note_id
stringlengths 13
15
| hadm_id
int64 20M
30M
| discharge_instructions
stringlengths 42
33.4k
| brief_hospital_course
stringlengths 45
22.6k
| discharge_instructions_word_count
int64 10
4.86k
| brief_hospital_course_word_count
int64 10
3.44k
|
|---|---|---|---|---|---|
17652521-DS-21 | 28,330,278 | Dear Mr. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
You were admitted to monitor you for withdrawal symptoms from
alcohol use.
What was done for me here?
You were monitored for alcohol withdrawal symptoms and treated
for any symptoms.
You were given pain medications for your alcoholic hepatitis.
What should I do when I go home?
- Please call the liver transplant social worker/coordinator to
get set up with alcohol abuse treatment.
- You also need to make an appointment with Dr. ___ in clinic.
Call the ___ at ___.
- Please continue to take all of your medications as prescribed
for your liver disease.
Sincerely,
Your ___ Liver Team | ___ yo male with HCV cirrhosis c/b HE, hepatocellular carcinoma
with recent etoh relapse presents with abdominal pain and desire
to get sober.
#Alcoholic hepatitis: He presented with abdominal pain and
elevated LFTs consistent with alcoholic hepatitis. His ___
discriminant function was 11 on admission so there was no
indication for steroid use. SBP ruled out based on diagnostic
para. He was given 5 mg oxycodone for his pain as needed and
pain improved. Bilirubin uptrended from 2.6 to 2.9 but remained
stable at 2.9 on day of discharge. Transaminases improved during
admission.
#EtOH abuse: Patient started drinking ___ and
arrived for detox. Received Ativan once for CIWA scale, but
otherwise did not have signs of withdrawal. Social worker was
not available to see the patient over the weekend but he agreed
that he wanted to be discharged and would call the liver
transplant social worker/coordinator to make a follow up
appointment to help him with sobriety.
# HCV cirrhosis: Patient had alcoholic hepatitis in addition to
known cirrhosis as above. LFTs downtrended during admission. He
was restarted on his home medications Lactulose, rifaximin,
Lasix and spironolactone. He was also started on MVI, thiamine,
folate. He did not have signs of HE during admission.
# Leukocytosis: Presented with WBC 11.9 which downtrended
during admission. Had no signs of infection. CXR, BCx, UCx, and
diagnostic paracentesis were negative.
# Anemia: Patient had Hgb 12.8 on admission with high MCV which
was felt to be due to alcohol and liver disease.
# Tobacco use:
- Given 14 mg nicotine patch.
# Thrush:
- Started on nystatin for 2 week course. | 107 | 271 |
15460401-DS-16 | 22,043,742 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had blood tests drawn that did not show signs of decreased
perfusion to your heart.
- You had a thorough workup for fevers and confusion, and there
were no signs of any active infection.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- If you are experiencing new or concerning chest pain that is
coming and going you should call the heartline at ___.
If you are experiencing persistent chest pain that is not
getting better with rest, you should call ___.
- You should also call the heartline if you develop swelling in
your legs, abdominal distention, or shortness of breath at
night.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ male with prostate cancer s/p XRT,
HTN, CVA who initially presented with chest pain and shortness
of breath. In the ED, patient was given lidocaine, morphine, and
LR fluids. Patient had no signs of ST changes on EKG along with
negative troponins. Also, no evidence of dissection, PE, or
pneumonia on CTA chest. Upon admission to cardiology floor,
pMIBI showed uniform perfusion. He denied chest pain.
Mr. ___ then began developing intermittently spiking fevers
___ with sinus tachycardia and concerns for altered mental
status in the form of increasing confusion and episodes of
agitation. Patient was pan cultured and CXR obtained. He showed
no obvious signs of infection. Given low suspicion that original
chest pain was cardiac, along with his fevers of unknown origin,
he was transferred to the General Medicine ward for further
evaluation.
On General Medicine, Mr. ___ was well-appearing and BPs were
stable. No leukocytosis and mostly afebrile with some low grade
temperatures. UA bland and CXR unremarkable. CT torso and bone
scan showed no evidence of infectious source. Neuro consulted
and had low suspicion for any acute neurologic changes. LP
deferred as he had a stable temperature curve and returned to
baseline mental status.
=================== | 187 | 204 |
11100694-DS-5 | 26,271,667 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You were transferred here for further evaluation and management
of your vision changes.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You were seen by an eye cancer specialist. Your vision changes
are likely due to metastatic disease (cancer spread).
-You were found to have new blood clots in your legs. Your
warfarin medication was held, but your INR level was too high
for us to safely start you on a blood thinning medication
(lovenox).
-Case management here worked to set you and your family up with
hospice services.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-You need to recheck your INR level with an outpatient provider
in the next ___ days. They should start you on lovenox (blood
thinning medication) when your INR is under 2.
-Continue to take all your medicines and keep your appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ yo man with h/o CAD s/p balloon
angioplasty,
DVTs and PE on lifelong warfarin, DM, and esophageal squamous
cell carcinoma (diagnosed ___ who presents with concern for
bilateral retinal detachment from metastatic lesions, opting to
transition to hospice care.
#Bilateral retinal detachment
Mr. ___ was seen by the oncologic ophthalmology service who
felt that his bilateral retinal detachment could represent
metastatic disease. They opined that chemo/radiation would offer
Mr. ___ the best chance of ocular recovery and deferred
surgical intervention. Given the rarity of esophageal squamous
cell carcinoma metastasizing to the choroid, they also raised
the possibility of a second primary cancer. Neuro-oncology
recommended MRI brain and lumbar puncture, but this was not
pursued as Mr. ___ had firmly decided against further
workup given what he considered a low likelihood of meaningful
recovery. In accordance with his wishes, Mr. ___ was
discharged to home hospice.
#New bilateral ___ DVTs
Mr. ___ has a history of DVTs/PE and was on lifelong
warfarin. In the setting of increased leg swelling, he was found
to have bilateral DVTs on ultrasound. Given that lovenox is
superior to warfarin in treating cancer-associated VTE, plans
were made to transition him to lovenox once his INR dropped
below 2. His INR on discharge was 2.4 in the setting of poor
nutritional intake, and he was discharged with plans to go for
an INR check in ___ days with an outpatient provider. Lovenox
should be started at 1 mg/kg BID dosing once his INR drops below
2.
#Metastatic esophageal cancer
Diagnosed on ___. CT A/P on ___ noted new mets to the
liver in the setting of lower abdominal pain. Mr. ___ was
planning to restart palliative chemotherapy (FOLFOX) but is now
no longer amenable given continued disease progression. His pain
was managed here with oxycodone 10mg q4hr PRN. He was discharged
with home hospice. MOLST form was completed and is in chart.
#CAD
He is s/p balloon angioplasty in the 1990s. TTE on ___
showed preserved EF 65-70%. His home atorvastatin was continued. | 180 | 335 |
18803647-DS-5 | 24,739,819 | Dear ___,
___ was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were feeling weak and fell
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- We gave you IV fluids
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the ___!
Sincerely,
Your ___ Care Team | ___ female history of NASH cirrhosis, DM, HTN, BIPOLAR
2,
PCOS, who presented to OSH after a fall with concern for
rhabdomyolysis, with downtrending CK after IVF. | 79 | 26 |
15068956-DS-21 | 20,343,841 | You were admitted with abdominal pain. After much testing it
was felt that your pain was related to liver inflammation from
alcohol. You were also diagnosed with cirrhosis of the liver.
It is very important that you stop any alcohol use. Please do
not take more than 2 grams of Tylenol per day.
Please follow up closely as scheduled with your PCP and the
___ Liver Team. Please obtain the EGD report from ___
___ before your Liver Appointment. | Ms. ___ is a ___ yo F PMHx prior EtOH abuse, recent detox with
no EtOH ingestion for almost 1 month, gastric bypass, who is
transferred from ___ for RUQ abdominal pain, possible
biliary disease, and findings consistent with cirrhosis and at
this point presumed alcoholic hepatitis
RUQ Abd pain, multifactorial
Presumed alcoholic hepatitis
Her symptoms were initially suspected to be biliary in nature,
but work up did not find a cause/concern for obstruction. Her
bili was indirect favoring against bile obstruction.
Cholecystitis was also excluded from HIDA scan. This pain could
be related to distention, ascites, and possibly MSK component as
well. Gastritis was possible but less likely, pancreatitis is
excluded on imaging/lipase. MRCP could NOT be performed due to
bladder stimulator. Another consideration was resolving
alcoholic hepatitis given pain, mild liver decompensation, and
lack of alternative diagnosis. In discussion with Liver team,
alcoholic hepatitis was the more likely cause given lack of
alternative diagnosis. She remained stable with slow
improvement. She was initiated on empiric PPI as a trial.
Alcohol sensation was discussed in detail with the patient. For
her acute pain she was given dilaudid with instructions to
follow up and communicate with her pain provider.
Cirrhosis
Ascites
Labs, exam, and imaging were consistent with cirrhosis. This
was discussed with the patient. She had ascites as well. EtOH
was the likely cause. Viral hepatitis was negative, iron
studies stable. AMA, ___, smooth muscle, Egg levels sent for
follow up purposes. In review of her imaging, there was not
suitable ascites to sample. She had an EGD at ___ 1
month prior which she will get the report for. She will follow
up closely with hematology as scheduled. For her ascites, she
was continued on Lasix which was increased to 40mg daily
HTN
- Continued home antihypertensives
EtOH use disorder
Sober for several weeks now. She is motivated to remain
abstinent and understands implications for her liver disease
- SW consulted
# Chronic back pain.
S/p MVA c/b multiple spinal surgeries and knee replacement.
