which was initially declined by the
insurance company. MRI done in the hospital consistent with
possible leptomeningeal spread. She had no neurologic symptoms
at time of discharge. Will plan for outpatient neuro-onc
follow-up.
================
CHRONIC ISSUES
================
# HTN: Held irbesartan/hydrochlorothiazide. Metoprolol continued
as above.
=======================
TRANSITIONAL ISSUES
=======================
[] Continue gefitinib until approval obtained for Osimertinib
[] Outpt PET/CT on ___. MRI done in the hospital
[] Follow up with Oncology as an outpatient
[] Neuro-onc follow up as an outpatient.
[] Complete course with levofloxacin for possible PNA (completes
on ___.
[] Letter of necessity for hospital bed sent to ___.
Follow up as an outpatient.
Greater than 30 minutes spent in care coordination and
counseling on the day of discharge. | 93 | 419 |
10988297-DS-12 | 26,941,900 | Dear Mr. ___,
You came into the hospital because you had redness and swelling
in your leg. You had an ultrasound that did not show any clots.
You also had an Xray that did not show any signs of infection in
the bone. The orthopedic surgeons and rheumatologists saw you
and did not think you had any signs of arthritis or infection in
the ankle joint itself.
You will need to continue taking antibiotics for 12 days after
leaving the hospital (two weeks total of antibiotics). Please
follow up with a primary care doctor within one week of leaving
the hospital. | ___ w/ hx chronic LLE swelling using compression stocking, who
presented with LLE erythema and edema consistent with
cellulitis. | 99 | 19 |
17157010-DS-16 | 24,413,956 | Dear ___,
It was a pleasure taking care of you at ___!
You came to us for worsening right upper quadrant abdominal pain
in the setting of known gallstone disease. You had an endoscopic
ultrasound performed that did not reveal evidence of an
obstructing stone, and ultimately went to the operating room for
a laparoscopic cholecystectomy (removal of your gall bladder).
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Please take care, we wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with h/o
cholelithiasis presenting with RUQ abdominal pain, found to have
cholestatic transaminitis but no CBD stone, and no e/o
cholecystitis on US, s/p CCY on ___. | 707 | 37 |
10900387-DS-43 | 28,246,942 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You will be
discharged to a rehabilitation facility following a prolonged
hospitalization for PEA complicated by brain injury with some
recovery of mental status. You have PEG tube to receive
nutrition and we recommend a video swallow evaluation at your
rehab to further evaluate your swallowing function. You were
treated with a course of antibiotics for an infected stage III
sacral ulcer, aspiration pneumonia and urinary tract infection.
You have completed all antibiotic treatment and are ready to
transition to a rehabilitation facility where you will continue
dialysis and close monitoring. | ___ w/ PMH of ESRD on HD (___), HIV on HAART (CD4 373),
HCV, polysubstance abuse on methadone, cryoglobulinemia, sCHF
___ NICM, resistant hypertension and GERD, s/p PEA arrest w/
neurologic devastation on ___ ___ the setting of HTN
emergency (flash pulmonary edema), ___ MICU w/ myoclonic seizures
prior to cooling protocol, and since protocol completed has
continued to have seizures on quadruple AED therapy. However,
neuro status improving, now intermittently responding to simple
commands and minimally interactive. | 103 | 79 |
12479159-DS-9 | 26,274,448 | It was a pleasure taking care of you during your stay at the
___. You presented from rehab
with worsening word-finding difficulties and a right facial
droop.
.
At ___ you had a CT scan which included an evaluation of the
vessels of the head and neck, and this image was stable from
your previous admission. An MRI, however, showed new small
strokes involving the left side of your brain which are likely
due to the very tight narrowing of one of your brain blood
vessels called the middle cerbral artery (MCA) which is very
sensitive to blood flow.
.
Due to your new strokes, your dabigatran dose was increased to
150mg twice daily to provide better blood thinning treatment.
You were doing well until you had a sudden worsening of your
speech between ___ which we felt was a result of a
transient period of low blood pressure which provided an
inadequate blood supply to your narrowed left MCA.
.
After this event, you were transferred to a higher care level on
the neurology floor, and closely monitored. We gave you fluids
to raise your blood pressure as well as an aspirin to allow even
better blood-thinning to occur. Unfortuately, you had further
new left brain strokes on MRI after this event as well.
.
You slowly improved as we held your blood pressure medications
to increase the blood through the narrowed MCA. You also
improved daily when we started a new blood pressure support
medicine called Midodrine and an antidepressant called Celexa.
.
A CT scan done during this admission also demonstrated a very
small nodule on your right lung which is unlikely of clinical
significance, but will need a follow-up CT on discharge from
rehab as a precautionary measure to ensure it is not getting
bigger.
.
Today, you were deemed medically fit for transfer to rehab where
you will continue your recovery.
.
Medication changes:
We INCREASED dabigatran to 150mg twice daily
We STARTED aspirin 81mg daily, midodrine 2.5mg daily, celexa
20mg daily
We STOPPED furosemide and verapamil
We INCREASED lovastatin to 20mg daily
.
Please continue your other medications as prescribed prior. | ___ with HTN, HLD, CHF, OSA not on NIV and previous RLE DVT in
___ and most pertinently recently discharged from stroke
service ___ after multiple embolic left hemispheric infarcts
with evidence of a small left MCA clot felt due to paroxysmal
atrial fibrillation and started on dabigatran but only at 75mg
bid due to verapamil, presented from rehab on ___ with
worsened speech, recurrence of his right facial droop and
confusion.
.
Neurological exam was significant for right lower facial
weakness and right pronator drift with mild UMN pattern of RUE
weakness, paucity of spontaneous speech with significantly worse
expressive aphasia and anomia more so than on discharge. His
examination improved slowly while the patient was in ED, but was
still a significant change from his discharge and was admitted
to the stroke service for further work-up.
.
CTA Head and Neck revealed a continued high-grade stenosis of
the distal M1 branch of the left MCA with mild stenosis of the
superior branch of M2 of the right MCA an incidental finding of
a 4-mm pulmonary nodule in the right apex. MRI showed small new
infarcts in the left MCA territory and evolution of prior
infarcts.
.
Stroke risk factors were assessed and he was monitored on
telemetry which showed persistent sinus rhythm. Due to
subtherapeutic dabigatran, a thrombin was measured and found to
be 34.8 and dose was increased to 150mg bid. Due to an elevated
Cr of 1.3, furosemide was decreased from 80mg to 20mg initially
to aid in perfusion pressure initially aiming for a goal BP of
120-160 given focal MCA stenosis. CXR showed bibasal atelectasis
and no evidence of CHF exacerbation given patient's history of
diastole CHF. UA showed no evidence of UTI. Due to issues with
dosing dabigatran, we stopped all anti-hypertensives, and he had
controlled BP and heart rate without this medication.
.
Patient still had significant aphasia and was assessed by OT, ___
in addition to S&S and was passed for a diet. Patient acutely
worsened some time between the evening of ___ to the morning of
___ with mild worse right UE weakness and markedly worse aphasia
and was only able to say yes initially. A stat CTA/CTP was
performed and showed some possible hypoperfusion in left MCA and
unchanged high-grade MCA stenosis with no hemorrhage or obvious
infarction. Given that the concern was of left MCA hypoperfusion
due to his focal stenosis, he was transferred to the stepdown
unit on ___ and started on IVF and kept on bedrest to raise
his BP and anti-hypertensives including furosemide were held.
Despite this, his examination only mildly improved and fluids
were latterly discontinued after 2 days with no signs of CHF.
Following this, the patient's examination slowly improved.
.
The likely cause of his decompensation was felt to be left MCA
stenosis with hypoperfusion and given persistence of symptoms
was felt to likely represent further infarct. The attending
vascular neurosurgeon was consulted regarding any possible
intervention on his left MCA stenosis but after discussion, due
to the distal position of the stenosis it was felt risks of
stenting or angioplasty outweighed the risks given operative
risks and the possibility of jailing his MCA branches with a
stent or causing distal MCA embolism and worsening his deficits.
The patient's examination improved slowly and BP was kept > SBP
130-180 with better verbalizing but he was still significantly
aphasic. In order to provide a new baseline, a repeat MRI
demonstrated multiple new acute infarcts in the left MCA
distribution in addition to expected interval evolution of his
previously seen infarcts which brought him here from rehab.
Since the patient has a high-grade left MCA stenosis which has
resulted in recurrent strokes at times of low blood pressure.
Ideally blood pressure should be between 130-180 systolic to
maximize his cerebral perfusion. For this reason, we were
holding all of his anti-hypertensive medications this admission
as well as giving Midodrine 2.5mg daily in the mornings to
support perfusion through the area of severe stenosis in his
left middle cerebral artery. Please continue monitor his blood
pressure several times per day and consider stopping the
Midodrine and/or restarting some of his anti-hypertensives as
the patient begins to regulate his own blood pressure back to
its normal range.
.
Repeat CXR showed bibasal atelectasis but given concern over
development of CHF being off furosemide, this was restarted at
low dose and BP was closely monitored. Due to clinical
improvement following his further strokes, he was fit to be
transferred out of stepdown unit on ___, but blood pressure
began to lag so Lasix was once again held. There were never
clinical signs of CHF in this patient during this stay, but this
should be monitored for very closely. TCD on ___ revealed
no signs of microemboli.
.
Patient had a persistent mild hypochromic microcytic anemia in
house which was also seen during his last admission. Iron
studies were sent which revealed a low serum Fe 32, TIBC 211,
and ferritin was normal 364. He was started on ferrous sulphate
325mg daily and PCP should consider ___ routine colonoscopy as an
outpatient. Stool guaiac was negative in house the entire time.
.
He did have an EEG near the end of his hospitalization which
showed global left hemisphere slowing as well as frequent T5
epileptiform activity. For this reason, and the fact that the
patient's exam was slowly improving if at all, the team decided
to try a one time dose of Keppra 1 gram IV on the morning of
discharge. No significant improvement was noted so this
medication will not be continued.
.
He clinically improved and ___, OT and S&S therapy felt he was
fit for transfer to rehab on ___.
. | 340 | 940 |
10347477-DS-19 | 27,385,785 | Dear ___,
It was a pleasure caring for you at ___
___. You were admitted because you had chest and
shoulder pain. We were initially concerned about blood clot in
your lungs (pulmonary embolism), and so you were started on
anticoagulation with Lovenox. You received an ultrasound of your
legs, CT of your chest, and echocardiogram of your heart. You
were also evaluated by our pulmonary specialists. Since the
likelihood of pulmonary embolism was low, Lovenox was stopped.
Your echocardiogram was normal, except that it showed a slight
dilation of your aorta. This should be followed up with a repeat
echocardiogram in ___ years.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below.
We wish you the very best!
Warmly,
Your ___ Team | ___ is a ___ y/o man with a PMH of stage Ia lung
adenocarcinoma, celiac disease w/ SBO s/p resection and
enteropathy-associated T-cell lymphoma, s/p 6 cycles of EPOCH
and cyclophosphamide with stem cell collection, who presented
with pleuritic chest pain and findings on CTA concerning for
lingular infarction vs. infection.
============
ACUTE ISSUES
============
# Pleuritic chest pain. CTA did not demonstrate clot, and there
was no evidence of splenic infarction. ACS work-up negative
(negative troponin and no EKG changes). Initiated on therapeutic
dose Lovenox. Lower extremity ultrasound negative. TTE
demonstrated no right heart strain and no effusion. No
infectious symptoms. Evaluated by the pulmonary service; this
was deemed not to be pulmonary embolism, and may be
musculoskeletal in nature (as the pain had worsened by lying on
his side). Pain was wholly resolved by the time of discharge.
Lovenox was halted, with plan for follow-up imaging in 6 weeks.
# Enteropathy-associated T-cell lymphoma. Continued on home
acyclovir, Bactrim, and allopurinol.
==============
CHRONIC ISSUES
==============
# Hypertension. Continued home metoprolol succinate 25 mg and
spironolactone 25 mg daily.
===================
TRANSITIONAL ISSUES
===================
# Thrombophilia work-up. Will have discharge follow-up in
hematology to investigate possible thrombophilia (has history of
prothrombin gene mutation).
# Follow-up imaging. Recommend follow-up chest CT in 6 weeks to
evaluate for interval change.
# Repeat TTE. The patient has a mildly dilated ascending aorta.
Based on ___ ACCF/AHA Thoracic Aortic Guidelines, a follow-up
echocardiogram is suggested in ___ years.
# Contact: ___ (sister), ___
# Code status: FULL | 127 | 241 |
12301841-DS-9 | 25,820,573 | Dear Mr ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for fever and rash.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received antibiotics to treat a possible skin infection
on your right hand.
- The skin rash on your torso was most likely due to
allopurinol. The rash improved after we discontinued the
allopurinol.
- You had a broad infectious workup to determine the cause of
your fevers. The fevers were most likely secondary to the
chemotherapy you received.
- You had an ultrasound and CT scan of your arm because you had
a palpable blood vessel. The imaging showed that this was a
benign finding with no need for intervention.
- You had some increased fluid in your lungs. You received an
IV diuretic in order to remove the fluid. You also had an
ultrasound of your heart that showed some dysfunction, but
overall improved from your prior ultrasound.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | HOSPITAL SUMMARY:
=================
___ with hairy cell leukemia being treated with Cladirbine
presented with febrile neutropenia, along with significant skin
findings concerning for disseminated fungal infection +/-
additional process.
TRANSITIONAL ISSUES:
====================
[ ] ___ Oncology appointment scheduled for ___ at 8:45AM
[ ] Consider acyclovir for viral prophylaxis in setting of
Cladirbine
[ ] Discharged after Neupogen administration for continued
pancytopenia. Neupogen was not continued on discharge given high
cost. Labs should be obtained at oncology follow up appointment
on ___ to monitor neutropenia.
[ ] Developed skin reaction to allopurinol- should be listed as
a drug allergy in ___ system.
[ ] Furosemide was held at discharge given softer BPs. Should be
restarted as necessary in outpatient setting.
[ ] Consider starting low dose Metoprolol for cardioprotection
(likely limited by bradycardia)
[ ] Has vascular surgery follow up scheduled for tortuous
brachial artery | 208 | 137 |
10798756-DS-18 | 29,002,696 | Dear Ms. ___,
We admitted you to the hospital for a severe headache and neck
pain. While you were here, we repeated your spinal tap to see if
you may have an infection that needs specific medicine.
Although not all of the tests were final at the time of
discharge, this headache appears to be in the setting of a viral
encephalitis, which should heal with time.
It was a pleasure to participate in your care,
Your ___ team
We wish you the best,
___ Medicine | Patient is a ___ with COPD on 2L home O2 presenting with
headache
and concern for sarcoid v. TB v. fungal meningitis and found to
have ___.
#Headache concerning for meningitis with high CSF protein:
CSF from ___ suggestive of aseptic meningitis.
Unfortunately there was not enough sample to send viral studies.
She was transferred here for further mgmt. She was admitted to
the hospitalist service where we stopped acyclovir on ___. She
had an MRI of the head and C spine on ___ which shows low CSF.
Neurology followed the patient and recommended repeat LP. LP
attempted on ___ AM was unsuccessful, so ___ did this on ___
___. The protein was mildly elevated at 52, but other studies
were largely unremarkable, though final culture of AFB and
routine culture were not finalized at the time of discharge.
Cryptococcal Ag negative as was Quant gold and ACE level. CT
torso looking for sarcoid or malignancy is negative for both
given IV contrast study only. She did have increased
inflammation markers with ESR 50 and CRP 18. Ultimately, this
was thought to be a possible mild viral encephalitis of unclear
etiology, which will take time to recover. She was given pain
management initially with Dilaudid ___ PO and Tylenol and
Flexaril. None of these was very effective, so Dilaudid was
tapered off. On the day prior to discharge, she was trialed on
Toradol (but could not continue secondary to IV burning) as well
as Topomax and Reglan. I explained that steroids would be
effective, but she was very adamantly against this since she has
had bad reactions to prednisone for lung disease in the past.
Her headache had improved on discharge but not resolved. She was
given Rx for Trazodone for insomnia (which she said also helped
her headache) as well as Topomax. She could not see ___
Neurology given she is an ___ patient, so will see a
neurologist near her in follow-up for these studies.
#Acute renal failure - resolved. Her Cr was as high as 1.4, but
resolved to 0.8
Unclear etiology. Possibly mild hypovolemia, possible
contribution of acyclovir nephrotoxicity. We initially held her
home furosemide and lisinopril but these were restarted on
discharge.
#Ear ache - this was present on ___, mild, with no trauma.
There was no abnormality seen on exam, so this may be related to
headache. She will continue meds for headache, but if not
improved, was advised to see her PCP to discuss if any
additional wok-up may be needed.
#COPD - stable -Continue oxygen supplementation with goal O2 sat
> 91%
-Albuterol PRN; Advair in place of Symbicort
#Hypothyroidism - TSH on repeat is 16 and T3 is mildly low,
consistent with mild hypothyroidiem v. euthyroid sick. She
should continue on her current dose of Synthroid and follow-up
with her PCP for recheck LFTs 2 weeks after discharge. She
continued levothyroxine 25 mcg daily.
#GERD
-Continue omeprazole
#Psych
-Continue fluoxetine | 86 | 492 |
17074609-DS-22 | 26,358,899 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Nonweight bearing in the right leg
Physical Therapy:
NWB RLE
Treatments Frequency:
Please apply silvedene generously to medial aspect of ankle over
fracture blisters QD.
Please keep pin sites clean. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right pilon fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for external fixation, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweight bearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 146 | 236 |
15307141-DS-21 | 22,536,726 | Dear Mr. ___,
You were admitted to the ___
because of urinary retention. You were found to have a urinary
tract infection that is being treated with antibiotics.
You will continue to take the antibiotic that you started in the
hospital.
Since you were unable to make urine without a catheter, you will
go home with a catheter and visiting nursing services. You will
follow up in ___ clinic to have the catheter removed.
Thank you for allowing us to participate in your care. We wish
you the best.
Sincerely,
Your ___ Team | SUMMARY:
___ y/o M with PMHx significant for BPH, Afib on abixiban, HTN,
HLD, peripheral neuropathy who presented with urinary retention.
# Urosepsis
On admission, the patient had a leukocytosis and a fever. Urine
culture revealed E.coli bacteruria, likely secondary to urinary
retention. Blood cultures showed no growth. The patient was
initially started on ceftriaxone which was later switched to
ciprofloxacin as the E.coli was pansensitive. By day of
discharge the patient's fever and leukocytosis resolved. Patient
was discharged to complete a two week course of ciprofloxacin.
# Relative ___: Due to initial hypotension, initially
antihypertensives were held. Lasix were restarted before
discharge and tolerated well. Given soft blood pressures, his
home doses of carvedilol and lisinopril were decreased and he
was discharged on lower doses.
# Urinary retention
The patient has a history of BPH an had been taking terazosin.
Prior to admission his PCP started him on tamsulosin as well. On
admission, due to the presence of urosepsis, his terazosin was
stopped. He required a foley catheter during hospital stay and a
voiding trial was unsuccessful. He therefore was discharged with
a foley catheter with an appointment at voiding clinic after
discharge. Per recommendations from urology, he was discharged
on tamsulosin alone.
# ___ on CKD
On admission the patient's creatinine was elevated at 3.1, above
his baseline of 1.5. A renal ultrasound revealed no
hydronephrosis. ___ was most likely secondary to urinary
retention with a possible prerenal component, as the patient had
had poor PO intake prior to hospital stay. By day of discharge
the patient's creatinine improved to 1.1
# Fall
The patient experienced a fall walking into the hospital, which
was likely secondary to weakness given urosepsis. He also has a
history of chronic peripheral neuropathy. He was evaluated by ___
and found to have good balance with a cane despite his chronic
proprioception difficulties. Home ___ was recommended, as well as
outpatient occupational therapy for evaluation of driving
safety. In addition terazosin was also discontinued prior to
discharge.