- Continued home methadone
- Continue dhome duloxetine
- For acute pain will give a short course of oral dilaudid. PMP
reviewed, she will communicate with pain service provider
# ___
- ___ home Ativan
# Bladder dysfunction
Patient has a bladder stimulator in ___, only MRI compatible
for HEAD MRI
- Urology follow up | 83 | 392 |
15138144-DS-10 | 28,107,549 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital with bloody diarrhea and fevers of 4
weeks.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were started on IV steroids, called methylprednisolone.
- You were found to have a heart murmur, and a cardiac
ultrasound, called echocardiography, was done.
- A mass was found near one of your heart valves, called the
aortic valve, that was suspicious of an infection.
- Despite extensive work-up, we could not identify the cause of
this mass. No specific organism was found.
- You were started on IV antibiotics, vancomycin and
ceftriaxone. Vancomycin was discontinued, and you were continued
on ceftriaxone with a plan to continue on that for 6 weeks (end
date ___.
- Since your ulcerative colitis (UC) flare did not improve on 72
hour mark of starting steroids, you were considered at increased
risk of developing complications when off-steroids. After
extensive discussion with the medical team, infectious disease
team and gastroenterologists, a shared decision with you and
your wife was made to start infliximab. You received your first
dose on ___.
- You improved on infliximab and were ready to leave the
hospital.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Please continue to take all your medicines as prescribed
below.
- Please follow-up with your doctors as ___.
- Please arrange an appointment with your ophthalmologist to
check on your eyes given UC flare.
- Please continue prednisone taper as follows:
-- 60mg for a week - ___
-- 50mg for a week - ___
-- 40mg for a week - ___ - ___
-- 30mg for a week - ___
-- 20mg for a week - ___
-- 15mg for a week - ___
-- 10mg for a week - ___ - ___
-- 5mg for a week - ___ - ___
- Please call your doctor or visit the ___ if you experience
sudden onset of shortness of breath, fainting, body weakness,
labored speech, bloody diarrhea, abdominal pain, fevers, chills,
or other concerning symptoms.
We wish you speedy recovery!
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with history of ulcerative
colitis(Proctosigmoiditis), GERD, non-dysplastic ___,
remote prostate cancer s/p prostatectomy (___) and history of
central serous retinopathy presenting with bloody diarrhea and
low grade fevers concerning for UC flare. Patient was found to
have diastolic murmur and discovered to have echodensity on the
LVOT side of the aortic valve c/f vegetation. | 382 | 61 |
19410285-DS-24 | 29,892,824 | Dear Ms. ___,
You came into the hospital for left ankle pain and swelling.
You had an x-ray of your ankle that did not show any fracture or
dislocation. The orthopedic surgeons removed some of the fluid
from your ankle while you were in the emergency room. The cells
that made up that fluid did not appear consistent with an
infection and you had no fever, but given that you take a
medication called tacrolimus, your immune system might not react
as strongly as usual. You therefore received antibiotics and
were admitted to the hospital.
Your ankle appeared less swollen and you reported less pain on
the day of discharge. The swelling ___ have been due to
inflammation of one of the tendons in your leg. Given that the
fluid from your ankle did not grow any bacteria, you were
discharged home.
You should rest, ice, and elevate your leg. You can take Tylenol
and the tramadol you have at home for pain control. DO NOT use
NSAIDs because of your kidney function. You worked with physical
therapy who recommended that you use crutches for the time
being.
We wish you the best!
Your ___ Care Team | Summary:
=======
___ with history of DMT2, ESRD due to ADPKD s/p renal transplant
c/b allograft failure 8 months ago, now on peritoneal dialysis,
on tacrolimus, presented with 3 day history of left ankle pain
and swelling.
Acute Issues:
=========
#L ankle pain/swelling: No overlying erythema or warmth. Denied
trauma, injection, or recent instrumentation to area. No
preceding systemic symptoms. Underwent left ankle arthrocentesis
by orthopedic surgery in ED that revealed 765 WBC, 67 PMN, no
crystals. Patient afebrile and without leukocytosis. Given
immunosuppression (on tacrolimus) was treated with empiric
vancomycin in ED. On medical floor underwent usual overnight
peritoneal dialysis and pain control was achieved with prn
tramadol, standing Tylenol. Left ankle demonstrated clinical
improvement with decreased swelling and improved pain, resulting
in improved ROM. The most likely etiology of her symptoms is a
tendonitis vs bursitis (surrounding the lateral malleolus). She
was advised to rest, ice, and elevate her leg and to avoid
NSAIDs given her kidney function. She is discharged with
crutches. She will follow up with her PCP on ___.
# AMS: AAOX3 on admission but falling asleep during exam. Likely
secondary to IV morphine received in ED for pain control. No
flapping tremor to suggest uremia. VSS and afebrile, arguing
against sepsis. Sedation improved with time. Alert, oriented and
appropriate at time of discharge.
Chronic Issues:
===========
# ESRD on PD: Dialysis nephrology was consulted. Underwent
overnight PD per usual schedule. Bowel regimen ordered to ensure
daily bowel movement. Home sevelemer continued.
# Failed allograft: Home tacrolimus 5mg BID continued and
tacrolimus trough checked with AM labs. Returned at 8.8.
# HTN: No evidence of volume overload on exam. Continued home
amlodipine, losartan, torsemide with holding parameters
# HL: Continued fenofibrate.
# DMT2: Denies checking BS at home and does not take insulin or
oral hypoglycemic. Managed with ISS with QACHS ___.
Transitional Issues:
==============
- Follow up blood cultures and synovial fluid cultures from ___
- Discharged with crutches per ___ recommendations
Code Status: Full | 197 | 328 |
15568805-DS-17 | 20,201,731 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
Why were you admitted?
You were confused and your family was worried you were having a
seizure.
What happened while you were here?
You were given medications to stop your seizure. You were
monitored on EEG. Your medication, zonisamide, was increased.
You were continued on your other home anti seizure medications.
You had an MRI that showed stable changes in the location of the
previous left frontal biopsy and in some parts of the white
matter.
What should you do when you get home?
-Continue to take increased dose of zonisamide (500mg daily)
- Take all your other medications as prescribed
- Follow up with neurology
- Follow up with your PCP.
All the best,
Your Neurology Care Team | ___ old right-handed woman with a history significant for
HIV, possible CNS toxoplasmosis (biopsy non-specific, followed
with serial imaging) and medically-refractory focal-onset
epilepsy with recurrent episodes of status epilepticus who
represented with concern for breakthrough seizures and
recurrence of NCSE.
#Epilepsy, breakthrough seizure:
EEG once placed did not show ongoing seizures. Exam slowly
improved throughout admission with improvement in perseveration
and expressive aphasia. No evidence of infection on labs, per
family patient has been compliant with all medications. MRI was
negative for any new focal lesions. Overall unclear cause of
breakthrough seizures. Her zonisamide was increased to 500mg
QHS. She was continued on home 1000mg BID keppra, and 200BID
Vimpat. Levels were checked though not on admission
unfortunately, trough of vimpat was 8.3. Levels of keppra and
zonisomide were pending at time of discharge.
#Prior probably CNS toxo s/p treatment: Patient was due for
monitoring MRI which was done during admission and showed stable
enhancement at L frontal biopsy site and nonspecific
periventricular white matter changes.
#HIV: Continued on home HAART
Transitional Issues
==============
[] Zonisamide dose increased to 500mg
[] Zonisamide and Keppra levels pending at discharge
[] Screening MRI done during admission that showed enhancement
at prior L frontal biopsy site and nonspecific periventricular
white matter changes.
[]f/u with neurology appt with Dr. ___
[] f/u with PCP ___ 2 weeks.
[]Repeat EKG at next PCP appointment to check PR interval. | 132 | 231 |
15249915-DS-14 | 24,580,384 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You came to the hospital for a bone infection in your mid-back.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-We got an MRI of your back which confirmed a bone infection in
your spine.
-Our interventional radiologists obtained a biopsy of your bone
infection.
-We gave you IV medications for your bone infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You should continue receiving IV antibiotics (called
vancomycin) at dialysis. We called your ___ facility at
___ and they said they will be giving you this antibiotic
there.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ yo man w/ CAD ___ CABG ___, Aflutter
___ ablation at ___ ___ (on warfarin), h/o DVT (RUE DVT,
saphenous vein DVT resolved), cardiomyopathy ___ CRT-P ___
(previously removed ___ iso MSSA bacteremia),
hyperthyroidism
___ amiodarone toxicity, R. pleural effusion, and recent
hospitalization for polymorphic VT/cardiac arrest on ___
c/b new diagnosis of ESRD with unclear etiology (HD initiated
___. He initially presented to ___ for worsening
mid-lower back pain on ___ and was subsequently admitted to
___ for further evaluation of suspected osteomyelitis.
He was evaluated by Spine in the ED, who felt he was clinically
stable. ___ MRI w/wo contrast shows T8-9 osteo/discitis with
associated phlegmon and ___ ___ bx of osteo on ___ that
showed no growth to date. ID was consulted and he was started on
IV Vanc/CTX initially and narrowed to complete a 6 week course
of cefazolin dosed at HD (___) at ___
dialysis | 133 | 154 |
16444272-DS-24 | 20,691,892 | Dear Ms. ___,
You were admitted to the hospital because you had one week of
nausea, vomitting, and diarrhea and found to have worsening
renal function. We also noted that your INR was elevated, above
the proper range. We replenished your hydration with fluids. We
stopped medicines that can worsen your kidney function
(Lisinopril and Lasix) and we checked for causes of the diarrhea
and vomitting. While in the hospitals you started to eating
food, your nausea resolevd, and you no longer had diarrhea. Your
renal function improved, however, it needs to be monitored by
your kidney and primary care doctors. Your INR remains elevated
and needs to be closely monitored by the ___ clinic. You
should have a your ___ draw your INR tomorrow and have this sent
to the ___ clinic.
Weigh yourself every morning, call MD if weight goes up more
than 5 lbs.
Please take only the medications on the provided list. We made
the following changes to your medications.
- STOP Warfarin until further instruction by your
___ clinic
(You have an appointment with the ___ clinic on ___
___
- HOLD Lasix until ___, as long as you are no longer
vomitting or having diarrhea. Call your Kidney doctors ___
have any quetions.
- STOP Lisinopril until further instruction from your outpatient
Kidney and Primary care doctors
- START Iron Supplements
- Continue all other medications | Ms. ___ is a ___ year old woman with a PMHx of FSGS s/p 3
failed transplants with a baseline Cr ~2.8, who presents with
___ (Cr~7) after one week of poor PO intake, nausea, emesis,
diarrhea and continuing ACEI and Lasix.
.
For her acute on chronic renal impairment, the etiology was
presumed to be secondary to poor hydration status and
continuation of nephrotoxic medicines. We started IVF with LR,
held lasix and lisinopril, placed her on a low phos/low k diet.
On day of discharge her Cr was 4.9 from 7.1 on admission. Her
physical exam was significantly improved in regards to hydration
status. On day of discharge her orthostatic blood pressure and
heart rate variation was within normal limits. On day of
discharge her urine output was ~45cc/hr.
.
For her renal transplant Sirolimus was continued and her levels
were checked daily. Prednisone was continued. Nephrocaps were
continued. Bactrim was continued for PCP ___. On day of
discharge the patient was placed on all of her home medications
for per the renal transplant service.
.
To evaluate the etiology of her GI illness we checked her Stool
for CDiff and stool culture. We checked a UA, UCx, and CMV + BK
virus serology. No signs of UTI, and serologies are pending. She
was given, although did not require Zofran for nausea.
On day of discharge the patient tolerated a full PO diet without
n/v/diarrhea.
.
For her chronic afib, we continued her beta blocker and held her
Warfarin as the INR was supra therapeutic. She was given
discrete instructions to follow her INR with the ___
clinic.
.
On day of discharge the patient was able to tolerate a full PO
diet, ambulating with walker, urinating appropriately without
problem, and moving bowels appropriately without problems. | 225 | 295 |
11150876-DS-16 | 23,520,308 | Dear Ms. ___,
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital with shortness of breath. We
believe this was caused by increased fluid in your body due to
heart failure. We treated you with medicine to help remove this
fluid and your symptoms improved.
We believe you may also have had infection in your lungs. We
treated you with antibiotics.
After discharge, please weigh yourself every morning, call your
doctor if your weight goes up more than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ with PMH of Afib on warfarin, CAD s/p
CABG, SSS s/p PPM, HFpEF (EF55-60%) and mild aortic
stenosis/moderate tricuspid regurgitation/severe mitral
regurgitation, who is presented with dyspnea, found to have CHF
exacerbation. The exacerbation was thought to be secondary to
infection vs. ischemia vs. arrhythmia. Pt was treated with IV
diuretic and 5 day course of antibiotics for community acquired
pneumonia and her symptoms improved. Pt was without troponin
elevation and ECG changes on admission. Further work-up of
ischemia was deferred given pt's age and comorbidities. Pt was
transitioned to oral regimen of torsemide 20mg daily with
stabilization in volume status and renal function.
# Acute on chronic systolic heart failure: Patient presented
with shortness of breath and evidence of volume overload on
exam. This was thought to be secondary to heart failure
exacerbation. The exacerbation was thought to be secondary to
infection (community acquired pneumonia) vs. ischemia (TTE with
worsening EF 40% from 55-60% with regional systolic dysfunction,
moderate AS, MR, and TR, moderate pulmonary hypertension) vs.
arrhythmia (brief episode of AF with RVR on arrival to ED).
Pneumonia was treated as below. Ischemic work-up showed no ECG
changes and no troponin elevation. Further work-up was deferred
given the patient's age and comorbidities. AF with RVR resolved
upon admission and the patient's HR remained stable throughout
admission. She was medically optimized with lisinopril 2.5mg
daily and metoprolol succ 25mg daily. She was diuresed was
intravenous furosemide and eventually transitioned to torsemide
20mg daily with stabilization of her weight and renal function.
Her discharge weight was 44.5kg.
# Sick Sinus Syndrome/Atrial Fibrillation: Pt has an isolated
episode of atrial fibrillation with rapid ventricular response
on arrival to the emergency department which was rate controlled
with metoprolol. Pacemaker was interrogated which showed HR <100
for 90% of beats. Patient was started on metoprolol succ 25mg
daily for CHF and for rate control. Her INR fluctuated during
the hospitalization, likely related to antibiotic treatment for
community acquired pneumonia. Despite CHADS ___, decision made
not to bridge for sub-therapeutic INR given the patients age and
comorbidities. She was treated with higher dose warfarin. INR
will be followed by rehab facility after discharge.
# Community acquired pneumonia: Patient presented with shortness
of breath, neutrophilic leukocytosis, and a chest x ray that
showed a possible infiltrate in the left apex. Blood cultures
and urine legionella antigen were negative. Patient was treated
with 5 day course of ceftriaxone and azithromycin which she
completed in house.
# Left calf wound: Patient has a wound from a basal cell
carcinoma removal that did not heal. Wound is mildly odorous and
has exposed tendon, no evidence of active infection. She was
evaluated by wound care while hospitalized with the following
recommendations:
- Tramadol 25mg prn dressing changes
- Acetaminophen 650mg po Q6 prn pain
- Gabapentin 100mg daily
- Sterile water for dressing changes
- Petrolatum Xeroform gauze
- Normlgel
Transitional Issues:
# Continue to titrate metoprolol and lisinopril for BP control
and for optimization of heart failure regimen
# Continue to titrate torsemide dosing for management of volume
status
# Continue to monitor wound on left anterior calf.
# INR 1.5 on discharge, decision made not to bridge given age
and comorbidities. Patient treated with 2mg warfarin, please
continue to check INR and titrate warfarin to goal ___. Check
next INR ___
# Please check Chem 10 on ___ to ensure stability
# Continue to monitor daily weights on patient, call MD if
weight increases > 3lbs
# Discharge weight: 44.5kg
# Consider repeat CXR PA and lateral in ___ weeks for evaluation
of resolution of heterogeneous opacification in left upper lobe
of lung | 96 | 604 |
13996551-DS-26 | 28,147,033 | It was a pleasure taking care of you at ___. You were admitted
for swelling of your right arm. Imaging studies did not show any
signs of clot and your fistula remains patent. You did not
appear to have any infection.
We think the swelling was caused by a narrowing in the blood
vessels of your right arm. You should contact AV Care at
___ on ___ morning to arrange for a procedure to
open up that narrow vessel. In the meantime, keep your arm
elevated above the level of your heart and squeeze a stress ball
to keep exercising the muscles of your right arm.
If you have any fevers, chills, worsening pain or coolness of
the arm, you should come back to the hospital. | Ms. ___ is a ___ yo F with h/o ESRD ___ DMT2 now s/p SCD
transplant ___ with good renal function, also with h/o HIV on
HARRT who presents with right upper arm swelling x 5 days.
# Right upper extremity swelling: The arm was not painful, red,
or warm and she denies fevers and no leukocytosis which all
argue that deep tissue infection and cellulitis are unlikely.
DVT was ruled out with US and CTA. Most likely explanation is
lymphatic or venous congestion either from brachiocephalic
stenosis noted on CTA or from patent fistula. Transplant surgery
recommended angioplasty of stenosis; they were hesitant to
ligate fistula at this time in case patient requires dialysis in
the future. Patient will follow-up with AV Care to arrange for
angioplasty as an outpatient. In the meantime, patient was
instructed to continue elevating her arm and performing hand
grips.
CHRONIC ISSUES
# HIV: Stable. Continued truvada + raltegravir
# ESRD s/p transplant ___: Stable creatinine and tacro level.
Continued home dose tacrolimus, mycophenolate mofetil,
prednisone, bactrim, calcium, and vitamin D
# DM2: Poorly controlled with last A1c 8.4 on ___. Continued
lantus and ___.
TRANSITIONAL ISSUES
-Please check a CD4 and HIV VL as an outpatient
-She will follow-up with AV Care in the next two weeks for
angioplasty of her stenosis. If this fails to improve her
symptoms, she will likely require ligation of her patent AV
fistula. | 125 | 232 |
15653428-DS-13 | 28,013,205 | ___,
You were admitted to the hospital for cellulitis (skin
infection) on your right thigh. You were treated with IV
antibiotics and you got better. These antibiotics were
transitioned to oral antibiotics (clindamycin) and you will take
these until you run out. Please ___ with your primary care
physician and your oncologist below.
It was a pleasure caring for you,
-Your ___ care team | This is a ___ year old female with a stage IIIB ovarian cancer on
study ___ (Olaparib vs. placebo) who presented with
cellulitis. She was started on IV vancomycin originally and this
was transitioned to PO clindamycin upon discharge. She was
febrile (~102) with an elevated WBC count (~17) originally, but
she was afebrile upon discharge and her WBC normalized (7). The
day prior to discharge, she noticed worsening soft-tissue
swelling at the site of her cellulitis. An US was performed and
showed no signs of abscess.