# Chronic systolic CHF (EF 45%), compensated:
The patient has known sCHF with last EF 45% ___. The patient
was not taking his home furosemide two days prior to admission
given his urinary retention. The patient was euvolemic during
hospital stay. On ___ he desaturated to 90% while walking with
___, so his home furosemide was restarted. His carvedilol and
lisinopril were halved, as noted above. His ___ should perform
BP checks and his BP meds should be titrated as an outpatient.
# Hyponatremia
On admission the patient's sodium was 132, considered to be
hypovolemic hyponatremia secondary to poor PO intake. His sodium
increased to normal after 1L NS upon admission.
# Afib
The patient was continued on home dose apixiban and aspirin.
# Peripheral neuropathy
The patient was continued on home dose gabapentin.
TRANSITIONAL ISSUES
-HTN: Lisinopril reduced to 2.5mg, carvedilol reduced to 6.25 mg
BID due to soft pressures. Will need to follow up blood pressure
and consider up-titrating if indicated
- Terazosin was stopped due to orthostasis, and it was
recommended by urology that the patient continue on tamsulosin
alone.
- On admission patient was noted to have thrombocytopenia,
improved by day of discharge, would recommend checking CBC.
- Patient has baseline paresthesias; would recommend referral to
OT for testing of driving safety | 89 | 544 |
12233133-DS-15 | 26,056,027 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were having more difficulty breathing than usual
- Your doctor in clinic was concerned that your oxygen levels
were quite low
What was done while I was in the hospital?
- You had a CT scan of your chest which showed signs suggestive
of a pneumonia
- You were started on antibiotics (azithromycin and ceftriaxone)
and steroids for a flare of your COPD, as well as pneumonia
- You were given nebulizers and oxygen to make you feel more
comfortable
- Your breathing began to improve
What should I do when I get home from the hospital?
- You should continue to take your antibiotics and steroid until
___ (until you run out of these medications in the pill
bottle). Start Azithromycin and Cefpodoxime on the night ___
(at 8PM) and take until you run out. Start prednisone ___ and
take until you run out.
- Continue to take your home medications as prescribed
- Be sure to follow-up with your doctors at the ___
scheduled for you
- If you experience any of the danger signs listed below please
call your doctor or go to the emergency room immediately.
Sincerely,
Your ___ Treatment Team | Ms. ___ is a ___ year-old woman with a history of DM type I,
OSA, tracheal resection (___) following tracheal cartilage
fracture ___ tracheostomy, COPD, and possible ILD, who presents
with dyspnea and increased oxygen requirement likely ___ COPD
exacerbation in the setting of pneumonia.
ACUTE ISSUES
#ILD
#COPD exacerbation
#CAP
#Acute on chronic hypoxic respiratory failure:
The patient presented with worsened dyspnea on exertion and
worsened O2
requirement with increased cough, SOB, and sputum production,
consistent with a likely COPD exacerbation. In the ED, the
patient had a CTA that showed no PE, but worsened ground glass
opacities in the lower lung fields. She was also noted to have a
new leukocytosis on labs. Given these changes, the patient was
started on azithromycin and ceftriaxone for community acquired
pneumonia, as well as steroids for her presumed COPD
exacerbation. The patient also received nebulizers as needed and
supplemental O2 during her admission. On the day of discharge,
the patient noted significant improvement in her shortness of
breath and was deemed stable for discharge, back on her baseline
home O2 (2L only at night) with O2 sats 88-92%.
#DM type I
#Hyperglycemia: History of type I diabetes mellitus on glargine
and Humalog SSI. BG on admission was 343. HCO3 27, AG 15, urine
ketone negative. The patient was continued on her home insulin
regimen, though she did note that when she is sick at home, she
normally will increase her sliding scale.
CHRONIC ISSUES:
===============
#Depression: 417/448 qtc on ___
-continue home latuda, Seroquel, and clonazepam
#Fibromyalgia:
-continue home pregabalin and duloxetine
#Hypothyroidism:
-continue levothyroxine 100mcg daily
#Vitamin D deficiency:
-hold vitamin D 5000units daily
#Hypertension:
-continue home lisinopril and metoprolol succinate
#GERD:
-interchange home esomeprazole 40mg BID with omeprazole
#Hyperlipidemia:
-continue home rosuvastatin
TRANSITIONAL ISSUES
[ ] discharged on azithromycin and cefpodoxime to complete 5 day
course (last day ___ also discharged on 40mg prednisone to be
completed on ___, no taper needed. Instructed patient to take
Azithromycin and Cefpodoxime on the night ___ (at 8PM) and take
until she runs out of pills in the bottle. Instructed her to
start prednisone ___ and take until you run out.
[ ] baseline O2 is 2L only at night; patient desaturates to
88-89% with activity on room air at baseline
[ ] Ambulatory saturation on afternoon of ___ with patient
consistently 88-90%, with 1 second dip to 87 at end of a ~ ___ode status: FULL CODE (presumed)
#Health care proxy/emergency contact:
Name of health care proxy: ___
Relationship: husband
Cell phone: ___
Ms. ___ is clinically stable for discharge. The total time
spent on discharge planning, counseling and coordination of care
was greater than 30 minutes. | 202 | 424 |
11227287-DS-4 | 25,148,751 | You were hospitalized with shortness of breath and cough due to
an infection. You were also found to have low oxygen levels.
Chest X ray and sputum tests were performed. The results of the
sputum test remain pending at this time. You were treated with
antibiotics, but you decided to leave the hospital against
medical advice. Please call your primary care physician
tomorrow to schedule a follow up appointment within the next ___
days. | ASSESSMENT & PLAN:
Mr. ___ is a ___ year old gentleman with dyspnea.
Hypoxia with Dyspnea due to: Infectious in nature given acuity
and symptoms. CXR negative for bacterial PNA. There was
initial concern for PJP PNA given his HIV status and borderline
CD4 count. However, making this less likely was a CD4 count of
230, with normal LDH and more likely probability of
viral/bacterial URI with bronchospasm. He was given nebulizers
and Levofloxacin. Induced sputum was sent to exclude PJP PNA.
In the evening of ___ the patient reported feeling better, off
oxygen and breathing well. He decided to leave AGAINST medical
advice. He was informed of the risks of leaving, to include
possible mobidity of untreated PJP, or other diagnoses. The
patient decided against staying nevertheless, and was deemed
competent and with capacity to make this decision. He was given
a 5 day course of Levofloxacin and instructed to call his PCP
the next day for a follow up appointment.
HIV: Continued Atripla
Hypertension: continued clonidine
Anxiety: Continued Zoloft & Buspar
Post-herpetic neuralgia: Continued Gapapentin
Patient left AGAINST MEDICAL ADVICE
Pending study: Induced sputum for PJP | 78 | 193 |
15642594-DS-7 | 26,882,685 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why were you admitted to the hospital?
- You were having trouble breathing and became very short of
breath.
What was done while you were in the hospital?
- You had to be intubated because you were having so much
trouble breathing.
- Images of your chest showed that you had a pneumonia so you
were started on antibiotics.
- Your breathing improved so you were extubated and weaned off
of extra oxygen.
- While admitted you were found to intermittently have an
irregular heart rhythm called atrial fibrillation. Our
cardiology team saw you and you were started on a blood thinner
to prevent stroke, which can occur with atrial fibrillation.
What should you do when you go home?
- Please follow up with your PCP as listed below.
- It is also important for you to be seen by a cardiologist.
Please discuss with your PCP about getting set up with a follow
up cardiology appointment at ___.
- You should take all of your medications as directed.
- You should continue a bariatric 3 diet, which means avoiding
solid foods.
We wish you the best!
Your ___ Care Team | ___ PMH COPD, CHF, DMII, RNY bypass and chronic back pain with
recent perforated marginal ulcer s/p reversal of RnY, resection
of roux limb, partial gastrectomy ___, initially presented
with hypoxia and altered mental status, found to have a LLL
pneumonia, now improved on antibiotics.
ACUTE PROBLEMS
===================
# Hypoxic respiratory failure due to
# Bacterial Pneumonia
The patient presented with respiratory failure, altered mental
status, and sepsis due to a LLL pneumonia discovered on chest
CT. On arrival, he was intubated in the ED for airway protection
and managed in the SICU, and then subsequently extubated and
transferred to the medicine floor. BAL and sputum cultures
demonstrated growth with pan sensitive proteus. He had been
initially started on broad spectrum antibiotics but was then
narrowed to IV ceftriaxone and finally transitioned to PO
cefpodoxime for the remainder of an 8 day course (___).
# Acute on chronic diastolic CHF
After extubation, the patient still had a mild O2 requirement
with bibasilar decreased breath sounds. His symptoms improved
with intermittent diuresis and the patient was euvolemic sating
well on room air by time of discharge.
# ___
The patient's Cr had increased to 1.0 from baseline of around
0.4. Unclear etiology, of renal injury, though suspected
cardiorenal given current concerns for volume overload and
respiratory status as discussed above. Cr was stable at 1.0 for
several days prior to discharge.
# Paroxysmal atrial fibrillation
While admitted, the patient had an episode of atrial
fibrillation with rapid ventricular rate, but converted back to
sinus without intervention. CHADS-VASc=3. Cardiology was
consulted and he was started on apixaban 5mg BID in addition to
be continued on metoprolol.
# Toxic Metabolic Encephalopathy
While in the ICU, the patient experienced several episodes of
AMS and
confusion, which responded well to restarting his home methadone
regimen in addition to Seroquel as needed.
# Pain control
He was continued on Tylenol, home methadone, and gabapentin.
# HTN
The patient was continued on home lisinopril 20mg.
# Abdominal fluid collection
CT abd/pelvis with small perihepatic fluid collection. The
patient underwent UGI which demonstrated slow transit of
contrast however no leak was seen. Per surgery recomendation, no
attempt was made to drain this fluid collection.
# s/p reversal of RnY, resection of roux limb, partial
gastrectomy
# Aspiration risk
The patient was followed by bariatric surgery while admitted. He
was continued on a stage 3 bariatric diet in addition to a
multivitamin. Speech and swallow were consulted and also
recommended restricting diet to pureed solids and thin liquids.
# DM
He was continued on an insulin sliding scale.
TRANSITIONAL ISSUES
=====================
[] The patient is continuing PO cefpodxime on discharge. Last
day of antibiotics is ___.
[] Cr noted to be elevated from baseline. Cr 1.0 on day of
discharge. Recommend repeat Cr within 1 week of discharge.
[] If Cr improved to baseline, consider increasing gabapentin
dose back to 400mg TID, which was dose reduced for renal
function.
[] A small perihepatic fluid collection was seen on CT A&P,
consider repeat imaging to assess for resolution.
[] BPs continued to be elevated this admission. Would consider
increasing lisinopril dose ___ improved vs starting
alternative antihypertensive regimen.
#CODE: Full code
___ ___ | 190 | 502 |
16717341-DS-20 | 21,898,131 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Ms. ___ was admitted under the acute care surgery service
for management of her acute appendicitis. She was taken to the
operating room and underwent a laparoscopic appendectomy. Please
see operative report for details of this procedure. She
tolerated the procedure well and was extubated upon completion.
She was subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced to regular, which
she tolerated without abdominal pain, nausea, or vomiting. She
was voiding adequate amounts of urine without difficulty. She
was encouraged to mobilize out of bed and ambulate as tolerated,
which she was able to do independently. Her pain level was
routinely assessed and well controlled at discharge with an oral
regimen as needed. On the day of discharge she was afebrile with
stable vital signs. She was tolerating a regular diet,
ambulating, and having normal bowel and bladder function.
She was discharged home with scheduled follow up in ___ clinic. | 766 | 188 |
17366897-DS-14 | 25,500,858 | Dear Ms. ___,
You were admitted to ___ for back pain and headache. MRIs of
your brain and spine showed stable metastatic disease. There
were no blood clots in the brain. Your headache and back pain
were well controlled with the addition of a long-acting pain
medication, oxycontin. Your pain may have been related to your
recent intra-thecal chemotherapy. You should take the steroid
dexamethasone daily until your follow-up appointment with Dr.
___. This should reduce the inflammation caused by the
chemotherapy. | ASSESSMENT/PLAN:
Ms. ___ is a ___ year old woman with metastatic NSCLC
with brain mets and leptomeningeal disease who presents with
back pain and headache after receiving IT depocyte.
#. Back Pain / Headache: Most likely this is related to a
chemical meningitis from IT chemotherapy. Her symptoms started
shortly after discontinuing dexamethasone after last IT
infusion. She was afebrile and had no other signs or symptoms of
CNS infection. Imaging with MRI of the head, neck and thoracic
spine did not reveal an etiology of her back pain. MRV was
negative for sinus thrombosis. She was started on oxycontin 10mg
BID for pain with good effect. She received 8mg dexamethasone on
___ and was discharged on 4mg daily until scheduled follow-up
with neuro-oncology, Dr. ___, on ___.
#. Metastatic NSCLC:
Further management per outpatient team of Drs. ___
(pt is due for cycle 2 of ___ on ___ | 82 | 155 |
15401084-DS-3 | 24,161,381 | You were admitted into the gynecology service briefly because
there was a finding of a rim-enhancing fluid collection on CT
scan. This was confirmed to be a Right hemorrhagic cyst on
pelvic ultrasound. You were hemodynamically stable. | Ms. ___ was admitted into the gynecology service because the
initial finding on her CT was concerning for a pelvic abscess.
She was started on intravenous antibiotics, which were
discontinued later on the same day because the ultrasound
confirmed that it was in fact a Right ovarian hemorrhagic cyst.
She was hemodynamically stable thoughout her hospital course
with no evidence of rupture. Ms. ___ was initially
___ on the same day of admission. However, she continued
to have nausea and vomiting and was unable to tolerate oral
intake so she was kept in house for one more day. She received
intravenous zofran as needed.
Regarding her psychiatric history, she was seen by psychiatry
and patient had also been refusing her psychiatric meds.
Psychiatry saw her and thought her history was complex and more
consistent with PTSD. They reported that it was okay if she
refused some of her medications as she was not actively
suicidal. They recommended oral ativan as needed. They initially
had some problems getting her situated back at ___ because
of some lapse in her insurance. She was evaluated by BEST team
and they were eventually able to confirm that she was going back
to ___
Ms. ___ was discharged on hospital day 2 back to ___.
We recommended that she follow up with her gynecologists at
___/GYN in 6 weeks for a repeat ultrasound to ensure
resolution of her cyst. She was discharged home with some oral
zofran for her nausea. | 37 | 244 |
11616264-DS-12 | 24,212,468 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why were you hospitalized?
- You were admitted to the hospital because you were having
chest pressure and shortness of breath.
- You were also having abdominal pain.
- In the ED, CT scan of your chest was done which showed that
there was a blood clot in your aorta.
What was done while you were in the hospital?
- We started you on an IV medication to thin your blood to
prevent the clot from growing bigger.
- We got a CT scan of your abdomen, which did not show any clots
or anything else concerning.
- The vascular surgery and hematology teams were consulted and
recommended that you did not need any surgical intervention but
advised that you keep taking a blood thinning medication.
- Because you were having chest pain, we did a stress test on
your heart which showed that your pain was probably not related
to your heart.
- We tested your blood and found that you have anemia, meaning
that you have low levels of a protein called hemoglobin, which
carries oxygen in the body. Because of this, we tested you for
common causes of anemia, and found that you are have low levels
of vitamin B12 and iron, both of which are important for your
blood cells. We gave you injections of both of these vitamins
while you were in the hospital.
What should you do when you go home?
- You should follow up with Vascular Surgery, Hematology, and GI
in addition to your primary care provider (appointment details
below).
- You will need to have weekly B12 injections for the next
month, this can be arranged at your PCP's office.
- Continue taking all your medications as directed.
- Of note, you are being started on new medications to thin your
blood called Lovenox and warfarin. You will need to continue to
take the Lovenox injections until the warfarin has had time to
take effect. This is measured by a blood test called the INR.
You will need to follow up with your PCP on ___ to have your INR checked. Dr. ___ will then instruct you
on how much warfarin to take every day and how long to keep
doing the Lovenox injections.
NEW MEDICATIONS:
- Lovenox injections 80mg twice daily
- Warfarin 5mg daily
- Omeprazole 40mg daily
- Aspirin 81mg daily
- Atorvastatin 80mg daily
- Sulfameth/Trimethoprim (Bactrim) 1 TAB dialy
CHANGED MEDICATIONS:
- Metoprolol succinate increased from 100mg to 150mg
STOPPED MEDICATIONS:
- Clopidogrel 75mg
MEDICATIONS on HOLD (Do not take unless instructed to restart by
your PCP):
- Hydrochlorothiazide 25mg daily
- Lisinopril 20mg daily
Wishing you all the best!
Your ___ Health Care Team | ___ F with history of asthma, HFpEF, prior spontaneous arterial
subclavian thrombosis s/p thrombectomy via sternotomy, who
presented for chest pressure, SOB, and RUQ abdominal pain, was
found to have a possible aortic thrombus on CT imaging. The
patient was started on anticoagulation and further work up was
revealing for iron deficiency and B12 deficiency anemia. | 434 | 56 |
14474128-DS-17 | 22,871,392 | 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.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this when cleared by the Neurosurgeon.
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. | ___ y/o M s/p foreign body to L temporal region presents with L
frontal bone displaced skull fracture. Patient was admitted to
neurosurgery for further management and monitoring. He is intact
on exam. On ___, no drainage was seen from puncture site. An
MRI head was ordered to evaluate for soft tissue damage. ID was
consulted and he was started on CefazoLIN.
On ___, per ID cefazolin was discontinued and he was started on
flagyl and naficillin. On ___, he was experiencing dizziness
and nausea with one episode of vomiting which was relieved with
zofran. He was also given a 500cc bolus for low blood pressure.
His blood pressure continued to be low, he was started on
continuous IVF. On ___, he continued to have one episode of
n/v. He was encouraged to ambulate and reasured that he was
experiencing concussive symptoms. ID recommended PO flagyl and
levofloxacin x 1 week. On ___, he was discharged home. | 155 | 158 |
17892150-DS-9 | 28,393,520 | Ms ___,
You were admitted with abdominal pain,distension, and found to
have rectosigmoid stump stricture on CT scan, and subsequently
taken to the operating room on ___ for laparoscopic converted
to open resection of upper rectum, lysis of adhesions. You have
recovered from this procedure, tolerating a regular diet,
adequate ostomy output, pain control and are now ready to return
home.
You have a long vertical surgical incision on your abdomen and
have a "seroma-" clear serous fluid that sometimes develops in
the body after surgery; most often seromas are reabsorbed by the
body over a period of time. Please cover your incision with dry
gauze dressing, change daily and as needed. It is important
that you monitor your surgical incision for signs and symptoms
of infection including: increasing redness of the incision
lines, white/green/yellow/foul smelling drainage, increased pain
at the incision, increased warmth of the skin at the incision,
or swelling of the area.
You may shower; pat the incisions dry with a towel, do not rub.
If you have steri-strips (the small white strips), they will
fall off over time, please do not remove them. Please do not
take a bath or swim until cleared by the surgical team.
Pain is expected after surgery. This will gradually improve
over the first week or so you are home. You should continue to
take 2 Extra Strength Tylenol (___) for pain every 8 hours
around the clock. Please do not take more than 3000mg of Tylenol
in 24 hours or any other medications that contain Tylenol such
as cold medication. Do not drink alcohol while taking Tylenol.
You may also take Advil (Ibuprofen) 600mg every 8 hours for 7
days. Please take Advil with food. If these medications are not
controlling your pain to a point where you can ambulate and
perform minor tasks, you should take a dose of the narcotic pain
medication TRAMAFOL. Please do not take sedating medications,
drink alcohol, or drive while taking the narcotic pain
medication.
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs, and
go outside and walk. Please avoid traveling long distances until
you speak with your surgical team at your post-op visit.
LOVENOX DISCHARGE INSTRUCTIONS:
You are being discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this medication for a
total of 30 days (including doses in hospital), please finish
the entire prescription. Please monitor for any signs of
bleeding: fast heart rate, bloody bowel movements, abdominal
pain, bruising, feeling faint or weak. If you have any of these
symptoms please call our office or seek medical attention
immediately. Please avoid any contact activity and take extra
caution to avoid falling while taking Lovenox.