#Cellulitis: Her leg pain and erythema are suspicious for
cellulitis, no purulence and no area of skin break however
patient did recently shave the groin area and there is mild
folliculitis there. Edema is chronic and lower extremity US
(___) was negative for DVT. She had a fever throughout her
first couple days and her WBC was 17.3 on admission. She was
started on IV vancomycin and after 3 days of this, her vanc
level was subtherapeutic (2.8) and her erythema was not notably
improving. Her vancomycin dose was increased and on repeat
check, her level was therapeutic. Given her absence of fevers,
normalized WBC count, and improving erythema, she was
transitioned to PO clindamycin, which she will complete a 7 day
course of. On the day of discharge, she was complaining of a
soft tissue swelling on her medial right thigh in the area of
her cellulitis. She received a lower extremity US which showed
no sign of abscess.
#Headache: She presented with a headache consistent with prior
migraines. She has tried many medications in the past and
finally botox was the only time she got relief. She was given
some IVF, tylenol, and reglan with improvement.
#Ovarian cancer: She was continued on her study drug while
in-house.
#Depression: She was continued on her home fluoxetine 50 mg qd
and ativan.
#Thyroid carcinoma s/p thyroidectomy: She was continued on her
home levothyroxine | 61 | 318 |
14483422-DS-22 | 23,938,393 | Dear Ms. ___,
It was a pleasure to care for you during your hospitalization.
You were admitted to the hospital after having a fall and
hitting your head as well as for significant nausea and vomiting
recently. You underwent a thorough evaluation which revealed
only some bruising on the back of your head but without any
significant abnormalities in your brain. We also evaluated your
heart and determined you did not have a heart attck. Your heart
function has actually improved since your recent heart attack.
.
We found that you had a urinary tract infection, and started an
antibiotic called Bactrim that you should take for a total of 7
days and complete on ___. You were treated with medications to
help control your nausea, vomiting, and pain. We also gave you
IV fluids for rehydration. Your symptoms may be related to a
decreased food and fluid intake, and we started a
medication(methylphenidate/Ritalin) to help stimulate your
appetite and give you more energy.
Please review your medication list for the details of the
changes. We have also made followup appointments for you, as
below. | ___ year old female with stage IV NSCLC s/p palliative
chemo/radiation, recent SBO s/p ex lap with resection and
primary anastomosis ___, CAD s/p NSTEMI with bare metal
stent to LAD ___ who presents with nausea, vomiting,
delirium s/p fall with sub-galeal hematoma. | 182 | 45 |
12290018-DS-13 | 28,181,716 | Surgery
Your dressing may come off on the second day after surgery.
*** Your incision is closed with staples or sutures. You will
need suture/staple removal. Please keep your incision dry until
suture/staple removal.
*** Your incision is closed with dissolvable sutures
underneath the skin and steri strips. You do not need suture
removal. Do not remove your steri strips, let them fall off.
Please keep your incision dry for 72 hours after surgery.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
*** You may take Ibuprofen/ Motrin for pain.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | Mr. ___ is a ___ yo M presents with low back pain and bilateral
lower extremity pain, numbness, and tingling that has
progressively worsened since ___. There was no clear
antecedent trauma or event. On exam at admission, he had no
focal neurologic
deficit. A MRI lumbar spine showed a large disc protrusion at
L4-5 withcentral stenosis.
#Herniated Disc
MRI revealed a large herniated disc L4-5. After admission
patient pain worsened. On repeat examination patient was noted
to have new distal LLE weakness however rectal tone remained
intact, PVR 20. He was added on to the OR schedule for ___. On
___, the patient complained of increased pain and numbness in
his penis and perianal area. He also had decreased rectal tone.
He was taken to the OR for bilateral L4-5 laminectomy and left
microdiscectomy. The procedure was performed without
complication. Please refer to the operative report for full
details regarding the procedure. He recovered in the PACU
post-operatively and was then transferred to the floor. On POD
#1, his pain was much improved. His extensor hallicus longus was
___ bilaterally but otherwise his motor exam was ___. He
continued to have perianal numbness and tingling but he had
pressure sensation. Physical therapy was consulted and
recommended acute rehab. Endorses continue urinary incontinence
with weak stream. Bladder scanned PVR 200. He was discharged
to acute rehab ___ and will follow up in the office.
#Constipation
The patient has not had a bowel movement since ___ so
his bowel regimen was increased. Large BM AM of ___. | 257 | 255 |
11868033-DS-16 | 24,930,751 | Dear Mr. ___,
You were admitted to the hospital with pneumonia. We started you
on an oral antibiotic and you were doing well at the time of
discharge. You have an appt scheduled at your geriatrician's
office in a few days on ___ to make sure that you are
feeling better. You should have a repeat chest xray in ___ weeks
to make sure that the pneumonia is gone.
Because you were having some weakness, our physical therapists
saw you and recommended you go to rehab, however you chose to go
home instead. In that case, they recommended you have in-home
physical therapy and visiting nurse
The following changes were made to your medications:
1. Start azithromycin daily for the next 4 days.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you at ___! | ___ year old male with PMH Atrial fibrillation, CHF, HTN, Sick
Sinus Syndrome presents with possible mechanical fall and found
to have pneumonia. | 151 | 23 |
13837194-DS-5 | 28,367,512 | Dear Ms. ___,
You were admitted for symptoms of dysequilibrium. Because this
can be a sign of stroke, you were evaluated on the Stroke
Neurology service. Thankfully, an MRI of the brain did not show
any evidence of neurovascular disease. Your hemoglobin A1c,
which is a test for diabetes, was within normal limits. Your
cholesterol levels are pending. The most likely diagnosis is a
vestibulopathy, or dysfunction of a peripheral vestibular
system. The cause was not identified, but likely will improve
with time. Please make sure to continue hydration.
Please follow up with your primary care provider as scheduled
for resolution of symptoms and follow up of laboratory data.
It was a pleasure taking care of you.
-___ Neurology | ___ is a ___ year old woman with a history of
pituitary microadenoma who presented after several episodes of
dysequilibirum and veering to right. Exam was notable for slight
R sided dysmetria and veering to the right while walking, which
resolved the morning following admission. Given her symptoms,
she underwent a work up for stroke specifically to rule out
posterior circulation stroke, vertebral dissection. MRI did not
show findings that could explain her symptoms. Her symptom of
dysequilibrium resolved by the following morning. The most
likely cause of her symptoms was felt to be a type of
vestibulopathy. We advised her to follow up with her PCP.
Transitional Issues
#Neurology
[ ] No specific follow up with Neurology set up at this time.
Patient may call ___ to schedule a follow up if
symptoms do not resolve or change in quality
[ ] Pituitary microadenoma: records from ___ showed an
MRI with contrast in ___ to evaluate for progression which
apparently showed regression of the previously suspected
right-sided pituitary microadenoma, per report.
[ ] Follow up lipid panel | 115 | 176 |
12321369-DS-13 | 28,489,560 | Dear Ms ___,
It was our pleasure to care for you at ___. You were admitted
for elevated blood sugars in the setting of a urinary tract
infection. We treated you with antibiotics to treat your
infection and gave you insulin to help control your blood sugar.
Your blood sugars improved and we were able to switch you to
oral medications to treat the infection.
We made the following changes to your medications:
Please START cefpodoxime
Please CHANGE your insulin humalog sliding scale. See attached
sheet please
Please CONTINUE insulin glargine 20 units every morning and 20
units every evening | ___ w/ DM, CKD approaching dialysis, HTN, sarcoid on prednisone
p/w hyperglycemia and UTI.
#Hyperglycemia: likely in the setting of UTI below and patient
also been missing doses of insulin. Also contributing is
prednisone dosing, although patient on less than previously.
Got 20 units Lantus this morning and 12 units of Humalog in the
ED. Sugars are still critically high and anion gap is 17 at
admission. Patient was treated with 32 units of Humalog and 30
units of glargine night of admission and her gap closed to
normal with sugars down to the 100-200 range. We enjoyed
consultation with the ___ team and modified her sliding scale
to their recommendations (increased doses). We continued home
glargine 20U qam and 20U qpm.
- ___ follow up ___
#UTI by Positive UA: patient with dysuria, frequency, and
urgency x1 month. Malodorous urine in room. Urine cultures were
not drawn prior to antibiotics, so we empirically switched her
away from the Cipro treatment in the ED (previous UTI e coli
Cipro resistant) and treated her with ceftriaxone and her
leukocytosis resolved. The following morning her foley catheter
was removed. She reported no more dysuria following a day of IV
ceftriaxone. Patient was given a prescription of cefpodoxime to
complete for 5 more days as an outpatient.
#Hypokalemia and hypertension in setting of steroid use and
ESRD: Patient approaching dialysis, has fistula in place left
side, does not appear matured by my basic exam. Is not volume
overloaded currently. She was however hypokalemic despite
receiving 40meq of potassium twice while in house. She has had
labile potassiums in the past and despite considerations of
hyperaldosteronism as an underlying cause, we did not send off
serum renin levels or add on an aldosterone receptor antagonist.
We did continue furosemide 100mg daily and metolazone 2.5 mg
BID
- consider hyperaldosteronism and aldosterone antagonism therapy
in the future pending initiation of dialysis.
#Sarcoidosis: Residual lymphadenopathy on CXR. Otherwise not
active. We continued prednisone 10 mg DAILY and budesonide 180
mcg/Inhalation Aerosol Powdr Breath Activated Sig: One (1) puff
Inhalation BID (2 times a day) as needed for
cough.
#Prolonged QTc: Avoided Zofran and other QT prolonging meds.
#Hypertension: Patient normotensive, ? hypotensive in ED.
Normotensive during hospitalization. We continued hydralazine
25 mg PO Q6H Diltzac ER 360 qd (dosed as 90 QID) and restarted
furosemide 100mg daily and metolazone 2.5 mg BID day after
admission.
#Primary prevention of coronary artery disease. EKG with NSST
changes likely due to LVH. We continued aspirin 81 mg qd and
pravastatin 80 mg qhs
#Depression: Patient euthymic. We continued citalopram 40 mg qd
#Transitional:
- Patient with prolonged QT interval. Avoid QT prolonging
medications.
- Follow up with ___ day after discharge.
- Patient discharged with ___ and ___ assistance. | 99 | 477 |
11296936-DS-115 | 20,876,268 | Dear Mr. ___,
You were admitted to ___ due to low blood pressure and chest
pain. We monitored you overnight, and you blood pressure went
back up to normal and your chest pain resolved. We are glad to
tell you that you did NOT have a heart attack.
Please follow up with your scheduled appointments as listed
below.
It was a pleasure taking care of you at ___. We wish you well.
Sincerely,
Your Team at ___
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | This a ___ year old gentleman with history of ESRD on
hemodialysis, diabetes mellitus, atrial fibrillation not on
coumadin, hepatitis C, left brachiocephalic AV fistula with
steal syndrome s/p banding who presented with dyspnea and
hypotension during dialysis. He was monitored overnight for
acute coronary syndrome. Workup was negative and his blood
pressure normalized with diet.
BRIEF HOSPITAL COURSE
========================
ACTIVE ISSUES
#Hypotension: After dialysis SBP 70, in ED SBP 90, likely in
context of volume reduction. On admission, SBPs normotensive in
120s. Patient reported chest pressure with associated
palpitations, diaphoresis and nausea. EKG with no ischemic
changed. Troponins cycled thrice with plateau at 0.40 x 3.
Patient was hemodynamcially stable with resolution of cardiac
symptoms, and therefore was transferred back to his skilled
nursing facility. No medication changes were made on transfer
STABLE CHRONIC ISSUES
#Leg pain: As previously described, most likely due to diabetic
neuropathy.
Patient was continued on gabapentin and lidocaine patches.
#Atrial Fibrillation: CHADS-VASc2 = 4. Patient with mild RVR HR
120s. Patient was continued on dilitiazem and digoxin. Heart
rate normalized
#Systolic and diastolic Congestive Heart Failure: Patient was
continued on digoxin and diltiazem. Admission Weight:73.94 kg.
Discharge Weight: 74 kg
#End Stage Renal Diseae on Hemodialysis: baseline Cr ~6. Patient
was continued on midorine, gabapentin, nephrocaps, sevelamer and
Renal caps. Patient did not require hemodialysis this admissio.
Continue dialysis T/R/S schedule
#Obstructive Sleep Apnea: Patient was continued on CPAP and
trazodone.
#Diabetes Mellitus Type II: Patient was continued on glargine 10
U qHS and home insulin sliding scale. Patient should follow up
with ___ continued management of diabetes.
TRANSITIONAL ISSUES
[] Please arrange follow up with ___ continued
diabetes management. ___
[] Please ensure follow up with PCP ___ transplant
surgeon Dr. ___ care of patient's ongoing issues
[] Reconfirmed discontinuation of Imdur with ___
has NOT been updated in the OMR (only under discharge meds)
[] PCP: ___ augmenting patient's antidepressant (his age
and
cardiac risk factors contraindicate increasing celexa) vs
switching to different agent
[] Hip Pain: Pelvic XRay neg. ___ with PCP as outpatient, may
require additional imaging (XRay negative) if does not resolve.
Patient requests orthopedics appointment for management of known
humeral fracture. This appointment was not made on this
admission. | 85 | 364 |
14446362-DS-19 | 26,798,496 | Dear ___,
___ was a pleasure taking part in your care during your
hospitalization at ___. You were admitted for a severe
allergic reaction to IV iron supplementation. You were treated
with medications including steroids to control the reaction. On
admission you were noted to be anemic. You were transfused with
one unit of red blood cells and your anemia improved. You also
experienced chest pain while you were here, but an EKG and blood
tests did not show evidence of heart muscle damage.
It is important that you continue taking prednisone as follows:
- 40mg for one more day (on ___
- 20mg daily for three additional days (___)
Please discuss tapering down your prednisone dose with your
endocrinologist at the appointment listed below.
Please follow up with your PCP at the appointment listed below
to discuss the blood test result for celiac disease and to
discuss increasing your dose of pantoprazole long term for your
stomach discomfort. | ___ woman with a history of iron deficiency, asthma, atypical
chest pain, and chronic stable asthma, admitted after
anaphylactic reaction to IV iron in ___ clinic.
# Anaphylaxis: Patient with anaphylactic reaction to IV iron
despite premedication with dexamethasone, benedryl, famotidine,
and despite distinct formulation from prior anaphylaxis-inducing
IV iron infusion. Initially patient was transferred from
hematology clinic to emergency room for observation, but given
recurrence of SOB, airway edema after each of two injections of
epinephrine, patient was admitted to medicine. Patient was
closely monitored and treated with famotidine, fexofenadine, and
prednisone as well as prn IV diphenhydramine and albuterol
following discussion with allergy consult service.
-40mg PO prednisone x3 days, then 20mg PO x3 days (last day
___, then taper will be deferred to
outpatient endocrinologist
-Iron supplementation (in any form of administration) noted as
SEVERE allergy for this patient in OMR
# Microcytic anemia: Iron deficiency anemia with positive guaiac
in ___ woman s/p TAH raises concern for occult GI malignancy or
possibly slow GI bleed. Other considerations include
malabsorbtion, hereditary or autoimmune. Has strong family
history of anemia. Past work up has included unrevealing
investigation for hemoglobinopathy and upper and lower endoscopy
in ___. Patient has history of severe anaphylactic reactions to
supplemental iron. She was scheduled for outpatient colonoscopy
which was missed on second day of admission. Given severe
allergy to iron supplementation and labs showing serum iron of
10 and slowly down-trending hematocrit on admission patient was
transfused 1U pRBC with appropriate bump in hematocrit.
-TTG IgA to evaluate for celiac disease as cause of
malabsorption pending at time of discharge
# Atypical chest pain: Angina vs GERD vs anxiety. Patient
presented with chronic epigastric/substernal pressure that had
been stable and ongoing for 2 weeks prior to admission. Inital
cardiac enzymes were negative x2 and EKG showed stable t-wave
abnormalities. During this admission patient had one episode of
left-sided squeezing ___ chest pain radiating to the left arm
that felt subjectively similar to episode in ___ that resulted
cardiac cath and balloon angioplasty back in ___. Pain was
not relieved with 325mg chewed ASA, but was relieved by SL NTG
x1. Cardiac enzymes were again negative and EKG was stable. Pain
may be secondary to esophageal spasm, given response to
nitrates. She underwent exercise MIBI here ___ which was
normal and is followed by Dr. ___ outpatient cardiology.
-Follow up with Dr. ___ as outpatient.
# Asthma - continued home albuterol, fluticasone. Patient
complained of asthma worsening when patient in adjacent room lit
a cigarette just prior to Mrs. ___ discharge. SOB and
subjective wheezing improved with 1x albuterol nebulizer. No
wheezes heard on auscultation following nebulizer, was moving
air well. Patient was given a script to fill for albuterol
inhaler to take with her in the car ride home, knows to return
to an emergency room or call her doctor if her SOB or wheezing
recurs and is not controlled with her rescue inhaler. | 157 | 486 |
18889286-DS-8 | 21,804,229 | Dear Ms. ___,
You were admitted to the hospital because of bleeding, and you
were found to have undetectable platelets (<5). You were
evaluated by the hematology team, and you were diagnosed with
immune thrombocytopenic purpura (ITP). Per the rheumatology
team, it did not seem that this was due to your mixed connective
tissue disease as your bloodwork did not show active disease
(negative dsDNA, normal complement levels C3 96, C4 13). Rather,
this seems to be a separate autoimmune process. You declined the
first line treatment for ITP, which is steroids, despite
multiple conversations. You then had two days of IVIG (full dose
for ITP), which you did not respond to. You were started on
N-plate, and had 2 doses of this inhouse, without improvement so
far (though the N-plate can take longer to work). We had several
discussions about a possible splenectomy, which would be the
next line of treatment. We discussed the vaccines that would be
needed (pneumococcal, meningococcal and h. influenzae) prior to
a splenectomy, and we confirmed their safety in terms of your
autoimmune disease with your rheumatologist Dr. ___.
We also discussed the use of Lupron to help decrease your
vaginal bleeding- after discussion with the gynecologists,
hematology/oncologists, and your rheumatologist Dr. ___,
___ determined that it would be safe for you to get a Lupron
injection in the short term to help with vaginal bleeding. Note
that after 12 months of usage it can cause ___ weakness as it
mimics the symptoms of menopause.
We finally discussed the possibility of a tagged platelet indium
scan to assess the success rate for a splenectomy, but we are
unfortunately unable to perform this test here at ___.