Thank you for allowing us to participate in your care, we wish
you all the best! | Ms. ___ is a ___ female with the past medical
history of Crohn's with s/p partial colectomy with rectosigmoid
stump and ileostomy age ___, with 1 week abdominal pain and
distention with concerns for flare or stricture. Initially
admitted to medicine service. She was found to have
rectosigmoid stump stricture on CT and brought to operating room
on ___ s/p Laparoscopic converted to open resection of
upper rectum, lysis of adhesions. (Please see operative note for
further details). After a brief and uneventful stay in the PACU,
the patient was transferred to the floor on colorectal service
for further post-operative management.
Neuro: Pain was well controlled on Dilaudid PCA and transitioned
to oral pain medication.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. She had good
pulmonary toileting, as early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI: The patient was initially kept NPO after the procedure. The
patient was advanced to and tolerated a regular diet. Patient's
intake and output were closely monitored. Patient had good
ostomy output.
GU: The patient had a Foley catheter that was removed per
pathway and voided spontaneously. At time of discharge, the
patient was voiding without difficulty. Urine output was
monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. She was encouraged to get up and
ambulate as early as possible. The patient is being discharged
on prophylactic Lovenox.
On POD#3, the patient was discharged to home. At discharge, she
was tolerating a regular diet, had ostomy output, voiding, and
ambulating independently. She will follow-up in the clinic in 2
weeks. This information was communicated to the patient directly
prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge. | 517 | 515 |
12883998-DS-11 | 21,120,299 | You were admitted to the hospital because of a blockage in your
bile duct due to a gallstone. You had a procedure called ERCP,
which removed the stone and placed a stent into the bile duct.
You will need to have a repeat ERCP procedure on ___ to remove
the stent and reassess the bile duct. Since removal of the
gallbladder can reduce the risk of similar episodes in the
future, we recommend seeing the surgical team in their clinic to
discuss whether or not you would be interested in this option.
You also had continued right sided hip pain while in the
hospital, although it improved somewhat before discharge. If
this does not continue to improve while getting rehab then you
may consider returning to the orthopedic surgeon you saw
previously. | ___ is a ___ woman with diastolic CHF, afib
on apixaban, nephrolithiasis, HTN, rheumatoid arthritis, history
of C diff, possible DVT, and recent pelvic fracture who
presented with pelvic and abdominal pain, found to have
choledocholithiasis on imaging and lactic acidosis, for which
she underwent ERCP with stone extraction, sphincterotomy, and
stent placement. Course notable for ongoing severe R hip pain
related to her recent fracture.
# Choledocholithiasis, possible cholangitis
# Possible intra-ampullary mass
# Possible sepsis (lactic acidosis)
Presented to ___ with both back/hip pain as well as
RUQ abdominal pain with CT demonstrating choledocholithiasis and
severe biliary dilation, prompting transfer for ERCP eval. RUQUS
here without evidence of cholecystitis. No cholestatic LFT
derangements. No documented fever or significant leukocytosis,
though in the ED she had a rising lactate without clear
alternative etiology, and so was treated for cholangitis given
the concern for a septic presentation. She underwent ERCP with
sphincterotomy and stent placement. During the procedure the
intraampullary tissue appeared fleshy and frond-like causing
concern for malignancy, although the cytology did not show any
malignant cells. She was not felt to be a candidate for
same-admission cholecystectomy. She will follow-up with surgery
as an outpatient. She will also need a repeat ERCP (___) for
stent removal and biliary evaluation.
It was ultimately decided to treat her with a 5 day antibiotic
course with ceftriaxone/flagyl -> cefpodoxime/flagyl
(___). Her apixaban was held post-sphincterotomy but can
be restarted on ___.
#Pelvic fracture
#R hip pain
#Lumbar compression fractures (uncertain chronicity)
Known healing right sided pelvic fractures. Was evaluated by
outpatient orthopedic surgeon a few weeks ago without need for
intervention. Per report her hip pain had improved until a few
weeks ago, when it worsened possibly due to a mild trauma, and
has not improved since then. No concerning findings on exam nor
CT from ___ (showed healing known fractures) but patient
significantly impaired by pain with movement. No midline spine
tenderness, so did not feel that her lumbar compression
fractures were likely to be contributing. Improved somewhat on
the day prior to discharge. Discussed with patient and
daughter, and will plan for rehab with referral back to ortho if
not improving. Pain treated with PRN tylenol and tramadol. Will
likely need orthopedics follow-up, especially if pain not
improving.
#Paroxysmal Afib
#?Hx of DVT
Continued on home metoprolol tartrate, amiodarone. Held eliquis
for 5 days after sphincterotomy (restart ___
#Chronic diastolic CHF
Unclear EF and last TTE, but documented as diastolic. Patient
had poor PO intake during most of the admission and required IV
fluids but remained hypovolemic-to-euvolemic. By the time of
discharge her PO intake had improved and so she was restarted on
torsemide at the time of discharge. She should have labs in ___
days to ensure she is tolerating this.
___ on CKD:
Uncertain baseline creatinine. She presented with creatinine
1.7, which gradually improved to 1.1 by the time of discharge
with fluids and antibiotics.
#Asymptomatic E coli bacteruria
Only 6 WBCs on UA, small leuks, and no symptoms, so this is
likely not an infection.
Additionally, it would be covered by her ceftriaxone for
cholangitis
#Rheumatoid Arthritis
Continued home prednisone 15mg daily
#HTN
Continued home amlodipine
#T2DM
Reduced insulin in the setting of poor PO intake. Would
gradually uptitrate as appropriate while at rehab
#COPD
Continued home prn duonebs and albuterol
#GERD
#Steroid GI PPx
Continued home PPI
#Depression
Continue home Escitalopram and mirtazapine
#H/o C diff infection
Continued PO vancomycin ppx. PCR negative on ___
======================================
====================================== | 132 | 556 |
16454295-DS-11 | 28,573,264 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You had an infection called c. diff, which causes diarrhea.
- Your kidney function was also worse than your usual.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were started on an antibiotic called vancomycin for the c.
diff.
- You were given fluids through your IV, and your kidney
function returned to normal.
- Your tacrolimus levels were high in your blood. This can
happen with diarrhea. Your tacrolimus dose was decreased to 3mg
twice a day.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all your medicines as described in this paperwork.
- You should take 3mg of tacrolimus twice a day until your
doctor tells you to increase your dose.
- You will need to get your blood tests checked on ___.
- Please keep all your follow up appointments as listed below.
We wish you all the best.
Sincerely,
Your ___ team | Ms. ___ is a ___ year old female with a history of Type 1
diabetes complicated by neuropathy and retinopathy, with ESRD
s/p live donor kidney transplant in ___, s/p deceased donor
simultaneous kidney/pancreas transplant ___ on MMF, prednisone
and tacro, and c. diff in ___ who was admitted with ___ and
diarrhea, found to have c. diff. Cr returned to baseline with IV
fluid. Her course was complicated by supra-therapeutic
tacrolimus level in the setting of diarrhea as well as
hyperkalemia. | 170 | 83 |
17024159-DS-7 | 27,704,670 | Dear Mr. ___,
You were admitted after you came in for your urology procedure
and were found to have a fever. We found that you had an
infection in your bladder and kidneys. We treated you with IV
antibiotics and the infection improved. You will need to
continue antibiotics through ___ ___.
You will need to follow up closely with the urologists to have
your kidney stones and stents removed. This is currently
scheduled for ___. You will need to not eat
anything after midnight, the night prior to your procedure.
While you were here, you were seen by psychiatry who recommended
that you start trazodone to help with sleep while you are here.
You also had a fall in the shower with laceration (cut) on your
left elbow. You were seen by surgery who placed 4 stitches which
need to be removed on ___. There was initially concern for
a fracture of your elbow however you were seen by orthopedics
who did not think that there was any fracture.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Your ___ Care Team | Mr. ___ is a ___ male with the past medical history
and findings noted above who presented septic with likely urine
source | 188 | 22 |
19546107-DS-12 | 25,735,987 | Dear Mr. ___,
It was a pleasure taking care of you on this hospital stay at
___.
Why was I admitted to the hospital?
You experienced dizziness, chills, abdominal discomfort, and
shortness of breath, similar to previous episodes of diabetic
ketoacidosis, after being unable to take your insulin earlier
this week. In the ___, you were found to be in diabetic
ketoacidosis.
What happened on this hospital stay?
You were given anti-nausea medication and insulin and dextrose
through an IV. You were admitted to the ICU for close
monitoring. Endocrinologists from the ___ came to see you and
guide your treatment. After treatment, blood labs showed that
your sugars and other abnormal labs improved back to normal
levels. You were transitioned off IV insulin and back to Lantus
and Humalog.
When you return home, please take insulin as follows until you
see your PCP or an endocrinologist at ___:
- 24 units of Lantus daily
- Humalog 8 units standing with every meal
- Humalog sliding scale: for glucose >120, give 2 units + 2 per
additional 50 mg/dl glucose
Sincerely,
Your ___ Care Team | ___ presenting with vomiting after not taking insulin for 1.5d,
now being treated in ___ for DKA. Sister described patient's
social situation as being under a lot of stress, living with
ex-girlfriend, had been locked out of a house he was staying in,
which is why he missed meds for at least 24 hours. She also said
he works in high stress job, ___. | 174 | 64 |
15284302-DS-17 | 23,069,643 | You came to the hospital for an episode of incomprehensible
speech.
Your labs showed your kidneys were not working well and your
blood pressure was lower than normal. We held your blood
pressure medications, gave you fluids through the vein and your
kidney function and blood pressures improved.
We watched you closely for over 48 hours and you had no
recurrence of your symptoms.
There were no signs of infection to account for your symptoms.
Extensive testing showed no evidence of a stroke and you
echocardiogram, carotid ultrasound and MRI did not show any
signficangt abnormalities to account for your symptoms.
It is possible that you became dehydrated and developed low
blood pressure which led to your initial symptoms. Sometimes
when the kidney are not working as well, toxins can build up in
your system that can add to confusion as well.
Moving forward it will be very important to stay hydrated and
let your doctor know if you are not eating well for days. Please
take only the medications prescribed in your discharge
paperwork.
If you develop recurrent difficulty with speech, nausea,
vomiting, fevers chest pain, shortness of breath,
lightheadedness/dizziness, chest pain or any other symptom that
concerns you, please call your doctor or return to the emergency
dept.
It was a pleasure taking care of you!
What is type 2 diabetes?
Type 2 diabetes (sometimes called type 2 "diabetes mellitus") is
a disorder that disrupts the way your body uses sugar.
All the cells in your body need sugar to work normally. Sugar
gets into the cells with the help of a hormone called insulin.
If there is not enough insulin, or if the body stops responding
to insulin, sugar builds up in the blood. That is what happens
to people with diabetes.
There are 2 different types of diabetes. In type 1 diabetes, the
problem is that the body makes little or no insulin. In type 2
diabetes, the problem is that:
___ body's cells do not respond to insulin
___ body does not make enough insulin
___ both
What are the symptoms of type 2 diabetes?
Type 2 diabetes usually causes no symptoms. When symptoms do
occur, they include:
___ to urinate often
___ thirst
___ vision
If type 2 diabetes rarely causes symptoms, why should I care
about it?
Even though type 2 diabetes might not make you feel sick, it can
cause serious problems over time, if it is not treated. The
disorder can lead to:
___ attacks
___ disease
___ problems (or even blindness)
___ or loss of feeling in the hands and feet
___ need to have fingers, toes, or other body parts
removed (amputated)
How is type 2 diabetes treated?
There are a few medicines that help control blood sugar. Some
people need to take pills that help the body make more insulin
or that help insulin do its job. Others need insulin shots.
Depending on what medicines you take, you might need to check
your blood sugar regularly at home. But not everyone with type 2
diabetes needs to do this. Your doctor or nurse ___ tell you if
you should be checking your blood sugar, and when and how to do
this.
Sometimes, people with type 2 diabetes also need medicines to
reduce the problems caused by the disease. For instance,
medicines used to lower blood pressure can reduce the chances of
a heart attack or stroke.
Medicines are not the only tool to manage diabetes. Being
active, losing weight, eating right, and not smoking can all
help people with diabetes stay as healthy as possible.
Can type 2 diabetes be prevented?
Yes, it can. To reduce your chances of getting type 2 diabetes,
the most important thing you can do is control your weight. If
you already have the disorder, losing weight can improve your
health and blood sugar control. Being active can also help
prevent or control the disorder. | ___ with h/o CAD s/p DES to pLAD, DM (A1c 9.8%), HTN, HLD,
iron-deficiency anemia presenting with dizziness and possible
transient aphasia, found to have leukocytosis and ___.
# Possible transient aphasia:
# Dizziness:
# Headache:
# Essential HTN
Patient presented with minutes of "incomprehensible speech"
(without slurred speech or facial droop) in setting of
dizziness/lightheadedness. Potential etiologies included
transient cerebral hypoperfusion (orthostatic hypotension
present in ED & ___ on presentation, resolved with IVFs) and
possible "toxic metabolic encephalopathy" d/t significant ___.
Other etiologies seem less likely after workup including aphasia
secondary to TIA (though multiple risk factors; carotid US, TTE,
Tele, CTH, MRI reassuring) nor hypoglycemia (given nl BG this
AM) or seizure.
WBC initially elevated, but no clear localizing signs/symptoms
of infection. This may have actually been hemoconcentration. The
patient also initially had a headache, but it was similar to
chronic headaches, likely tension etiology in absence of
evidence of fevers or other symptoms, and it resolved. CRP was
mildly elevated but otherwise clinically not c/w temporal
arteritis. No temporal artery tenderness and jaw pain is not
associated HA or vision changes. Neurologic exam remained non
focal throughout her hospital course. Ziopatch ___ with only
SVT. No valvular abmonormalites noted on TTE. The cause of her
presenting orthostatic hypotension and ___ may have been from
hyperglycemia-induced polyuria. Her son questions whether she
has been vigilant with her insulin usage, and her A1c also
brings this into question. Home ASA 81 and Atorv 80 were
continued and her lipid profile indicated excellent control. Her
losartan was resumed after kidney function normalized, but her
thiazide is still being held. This she be re-evaluated at follow
up.
# ___:
Cr 2.7 on admission from 0.6-0.7 ___. Secondary to
hypovolemia as demonstrated by orthostatic hypotension (with
FeNa 0.5%, FeUrea 16%), now with improved following IVFs. Renal
US negative for obstruction/hydronephrosis. Cr improved to 0.9.
Of note a foley was initially placed for accurate I/o and was
easily removed without any evidence of subsequent retention.
# Leukocytosis: - RESOLVED
WBC 10.3 on presentation, peak up to 12.3. Possible stress
response in absence of clear localizing signs/symptoms of
infection (UA neg, CXR without PNA, no abdominal pain/diarrhea
to suggest GI source, no URI symptoms to suggest influenza, low
suspicion for CNS infection as above). ___ be a component of
initial hemoconcentration as baseline range appears to be ___.
BCx x 2: NGTD. UCx - NGTD
Empiric antibx deferred.
# CAD s/p DES to pLAD:
Low suspicion for ACS in absence of chest pain and with negative
trop x 2. EKG non-ischemic. Recent stress test ___ WNL. As
above, continued ASA, statin. Metop resumed prior to discharge.
Lipid panel indicated excellent control: LDL 42 HDL 36
# DM:
Uncontrolled with A1c 9.8%. Hypoglycemia was not present
initially, rather she was hyperglycemic initially though not
profoundly.
# Iron-deficiency anemia:
Hgb 9.9 on admission, at baseline. No e/o active bleeding or
hemolysis.
# GERD: Continued home omeprazole 40mg daily | 622 | 473 |
17051588-DS-5 | 20,940,192 | Dear ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with shortness of
breath and it was found that you had a lot of fluid in your
lungs. This was removed with several dialysis sessions. Your
heart rates were sometimes fast and sometimes slow from your
atrial fibrillation. The Cardiology doctors met with ___ and
decided that you should STOP taking your diltiazam for the time
being. You will wear a heart monitor for several days after
leaving the hospital and they will update you with the results.
You will continue to have dialysis at a center near your sons
house. You were also started on a new medication to reduce your
risk of stroke in the setting of atrial fibrillation. This
medication is called Apixiban. You were ___ a 30 day free
prescription of this medication and our social worker initiated
the process for you to receive this medication at a reduced
___ long term. Please follow up with your primary care doctor
or cardiologist about continuing to receive this medication at a
reduced ___. If you can't continue to take apixiban, please
take with your PCP and ___ about starting warfarin
instead.
We are working on an appointment for you to see Cardiology at
___ prior to you returning to ___. If you don't
hear from their office by ___, please call ___ to
schedule this appointment.
If you feel your atrial fibrillation return with fast heart
rates, you should seek medical attention.
We wish you the best,
Your ___ Treatment Team | SUMMARY
=======
___ with ESRD from ___, HTN, AR, MR, and HF(EF45%) presents
with dyspnea for acute heart failure, with Afib complicated by
RVR and bradycardic pauses. She was initially admitted on
diltiazeam which was switched to metoprolol in the setting of
her known heart failure. She underwent multiple HD sessions for
volume removal. After her second to last dialysis session she
converted from sinus to atrial fibrillation with RVR. In the
setting of receiving PO metoprolol at dose of 25mg, in addition
to IV metoprolol, she experienced symptomatic bradycardic pause
___ seconds. This occurred 2 other times during admission with
eventual conversion back to normal sinus rhythm. In the setting
of arrhythmias, EP was consulted and recommended discontinuation
of all nodal blocking agents with ___ of hearts monitor on
discharge. She remained in normal sinus rhythm off nodal agents
for >36 hours prior to discharge. She was started on apixiban
for anticoagulation. She will be staying with her son nearby for
dialysis at ___ for at least a week prior to
returning to her home on ___.
ACUTE ISSUES
============
# Afib with RVR complicated by RVR and bradycarida with
symptomatic pause.
Patient was not on anticoagulation on admission. Her diltiazem
was changed to metoprolol as below in the setting of HFrEF. She
converted back and forth between NSR and Afib several times. She
also experienced several episodes of Afib with RVR, treated with
IV and increased doses of PO Metoprolol. She experienced pauses
up to 3 seconds with increase in symptoms of lightheadenss and
vision change. Pauses were thought exacerbated by increased
doses of metoprolol (25mg PO q6) and it was thought that she was
more sensitive to BB. EP was consulted. ___ questionable
symptomatic conversion pauses, they recommended discontinuation
of all nodal blocking agents. She converted to NSR and remained
in normal sinus rhythm with rates in the 60-70s for >36 hours
prior to discharge, including during an HD session. She was
___ of hearts cardiac monitor on discharge to be
followed by Cardiology at ___. Care Connections reached out to
the ___ cardiology department to schedule an appointment with
___ Cardiology within ___ weeks of discharge. Patient will be
staying with her son outside ___ for the next
several weeks before returning to ___. She will
re-establish care with Cardiologist on ___ upon
returning home. Additionally, she was started on Apixiban 2.5mg
BID after risk benefit discussion regarding stroke and bleeding
risk in the setting of Atrial fibrillation with ESRD. She was
___ a 30 day free prescription and social work initiated the
application for patient to receive apixiban long term with
financial assistance. The results of this application were
pending at the time of discharge. Patient instructed to contact
her Cardiologist/PCP if this application is denied, as she will
then be unable to afford apixiban and would need to have a
conversation about starting warfarin for anticoagulation
management instead.
# Acute Systolic Heart Failure with reduced EF% (45%): Patient
presented in marked hypervolemia c/b pleural edema, worsening
valvular disease. No clear precipitant identified but possible
contribution from ESRD on HD and Afib. Her preload was managed
with aggressive dialysis on consecutive days. Her diltiazem was
switched to metoprolol in setting of HFrEF initially and then
all nodal blocking agents were eventually discontinued as
detailed above. Worsening valvular disease seen on TTE was
thought difficult to interpret in the setting of concurrent
volume overload. ___ that she was discharging to stay with her
son temporary near ___, she was set up for a Cardiology
appointment at ___ prior to her traveling back to ___
___. Consideration can be ___ to repeat TTE when not
volume overloaded in the outpatient setting to trend valvular
pathology.