Tests that were done in the workup of your ITP included:
CMV IgG positive, IgM negative--> infection in the past with
antibodies made
EBV IgG positive, IgM negative--> infection in the past with
antibodies made
dsDNA negative
folate >20
vitamin B12 269 (borderline low)
HIV negative
HCV negative
H. pylori in the stool negative
A ___ marrow biopsy was not performed because per the
hematology team there is no alternate differential diagnosis
that would lead to platelets that are this low; and additionally
it would be quite morbid in the setting of persistent platelets
<5.
Ultimately, given the fact that you were just being monitored
inhouse in between N-plate treatments, you decided to leave the
hospital against our professional medical recommendation given
that your platelets were still undetectable and you are at risk
of catastrophic spontaneous bleeding in your brain, abdomen,
lungs, legs that can cause death.
During the hospitalization, you also had a CT
chest/abdomen/pelvis done and a ___ scan for staging of your
breast cancer, and this did not show any metastatic disease.
You also had severe L leg pain and had a CT of your left leg,
and this did not show any bleeding or other abnormalities.
Please have your blood count (CBC) checked 2 times per week
___ and ___ and faxed to Dr. ___ at
___.
When you return to ___, please call the hematologist's office
at ___ as soon as you return to schedule a follow up
appointment with Dr. ___ any available physician. Please
ask to speak to ___ specifically as she will help
you to be seen expeditiously.
PLEASE watch for the following, and go to the ED for:
-vomiting any amount of blood
-coughing up blood clots or frank blood
-large black tarry stools or large volume bright red blood in
your stool
-large amount of vaginal bleeding
-any new large bruises on your legs or abdomen
-any new areas of swelling anywhere on your body
-lightheadedness or faster heart rate lasting >30 minutes
-any new numbness/tingling, weakness anywhere on your body
-any sudden changes in your vision
-any worsening of your normal headache, or a new sudden "worst
headache of your life"
-any sudden onset of dizziness and vertigo
-new worsening fatigue, or confusion
-or ANY other symptom that concerns you.
I cannot emphasize enough how important it be that you seek
medical care for any of the above.
It was a pleasure taking care of you.
-Your ___ Care team | SUMMARY/ASSESSMENT: Ms. ___ is a ___ female with the
past medical history of MCTD w/ SLE/myositis overlap c/b ILD and
b/l hip avascular necrosis and recently diagnosed invasive
ductal
carcinoma (ER+, PR+, Her2 neg) who presented due to concern of
bruising and BRBPR. Labs revealed significant thrombocytopenia
with concern for primary more so than secondary ITP.
#thrombocytopenia
#ITP
She was admitted to ___ on ___ because of mucosal bleeding,
and she was found to have undetectable platelets (<5). She was
evaluated by the hematology team, and was diagnosed with immune
thrombocytopenic purpura (ITP). She was seen by rheumatology,
and it did not seem that this was ___ her MCTD as her bloodwork
did not show active disease (negative dsDNA, normal complement
levels C3 96, C4 13). Rather, this seems to be a separate
autoimmune process. She declined the first line treatment for
ITP, which is steroids, despite multiple conversations, based on
prior experience. Therefore, she then had two days of IVIG (full
dose for ITP), which she did not respond to. She was also
started on N-plate, and had 2 doses of this inhouse, without
improvement so far (though the N-plate can take longer to work).
Several discussions were had with the patient about a possible
splenectomy, which would be the next line of treatment, but she
declined to consider this so far. She was encouraged to have the
vaccines administered that would be needed (pneumococcal,
meningococcal and h. influenzae) prior to a splenectomy, despite
confirming their safety in terms of her MTCD with her
rheumatologist Dr. ___.
Note that rituximab would not be an option in her case because
she had an anaphylactoid reaction to a rituximab infusion in
___ requiring steroids and epinephrine, and she is declining
the use of steroids for pre-medication.
Throughout the hospitalization she continued to have daily
oozing from her mucosae (oral with ulcers; vaginal, in her
stool) but her blood counts stayed stable. She had petechiae and
several small ecchymoses throughout, but no edema/large
hematomas.
The use of Lupron to help decrease her vaginal bleeding was
discussed with the gynecologists, hematology/oncologists, and
rheumatologist Dr. ___ it was determined that it
would be safe for her to get a Lupron injection in the short
term to help with vaginal bleeding. Note that after 12 months of
usage it can cause ___ weakness as it mimics the symptoms of
menopause. She declined this during the hospitalization
The possibility of a tagged platelet indium scan to assess the
success rate for a splenectomy was explored, but this is
unfortunately not a test that we can perform at ___ (or likely
nowhere in the ___ area as the external pharmacy that would
tag the platelets has no experience with this, but this was not
confirmed by calling other hospitals). | 660 | 453 |
14154307-DS-16 | 26,871,539 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after developing an infection of your
right foot
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your podiatrist did a procedure to drain the abscess
- You had a CT scan that showed a possible recurrence of
osteomyelitis
- You received antibiotics to treat your infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You were discharged on an oral regimen of antibiotics that is
not the most ideal regimen for your infection. Ideally, you
would be treated with IV antibiotics however this could not be
arranged before you left.
- You will need to continue taking these antibiotics until you
see your infectious disease team. From there, they will decide
if oral antibiotics can be continued or if you need IV
antibiotics.
- If you develop worsening symptoms in your foot, please call
your infectious disease team at ___ or your PCP, as
your infection may not be responding to the oral antibiotics.
- We have also changed your NPH schedule and reduced your NPH
dose given swings in your blood sugars and episodes of low blood
sugars. Starting on ___, you should take NPH in the morning
(dosing listed below) rather than in the evening.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ with h/o HTN, HLD, CAD s/p DES, gastric
bypass, gout, DM2 c/b diabetic neuropathy, retinopathy, and
chronic foot ulcerations c/b osteomyelitis s/p multiple
debridements including right ___ met head resection (DOS:
___ with recently healed wound who presented to ___ for right foot swelling and was transferred for further
evaluation concerning for cellulitis and abscess.
ACUTE ISSUES:
=============
#R foot Cellulitis
#R foot abscess
Patient developed pain, erythema and swelling in the R foot
concerning for cellulitis and abscess. Was started on
doxycycline at urgent care without improvement and referred to
ED for I&D with podiatry. Wound culture eventually grew MRSA.
CRP/ESR also very elevated. Initially started on
vanc/cefepime/flagyl then narrowed to vanc/CTX/flagyl. Xray not
concerning for osteomyelitis, and CT scan showed fat stranding
and edema likely from prior surgical changes, though raising
some concern for osteomyelitis. Per ID, given recurrent
infection in the same area, would recommend longer course of
antibiotic. We recommended staying inpatient until an antibiotic
regimen could be established, however patient insisted on
immediate discharge given prior family commitments. Attempted to
discharge on daptomycin 600mg IV daily given prior growth (MRSA
sensitive to Bactrim), but given difficulty with insurance
coverage, he was discharged on Bactrim. Unable to dose
vancomycin given dose required to maintain therapeutic levels
would be >4.5g/day. Will follow up with ID in 2 weeks to follow
up cultures and possibly deescalate antibiotics or switch to IV
antibiotics. Will continue to pack dressing and follow up with
podiatry to close the wound.
#T2DM on insulin
Last A1C was 7.8% per records. Home regimen prior to admission
was NPH 54U and Humalog ___ and HISS. He was on this regimen
given cost of Lantus and had frequent snacking at night which
lead to increased night time blood sugars. Was supposed to be on
NPH in the AM as well but patient preferred to only have one
injection of NPH. He has recently changed his diet and now per
wife, has had episodes of hypoglycemia in the evening. A1C
during admission was 7.3%. At discharge we planned to switch his
NPH to the AM to improve AM coverage and to decrease episodes of
evening hypoglycemia. Discharge regimen was NPH 30U qAM with
Humalog ___ + ISS. Should have endocrine follow up to follow
up blood sugars and possibly switch to Lantus.
CHRONIC ISSUES:
===============
#Diabetic neuropathy:
Continued gabapentin 1200mg TID
#HTN:
Continued lisinopril 40mg daily and metoprolol tartrate 25mg
BID.
#CAD
#ICM
Prior NSTEMI s/p DES with ischemic cardiomyopathy (EF 65% in
___. Appears euvolemic on exam. No chest pain. Continued
home aspirin. Continued rosuvastatin 10mg qPM. Continue
ezetimibe 10mg daily. Continue home metoprolol 25mg tartrate BID
#LEFT EYE RETINAL DETACHMENT:
Chronically dilated pupil on the left without vision. s/p eye
drops per patient. Follows with ophtho here and MEEI in the
past.
#GOUT:
Continued home allopurinol | 252 | 464 |
16917415-DS-17 | 26,289,761 | Dear Ms. ___,
It was our pleasure caring for you at ___. You were admitted
to the hospital on ___ for an ulcer on your R ankle that
was likely infected. You also had swelling in your R ankle and
R knee that may have been a manifestation of your Lupus. You
were treated with IV antibiotics (Vancomycin) and the ulcer on
your leg improved. We also increased your dose of steroids in
consultation with your rheumatologst, Dr. ___. You
should continue on this dose until you follow-up with Dr.
___.
Given your multiple prior back surgeries and description of pain
radiating down your right leg, we are concerned that a large
proportion of your pain may be related to compression of one of
the nerves in your back (radiculopathy). For this we started
you on pain medications and you will need to follow-up with your
back surgeon. | ___ w/ SLE (on mycophenolate mofetil, hydroxychloroquine, and
methylprednisolone) presents with RLE ulceration with
?cellulitis and R ankle swelling concerning for tenosynovitis
vs. vasculitis vs. septic arthritis | 154 | 27 |
15349002-DS-29 | 24,627,890 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital due to concerns for Addisonian
Crisis, worsening respiratory status.