# ESRD on HD (___): As above, she received consecutive days of
dialysis/ultrafiltration. She was continued on Nephrocaps 1 CAP
PO DAILY, Calcium Acetate 1334 mg PO TID W/MEALS. Several HD
sessions were complicated by chest pain and Afib with RVR as
above. Her last HD session prior to discharge was on ___. She
will have temporary HD at ___ facility outside ___ (next
___, ___ she is staying with her son and then
resume regular HD at her home facility in ___.
# Type II Demand NSTEMI: Troponin at 0.11 on arrival with volume
overload, without ischemic EKG changes likely Type 2 Demand
NSTEMI. Troponin subsequently stabilized. She was continued on
aspirin, statin. BB was held as above.
CHRONIC ISSUES
==============
# HLD: Continued home pravastatin.
# Anemia: Likely ___ CKD. Stable during admission.
# Nausea: Continued Zofran PRN, metoclopramide QIDACHS
TRANSITIONAL ISSUES
===================
- Discharge weight: 55.57 kg (122.51 lb)
- Next HD session scheduled ___ at ___. Upon
travel back to ___ patient to resume regular HD
sessions at established facility.
- Discharged with ___ of Hearts Monitor to be followed by
Cardiology at ___
- Consider repeat TTE in the outpatient setting when not volume
overload to assess status of valvular disease.
- Trend heart rates in the outpatient setting and during HD
sessions. If atrial fibrillation with RVR recurs would favor
Diltiaezam as rate control agent instead of metoprolol ___
observed sensitivity (with bradycardic pauses) to beta blocker
during admission.
- Verbal sign out on the above issues conveyed to patients new
PCP on ___ Dr. ___. PCP appointment on ___. D/c summary to be faxed to ___ office at ___
- In addition to cardiology appointment at ___, patient is
followed by Cardiologist on ___. Appointment to be
arranged by patient upon return to ___.
- Medication Changes
-- Started Apixiban 2.5mg BID for anticoagulation in the setting
of Afib on HD. Patient was provided 30 days medication at no
cost from ___ program upon discharge. Social worker
inpatient initiated application for patient to receive financial
assistance to cover this medication for an extended period of
time. Results of this financial assistance were pending at the
time of discharge. Patient will be contacted regarding approval
for this. If application denied, patient instructed to discuss
with Cardiologist and PCP about need to switch agents from
apixiban to warfarin ___ that without financial support,
apixiban is cost prohibitive for the patient).
-- Held home Diltiaezm on discharge per the recommendation of
Cardiology EP Inpatient Team. | 264 | 1,031 |
15728128-DS-11 | 20,346,195 | Dear Mr ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why were you hospitalized?
- You came to the hospital because you were having ongoing
confusion, tremor and difficulty speaking
What was done for you this hospitalization?
- You had a CT and MRI of your head, EEG and 2 spinal taps
(lumbar puncture). The CT, MRI and EEG were normal but the
spinal tap showed many white blood cells in the fluid around the
brain, which is not normal. Infectious studies of this fluid
including bacterial culture and viral testing were negative.
The fluid from the second spinal tap has no bacterial growth so
far either.
- You were treated for a urinary tract infection with
antibiotics
- We had our neurologists help us figure out why you were having
those symptoms. The fluid from the second spinal tap was sent
for testing called cytology and flow cytometry to see if there
was any signs of lymphoma, which is still pending.
What should you do after you leave the hospital?
- Continue to get stronger in rehab!
- Your Metoprolol was held due to your heart rate being at the
low end of normal in ___. Your Amlodipine was increased for
blood pressure control from 5mg to 10mg daily.
- Complete all your treatments
- Follow up with your primary care doctor
- Follow up with neuro oncology
We wish you the best!
Sincerely,
Your ___ care team | Mr. ___ is a ___ yo man with history of marginal zone
lymphoma (previously on Rituximab), renal and bladder stones
with recurrent UTIs, recent prolonged ___ stay for suspected meningoencephalitis without positive
cultures who was subsequently discharged to rehab. He presented
to ___ with 2 days of low grade fever, nausea,
vomiting and tremors, and was found to have Pseudomonas UTI and
recurrent neurologic abnormalities (confusion and tremors)
concerning for infectious v malignant CNS process. He underwent
LP on ___ with elevated CSF lymphocytes concerning for atypical
infectious vs malignant CNS process. He completed a course of
Cefepime for Pseudomonas UTI. He was treated empirically for
HSV infection (then discontinued after negative HSV result) and
worked up for possible malignant spread to the CNS. He
underwent repeat LP on ___ with flow cytometry pending to rule
out CNS involvement by mantle cell lymphoma.
# Acute toxic-metabolic encephalopathy
# Tremor, dysmetria
# Abnormal CSF studies with lymphocytic predominant CSF
He presented with confusion, inattention, dysmetria, tremor and
dysarthria in the setting of a UTI. He was already treated once
empirically for meningoencephalitis at ___ but
improved only briefly and partially while at rehab with
subsequent rapid deterioration. Exam was notable for dysmetria,
trouble with word finding, gross truncal and extremity tremor
worse with intention, and mild encephalopathy with intermittent
confusion initially. CT head, MRI and EEG were unrevealing.
Initial concern was for indolent infection versus viral
encephalitis versus CNS lymphoma. He was treated empirically for
bacterial meningitis with cefepime (___) and for HSV
infection w/ acyclovir (___) while awaiting results from
CSF studies. CSF from initial LP had negative bacterial culture,
negative HSV PCR, negative Enterovirus (preliminarily), negative
cytology, negative paraneoplastic panel. Neurology and
Neuro-oncology were involved. His mental status was overall
improved with treatment for UTI and he was AOx3 and close to
baseline. He had a second LP on ___ with negative bacterial
culture to date, with cytology and flow cytometry still pending
at discharge. Neurology and neuro oncology felt the improved
TNC and borderline protein of repeat CSF were reassuring against
carcinomatosis. Neurology noted that he may need serial LPs to
look for carcinomatosis as cytology is only positive 50% of the
time, but defer further LPs for now. He will need follow up in
___ clinic in ___ weeks.
# UTI secondary to Pseudomonas aeruginosa: He initially had
dysuria and positive UA with Pseudomonas on culture, resistant
only to ceftazidime, and GPCs consistent with Lactobacillus. He
received ceftriaxone pending culture results, thus day 1 of
treatment was ___ when cefepime was initiated and completed 7
day course (last day ___. Blood cultures at ___ and ___ were
both negative for bacteremia. Restarted Macrobid ___ daily for
UTI prophylaxis on ___, which was family's preference.
# Marginal Zone Lymphoma: Reported being treated by Dr. ___ at
___. Per wife, he is in remission; last rituximab
was given 4 months ago. CSF was sent from LP from ___ for
flow cytometry to look for any evidence of lymphoma involvement
and was pending at discharge.
# Anemia
# Leukopenia: WBC has been around 2.5-4, trending down,
afebrile, not neutropenic. Hb has been ___ and stable,
without signs of bleeding.
# Elevated globulin level: Noted at ___. Would
repeat outpatient after acute illness resolves.
# Hypertension: Increased amlodipine from 5mg to 10mg daily.
Held metoprolol in setting of relative bradycardia (HR in
___.
# CAD: Continued ASA. Held metoprolol given bradycardia.
# BPH: Continued tamsulosin, finasteride
# Multiple CT imaging abnormalities: Letter sent to PCP
==================== | 233 | 585 |
13326342-DS-3 | 24,730,154 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Patient was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. She was taken
to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently.
The patient's pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed. Her JP
drain was removed on the day she was discharged.
On ___ she was discharged home with scheduled follow up in
___ clinic two weeks later. | 729 | 187 |
13994738-DS-20 | 27,379,874 | Dear Ms. ___,
It was a priviliege to care for you at the ___
___. You were admitted for SOB, cough, and pleuritic
chest pain. You were found to have a recurrent episode of
pneumonia. You were treated with antibiotics and it is now safe
to continue recovering at home.
You were also noted to have an elevated liver enzyme, alkaline
phosphotase. Further work up revealed ***COMPLETE****
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team | ___ w/ COPD, ankylosing spondylitis on Enbrel, chronic pain,
recent pneumonia, who was sent from ___ clinic for
progressive coughing, shortness of breath, and malaise, now with
radiographic evidence of recurrent community-acquired pneumonia.
#CAP
Patient with progressive dyspnea, cough, and pleuritic chest
pain over past several weeks. CXR with LLL consolidation.
Sputum culture with 4+ GPC's ___ clusters and short chains. She
was treated with IV CFTX and PO azithro with notable improvement
___ her leukocytosis. No hypoxemia or tachypnea. At times
borderline hypotensive but not too far off from baseline and
respond with IVF. Patient with significant pleurisy and
prednisone considered, but ultimately deferred given preference
to avoid further immunosuppresion as the patient is on Enbrel
for Ankylosing Spondylitis. Antibiotics at the time of
discharge: switched to PO augmentin for 4 weeks to treat
necrotizing PNA as patient left AMA
#CHRONIC PAIN
Continue gabapentin 1200 mg PO TID . Continued Lidocaine 5%
Patch 1. Initially receiving PO morphine prn for severe
pleurisy. Patient was not discharged on opioids given concerns
for past misuse.
#ELEVATED ALP:
AlkP elevated to 200s with no other LFT derangements. RUQUS
showed mild prominence of extrahepatic common bile duct
measuring up to 9 mm is noted with limited visualization of the
more distal common bile duct due to bowel gas.
. Hep A ab positive
Rest of hepatitis panel negative. Anti smooth muscle ab
negative.
#NECK STIFFNESS WITH ROTATION
#NUMBNESS OF R OCCIPUT
CT C-spine obtained on admission with chronic DJD but otherwise
no acute concerning pathology such as vertebral body
subluxation. Lidocaine patch applied to affected area. Likely
would benefit from outpatient physical therapy
#REPORT OF A SMALL STROKE SEEN ON CT AT ___ :
No focal neurologic signs. OSH records were not received prior
to discharge. Verification and further workup deferred to PCP.
#COPD :
Continue Tiotropium. No evidence of concurrent exacerbation ___
setting of pneumonia. Steroids deferred.
#DEPRESSION AND ANXIETY:
Continued home buspirone and citalopram.
#ANKYLOSING SPONDYLITIS :
Takes weekly Enbrel. Resumption of this medication per
outpatient rheumotologist. | 90 | 335 |
12887982-DS-10 | 20,354,875 | You were admitted to the hospital with a small bowel obstruction
and stool in your colon. This was managed conservatively with
bowel rest, IV fluids, nasogastric tube suctioning, and a bowel
regimen. With this conservative management, your obstruction has
resolved. You may resume eating a regular diet.
You were also found to have a urinary tract infection, for which
you have completed at 3 day course of antibiotics. Please call
your PCP if you continue to have any urinary symptoms such as
pain with urination or increased urgency/frequency of urination.
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.
*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.
Avoid driving or operating heavy machinery while taking pain
medications.
Continue to take senna and colace as you were prior to your
hospitalization. You have also been started on a medicine called
reglan. Please discuss with your GI doctor at your follow up
appointment whether or not you should continue to take this
medication.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon. | Ms. ___ was admitted on ___ under the acute care service
for management of her small bowel obstruction.
A nasogastric tube was placed on admission for suctioning, and
she was placed on bowel rest with IV fluids for hydration. A
foley catheter was also placed for urine output monitoring. On
HD#1, she reported passing flatus and had a bowel movement.
Serial abdominal exams were performed and improved, and on HD#2,
her NG tube was removed. Her urine output remained adequate and
her foley catheter was also removed, at which time she voided
adequate amounts of urine without difficulty. She was given a
dose of SC methylnaltrexone as well as a fleets enema in an
effort to empty out her colon. She was also started on reglan to
increase GI motility. Over the next 2 days, her diet was slowly
advanced as tolerated, and she remained without increased
abdominal pain, nausea/vomiting.
She was noted to have a UTI on admission and given a 3 day
course of IV ciprofloxacin for this, which was completed on
HD#2. She remained afebrile and hemodynamically stable without
signs of infection.
She was encouraged to mobilize out of bed and ambulate as
tolerated during her hospitalization. She was also started on SC
heparin for DVT prophylaxis.
Her pain level was routinely assessed and she was administered
intermittent morphine as needed for control of her chronic pain
as well as some abdominal pain at the beginning of her
hospitalization. By discharge, her abdominal pain had resolved
and she was tolerating a regular diet. He regular home pain
management regimen was resumed.
On ___, she was discharged home with scheduled follow up in
the pain clinic as well as with her gastroenterologist. | 304 | 281 |
16044039-DS-11 | 22,680,372 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently admitted for cough, shortness
of breath, night sweats, and fevers. You underwent a
mediasteinotomy to help establish a diagnosis. You will follow
up on the results of this procedure with your PCP and Dr.
___. You were treated with antibiotics and you improved.
You will complete this medicine, amoxicillin clavulanate, at
home.
Please continue to take all of your medications as prescribed
and keep all of your follow-up appointments.
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team | SUMMARY:
Otherwise healthy ___ y.o. female presents from ___
after CXR performed for evaluation of cough and fevers
demonstrated large anterior mediastinal mass. She reported 6
months of night sweats and shortness of breath/shallow breathing
as reported by her wife (pt denies dyspnea), 9 days of
productive cough.
# Pneumonia: Likely post-obstructive given anterior mediastinal
mass. She did well clinically without fever and had improved
leukocytosis. She will complete a 7 day course of augmentin with
final day = ___. Negative urinary legionella ag. Blood
cultures were NGTD at time of this summary.
# Mediastinal mass: differential includes lymphoma, thymoma,
thyroid, and teratoma. Per radiology report imaging most
suggestive of lymphoma, and she also endorses B symptoms.
Negative micro on biopsy specimen.
- s/p mediasteinotomy ___
- pathology pending at discharge
# Pericardial effusion: intermediate density fluid vs. soft
tissue thickening of pericardium on CT without evidence of
tamponade. TTE without significant pericardial effusion
- no intervention | 93 | 157 |
19845944-DS-8 | 28,570,119 | Wound Care: You have been placed in a splint and should not get
this wet. You may shower but should cover your splint to prevent
it from getting wet. 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.
******WEIGHT-BEARING*******
non-weight bearing right 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 2 weeks post-operatively. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a R medial malleolar fracture. The patient was taken
to the OR and underwent an uncomplicated open reduction internal
fixation. 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 ___.
The patient was transfused 0 units of blood for acute blood loss
anemia.
Weight bearing status: nonweightbearing.
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 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 145 | 177 |
16381749-DS-4 | 25,902,519 | Dear Mr. ___,
It was a pleasure treating you at the ___
___. You were admitted with concern for your
shortness of breath. While admitted your bloodwork and heart
rhythm were monitored while we gave you medication to remove
your excess fluid causing your congestion. We started you on new
medications, which its critical you take as prescribed in order
to ensure that you continue to feel good. Its also important you
follow-up with your outpatient providers at your scheduled
appointments.
Wishing you the best of health,
Your ___ team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is a ___ with history of NICM, HCV, polysubstance
abuse, and pre-diabetes who presented with dyspnea. The patient
was undergoing cardiac MRI as furtherwork-up of newly discovered
cardiomyopathy and reported was feeling dyspneic while laying
flat for the procedure. The patient's cardiologist was contacted
who referred the patient to the ED. On arrival to the floor, the
patient reported feeling congestion in his chest and head. He
was monitored on tele with lytes trended and was actively
diuresed with IV boluses of furosemide then transitioned to PO
torsemide the day prior to discharge. He was discharged on
torsemide 20 mg daily as well as 12.5 spironolactone, with an
increased dose of metoprolol succinate 50 mg daily. His new dry
weight is 90.6 kg.
#Acute on chronic systolic CHF, compensated:
Fluid overload findings on initial exam as well as elevated BNP
as compared to recent discharge despite CXR without significant
edema. Patient's weight 91.9kg upon discharge in ___, found
to be 96.9 kg on admission. Possibly related to dietary
indiscretion in setting of new diagnosis and unfamiliarity of
heart failure diet. cMRI suggested sarcoid Vs other non-infarct
related insult. Further work-up with Non-contrast Chest CT
completed during inpatient stay per outpatient cardiologist.
Patient was diuresed with IV lasix boluses while monitored on
tele and with lytes trended. He was transitioned to PO torsemide
and spironolactone the day prior to discharge and his home
metoprolol was increased to 50 mg daily. Daily weights and I&Os
were followed. The patients new dry weight is 90.6 kg. He will
follow-up with his PCP and cardiologist as an outpatient.
#Polysubstance abuse
Patient with history of significant etOH use and IVDU. Patient
has been recently using etOH and heroin. UTox ___ neg. Social
work consulted and saw patient. The patient experienced no
withdrawal symptoms during inpatient stay.
#Chronic kidney disease
Patient found to have elevated creatinine upon last
hospitalization, last 1.5 upon discharge. Stable during
admission, 1.3 at discharge.
#Pre-diabetes
Patient was found to have A1c 6.5% upon last hospitalization. He
was not discharged on any glucose control. Did not require any
inpatient treatment. F/u as outpatient.
#COPD
Inhalers continued per home regimen
TRANSITIONAL ISSUES
-Patient reports difficulty reading labels as he is far sighted,
he should follow-up with an optometrist as an outpatient
-If possible, blister packs should be obtained for medications;
patient reports his daughter will help him with setting up a
pill box
-Patient recieved nutrition counseling about diet restrictions,
should be encouraged further as outpatient | 100 | 403 |
12106438-DS-8 | 23,101,076 | Dear Mr. ___,
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions are covered with Dermabond (skin glue). This
will wear off over time. Do not pick it off.
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Surgery Team | Mr. ___ presented to the ___ ED on ___ and was found
to have acute cholecystitis. He was started on IV antibiotics
and taken to the Operating Room where he underwent laparoscopic
cholecystectomy. For full details of the procedure, please refer
to the separately dictated Operative Report. He was extubated
and returned to the PACU in stable condition and after
satisfactory recovery from anesthesia, was transferred to the
surgical floor for further monitoring.
Diet was advanced as tolerated to regular which he tolerated
well. IV fluids were discontinued after oral intake was
adequate. Patient developed rash to Dilaudid and morphine and
his pain was controlled with Tylenol. He resumed his home
medications. Patient was able to ambulate with walker
assistance and void spontaneously.
He was discharged home on ___. At the time of discharge, he
was tolerating a regular diet, ambulating independently with
assistance of walker, voiding spontaneously and pain was well
controlled with oral medications. He was having random movements
of his upper extremities, which patient reported he had prior to
admission. He was discharged with instructions to follow up in
___ clinic with LFT's ordered prior to visit. Discharge
instructions were reviewed and questions answered. | 717 | 204 |
17744386-DS-3 | 20,458,661 | Dear Mr. ___,
You were admitted to the Neurology service at ___ due to a
prolonged seizure requiring intensive care. The seizure was
likely caused by a urinary tract infection, which we treated. We
did not find any new abnormalities in your brain imaging.
Medication changes:
Please take keppra to prevent seizures.
Please take augmentin through ___ (to complete a 10 day
course).
Please continue all other home medications as prescribed.
Please follow up with your primary care doctor and neurologist.
Sincerely,
Your ___ Neurology Team | Mr. ___ is an ___ yo M with history of intellectual disability,
HTN, HLD, who presented to the hospital with facial bruising and
had first time seizure in the ED >15 minutes, and required
Ativan, keppra, and intubation with propofol drip to resolve. He
was found to have a UTI which likely contributed to the seizure,
and had decreased brain volume and atrophy on MRI which lowers
seizure threshold. He will continue on keppra for seizure
treatment.