What did you receive in the hospital?
- While in the hospital we restarted you intricate regiment of
medications to ensure you were receiving the correct medications
at the correct time.
- We also had our palliative care doctors and ___
___ you and make recommendations for changing your pain
medications and helping with your anxiety.
- The interventional pulmonologists removed your stent on
___ due to concerns it was not functioning properly.
What should you do once you leave the hospital?
- Please continue to take all medications as instructed.
- You should follow up with your primary care provider at home
to help establish you with a local palliative care doctor and
therapist for further management of your pain and anxiety.
- You are being discharged with multiple opioid medications. We
would encourage you to only use them as instructed. Do no take
them with alcohol. Do not use more than the recommended amount
in a day.
We wish you the best!
Your ___ Care Team | ___ PMHx of TBM and tracheal stenosis s/p TBP, cervical
tracheoplasty, redo right thoracotomy and esophagopexy and
tracheopexy, soft tissue infection of the abdomen secondary to
malposition of jejunostomy s/p multiple laparotomies, admitted
with n/v and respiratory distress after recent discharge to
rehab. She was found to have significant pain control
difficulties and anxiety, for which palliative care and
psychiatry modified her medication regiment. On ___, she had
her temporary stent removed due to concerns it was no longer
effective.
ACUTE ISSUES
=============
# Anxiety
Patient with underlying anxiety, however seemed to be
significantly worse this admission concerning her pain control
and disposition. Multiple nights she had episodes of anxiety,
requiring small doses of ativan or increased pain medications to
improve her symptoms. Psychiatry evaluated the patient on ___,
and recommended initiation of Sertraline. Her dose was increased
on ___ to 50mg. They also recommended benefit from continued
work with a therapist outpatient. She was continued on her home
dose of Clonazepam.
[] Continue Sertraline daily, and monitor response. Uptitrate as
appropriate.
[] Patient would benefit from working with a therapist
# TBM; chronic, progressive decline
Patient underwent bronchoscopy with tracheal silicone stent
placement on ___ with Dr. ___. She was discharged to a
rehab, but readmitted after her concerns that the facility could
not meet her level of care. She otherwise appeared to be stable
in terms of her respiratory status. She completed her course of
antibiotics for her PNA from previous hospitalization on ___.
Interventional pulmonology did not feel she needed further acute
intervention, nor that she had developed a new infection. Her
stringent medication regiment was restarted. Through
hospitalization, her respiratory status seemed to mildly
decline, as the patient reported increased mucus plugging and
chest pain. Extensive discussion was had with IP regarding
whether patient's stent could be placed prior to discharge. The
decision was made to remove her stent on ___, and few days
prior she was started on levaquin to treat any possible
underlying lung infection. The stent was removed on ___, with
patient continuing to report significant pain and dyspnea
afterwards. Her pain medications were adjusted as below.
[] Patient will complete 5 additional days of levaquin treatment
for possible respiratory infection (___)
# Pain control/QOL:
Followed by palliative care during prior admission and has a
great deal of chronic chest and musculoskeletal pain. Pain was
well controlled with her regiment initially, however over time
her pain became more significant, raising concerns for failure
of the stent as above. Thus palliative care re-evaluated the
patient and following removal of the stent recommended
concentrated morphine for help with both pain and dyspnea.
[] Reevaluate pain regiment with palliative care
# Asx Bacteruria
Ucx from ___ growing predominantly enterococci, but also has
mixed flora. Patient was no complaining of dysuria. Suspect this
was likely contamination, especially since UA does not appear
inflammatory. Thus, patient was not started on antibiotics. | 213 | 477 |
13299787-DS-31 | 21,228,693 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall sustaining left sided rib fractures and a fracture
of the vertebral body in your mid-back. You were seen by the
spine doctors who recommend ___ management and no need
for brace. You were monitored, given pain medication, and
encouraged to take deep breaths. You worked with the physical
therapist who recommended discharge home with continued physical
therapy. You are now doing better, and ready to be discharged to
continue your recovery.
Please note the following discharge instructions:
* Your injury caused left sided 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). | Mr. ___ is a ___ yo M with complex medical history including
history of PE/DVT on Eliquis, HIV, anal cancer s/p chemotherapy
and transanal excision of rectal tumor, orthostasic hypotension,
frequent falls, chronic diarrhea, who presented to the emergency
department via EMS after a fall from standing with head strike.
CT head, cervical spine, chest, abdomen pelvis obtained and
showed no acute intracranial process, left sided rib fractures
___, and compression deformity of T12. He underwent MRI that
again showed compression fracture of T12 vertebral body. He was
seen and evaluated by neurosurgery who recommended ___
management and no activity restrictions. The patient was
admitted to the trauma service for pain control and respiratory
monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with oral Tylenol
and oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. The patient
was orthostatic with lightheadedness and recovered with sitting.
He was given a 500 cc bolus with improvement in orthostatic
hypotension.
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 given a regular diet which he
tolerated without difficulty. Patient's intake and output were
closely monitored. He was continued on home antidiarrheals and
bowel movements remained at baseline.
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.
The medicine team was consulted for assistance and managing
orthostatic hypotension and frequent falls in the setting of
systemic anticoagulation. Given the patients extensive work up
of orthostatic hypotension in the past and current management,
no further work up was done inpatient.
The patient's primary care provider ___ was also
notified of the patients admission and recommended discussing
the risk/benefit of Xarelto with the patient and allowing the
patient to decide if he wanted to continue or stop the
medication. These risks/benefits were discusses with the patient
and the patient felt very strongly that he did not want to
experience a blood clot ever again, and chose to continue on
Xarelto despite the risk of bleeding with frequent falls.
The patient was seen and evaluated by physical therapy who
recommended home with home ___. The patient was in agreement with
the plan and recently had home ___ after his last
hospitalization.
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. | 335 | 481 |
10665897-DS-31 | 26,945,370 | Dear Ms. ___,
You were seen in the hospital for a bacterial infection in your
blood, which may have been related to your cathether. Your
dialysis cathether was removed and a new line was replaced.
There was no evidence of vegetations on your heart valves and
you will only need antibitoics for a total of two weeks (last
day ___, they will give you antibiotics at dialysis.
You should have a repeat chest CT scan in approximately 4 weeks.
You will also have to wear a cervical collar until you are seen
in the ___ clinic in 2 weeks.
START taking ceftazidime 1 gm with HD for a total of two weeks,
last day of antibiotics ___. | ___ yo F with h/o ESRD on HD (anuric), DM, CHF, HTN, Dementia,
and multiple PMHx who was transferred from her nursing home with
GNR sepsis, found to be pseudomonas sepsis.
# Pseudomonas sepsis: Patient presented with GNR bacteremia by
blood cx ___, hypothermia (T 95.8F) and leukocytosis (WBC
19) consistent with sepsis. Blood culture identified as
Pseudomonas aeruginosa which was also found on the tunneled cath
dialysis tip that was removed per renal consult. She also had a
cavitary lesion on CXR, which could be a source of pseudomonas,
although it was noted that cavitary lesions are usually due to
TB, staph aureus or anaerobes. Patient's antibiotic course was
narrowed to Cefepime for pseudomonal coverage from Vancomycin,
Cefepime and Metronidazole. She was switched to Ceftazidime
after replacement of a tunneled cath line so that she could be
receive it during dialysis. The patient had a transthoracic
echocardiogram on ___ which showed no vegetations and
antibiotic course will be two weeks, should be continued at
dialysis through ___.
Patient also initially had a left mastoid fluid on CT head
concerning for mastoiditis and right mastoid tenderness on
admission. However, there was no erythema or ulceration
consistent with acute otitis externa, confirmed by ENT
consultation.
#Cervical spine ligament laxity: Pt had neck tenderness but no
stiffness on admission. She received a cervical spine x-ray that
showed anterolisthesis and ligament laxity. Neurosurgery
consulted and recommended a cervical collar for 2 weeks and
follow-up with the ___ clinic in 2 weeks, which will
need to be scheduled by rehab.
#ESRD: Last dialysis on ___. Pt is on ___ dialysis schedule
per Nursing home. Her tunneled cath was removed per renal. A
new tunneled cath was placed on ___ after patient was
afebrile and has had no new blood culture growth. Resumed HD on
___ and should continue with ___ schedule after discharge.
She will receive the above described antibiotics at dialysis
after each session.
#Mental status: Patient is lethargic at baseline but arousable
to voice and will answer with head nod. There was briefly some
concern that she was not able to take oral medications or food
and she had a repeat head CT which showed no acute intracranial
process. On the day of discharge, she was at her apparent
baseline mental status and was able to take PO medications
without difficulty.
Chronic Issues
#Chronic constipation: continued home bowel regimen
#Hypothyroidism: continue home Levothyroxine
#Hypertension: Hypertensive on admission because she had only
received labetolol overnight. She started her home meds
Amlodipine, Labetalol, Captopril and her blood pressure became
normotensive/mildly elevated (SBP's 120-160's).
Transitional Issues
-follow-up blood culture results
-will continue to receive ceftazidime for a total 2 week course
with her dialysis sessions, will be continued through ___.
-will need to wear c-collar for 2 weeks until she is seen by
___ clinic
-schedule follow-up in ___ clinic with Dr. ___ in 2
weeks (___) | 116 | 480 |
18154876-DS-21 | 29,452,436 | Dear Mr. ___,
You were admitted to ___ after
your motor vehicle accident with rib fractures. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
* DUE TO YOUR SEIZURE HISTORY YOU SHOULD NOT DRIVE OR OPERATE
HEAVY MACHINERY UNTIL YOU ARE ___ BY YOUR PRIMARY
NEUROLOGIST.