#Seizure/encephalopathy
The patient was admitted to the NeuroICU on midazolam gtt and
fentanyl. No further seizure like activity was noted. He was
continued on Keppra 500 mg BID. He was initially continued on
broad spectrum coverage for meningoencephalitis, though
antibacterials were discontinued with an LP showing 1 WBC. He
was continued on acyclovir until HSV PCR negative on ___.
MRI showed global brain atrophy, without acute lesions or other
structural problems. EEG showed generalized slowing in the ___
hz range with no seizures or epileptiform dischages. He was
weaned to extubate on hospital day 3. Urine culture from
admission turned positive, showed >100k CFU EColi, he was
started on ceftriaxone, however sensitivities showed CTX
resistance, and he was switched to IV Unasyn on ___. He was
discharged on augmentin 875mg BID for a total 10 day course
(ends on ___.
#Hypotension
Home BP medications were held as he had SBP90s while intubated
on sedating medications. His SBP ran in the 100-110 range after
extubation, so home medications continued to be held.
# Constipation
On ___ he vomited dinner, and again vomited breakfast on ___. He
had benign abdominal exam with KUB that showed large amount of
stool. He received Miralax, bisacodyl, lactulose, milk of
magnesia, and fleet enema x 2 and had multiple bowel movements.
He was able to tolerate PO prior to discharge back to nursing
facility. He was discharged on new medications for constipation.
# Pectoralis tear: CT chest showed an incidental finding of a
left pectoralis muscular injury/tear with evolving intramuscular
hematoma. Patient denied pain at that site and had full range of
motion of the shoulder. Orthopedics was consulted who
recommended nonoperative management with rest, ice, and pain
control.
----------------- | 78 | 355 |
19577479-DS-7 | 24,041,663 | Have a friend/family member check your laceration daily for
signs of infection.
Take your pain medicine as prescribed.
Your head laceration was closed with staples, please wait
until after they are removed to wash your hair. You may shower
before this time using a shower cap to cover your head.
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.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this after discussing with your doctor at
follow up.
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in ___ days and again in one week. This can be
drawn at your PCPs office, but please have the results faxed to
___. PLEASE TAKE DILANTIN FOR A TOTAL OF 10 DAYS. ___.
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. | The patient was admitted for observation after a traumatic fall
resulting in a subarchnoid hemorrage on early in the morning on
___. He was started on Dilantin for seizure prevention and
placed on a CIWA scale because of his history of alcohol abuse
and current use of alcohol. On ___, he was complaining of
headaches which were not being managed well with percocet so he
was started on Fioricet.
At the time of discharge in the afternoon on ___, the
patient was doing well, afebrile with stable vital signs,
tolerating a regular diet, ambulating, stable neuro exam and
pain was well controlled. Repeat head CT scan was stable. The
patient was discharged home on Dilantin for 10 days. The
patient was given written instructions concerning precautionary
instructions and the appropriate follow-up care. All questions
were answered prior to discharge and the patient expressed
readiness for discharge. | 243 | 151 |
15643963-DS-21 | 28,097,464 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were sent to the hospital from your outpatient clinic when
your labs revealed that your kidney function had decreased and
your potassium was found to be dangerously high.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Tests were done on your blood and urine, and biopsies were
taken from your kidney as well as from your bone marrow to
determine why your kidney function had decreased so rapidly in a
short amount of time
- You were diagnosed with multiple myeloma which was damaging
your kidneys and causing your potassium level to be elevated.
You were treated with steroids and a chemotherapy medication
called Cytoxan. We also filtered the proteins that were harming
your kidneys out of your blood using a process called
plasmapheresis. You were also started on a medication called
Velcade to treat the disease.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Your ___ team | Outpatient Providers: ___ with h/o recurrent squamous cell
carcinoma of lung s/p 8 cycles of pembrolizumab with progressive
disease and plan to enroll to a clinical trial as the next step.
Other PMHx significant for CAD (s/p CABG), T2DM, CKD (baseline
Cr 1.6-1.9), HTN - now presented with ___ and hyperkalemia,
with Cr remaining elevated at 4.0. Kidney bx on ___hain nephropathy, found to have elevated light chains
(kappa restricted) on SPEP and UPEP concerning for multiple
myeloma. He underwent treatment with pheresis, 4 days of
dexamethasone, and one dose of Cytoxan, and started on Velcade
on ___. | 177 | 100 |
15510494-DS-4 | 27,700,727 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
___ in ___ and ___ leg cast
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
Physical Therapy:
___ LLE
Treatments Frequency:
Sutures will be removed in 2 weeks at follow up. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L closed distal spiral oblique tibia-fibula fracture and
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for closed reduction and
casting Left distal tib, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. On
POD#1, she complained of severe pain and home pain medications
were adjusted where appropriate. Additionally, she was started
on gabapentin for increase in neuropathic pain. The patient
worked with ___ who determined that discharge back to rehab to
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing on the left lower
extremity, and will be discharged on lovenox 40mg x 2 weeks for
DVT prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 227 | 275 |
10177094-DS-13 | 28,906,835 | Dear Ms. ___,
You were admitted to the hospital for observation after your
procedure. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks
* Use a reliable form of contraception at least until you follow
up with your primary OB/GYN doctor.
* No heavy lifting of objects >10 lbs for 2 weeks.
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ was taken from the emergency department to the
operating room for an ultrasound guided D&C which resulted in
the removal of the suspected gestational sac. Ultrasound showed
a think cervical stripe and c-section scar at the end of the
case. She was admitted for observation overnight. Her bleeding
was minimal. Serial HCTs were drawn and were stable. She had no
symptoms of anemia. She was discarged home on post-operative day
#1 in good condition with outpatient follow-up. | 116 | 80 |
13724767-DS-13 | 22,194,365 | Dear Mr. ___,
It was our pleasure participating in your care here at ___.
You were admitted with nightsweats and a high fever. You had no
signs of infection in your lungs, urine, or heart valves,
gallbladder and stents in your bile duct all appeared well on
ultrasound and there were also no blood clots in your legs.
You did not have a high fever again and were otherwise feeling
well. It will be important for you to continue to follow-up with
your outpatient providers for further care.
It will also be important that you continue with a diabetic diet
and check your blood sugars frequently.
Thank you for allowing us to participate in your care.
We wish you the best
-- Your ___ Medicine Team | =============================
PRIMARY REASON FOR ADMISSION
=============================
___ year old man with a history of pancreatic cancer, s/p
cholecystectomy and biliary stenting ___, now s/p 3 cycles
of Gem/Abraxane, currently cycle 3 day 19 who presents with
fever and leg swelling.
.
=============================
ACTIVE ISSUES
=============================
# Fever: The patient presents with fever to 103 without a clear
etiology. He did not have pneumonia or urinary tract infection
and RUQ ultrasound did not show evidence of stent obstruction or
other biliary causes of his fever. TTE did not show any
vegetations on his valves and bilateral LENIs were negative for
DVT as well. It seemed unlikely to be related to his
chemotherapy as his most recent gemcitabine dose was ___.
He initially received vancomycin and cefepime in the ED and then
was narrowed to levofloxacin for one day. On arrival to the
floor, he remained afebrile (Tm was 100.1 but otherwise T 97-98)
and given no obvious signs of infection, the antibiotics were
stopped and he continued to feel well.
Blood cultures are currently pending
.
# Night sweats: The patient has a history of night sweats
intermittently with no obvious cause. As per above, infectious
workup was negative and this symptoms was thought possibly
related to his primary malignancy.
.
# Leg swelling: The patient presented with bilateral pitting
edema. Bilateral LENIs were negative for DVT. CXR and physical
exam without signs of pulmonary edema and EF on TTE was 60%
making acute CHF exacerbation unlikely. He was maintained on
his home dose of lasix (20mg daily) and leg swelling improved.
.
.
=============================
CHRONIC ISSUES
=============================
# Pancreatic Cancer: Appears improved based on recent CT scan.
He has plans to follow-up with his outpatient surgeon to discuss
possible Whipple's (although he has had biopsy proven liver
mets).
.
# DM type 2: Last HgbA1c >10. His sugars were difficult to
control and his sliding scale was adjusted although FSBG
remained consistently in the 200s-300s. He will benefit from
continued outpatient monitoring.
.
# CAD s/p MI: Stable. Continued his asa.
.
# HTN: Stable. Continued enalapril, atenolol, furosemide
.
# Back pain: Stable. Continued gabapentin.
.
# Insomnia: Stable. Continued benadryl prn
.
.
=============================
TRANSITIONAL ISSUES
=============================
- He will benefit from close blood glucose monitoring
- Full code | 122 | 350 |
17575643-DS-10 | 22,788,281 | -Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ reduce the strain/pressure on your abdomen and incision
sites; remember to log roll onto your side and then use your
hands to push yourself upright while taking advantage of the
momentum of putting your legs/feet to the ground.
--There may be bandage strips called steristrips which have
been applied to reinforce wound closure. Allow these bandage
strips to fall off on their own over time but PLEASE REMOVE ANY
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may
get the steristrips wet.
-UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing
products and supplements that may have blood-thinning effects
(like Fish Oil, Vitamin E, etc.). This will be noted in your
medication reconciliation.
IF PRESCRIBED (see the MEDICATION RECONCILIATION):
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
For pain control, try TYLENOL (acetaminophen) FIRST, then
ibuprofen, and then take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment in 4 weeks AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
AVOID lifting/pushing/pulling items heavier than 10 pounds
(or 3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room. | ___ male presents with penile infection and fungating penile
mass concerning for soft tissue necrotizing infection
superimposed on potential malignancy. He was started on broad
spectrum antibiotics. Taken to the OR on ___ where he
underwent penile biopsy of involved areas, and was found to have
a completely obliterated urethra. He was sent to ___ post-op for
SPT placement.
Post-op course notably for intermittent AMS (aphasia, unable
to follow commands) necessitating consult with neurology. There
was concern for possible seizures and so he was started on EEG
monitoring. He also underwent CTA head/neck and MRI head/neck
which showed concern for possible stroke. He was started on
daily ASA and high dose statin. Endocrinology was consulted for
uncontrolled blood sugars (HbA1c = 13). He was started on an
insulin regimen which he will continue upon discharge (Humalog
12, 8, 10 units with meals + humalog
sliding scale as necessary, and glargine insulin to 15 units
QHS). He also had uncontrolled hypertension, and given his
multiple medical issues he was transferred to the medical
service while we awaited his biopsy results.
His penile biopsy results took 7 days before they were
finalized. He continued on BID dressing changes until the report
was finalized. The final report was as follows:
1. Penis, glans, biopsy:
- Atypical verruciform squamous proliferation with foci
suspicious for invasion, extending to tissue
edges, see note.
- A p16 immunostain is negative, while a p53 immunostain is
increased on basal layers.
- Superficial bacterial and fungal (___) colonization in
stratum corneum is also present.
2. Penis, proximal, biopsy:
- Atypical verruciform squamous proliferation with foci
suspicious for invasion, extending to tissue
edges, see note.
- A p16, p53 and treponema immunostains are negative.
- Gram and GMS stains highlight superficial bacterial and fungal
(___) colonization in stratum
corneum.
Note: Both specimens exhibit an exuberant verruciform squamous
proliferation with striking basal
atypia consistent with at least differentiated penile
intraepithelial neoplasia. There are also foci
suspicious for lamina propria invasion as a well-differentiated
invasive squamous cell carcinoma. In
addition, transformation from a background verrucous squamous
cell carcinoma cannot be entirely
excluded. Final classification is deferred to complete excision
of the mass/lesion, if clinically
applicable.
Hence, he was taken back to the OR on ___ where he underwent a
total penectomy with perineal urethrostomy. A foley was placed
through the perineal urethrostomy and his SPT was removed. A
perineal ___ drain was left in place (removed prior to
discharge).
The remainder of his post op course was relatively
uncomplicated. His mental status improved, as did his blood
sugars and blood pressure. He was evaluated by physical therapy
who felt he needed to go to short term rehab. | 483 | 425 |
18817690-DS-9 | 21,488,832 | Dear Ms. ___,
You were admitted to ___ were
you were evaluated and treated for a fracture in your back
(thoracic 11 vertebral compression fracture) left rib fractures,
and a small bleed in your lung(hemothorax). You are recovering
well and are now ready for discharge. Please follow the
instructions below to continue your recovery:
Your injury caused a thoracic ___ vertebrae and left ___
rib fractures which can cause severe pain and subsequently cause
you to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
The neurosurgery specialist examined you and found no indication
for surgery and recommended the following:
- Thoracolumbosacral orthosis brace when out of bed. You may put
it on while sitting at the edge of the bed.
- Follow up in 4 weeks at the ___ at ___
___ with Dr. ___, with AP/Lateral
X-rays. An appointment has been requested for you. If you need
to change the appointment time or do not hear from the office in
2 business days you can call ___. | Ms. ___ is an ___ yo F with atrial fibrilation and severe
dementia admitted to the Acute Care Trauma Surgery Service on
___ after a fall from standing in her assisted living
facility. She initially presented to an outside hospital where
she was found to have a T11 compression fracture with
retropulsion, left rib fractures, and a small left hemothorax.
She had a CT scan of her head and neck that were negative for
acute injury. She was admitted to the surgical floor for pain
control and further monitoring.
She was seen and evaluated by the neurosurgery team who
determined her injuries to be non-operative and recommended a
TLSO when out of bed. She remained at her baseline level of
confusion. Pain was managed with oral Tylenol and tramadol. She
remained afebrile and hemodynamically stable. Of note the
patient has known atrial fibrillation and is not on any systemic
anticoagulation related to a fall in ___ where she sustained an
intracerebral hemorrhage. On HD2 she had 6 beats of asymptomatic
ventricular tachycardia. An EKG was obtained which was
consistent with her baseline. She tolerated a regular diet. She
had a foley catheter placed for urine output monitoring and made
adequate urine. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. She was seen and
evaluated by physical therapy who recommended discharge to an
acute care rehab facility.
On HD3 she was hemodynamically stable and discharged to rehab.
Follow up appointments were scheduled. Her foley catheter should
be removed at the discretion of the medical staff at rehab. | 381 | 286 |
15394326-DS-27 | 28,441,294 | Dear Mr. ___,
You were admitted to ___ because you were sleepy and not
responding to questions while you were at dialysis. We made sure
you did not have a stroke or bleed in your brain with a CT scan
of your head. Our Neurology doctors saw ___ and did not think
you had a stroke. We noticed that you seem depressed and that
you have not been yourself lately. The Geriatric doctors saw ___
and recommend that you continue to take your Remeron and
Sertraline. You should try to participate in activities at your
rehab facility and to avoid napping during the day.
You were also seen by physical therapy because you have not been
walking well.
You will see your Primary Care doctor and ___ Psychiatric Nurse
Practitioner at ___.
It was a pleasure taking care of you!
Your ___ Team | ___ with ESRD on dialysis and cognitive impairment ischemic
infarct presents from dialysis after becoming acutely altered,
which resolved without intervention, thought to be secondary to
fluid shifts during dialysis.
# Acute Encephalopathy
Patient presenting form dialysis with interval of decreased
responsiveness. Per report from dialysis center no episodes of
hypotension noted during dialysis session. On presentation ED he
had decreased responsiveness with sluggish response to noxious
stimuli. He was only responding to simple commands. Episode was
transient and he notably improved after neurologic evaluation.
He was evaluated by Neurology in ED with no evidence of stroke.
CTA H/N neg for acute stroke or bleed although notable for
stable stenosis of vertebral vessels and carotid plaque.
Episode may have been secondary to dialysis-induced fluid shift
poorly tolerated by stenotic vessels. No localizing signs of
infection; afebrile with no leukocytosis, CXR with no evidence
of pneumonia, blood culture with no growth, anuric. B12, RPR and
TSH wnl. Also with baseline dementia, which may contribute to
episode of confusion.
#Depression
Patient reports worsening in depression over the past ___
months. He reports feeling more withdrawn and less interactive,
which was corroborated by At times he feels that nobody cares
about him at his nursing ___. He has a poor appetite and at
times only eats one meal per day. He has lost interest in
activities he previously enjoyed, such as reading the news
paper. He was evaluated by Geriatrics who recommended
continuing ___ antidepressants (Remeron 15mg QHS and Sertraline
75mg). He is seen by psychiatry as an outpatient and they can
make medication adjustment. Recommend increasing participation
in group activities at ___ and advised the patient to
make an active effort to become more interactive. He can follow
up with outpatient ___ NP at ___.
#Visual hallucinations
Patient reports visual hallucinations for the past year
confirmed by nursing ___ in setting of dementia. He usually
sees a young boy. He recognizes that he is having delusions and
they are not disruptive. ___ be secondary to delirium in nursing
___ setting. Depression could also be contributing to symptoms.
Could also be related to underlying dementia ___ body
dementia), although other symptoms not consistent with ___ body
dementia. As these are not distressing to the patient they can
be monitored for now.
#Dementia/prior infarct:
Patient with prior L striatocapsular infarct and extensive small
vessel disease (follows with Dr. ___ and cognitive
impairment, likely vascular dementia. Patient with poor
nutrition and some concern for thiamine deficiency; gave IV
Thiamine replacement (500mg TID) during hospitalization with
minimal improvement in cognition. Will continue multivitamin on
discharge. Can continue Donepezil, may benefit from outpatient
cognitive testing to determine utility of Donepezil.
# Poor mobility:
Patient has not been walking and has been wheel chair bound
following a gradual decline in mobility. ___ was consulted and
patient is deconditioned. Recommended continuing ___ at his rehab
facility in order for him to return to his baseline.
# ESRD on HD: TTS, had HD ___ and developed altered mental
status during final 30 min. Nephrology consulted, he received
dialysis on ___ and ___. Patient on 1.5L fluid restriction at
nursing ___, continued during admission. He will resume
dialysis at his outpatient facility.
#Mild aortic stenosis:
Patient with ___ mid-systolic ejection murmur on exam. Patient
with mild aortic stenosis with LVEF>55% on TTE from ___.
Recommend repeat TTE as an outpatient.
Chronic Issues
# CAD: Continued aspirin, metoprolol, atorvastatin
# Prior stroke: Continue ASA 325mg
# DM2: Continued lantus 2units QHS, ISS
# Hypertension: Continued amlodipine
# Anemia: Likely due to CKD, stable.
# Gout: Continued allopurinol.
# GERD: Continued omeprazole.
# BPH: Continued finasteride.
# Hypothyroidism: Continued levothyroxine.
# CODE STATUS: Full confirmed
Name of health care proxy: ___
Relationship: daughter
Cell phone: ___ | 141 | 608 |
14498233-DS-28 | 25,575,679 | Dear Ms. ___,
You were hospitalized due to symptoms of left sided weakness and
difficulty speaking 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. We found that your stroke
was caused by blockage of major blood vessel in your brain so
you received IV tPA in the emergency room to help open up this
vessel.
Strokes 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
- High Cholesterol
- Diabetes
- Heart Failure
You had a tube placed in your stomach so you can get nutrition
while you are unable to swallow.
We are changing your medications as follows:
- We are ADDING INSULIN
- We are ADDING METOPROLOL 12.5mg two times daily
- We are ADDING TYLENOL
- We are STOPPING CARVEDILOL 6.25mg two times daily
- We are HOLDING GLIPIZIDE XL 5mg daily
- We are HOLDING METFORMIN 1000mg two times daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Following tPA administration in the emergency room, Ms. ___ was
admitted to the neurology ICU for monitoring.
#NEUROLOGY - her exam improved somewhat, and she started to move
her right leg against gravity, and her right upper extremity
became ___. Routine post-tPA care was given, and systolic blood
pressure was kept between 120-180. HbA1c and lipid panel were
sent. Her LDL was found to be 101 and her HbA1c was found to be
12.2%. She was started on an insulin sliding scale and
Atorvastatin 80mg. She also started on metoprolol after being
transferred to the floor. Her eye opening apraxia and right
sided weakness improved. She had an NG tube placed after failing
a swallow evaluation. She was given tube feeds. Several repeat
head CTs showed that the right MCA infarct remained stable
without hemorrhagic transformation.
She was pan-cultured on ___ after she spiked a fever. Her
urine culture from ___ grew out vancomycin resistant
enteroccocus. She was breifly started on Linezolid but repeat UA
was negative and the VRE was thought to be from colonization of
the foley bag and not from an infection. The rest of her fever
workup was unremarkable. Her fever subsided and she has been
afebrile since.
She failed several repeat swallow evaluations. She had a PEG
tube placed by interventional radiology on ___. Tube feeds
were resumed and were at goal at the time of discharge.
She is on ASA 81mg. there is suspicion that her stroke is
cardioembolic due to depressed EF, and warfarin might be
considered, provided that the patient is an closely monitored
environment. Although this could be done while she is at Rehab,
the subsequent living situation is unclear. Therefore, given
thepossible risks of anticoagulation without a specific
supervision plan in place, aspirin has been chosen.
#CARDIOVASCULAR - cardiac enzymes were elevated on admission,
and remained stable when trended. EKG showed an old left bundle
branch block. TTE was performed showing LVEF 25% (unchanged from
prior) and increased MR. ___ blood pressure medications were
held initially for permissive hypertension, as well as ___
torsemide. Her
After 24 hours of ICU monitoring, she was transferred to the
floor, with telemetry. She was started on metoprolol on the
floor. Her blood pressure and heart rate remained well
controlled on the floor.
#TRANSITIONAL ISSUES:
- She will need ___ and speech therapy at rehab.
- She will likely need her diabetes regimen adjusted with a
HbA1c 12.2%. We held her oral hypoglycemic agents during her
admission and covered her with insulin instead.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
101 ) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? (x) Yes - () No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A | 256 | 666 |
12043836-DS-54 | 27,298,156 | Dear Mr. ___,
It was a pleasure taking ___ of you at ___
___.
You presented for concern of pneumonia from ___
___. You were found to have a pleural effusion, fluid around
your right lung. This looked the same on the x-rays we took, and
your breathing was okay. The thoracic surgery team that treated
you during your last admission when you had a pleural effusion
recommended no surgery for now since you were stably breathing.
During your admission, you also had bleeding from your nose that
required cauterization to stop the bleeding sources. From this
blood loss and your baseline anemia, low red blood levels, you
were given one unit of blood on ___.
During your last admission, you were started on antibiotics for
an infection in your blood. This is given to you at dialysis,
and is scheduled to end on ___.
If you experience fevers, chills, cough, changes in your
breathing, bloody stools, or any other concerning symptoms,
please seek medical ___. Furthermore, weigh yourself every
morning, and call your primary ___ physician or nephrologist if
your weight goes up more than 3 lbs.
For your recurrent nose bleed,
- Avoid nose picking and excessive nose blowing. Open your mouth
when you sneeze.
- Maintain nasal moisture by using a room humidifier at night,
especially during the dry winter months. You may also use nasal
saline mist, two sprays to each nostril at least four times
daily, or apply Vaseline to nares with one dab gently to each
nostril twice a day.
- Irrigate the nose twice daily with normal saline (salt water
rinses) to keep the nasal mucosa healthy.
We wish you the best in your health!
Your ___ Team | ___ M w/ h/o ESRD on ___ HD, MV/TV endocarditis c/b embolic CVA
s/p TVR & mechanical MVR in ___, CAD, dCHF, severe pulmonary
HTN, and HTN, with multiple prior admissions for bleeding, who
presents from rehab with concern for pneumonia. Per discussion
with ___, after patient refused a PPD as part of rehab
admission protocol, a CXR was performed with concern for
pneumonia. Patient remained afebrile with no localizing signs of
infection and therefore was not treated for a pneumonia.
Persistent pleural effusion was found on CXR, for which thoracic
surgery did not recommend thoracentesis or surgical drainage
given patient's clinical stability. There was also concern for
TB at ___. Patient's dialysis center, ___
___ in ___, confirmed a negative PPD in ___. Of
note, patient also had epistaxis that required cautery by the
otolaryngology team. Finally, due to acute bleed in the setting
of chronic anemia, patient's hemoglobin dropped to 6.6 and Mr.
___ reported light headedness while sitting; he was
transfused 1 unit of pRBC during dialysis on ___. | 283 | 173 |
16434307-DS-15 | 28,994,958 | You were admitted to the hospital for paranoia and there was
concern that you may have a medical cause for this. After
extensive work-up including imaging of your head and evaluation
of fluid in your spine, we did not find a medical cause for your
symptoms. Additionally you were found to have low white blood
cell count which improved with stopping your thorazine. You
will be discharged back to ___ Hospital for further
management of your psychiatric disease. | Mr. ___ is a ___ yo M with HIV/AIDS, HBV, HCV, DM2, HTN,
history of TB lymphadenitis, with ___ years of worsening
paranoia, who was admitted to ___ psychiatric unit with
severe paranoia, given IV thorazine, and developed
agranulocytosis. Given a history of non-adherence to his HIV
medications, he was transferred to ___ for a medical work up
of his paranoia. Notably, in the emergency room, he assaulted a
staff member while trying to elope. On admission, a lumbar
puncture was performed, which was normal. The patient had an MRI
which was normal. The psyciatric and neurology teams were
consulted, who both felt that his presentation was consistent
with a primary psychotic disorder. He was started on clonazepam
standing per psychiatry recs and discharged back to ___ for
ongoing care.
HOSPITAL COURSE BY PROBLEM
# Paranoia: most consistent with primary psychiatric diagnosis.
He was aggressive while in the ED and required haldol and ativan
for sedation, as well as a security sitter for the first 24 hrs,
however was less agitated throughout the rest of his stay.
While he was in the hospital, he had a nl LP, CT head and MRI.
He was followed by neurology and psych while in the hospital.
He was started on TID lorazepam per psych recs, will need
ongoing titration of psychiatric medications while ___ at
___. Of note, he was tapered off of his buprenorphine
while at ___ and complained of worsening pain while
inpatient at ___ this improved with a dose of suboxone and he
would likely benefit from a slower taper of buprenorphine. This
will need to be considered in the context of his current benzo
use as concurrent use of benzos/bup would be high risk, although
the patient has been on this regimen in the past. Ideally he
would be continued on suboxone and transitioned to an
antipsychotic instead of benzo. He was ultimately discharged
back to ___ on a ___.
# Neutropenia: resolved with stopping thorazine.
# Thrombocytopenia: stable while in the hospital, unclear
chronicity although there was a downtrend while at ___
suggesting that it may in part have been medication related.
Low concern for ITP, DIC, HIT, most likely med effect vs Hep C.
Would continue to monitor as an outpt and consider hematology
referral if persistent.
# Rash/phlebitis: pt with faint, errythematous rash on L arm,
and indurated area at the site of bloodsticks, low concern for
cellulitis, most concerning for phlebitis, outlined at the time
of discharge, please provide hot packs and monitor for
improvement.
# HIV/AIDS. On Truvada/Dalutegravir which were continued while
he was in the hospital. CD4 count while in the hospital was 230,
viral load peding at the time of dc
# Chronic lower back pain: No red flag symptoms, pt was recently
tapered off of TID buprenorphine and experienced worsening back
pain while in the hospital which resolved with suboxone, would
consider restarting with a more gradual taper. Gabapentin was
continued in the hospital.
# HTN: Home propranolol was continued
# Chronic HCV: viral load was pending at the time of DC
# DM2: pt was initially on an ISS while in the hospital, this
was stopped given stable blood sugars in the hospital. He was
restarted on his home meds on discharge.
# Depression: sertraline was continued
>30 min spent on dc related activities. Pt is medically stable
to return to ___ psych. | 81 | 565 |
13237774-DS-5 | 24,514,579 | Dear Mr ___,
You were admitted to the hospital because you had an infection
called hepatitis A, and this was causing your liver to fail
making you feel very sick, confused and look yellow (jaundiced).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were admitted to the intensive care unit in case you
needed a liver transplant.
- You began to improve, and so you left the intensive care unit
for the regular liver hospital floor until you were ready to
leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must not drink alcohol as this could damage your liver
further
- You should not use more than 2g of acetaminophen (Tylenol) in
a day until your liver doctor tells you otherwise.
- You need to go to the lab once a week to get your liver
numbers checked until you see the liver doctor. We gave you
prescriptions to get this done. They will fax the results to the
liver doctor, ___
- ___ all of your medications as prescribed (listed below, some
of them are new or changed)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
- Your close contacts like family members, roommates should make
sure they have been vaccinated against hepatitis A
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | Information for Outpatient Providers: ___
=======================================================
___ year old male w/ PMH of HTN and OSA with ten days of
generalized
malaise and jaundice, found to have acute liver failure
requiring
ICU monitoring and listing for liver transplant. However had
clinical and laboratory improvement over course of a week, was
taken off the transplant list, and discharged
TRANSITIONAL ISSUES
========================
[ ] needs once weekly CMP, CBC, ___, INR faxed to Dr. ___
___ ___. ___ given Rx to go to lab on weekly basis.
[ ] ___ is not immune to hepatitis B. Please vaccinate as an
outpatient.
[ ] Amlodipine held this hospitalization. Please restart as
needed as his liver labs improve.
[ ] Discharged on decreased dose of metoprolol with heart rates
in the low ___. Please uptitrate as needed as liver labs improve
[ ] ___ should ensure close contacts were vaccinated against
Hepatitis A
-- Discharge creatinine: 0.6
-- Code status: full code
-- Contact: ___ (girlfriend) ___
ACUTE ISSUES
===============
#Acute Liver Injury
#Hepatitis A
#Hepatic Encephalopathy
___ initially presented with acute time course of hepatic
injury, synthetic dysfunction and hepatic encephalopathy,
overall consistent with acute liver failure. Acuity and
pre-dominant transaminase elevation are overall c/w viral
hepatitis, and his positive Hep A IgM confirms this as likely
diagnosis. Of note his Hep B IgM was positive with negative
viral load and otherwise negative panel including total hepatis
b core antibody, indicating that this was likely a false
positive. His autoimmune work was notable for a positive smooth
antibody as well, though at a titer of 1:80, the clinical
significance of this is difficult to interpret nor does his
acute decompensation with no known history of liver disease
correspond with this etiology. His mental status, coagulopathy,
and transaminase elevation improved and he was removed from the
transplant list. He should ensure that his close contacts are
vaccinated against hepatitis A. | 277 | 300 |
12778102-DS-7 | 26,225,540 | You were admitted due to pancreatitis. This was cause by a
gallstone. The gallstone causing the blockage was removed.
You were evaluated by the general surgeons, thoracic surgeons,
anesthesiologist and cardiologist to determine if it was safe
for you to have your gallbladder removed. It was decided that
you are a high risk for cardiac or respiratory complications and
that this risk outweighs the benefit of surgery. Please follow
up with your PCP and the surgeons to determine if you could
tolerate surgery in the future.
You were also found to have ulcers in your small bowel and
should continue to take an acid suppressant for one month to
allow these to heal. | ___ w cholelithiasis, remote bladder CA, HTN, HLD, CKD,
provoked DVT p/w chest to abdominal pain, found to have
pancreatitis.
Gallstone Pancreatitis: MRCP consistent with passed stone,
however LFTs not downtrending as would be expected. s/p ERCP
___ with sludge removed. Surgery consulted for lap chole
however extensive preop eval by vascular surgery, anesthesia and
cardiology determined that risk of operation outweighed benefit
given pt's cardiac history and aortic aneurysms. Pt's pain
resolved with conservative treatment and she was pain free and
able to tolerate general diet without pain prior to discharge.
Duodenal Ulcer: seen on ERCP. Pt to complete 1month of PPI.
Chest pain: Resolved prior to arrival to floor. not typically
cardiac though at risk given age/HTN/HLD. Three negative
troponins. EKG with likely strain pattern rather than actual
ischemia. Though pain was pleuritic, wells score 1.5 for
previous DVT. No dissection on imaging. Per BID radiology
discussion, although OSH CT-A was protocol for aorta, can
comfortably exclude up to segmental PE. Pain was likely related
to pancreatitis.
All other chronic conditions remained stable. Pt should have
outpt echo and evaluation by vascular surgery for aneurysms. | 112 | 183 |
13363938-DS-18 | 23,013,069 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
an episode of loose stool and nausea. We ran tests to make sure
you did not have a serious infection, and these were negative.
Your chemotherapy was stopped on ___ for one week while you
got better. You were given IV fluids, and your symptoms
improved. Please follow up with Dr. ___ on ___
___ for chemotherapy.
We made the following changes to your medications:
START oseltamivir to prevent flu
STOP amlodipine
STOP arsenic
DECREASE lisinopril | ___ with history of RCC s/p RFA in remission, OSA, CKD stage
III-IV, mild cognitive impairment, recently diagnosed with APML
in ___ s/p ATRA, now in remission on maintenance therapy of
Arsenic 6mg IV who presented C3D5 of arsenic with 1 day of loose
stool x1, abdominal cramping, dry heaving, and low grade temp -
all resolved on admission.
#N/V/D: likely viral gastroenteritis, unable to collect
norovirus stool culture to confirm. Pt was given supportive care
with IV fluids. Had one episode of vomiting the evening after
admission and no further vomiting. No loose stools or fever.
Blood cultures were negative, and no infiltrate was seen on CXR.
#AMPL: in remission, on Week 11 of maintenance Arsenic per
clinic notes. Arsenic was held during his stay to be restarted 1
week later as outpatient. He will follow up with Dr. ___.
#Dementia: mild, currently AAOx3. continued home Namenda.
#Stage III/IV chronic kidney disease: Cr remained within
baseline throughout stay.
#HTN - Pt's amlodipine was held on admission in the setting of
volume depletion. Throughout his stay, BP's were noted to be
soft in the ___ systolic, so lisinopril was decreased from 5mg
to 2.5mg daily. It's possible his antihypertensive requirement
has decreased with wt loss since starting chemo. He was
discharged on only lisinopril 2.5mg daily.
#HLD - Simvastatin 80mg was reduced 40mg daily per new
guidelines | 87 | 223 |
10608802-DS-19 | 20,881,149 | Dear Ms. ___,
We admitted you to the hospital for shaking episodes. We did
multiple tests, including a MRI, and determined that your
shaking episodes are likely due to problems with your inner ear,
and these improved with a medication called meclizine.
We are now discharging you back to your facility. Please make
sure to follow up with your doctors and take ___ medications as
listed below.
We wish you the best with your health.
___ Medicine | ===============================
FICU COURSE ___ - ___
===============================
Ms. ___ is an ___ woman with a history of hypothyroidism,
amyloiod angiopathy, remote breast CA, as well as massive saddle
PE in early ___ who presents with fever, altered mental status,
hypotension, and sepsis likely secondary to UTI.
# Hypotension
# Fever
# Sepsis ___ UTI
Of note, patient has a history of recurrent UTIs. Broad
infectious workup was initiated in the ED; CXR was reassuring,
UA was intermediate/dirty. Pt was started on cefpodoxime 1 week
ago (on ___ and was supposed to end treatment today ___.
Given UA, favor partially treated UTI as the cause for her
fever, hypotension, sepsis, and altered mental status. Prior
cultures from ___ grew E. coli that was CTX resistant. For her
hypotension (of note, baseline BPs 90/50s), feel this is related
to urosepsis as she was fluid responsive. She was started on
Zosyn, which her prior cultures have been sensitive to, and
completed 5 day course. Required Norepinephrine briefly during
her ICU stay, however was quickly weaned off. Urine culture grew
<10,000 CFUs. On ___ she spiked a fever again to 102 degrees;
she was recultured at this time and has not had fevers since
then.
#Altered Mental Status
#Shaking episodes - ultimately felt to be vestibular in nature.
Per daughter, pt has baseline dementia (detailed below) and is
at times oriented x ___. On presentation she was
shaking/rigoring, however after talking with daughter and
reassuring patient, it was understood that she shakes at
baseline and clings on to her bed rails as she is afraid of
falling out of the bed. This increases at times of transfer.
Her daughter reports that these shaking episodes increased on
the day prior to admission and she could see that her mother was
off from her baseline. As per above, was treated for her
infection and started to improve by the time of transfer.
Throughout her FICU stay, she had several more of these shaking
episodes which again appeared to be driven by delirium/dementia.
Initially, during these episodes, zydis was given which was
effective in calming her down and the shaking episode stopped.
Neurology was consulted and recommended MRI, LP, EEG, and workup
with TSH, anti TPO, ___, 5CK, lactate, ESR, CRP, urine
5HIAA, urine serotonin, plasma metanephrines. This work-up was
discussed with the patient's daughter, who decided not to pursue
LP at this time. Neurology recommended discontinuing home
Risperdal. Total metanephrines mildly elevated but her
presentation is not consistent with pheochromocytoma. W/u
negative
MRI was done, which showed new punctate infarcts, but was not
felt sufficient to explain the shaking episodes, which were
ultimately felt to be secondary to inner ear pathology. TTE
showed moderate aortic stenosis, EF of 75%, and HbA1c and lipid
panel risk stratification showed LDL 118. Neurology recommended
against statin or antiplatelet agent for this patient.
Meclizine was started pre-movement and her shaking episodes
improved dramatically. When RNs attempted small movements of
the patient, they would reposition her very slowly.
#Lactic acidosis, resolved
Presented to the ED with a lactate of 8, decreased to 3 and
resolved to 1.3 by arrival to the FICU. Likely dehydration +
infection/sepsis. Treated her infection as per above.
#Dementia with behavioral disturbances
#History of delirium
Pt is on risperidone 0.25mg daily. Has become delirious in prior
hospitalizations - Zydis has been used but daughter would prefer
that risperidone be tried first as pt has been stabilized on
this regimen. The patient's home risperidone was discontinued
per neurology recommendations due to shaking movements as
mentioned above.
#Hypothyroidism: Continued home levothyroxine 88mcg daily
#History of saddle PE
Diagnosed in ___. Was initially treated with anticoagulation
however patient had subsequent massive GI bleed/also had small
ICH discovered at the time. IVC filter was placed. Patient
remains on twice daily SQ heparin as her only treatment for
this. Continued home heparin SQ BID.
# Elevated Prolactin: Likely due to Risperdal dose. Outpatient
providers can consider recheck.
#Hypernatremia: Pt had hyperNa likely secondary to poor PO
intake, which improved after IV D5W.
Greater than ___ hour spent on care on day of discharge. | 78 | 689 |
15076985-DS-4 | 21,009,055 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___.
You were admitted because you developed a right kidney infection
("pyelonephritis") with a small abscess. Your abdominal and back
pain along with your urinary frequency were thought to have been
caused by this infection. You got IV antibiotics for several
days before transitioning to oral antibiotics.
In addition, the CT scan showed evidence of inflammation at the
beginning of your small intestine ("duodenitis") for which you
were started on omeprazole. There was also dilation of your
common bile duct, and lab test showed an increase in one of your
liver tests (alkaline phosphatase). You should follow up with a
GI doctor to monitor this. There was also an area of concern
seen in your cervix on ultrasound which should be followed up
with your primary care doctor.
Please make the following changes to your medications:
- Start taking cefpedoxime 200mg tablet: take one tablet by
mouth every 12 hours until ___
- Start taking omeprazole 40 mg capsule delayed release
- Start oxycodone as needed for pain
STOP
- naproxen given your kidney injury for now | ___ yo female who is admitted with 10 days of lower back and
flank pain, found to have elevated WBC and positive urine
culture at her PCP. CT scan revealed right sided pyelonephritis.
. | 188 | 33 |
14187451-DS-7 | 23,979,690 | Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted for shortness of breath and
cough. You were diagnosed with pulmonary edema (fluid in your
lungs) as a result of chronic kidney disease and heart failure.
We treated you with diuretics and placement of a peritoneal
dialysis catheter on ___. You tolerated the procedure well
and experienced no complications. Your catheter will be ready to
use in several weeks. Your breathing improved during your
hospitalization. While hospitalized your received 2 units of
blood and were started on Epo for anemia (low blood count). Your
anemia is the result of your chronic kidney disease. Please be
sure to weight yourself daily at home. If you notice an increase
in your weight of three pounds or more call your doctor. Weight
gain can be the first sign of worsening kidney function and/or
heart failure. If you have any further questions about your
hospitalization feel free to contact your ___ providers.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STARTED furosemide for kidney diseaese and heart failure
STARTED isosorbide mononitrate for high blood pressure
STARTED carvedilol for high blood pressure
STARTED aspirin to prevent heart attacks
STARTED calcium acetate for kidney disease
STARTED Tylenol (acetaminophen) for pain
STARTED sodium bicarbonate for kidney disease
CHANGED vitamin D to 50,000 units weekly on ___
INCREASED calcitriol to 0.75 mg daily
DECREASED Lantus (insulin glargine) to 25 units in the morning
STOPPED metoprolol
No showers or baths until you follow up with surgery for your PD
catheter. Until that time, you may take sponge baths.
Surgical site dressing is to remain on. | ___ year old AA female with a PMH of DM2, HTN, diastolic HF,
dyslipidemia, and CKD Stage IV-V presenting with SOB, DOE,
cough, and chills.
#SHORTNESS OF BREATH
Mrs. ___ presented with pulmonary edema as a consequence of
her decompensated volume status. Her hypervolemia was the result
of stage V CKD and diastolic HF.
A repeat echo on admission showed mild symmetric LVH with
vigorous biventricular systolic function, moderate mitral
regurgitation and mild pulmonary hypertension. Prior echos have
demonstrated impaired diastolic function. Fluids and sodium were
restricted. She responded well to IV furosemide (80mg daily and
w/ transfusions) and maintained O2 saturations in the mid ___ on
room air for the majority of her hospitalization. She
experienced a small respiratory set back ___ due
to her intubation for open PD catheter placement. He peritoneal
dialysis catheter will be ready to use in several weeks. Daily
weights and strict I/Os were recorded. The patient's estimated
dry weight is 202 lbs. She was discharged on furosemide 80mg PO
daily.
#ANEMIA
Ms. ___ has a long history of anemia. Since youth, she has
experienced heavy menorrhagia and was found to have uterine
fibroids. She has required blood transfusions in the past
because of vaginal bleeding. She denies menorrhagia for the past
year. However, she was last hospitalized in ___ with
vaginal bleeding and received 2U PRBCs. Hematocrit dropped on
___ from 23.9 at 06:40 to 20.8 at 15:40. She received one
unit pRBC at that time. She had negative guaic x2, no vaginal
bleeding. Small volume epistaxis. Iron studies revealed Iron:
72, calTIBC: 263, Hapto: 257, Ferritin: 541 and TRF: 202. The
overwhelming majority of her anemia is most likely due to CKD,
no evidence of hemolysis. She was transfused an additional unit
of pRBCs on ___ and started on Epo. She was continued on
ferrous Sulfate 325 mg daily.
#HYPERTENSION
Ms. ___ has a history of poorly controlled hypertension. Blood
pressure in the ED was 140/61. She presented to the ED on ___
with SBP >200 in the context of not taking her blood pressure
medications for ~3 months, and has documented SBP >200 during
other hospitalizations. Of note, she was prescribed valsartan
80mg daily on ___ but was unable to fill it because of
insurance issues. In the setting of her worsening renal failure
and hyperkalemia valsartan was not started this admission.
Systolic blood pressures this admission ranged from 120-180s.
Her antihypertensive regimen was increased and now includes:
amlodipine 10mg daily, carvedilol 25mg BID and Imdur 120mg
daily. Her poorly controlled hypertension is partially volume
related and should improve with further diuresis with PO
furosemide. The nephrology team recommended SBPs of 130-140s to
aide with diuresis.
#CHRONIC KIDNEY DISEASE (STAGE V)
Secondary to DMII and HTN. PD catheter placed on ___ will
be ready to use in ___ weeks. No urgent need for dialysis this
admission. Volume status and presenting hyperkalemia adequately
controlled with IV furosemide. Patient is currently being
evaluated for a transplant, she will need to complete a stress
test as an outpatient. The nephrology service consulted during
this admission and made the following recommendations:
-low potassium, low sodium diet
-furosemide 80-100mg PO daily at discharge
-calcium acetate ___ mg PO/NG TID W/MEALS
-sodium Bicarbonate 1300 mg PO/NG BID
-vitamin D 50,000 weekly
-calcitriol 0.75mcg daily
#TYPE II DM
A1C on ___ 7.4 Prior to that A1C 11.6 on ___.
Fingersticks have shown reasonable glucose control this
admission. The patient experienced several morning glucose
readings in the ___. Her glargine was decreased from 30 units
QAM to 25 units QAM. Aspirin 81mg daily was initiated for
primary ACS prevention.
#Calf pain
Resolved. ___ negative on ___.
TRANSITIONAL ISSUES
*******************
-Continue erythropoietin as an outpatient, will need the week
after discharge
-No showers or baths (sponge baths only) until surgery follow up
in 2 weeks
-Surgical site dressing is to remain on for 2 weeks
-Initiation of PD in ___ weeks | 271 | 629 |
10585793-DS-5 | 28,463,594 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
appointment in two weeks.
10. ACTIVITY: Weight bearing as tolerated on the operative
extremity with the leg in the ___ brace locked in extension.
Physical Therapy:
WBAT LLE with knee in ___ brace locked in extension
Treatments Frequency:
continue dry sterile dressing changes
ice and elevation
inspect incision for sign of infection
staples/sutures to be removed at first post op visit. | The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics. | 375 | 44 |
13188963-DS-39 | 22,561,056 | Dear Mr. ___,
You were admitted due to shortness of breath. Workup showed you
had fluid in your lungs (pleural effusions). This was removed to
ensure it wasn't infected. Unfortunately the tube went into your
lung tissue and had to be removed by thoracic surgery. You had
no complications from the procedure to removed the tube.
Please expect a call from the Interventional Pulmonary team for
a follow up appointment with Dr. ___ in ___ weeks. You can
also reach them at ___.
Your family had also indicated reaching out to patient
relations. The number to call is ___.
Your shortness of breath improved while you were in the
hospital. We recommend caution/stopping with inhalation of any
toxins or medical marijuana given your immunosuppressed status.
Please also follow up with your doctors for ___ of your
tacrolimus level and adjustment of dosage and trending of your
creatinine. We will recommend repeat labs in the next 2 days to
be sent to Dr ___
___ count was elevated and has been so for a long time.
Our hemepath team recommended blood cytogenetics but you left
before we could draw this. Please see your doctor to have this
worked up.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure being part of your care and we sincerely wish
you the best in your recovery.
Your ___ team | ___ w/ ESRD s/p renal transplant in ___ ___ (on
prednisone/tacrolimus, Cr 1.8-2.0), CAD s/p 2-v CABG, AFib,
HFpEF and persistent bilateral transudative pleural effusions
with Nocardia asteroides pulmonary infection in ___ who
presented for evaluation of hypoxia and is being admitted to the
MICU for hypoxia and a misplaced chest tube he was stablized,
chest tube was removed, and he was stable on the floor.
# Chest tube misplacement: On ___, chest tube was placed in
the emergency department, after placement patient experienced
hemoptysis, CT chest w/o contrast demonstrated the chest tube to
be in the anterior right upper lobe with surrounding pulmonary
hemorrhage. Thoracic surgery was consulted and recommended
capping trial of the intraparenchymal chest tube. A second
pigtail tube was placed, CXR demonstrating catheter with the tip
projecting over the right costophrenic angle with small residual
right hydropneumothorax and was placed to waterseal. 1.8 L fluid
was drained from the pigtail in the pleural space. Removed by
thoracic surgery from lung parenchyma ___ without any
further complications or hemoptysis. This chest tube was removed
___. Repeat CXR on ___ showed mild interval increase in a
small right pleural effusion and persistence of a small right
apical pneumothorax. Patient relations number was given to
family for outreach. IP will be reaching out for follow up with
Dr ___ in ___ weeks.
# Hypoxia: Initially likely ___ volume overload given edema on
CXR and elevated BNP (possible Heart failure). Given that
patient received contrast for a CT scan, diuresis was avoided.
Initially treated for likely infection but antibiotics pulled
off once this was ruled out and effusion was transudative. His
oxygen saturation was >90% on room air through the rest of his
hospitalization
# Pleural effusion: Chest tube placed ___ in the ___, pleural
fluid send for cell count, gram stain, culture and cytology.
Pleural studies consistent with transudative effusion, similar
to prior. As above, effusion was drained with pigtail chest
tube.
# Chest tube misplacement in lung parenchyma:
# Acute on Chronic Leukocytosis: Acute increase certainly
concerning for infection given immunosuppression and hypoxia.
Likely source is pulmonary. Patient appears to have chronic
leukocytosis to ___, the exact etiology of which is unclear.
Vanc/Zosyn (___) were started treatment of presumed HAP
infection. However, these were stopped ___ given his clinical
stability and lack of infectious signs/symptoms.
# ESRD, s/p kidney transplantation (on
prednisone/tacrolimus/MMF, Cr 1.8-2.0) kidney function was at
baseline during this admission. Per reanl transplant team, MMF
was held given concern for potential infection. Dapsone was
continued for PCP ___. MMF was restarted on discharge.
TRANSITIONAL ISSUES
=======================
- No medication changes (MMF was initially held and restarted
prior to discharge)
- To follow up with renal team for labs and trending of
tacrolimus level within ___ days after discharge. Has
appointment with Dr ___ on ___
- IP will reach out to patient for appointment with Dr ___ in
___ weeks after discharge
- Please consider outpatient echo for further assessment of
cardiac function.
- Follow up with PCP ___ ___
- Advised to stop smoking and inhalation of medical marijuana
given immunosuppressed state
- Heme-path team recommended blood cytogenetics but you left
before we could draw this. | 228 | 523 |
16683014-DS-2 | 25,456,035 | Dear Ms. ___,
You were admitted to ___ because you were bruising and we
found on labwork that you had a disease called APML, a type of
leukemia. You were immediately started on the therapy for this
which consisted of ATRA, Idarubicin, and Arsenic. You tolerated
the therapy well.
Following the completion of your treatment we performed a
lumbar puncture and infused a small amount of chemotherapy into
the fluid which circulates inside your spinal cord. You
tolerated this very well.
During your treatment you had significant nausea which was
refractory to most medications as many we could not give you due
to drug interactions with your arsenic. For future reference you
were able to tolerate 0.25 mg of Ativan by mouth and
fosaprepitant provided mild relief. The nausea was most likely
secondary to the treatment itself.
Additionally, you experienced a mild fever and irritation of
your oral and intestinal mucosa. You were given antibiotics for
this which helped resolve your symptoms. Your voice was hoarse,
but slowly improved.
Lastly, you developed two small dots in your right visual
field. In the setting of low platelet counts we were concerned
for hemorrhage. Ophthalmology was consulted who identified that
you indeed had bilateral pre-retinal small hemorrhages. This
required no further intervention and will most likely resolve
over time (on the order of months). You will have outpatient
follow up with an eye doctor.
You also experienced allergies and rashes to two separate
medications: Cefepime and bactrim. You should avoid these
medications in the future.
It was a pleasure taking part in your care.
Best,
Your ___ ___ Team | ___ year old female without significant past medical history
presented with anemia, neutropenia, thrombocytopenia, elevated
blast count, consistent with APML started on
TRA/arsenic/Idarubicin, now s/p induction whose course
complicated by febrile neutropenia, mucositis and bilateral
pre-retinal hemorrhage.
#APML:
Diagnosed as above. Treated with induction with
ATRA/Arsenic/Idarubicin for high risk APML based on favorable
cytogenetics, but elevated WBC. APML based on final path report.
PML/RARA gene rearrangement,(15;17)(q24;q21) positive. Course
complicated by w/mild dyspnea and CXR changes concerning for
differentiation syndrome ___ with improvement s/p steroids
w/taper (end: ___.
Following induction treatment (end ___ LP performed w/addition
of intrathecal Cytarabine. Results of CSF showed no leukemic
cells. After count recovery Ms ___ was discharged w/close
follow up with Dr. ___ to repeat bone marrow to determine
if in clinical remission as well as to discuss further testing
and requirements prior to bone marrow transplant.
From a treatment standpoint, her course was complicated by
febrile neutropenia, mild mucositis, nausea and bilateral
pre-retinal hemorrhages (see below).
#Febrile Neutropenia
#Mucositis
Developed mild fevers at around 2 weeks into induction in the
setting of oral mucositis and mild diarrhea. With all imaging
and culture data returning negative, the most likely source was
translocation of bacterial GI oral or intestinal flora in
setting of mucositis. Symptomatically treated with topical
analgesics, oxycodone and PRN loperamide, respectively with
fairly easy control.
Timeline for development of febrile illness in setting of
neutropenia was expected as myelosuppression with idarubicin
typically nadirs around day ___ of treatment and count
recovery expected around week ___. By the end of induction
therapy (35 day course) ANC was finally starting to recover. Her
symptoms of mucositis had entirely resolved w/relatively rare
episodes of loose stool ongoing. Afebrile since ___. ANC 250
at discharge. Patient was discharged on ciprofloxacin,
posaconazole and acyclovir with pantamadine ppx.(Patient was
unable to tolerate atovaquone and had a reaction to Bactrim)
Of note: Patient had allergic reaction to cefepime which
included itching of mouth and throat w/o facial edema or airway
compromise. Cephalosporins should be avoided in the future.
Additionally, with respect to prophylaxis, bactrim for PCP
coverage elicited ___ significant drug rash and should also be
avoided in the future.
#B/L Pre-Retinal Hemorrhage
First noticed ___ in AM when looking into bright light noting 2
small gray spots which stayed centrally in visual field with
lateral gaze. ___ seen by ophthalmology. Shown to have b/l
pre-retinal hemorrhages with 2 small cotton wool spots on right.
Nothing to do. Standard transfusion guidelines w/some added
benefit to higher Hb per Ophthalmology. With respect to follow
up, will see Dr. ___ as an outpatient.
#Nausea
Refractory moderate nausea secondary to cumulative effects of
ATRA and arsenic. With respect to antiemetic regimen,
Dronabinol, Ativan failing pt. Fosaprepitant w/o dex with
fleeting relief. When on treatment was using ativan and 2.5mg
zyprexa prn.
Improved significantly after discontinuation of arsenic and
ATRA. Since d/c of regimen able to take Zofran w/great relief.
Future anti-emetic plan when on regimen poses significant
difficulty. Psychiatry consulted and discussing with
psychopharmacology and psych-onc to come up with future plan and
recommended 0.125 - 0.25 mg of Ativan po or IV standing one half
hour prior to meals or mirtazapine (Remeron) 7.5 mg po qhs
#Rashes
#Eczematous Dermatitis
#Drug Rash - Bactrim
Pt stated personal history of very sensitive skin. Had episodes
of contact dermatitis with tegerms and other topical agents.
Developed distal extremity contact dermatitis. Additional drug
rash ___ bactrim. Dermatology consulted in both instances to
ensure simple contact dermatitis and drug rash. Agreed and
prescribed short course of topical corticosteroids. Avoid
Bactrim in future.
#Allergic Rhino-sinusitis
Pt described moderate headaches developing shortly after
admission. Symptoms consistent with allergic rhino sinusitis.
Previously uncontrolled with intermittent tylenol and nasal
saline. Stated that had developed significant allergies,
typically ___, since moving to ___. Given inh
fluticasone as well as daily fexofenadine and she experienced
significant relief and no longer complained of headaches
throughout admission.
#Hx Depression
Asked to see psych given hx MDD. D/w ___. No acute need to
start medication. Given personal hx of MDD and significant
family history, similar to anti-emetic plan, will think of which
medications to start as all can potentially prolong QTc
w/Sertraline being safest (SAD HEART Trial). Could start slowly
when/if needed. Also possible would be Remeron. They will follow
up with her as an outpatient.
#Tachycardia
Patient with persistent mild tachycardia. Baseline TTE wnl.
Repeat TTE wnl. EKGs w/ sinus NCT.
#Right ___ Cramping
___ negative ___. "Athletic compartment syndrome." Receives
monthly deep tissue massage, but missed ___ session. Had
friend who is physical therapist come visit and perform "deep
myofascial release" treatment. Seen by our ___ dept. Nothing to
do.
*****TRANSITION ISSUES*****
#CODE: FULL
#Contact/HCP: ___ (sister) - ___
___ week post discharge follow up with Dr. ___
(Retinal Specialist) ___ Opthalmology - Office Administrator
to schedule appointment with patient directly.
[ ]WILL NEED LUPRON AT CLINIC FOLLOW UP
#QTC 455; please recheck at follow up
#Discharged on acyclovir, posaconazole, pentamadine,
ciprofloxacin for ongoing neutropenia
#Pt had significant reaction to Bactrim and cefepime
#Anti-emetic regimen: 0.125 - 0.25 mg of Ativan po or IV
standing one half hour prior to meals or mirtazapine (Remeron)
7.5 mg po qhs | 275 | 845 |
16957428-DS-11 | 20,189,355 | You were admitted to ___ after you fell and sustained a
mandibular fracture. You are able to eat a soft diet, and can
take oral pain medications to control your pain. You will need
to followup with the Oral Maxillary Facial surgeons upon
discharge for mandible fiaxation.
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. | The patient was admitted after she fell and sustained the
following injuries: nondisplaced parasymphyseal mandible
fracture and left mandible condyle fracture-dislocation. She was
admitted to the acute care surgery service for pain management
with plan to go to the operating room with OMFS. The patient was
started on a soft diet the day prior to surgery, which she
tolerated well. Her pain was well controlled with tylenol.
Occupational therapy evaluated the patient and did not recommend
any followup cognitive neurology. Due to scheduling conflicts,
the patient was discharged to have surgery as an outpatient. Her
vital signs were stable and she was afebrile. She was given
instructions to followup with OMFS at the ___ clinic. | 266 | 116 |
16755805-DS-13 | 20,756,096 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | The patient was re-admitted with volume overload. He was
diuresed with IV Lasix. His shortness of breath and lower
extremity edema showed improvement. He was discharged back to
rehab at ___, ___ the following day. | 132 | 39 |
12021242-DS-4 | 27,979,046 | You presented to the hospital with headache, vertigo, double
vision, and altered sensation throughout your body.
Your vertigo was likely caused by peripheral vestibular
dysfunction. This is a condition where your ear canals have
difficulty with interpreting your position in space.
Your altered sensation and double vision is likely due to a
functional neurologic disorder. This means that your nervous
system is intact and has the capacity to function normally.
However, for some reason it is not functioning the way that it
is supposed to. Another way to think of this is that the highway
for the signals to travel is intact but for some reason there is
a traffic jam. We saw several finding on your exam that are
consistent with this diagnosis. Functional neurologic disorders
are managed by avoiding stressors in your life and working with
___ to learn to adapt and accommodate for your symptoms. For
more information about functional neurologic disorder please
visit neurosymptoms.org.
Pertinently, your brain imaging studies were negative for any
acute phenomena including stroke and the meningioma in your
brain is stable and is not causing your symptoms.
Please follow up with neurology and neurosurgery as previously
planned. There were no changes in your medications.
Thank your for allowing us to care for you,
___ Neurology | Patient is a ___ year old woman with past medical history of
suspected focal-onset epilepsy, migraines without aura, bipolar
disorder, and grade I posterior fossa meningioma status post
partial resection in ___ whom presented ___ with complaints
of headaches, vertigo now resolved, persistent double vision,
and patchy numbness and tingling sensations.
Her exam was significant for forced eye closure/blinking on
testing extraocular movements with no true nystagmus or
limitation in eye movements. Her horizontal diplopia was
inconsistent with the left image disappearing always regardless
of which eye was closed. On upgaze she had vertical diplopia
without any clear misalignment of the eyes with the upper image
disappearing with the left eye covered and the lower image
disappearing with the right eye covered. VFF to confrontation.
Pinprick split the midline over her face and vibration did as
well. Give way weakness throughout much more on the right than
the left but ultimately able to give full strength throughout.
She was able to ambulate and initiate gait independently with
slow steps but narrow based gait.
We suspect that her symptoms of vertigo (forward tumbling) and
possible vertical oscillopsia could have had contribution from a
peripheral vestibulopathy.
Currently, her diplopia has functional features as above due to
inconsistency and her sensorimotor exam has functional features
as well due to splitting the midline and giveway weakness.
Brain MRI and CTA negative for any signs of stroke -- prior
meningioma unchanged and not causative of her symptoms.
Therefore, we suggested outpatient PCP and neurosurgery follow
up as well as psychiatry follow up as it sounds like she is
undergoing significant stress in her life with small children
and sleep deprivation.
TRANSITIONAL ISSUES
- PCP follow up
- Psychiatry follow up
- Neurosurgery follow up | 219 | 286 |
16439884-DS-39 | 24,730,311 | You came to the hospital because you had altered mental status
and could not stay awake. You were found to have overdosed on
percocet and were given medications to reverse this. Your kidney
function was found to be abnormal. Supportive measures did not
improve your kidney function so you were initiated on
hemodialysis through a tunneled line. You were also treated for
a urinary tract infection. You should follow up with your
primary care doctor, ___, and cardiologist about this
new change in your care. You should review your medication list
with them and try to find a way to reduce unnecessary
medications.
Your new medication list has been attached. Several medications
have been stopped because they were not felt to be needed or
were thought to be worsening your kidney function. You should
discuss with your doctor whether or not to restart these in the
future.
STOPPED:
atorvastatin
folic acid
gabapentin
lorazepam
omeprazole
opium tincture
percocet
trimethoprim
B-complex
co-enzyme Q10
STARTED:
--tylenol ___ three times a day (standing)
--calcium acetate 667 mg Capsule 2 capsules 3 TIMES A DAY WITH
MEALS
--Nephrocaps (B complex-vitamin C-folic acid) 1 mg Capsule DAILY
--ranitidine HCl 150 mg Tablet ___ tab twice a day
--ondansetron HCl 4 mg Tablet ___ Tablets every 8 hours as
needed for nausea
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | This patient is a ___ year old female with history of CHF,
chronic kidney disease, chronic back pain, presenting with
altered mental status in the setting of acute on chronic kidney
injury.
# Metabolic encephalopathy with respiratory depression: likely
secondary to opioid stacking in the setting of acute on chronic
renal failure. Pt thought to have had build up of percocet due
to decreased renal clearance. responded well to narcan, becoming
AAOx3 with each administration, but required total of 4 doses of
0.4mg before stabilized. This includes doses from EMS, ED, and 2
on floor. MICU consult called initially but transfer was not
required. Though her excessive somnolence resolved the evening
of admission with repeated narcan, she was kept on continuous O2
monitoring for several days to monitor for stability. Pt had
sats overnight regularly dropping to ___ and, rarely, to ___.
she has OSA so it was suspected that this is her baseline, and
this occurred even while she was kept on BiPap, which she also
uses at home. On exam, she was alert and answering questions
with O2 sats in the upper ___ though sats increased to upper
___ on RA with instructions to breathe deeper. pt was
asymptomatic throughout this and denied SOB. Suspected her
baseline may be upper ___ at home and set O2 goals of 88-92%
with supplemental oxygen to achieve this. Held other sedating
medications including ativan and gabapentin during admission.
No other acute respiratory issues during hospitalization.
# Acute on chronic kidney injury/hyperphosphatemia: creatinine
elevated to 4.4 on admission from baseline of 2.0-2.5 per prior
lab values and pt had phos 7.3. ___ was thought to be ___ NSAID
use for back pain vs prerenal ___ diarrhea vs intrarenal
pathology, but pt and family later denied NSAID use despite
initially endorsing it. Renal was consulted in ED and felt there
no indication for urgent dialysis, but continued to follow the
patient. Renal u/s unremarkable. Held torsemide in setting of
___. Placed pt on low phos, low K diet and started phos binders.
Omeprazole switched to ranitidine due to concerns for AIN in
setting of mild eosinophil elevation on admission. creatinine
continued to rise and was unresponsive to IVF. HD initiated
___ due to rising K (up to 5.5, then kayexelate given) and
uremia characterized by nausea, headaches, and asterixis. Temp
line placed initially and then replaced with permanent tunneled
line. Pt received 4 sessions of HD in-house. She continued to
make urine but in small amounts of a couple hundred mL per day.
# Urinary Tract Infection (UTI): pt found to have UTI on
admission and c/o dysuria. UCx negative but due to sx treatment
with ceftriaxone for 3 days was given. Held trimethoprim, which
pt takes for suppression, due to possible contribution to ___.
# CK elevation: Pt with mild CK elevation in admission that
trended up overnight. suspected ___ dehydration and immobility
while oversedated on percocet; pt found down so unsure how long
she was like that. CK-MB fraction stable and minimal, so cardiac
etiology very unlikely. TSH WNL. no muscle aches to suggest
myositis. stopped statin anyway and CK trended down after
stopping
# dCHF: LVEF 55%. Last hosp discharge weight was 232 lbs. goal
weight listed as 225-227lbs. Pt was 228 on admission. held
torsemide in setting of renal failure but restarted prior to
discharge. Kept pt on 2L fluid restriction. Will plan to follow
up with cardiology as outpatient. No acute cardiac issues
in-house
# Anemia: chronic, at baseline on admission. likely ___ CKD.
Small dip in Hct after initiation of HD but it rebounded back to
baseline prior to discharge.
# Hypertension: continued amlodipine, hydralazine, isosorbide
mononitrate, metoprolol and doxazosin.
# CAD: history of MI and s/p 4 coronary stents per patient
report. continued ASA, BB, isosorbide mononitrite and
hydralazine. Stopped statin due to CK elevations on admission.
# DM2: continued home glargine at a reduced dose with SSI
# Peripheral neuropathy: held gabapentin in setting of
somnolence and resp depression
# Dyslipidemia: stopped statin due to CK elevation on admission.
CK trended down after stopping.
# Severe pulmonary hypertension: Likely secondary to OSA.
continued 2L O2 at night with biPAP.
# Hypothyroidism: Continued home Levothyroxine. TSH WNL
# Rheumatoid arthritis: continued home Prednisone and
Leflunomide
# Depression/anxiety: continued Citalopram; held ativan in
setting of resp depression
# Atrophic vaginitis: stable. Continued estradiol ring.
# Chronic back pain: maintained pt on standing tylenol with
tramadol 25mg po BID prn for breakthrough pain. well-controlled
on this regimen, and rarely needed tramadol. recommend
continuing standing tylenol as outpatient and avoiding all
narcotics if possible | 219 | 810 |
19007010-DS-7 | 20,441,049 | You were admitted to the hospital with abdominal pain. You were
subsequently placed on bowel rest, given intravenous antibiotics
and monitored overnight. Your pain has resolved and you are now
preparing for discharge to home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | Mr ___ presented to the Emergency Department on ___
with complaints of 2-day history right lower quadrant abdominal
pain without associated symptoms; WBC 4.4. An abdominal CT scan
was performed and a preliminary report was consistent with a
'dilated possibly fluid-filled appendix measuring up to 8 mm
with minimal stranding which may represent an early tip
appendicitis'. The patient was subsequently placed on bowel
rest, given intravenous fluids and antibiotics. He was then
transferred to the general surgical ward for further observation
including serial abdominal exams.
On HD2, the patient remained afebrile with stable vital signs.
He reported complete resolution of abdominal pain; abdominal
exam benign. His diet was subsequently advanced to regular,
which was well tolerated without nausea, vomiting, or abdominal
pain; antibiotics were discontinued. Additionally, he was
voiding adequately and ambulating independently. He was
subsequently discharged to home and has a follow-up appointment
scheduled with his PCP on ___. | 237 | 159 |
15726871-DS-9 | 23,299,126 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with a severe foot infection involving the deep tissues. MRI did
not show signs of bone infection. The podiatry team cleaned out
your wound ___ the operating room and you were treated with IV
antibiotics which you will continue for 2 weeks.
Please note the following changes to your medications:
-START Daptomycin for your foot infection through ___ | ___ year-old woman with severe RA, HLD, here with infected right
foot ulceration with abscess and surrounding cellulitis. | 73 | 20 |
17874983-DS-14 | 25,691,162 | Mr. ___ was admitted for shortness of breath and was treated
presumptively for a COPD exacerbation while further workup was
pursued. Shortly after being admitted to the ward, he became
anxious and upset, endorsing a wish to leave the hospital. He
demonstrated capacity to understand the dangers of leaving
against medical advice, including a serious risk of death. He
was given prescriptions for a short course of prednisone and
azithromycin as well as refills for albuterol and Duonebs. | Mr. ___ is a ___ gentleman with hepatitis C,
obstructive lung disease, chronic knee pain, and depression who
presented with 2 months of shortness of breath. Given the
findings of diffuse wheezing with prolonged expiration in the
setting of increased cough and sputum production, it was
presumed that he had a COPD exacerbation, and he was treated
with oral prednisone, albuterol nebulizers, and ipratropium
nebulizers. However, before the patient could be treated, he
became very agitated and became upset that he had to wait "13
hours before getting medications" for his knee pain and
breathing. The patient decided to leave against medical advice,
and he was unable to be persuaded to stay for further treatment.
He acknowledged the risks of leaving, which included worsening
respiratory distress and possible death. Given that he had no
fever or leukocytosis or chest x-ray findings to support a
pneumonia, he was sent home with prescriptions for a 5 day
course of prednisone 40 mg PO daily and 4 days of azithromycin
250 mg PO daily to complete a 5 day course in addition to the
500 mg dose he received in the ED. In addition, he received
refills for albuterol and ipratropium nebulizers. He was also
instructed to contact his PCP as soon as possible and return to
the ED if his symptoms worsen.
ATTENDING ADDENDUM
I did not meet this patient as it was out of hours when he was
admitted to the floor and decided to leave AMA. I discussed his
case with the resident on call and he documented the sitaution
as described above. We felt the patient had capacity to make
this decision and did not need to be restrained against his
will.
___, MD
___ | 78 | 284 |
11126841-DS-22 | 24,356,282 | Dear Mr ___,
You were admitted to the hospital because your were confused and
needed oxygen. You were found to have a urinary tract infection
and treated with antibiotics. You will now return to rehab.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team | Mr ___ is an ___ year old man with a history of
ischemic cardiomyopathy with HFrEF, AFib/DOAC, recent right
sided MCA stroke in ___ w/ residual left-sided deficits,
multiple GNR UTIs, who was admitted with apneic episodes and
encephalopathy, found to have enterococcus (VRE) UTI, and
AFib/RVR.
# Enterococcus UTI: UA with pyruia and bacteruria on admission.
GIven prior ___ and ___ records of psuedomonas and klebsiella
UTIs he was initially started on ceftazidime. However, urine
culture speciated as VRE (neither hospital had record of prior
enterococcal UTI) sensitive only to linezolid. He was
transitioned to linezolid with intent to continue a 7 day course
through discharge. Bladder scans were without signs of urinary
retention. Blood cultures were negative for enterococus and no
other signs of systemic or ascending infection. Sertraline held
while on linezolid.
# Acute Hypoxemic Respiratory Failure:
# Acute on Chronic Encephalopathy:
# Central Apnea ___ recent MCA Stroke: Patient was admitted with
worsened mental status with prolonged periods of apnea. with
significant hypoxia. CXR was without pneumonia or effusions. He
transferred to ED on NRB but brought to floor on 2L NC, which
was eventually weaned off by day prior to discharge. NCHCT was
without acute changes. After treated with antibiotics, his
mental status returned to near normal. It was thought that UTI
worsened apnea symptoms resulting in presentation. Home aspirin
and statin were continued. TF initially held for AMS, and later
restarted without issue.
# Coag Negative Staph in ___ BCx: Patient's initial blood
cultures were positive in ___ bottles for GPCs in clusters. He
was subsequently started on vancomycin. However, this speciated
as coagulase-negative staph and no other blood cultures were
negative. This was deemed to be a contaminant and vancomycin
stopped, patient subsequently did well afterwards.
# AFib: Patient originally presented with rapid Afib requiring
IV pushes of mediation. He subsequently reverted to NSR, but
later returned to rate-controlled Afib for the remainder of his
hospitalization. APixaban was held on night of HD#0, but then
restarted throug remainder of hospital course.
# HFrEF: EF 35-40%, presumably ischemic: Patient actually
appeared clinically dry on admission. Home lasix was initially
held in the setting of UTI treatment, and restarted later during
admission. Lisinopril initially held, but restarted at time of
discharge. Home metoprolol and digoxin continued.
# Elevated troponin:
# CAD: Troponin was found to be elevated on admission, but
subsequent checks were flat. EKG was without ischemic changes.
Serial cardiac biomarkers were flat. Thought to be demand in the
setting of Afib with RVR. Continued home aspirin, statin, and
metroprolol.
# IDDDM2: Home insulin initially reduced when NPO, titrated back
to normal after tube feeds were resumed.
# Acute on chronic hematuria: Recurrent hematuria with
unremarkable comprehensive workup at ___ w/ benign path on
cystoscopy. Chronically may be due to trauma from Foley iso AC
w/
apixaban. Required foley and urology consultation last
admission,
compelted ceftaz ___ for pseudomonal UTI
- Outpatient urology f/u
# Anemia: Remained stably low while hospitalized.
# Ophto: Continued home eye drops of brimonidine, dorzolamide,
and timolol
# BPH: Home terazosin was continued.
TRANSITIONAL ISSUES
- Discharged to complete a 7-day total course of linezolid for
VRE UTI.
- Given frequent UTIs despite no instrumentation, patient may
benefit from future urology workup for etiology of recurrent
infections.
- Sertraline was held while patient on linezolid.
- Per nutrition recommendations, started on a 10-day course of
zinc, vit A and vit C repletion.
Time spent coordinating discharge > 30 minutes. | 92 | 571 |
10014354-DS-10 | 22,741,225 | Dear Mr. ___,
You were admitted to ___ after being treated with a blood
thinning intravenous medication called tPA for concerns of an
acute stroke as you presented with worsening left leg weakness
and numbness. We found no stroke on repeated brain imaging, the
weakness and numbness has been improving. You also complained
of left shoulder pain for which we obtained an x-ray and that
was normal. You should continue your home medications. | Mr. ___ presented to OSH with acute onset left leg numbness and
weakness. He received IV tPA and was transferred to ___ for
monitoring.
# NEURO
At ___, he was found to have proximal>distal weakness of the
left lower extremity with some improvement in his sensory
deficit. His lower extremity exam had some functional overlay
and was variable from day to day. He was monitored in the ICU
for 24 hours without change in his examination and there was no
evidence hemorrhagic transformation on his CT head. The
etiology of his symptoms remained unclear. CTA head and neck was
difficult to interpret given timing of contrast, possibly with a
cutoff in R ACA territory, but there was no evidence of evolving
infarct within the limits of CT on repeat scan. An echo was
done, but was of poor quality.
His stroke risk factors were assessed and include: 1)
dyslipidemia, 2) IDDM, 3) HTN, 4) Obesity. Lipid panel revealed
low LDL and HDL and elevated triglycerides with a high
triglyceride to LDL ratio. Diabetes management is discussed
below. His blood pressure was in good control ranging between
130-160's/50's-70's. His home aspirin was restarted and his
simvastatin and fenofibrates were continued. No meds were
changed.
# HEME/ONC
His outpatient oncologist recommended holding is ibrutinib for
24 hours after tPA due to elevated bleeding risk. This will be
restarted as outpatient.
# THYROID
He was continued on his home levothyroxine. His thyroid function
tests were notable for an elevated TSH at 30 T3-93.
# DIABETES
His A1c was elevated at 7.4% and his metformin was initially
held after contrast. He was maintained on insulin glargine and
sliding scale. His ___ were elevated and that was the result of
giving him 50 ___ at bedtime when he typically has it
twice a day. At discharge, his diabetes regimen was restarted
as per his home regimen given that his blood glucose was well
controlled ___ that regiment and this was confirmed with ___
Diabetes consult team.
# MUSKULOSKELETAL
He complained of Left shoulder pain with a remote hx of trauma,
we had a shoulder X-ray that was negative and pain was well
controlled on Ibuprofen and Vicodin which he sues at home | 76 | 369 |
15451467-DS-20 | 21,482,614 | Dear Mr. ___,
You were admitted for symptoms of lethargy since you have been
on clobazam. You have been monitored on video EEG as your
clobazam has been tapered off. We were concerned about increased
seizure frequency off of clobazam, so you have been started on
rufinamide, and your seizure frequency decreased. You will
follow up with your outpatient Epileptologist. | Mr. ___ is a ___ year old man with history of ___
syndrome who presented with lethargy in setting of clobazam
initiation and multiple dose adjustments. He was admitted for
clobazam wean while on EEG monitoring. His seizure frequency
increased as the clobazam was weaning off, so he was started on
rufinamide per his outpatient Epileptologist's plan.
On EEG initially he was having ___ subclinical seizures per
hour, each lasting ___ sec, consistent with prior EEG
recordings. Once the clobazam started weaning down, he increased
to having ___ seizures lasing ___ sec every 10 minutes.
However, prior to the first dose of rufinamide, he decreased to
___ events per hour lasting <10 sec each. The day of discharge,
he had gone the previous 24 hours without any seizures for
several hours, then with a few seizures in an hour; this was an
overall improvement since admission. | 59 | 145 |
17686592-DS-19 | 24,057,947 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital with
acute onset abdominal pain which improved. You had labs checked
which were concerning for pancreatitis. However, you had a CT
scan of your abdomen which did not show signs of pancreatitis
but did show a tightening of one of your abdominal arteries.
Because of this finding we asked our Vascular Surgery colleagues
to evaluate you and they did not think it was related to your
episode of abdominal pain. However, if you continue to have
abdominal pain you can see them in clinic. You should also
discuss having an ultrasound of your abdomen as an outpatient
with your primary care doctor.
All the best,
Your ___ Team | Mr. ___ is a ___ year old man with a history of HIV on
HAART who presented with acute onset abdominal pain, found to
have an elevated lipase to 1184, as well as imaging findings
concerning for stenosis of the celiac axis/ median arcuate
ligament syndrome.
# Abdominal Pain/Elevated Lipase/Mild Transaminitis
Patient admitted with acute onset lower abdominal pain with
radiation up his chest. His pain had resolved on admission to
the ED. No evidence of ACS with non ischemic ECG and negative
troponins x2. Patient underwent CTA torso which was notable for
stenosis of the origin of the celiac axis due to an impression
of the median arcuate ligament, which can be found in patients
with median arcuate ligament syndrome. However no other acute
process found in the chest, abdomen or pelvis to explain the
pain. Labs were notable for mild transaminitis but elevated
lipase to 1184. He was admitted with presumed acute
pancreatitis. However his history was somewhat atypical for
acute pancreatitis given lack of risk factors and a single
episode of 1 hour of sharp abdominal pain with radiation up
through the chest. No report of pancreatitis on CTA Torso. His
BISAP score on admission was 0 (BUN <25, no impaired mental
status, <2 SIRS criteria (leukocytosis only),age <___, no
reported pleural effusions). Pancreatitis is a rare side effect
of Atripla but this was thought an unlikely cause given the
patient's stability on this medication for years. It was thought
possible that the patient had possible transient passage of a
gallstone causing acute pain and elevation in lipase which then
resolved. UCx grew <10K organisms. Vascular surgery was
consulted due to concern for median arcuate ligament syndrome.
They believed that the pain was unlikely due to the stenosis.
The patient remained pain free without medications, and he was
tolerating a general diet on discharge and moving his bowels.
The patient's transaminitis and elevated lipase had also
improved by discharge.
# HIV on Atripla
The patient has well controlled HIV on Atripla, followed at
___. He continued on HAART while inpatient.
# Headache
The patient had a non focal frontal headache on admission
thought likely secondary to NPO status and lack of sleep, with
improvement with acetaminophen.
==================== | 128 | 367 |
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