* Your injury caused 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). | ___ male with a pmh significant for seizure disorder presented
following a high speed motor vehicle collision with positive
loss of consciousness. He was evaluated in the trauma bay and
pan scanned and found to have R ___ anterior nondisplaced rib
fx, R ___ anterior mild displaced rib fx. He was admitted to
the floor for pain control and pulmonary toilet.
On hospital day 1 the patient's diet was advanced to a regular
diet and he was tolerating oral pain medication. He worked with
___ and OT who recommended that he follow up with cognitive
neuroscience as an outpatient for his loss of consciousness
after the incident. The patient was also instructed to follow up
with his primary neurologist after discharge to discuss his
medications and possible seizure as a cause of his motor vehicle
accident.
Prior to discharge the patient was tolerating a regular diet, he
was ambulating independently. His pain was well controlled on
oral pain medications. He was instructed to follow up with the
___ surgery clinic, as well as the cognitive neurology clinic
for his loss of consciousness. He was also instructed that under
no circumstance should he drive or operate a motor vehicle until
his is cleared to do so by his primary neurologist. He was
instructed to follow up with his neurologist within the next
week. The patient was in agreement with this plan and was
discharged home in good condition. | 297 | 238 |
15376758-DS-8 | 21,960,854 | Ms. ___, you were admitted for slow heart rate and
low blood pressure prior in the setting of vomiting prior to
getting a cardiac catheterization. In the ER you had a slow
heart rate in a rhythm called a junctional rhythm, which is
slower than a normal heart rhythm. You initially given IV fluids
and antibiotics and sent to the ICU for blood pressure support,
however, by the time you arrived in the ICU your symptoms had
resolved. The likely cause of your slow heart rate and low blood
pressure is what is called a "vaso-vagal" reaction from
vomiting. There was no evidence that you had a heart attack. You
were observed in the hospital so that you could get your
scheduled cardiac catheterization. Your blood pressure was
treated with your home medications. You had the cardiac
catheterization procedure on ___ which showed 90% blockage of
the left anterior descending artery (LAD), which was opened with
a drug-eluting stent. You were discharged home with a medication
called clopidogrel to help keep the stent open, as well as with
higher doses of blood pressure and cholesterol medications.
Please go to your outpatient follow up appointments in the
future. | ___ y/o woman with type 2 diabetes mellitus hypertension,
hyperlipidemia, CAD, atrial fibrillation on warfarin who
presents with bradycardia and hypotension in the setting of
emesis. After stabilization, she underwent elective coronary
angiography (as previously intended to evaluate new focal
hypokinesis at rest) and was found to have 90% a mid-LAD
stenosis which was stented with DES.
ACUTE ISSUES
------------
# Bradycardia - Unclear etiology. ___ have had increased vagal
tone in the setting of her nausea and vomiting. She is also on
large doses of carvedilol (25 mg bid) but has been on this for a
while. By the time she arrived to the ICU, her bradycardia had
resolved. She had negative cardiac biomarkers. She remained in
sinus rhythm for the rest of her admission and her carvedilol
dose was actually increased to 50 mg BID for better BP control.
# Hypotension - Placed on norepinephrine briefly on admission
for SBPs in ___ (nadir), which was weaned soon after arrival to
the MICU. No clear source of infection, and she was not
continued on antibiotics after her initial dose of ceftriaxone
in the ER. She was likely hypotensive secondary to a combination
of junctional bradycardia and hypovolemia from vomiting and poor
PO intake (including npo for her outpatient procedure). Her home
antihypertensive were reintroduced when she became hypertensive
again.
# CAD+hypertension - The patient was scheduled for coronary
angiography for symptoms of angina and evidence left ventricular
systolic dysfunction with hypokinesis of the basal inferior wall
(EF 60%) on ___ TTE. Her outpatient procedure was cancelled
for vomiting and at home later she developed bradycardia and
hypotension that prompted representation to the ER. She was
managed medically over the weekend until her procedure on ___,
which showed 90% mid LAD stenosis, now s/p DES. Renal arteries
were notably free of disease. Her statin dose was raised and her
home carvedilol dose was increased to 50 mg BID for uncontrolled
BPs while in house. Her blood pressures on all of her home meds
were better controlled but still slightly hypertensive 140-150s
on the day of discharge.
# Atrial fibrillation: CHADS2 score is 3 (HFpEF, HTN, DM). INR
goal ___. She takes warfarin at home. This was held for her
invasive cardiac procedure and she was treated with subcutaneous
heparin. Warfarin was started post-procedure, but she was
subtherapeutic at discharge. She will need follow up of her INR
as an outpatient to ensure that she becomes therapeutic again.
Notably, she is now on dual antiplatelet medications as well as
systemic anticoagulation. Patient counseled on increased risks
of bleeding on the combination of these 3 agents.
# Elevated anion gap metabolic acidosis - Caused by lactic
acidosis with lactate of 5 on admission. This resolved with
volume resuscitation and there was no evidence of toxic
ingestion or impaired tissue perfusion subsequently.
# ___ - The patient presented with sCr of 1.2 from baseline
~0.7. This was thought to be from hypovolemia and this improved
with IV fluids. Cr was at baseline value upon discharge.
# Asymptomatic bacteriuria: The patient grew >100k pan-sensitive
Klebsiella from an admission urine culture obtained in the
setting of her nausea/emesis. She did not have symptoms of a
UTI. However, given that she briefly had a Foley after
admission, it was decided to treat her with 3 days of
nitrofurantoin.
CHRONIC/STABLE ISSUES
# T2DM - Oral agents held on admission, placed on insulin
sliding scale. Discharged on her home medications.
# GERD - Continud on pantoprazole
# Hyperlipidemia - Continued on pravastatin, with dose raised to
80 mg nightly prior to admission.
# Code status this admission - FULL CODE
TRANSITIONAL ISSUES
-------------------
-INR follow up to ensure she returns to therapeutic level
-BP monitoring in clinic to ensure adequate control on higher
dose carvedilol | 196 | 612 |
16630968-DS-2 | 28,809,121 | Dear Mr ___,
You were admitted to ___ because you were having trouble
breathing. You were found to have extra fluid due to your heart
failure.
We have changed your medications. Please pay close attention to
your medications and take them every day, otherwise there is a
high chance you will return to the hospital. You will also need
to see a cardiologist in clinic at follow up for further care of
your sick heart.
We wish you all the best!
- Your ___ care team | SUMMARY: ___ y/o male with psychotic disorder (one previous
hospitalization)m HTN, CAD s/p CABG in early ___ and stenting
in ___, CHF who presented with dyspnea on exertion. He was
thought to have an acute decompensation of his heart failure,
most likely in the setting of medication noncompliance. He was
diuresed with boluses of IV furosemide with good response and
transitioned to PO torsemide 20 mg, on which he maintained a
stable volume status for several days. He had an echo that
showed reduced EF of ___ consistent with ischemic
cardiomyopathy. His medications were optimized for systolic
heart failure; further cardiac ischemic evaluation was deferred
at this time. He was followed by our psychiatry team for his
psychosis, and his quetiapine uptitrated from 25mg BID to ___
BID.
# CAD s/p CABG and stents:
# Acute on chronic systolic heart failure: Presented with acute
decompensation of heart failure with dyspnea on exertion and
elevated BNP. Diuresed over the course of several days with
boluses of 80mg IV furosemide. When he reached euvolemia he was
transitioned to PO torsemide 20mg daily with stable I/O. He was
found on echo to have EF ___ with changes c/w ischemic
cardiomyopathy. For medication optimization, his carvedilol and
lisinopril were uptitrated and he was started on spironolactone.
He will require further ischemic evaluation for stress test as
well as consideration of ICD in the future; this was deferred
during this admission due to psychiatric decompensation and low
likelihood of sufficient followup, ie compliance with DAPT if
ultimately stented.
# Psychotic disorder, NOS: Patient was transferred from ___
psych facility to ___. During this admission, he was followed
by our psychiatry team. He continued to have agitation and
paranoia intermittently. His quetiapine was uptitrated from 25mg
BID to ___ BID. He was kept with a 1:1 sitter but did not
endorse any suicidal or harmful ideation. He was discharged to
psych facility.
# Transaminitis: On admission ALT/AST elevated in 300s
consistent with hepatocellular pattern of injury. Hepatitis, HIV
serologies checked and negative. Likely congestive hepatopathy,
and improved during diuresis. | 82 | 341 |
17289025-DS-9 | 21,076,457 | Ms. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted for a low
temperature. You were found to have mild pancreatitis, which is
inflammation of your pancreas and can cause abdominal pain,
nausea and vomiting. This was likely caused by your alcohol
consumption. We continue to recommend decreasing the amount you
drink with the goal of quitting if possible.
Please check your blood sugar levels twice a day. If it is < 70,
please take some juice to keep your sugar levels appropriate.
Bring your blood sugar recordings to your next visit with your
PCP.
Please follow-up with your providers as previously scheduled.
Take care,
Your ___ Team | Ms. ___ is a ___ woman with h/o afib on flecainide and
apixaban, s/p Roux-en-Y gastric bypass, s/p CCY, htn, thyroid
nodule presenting with weakness and chills, found to have mild
hypothermia, course c/b mild acute pancreatitis.
# Hypothermia:
Unclear etiology at admission with large differential. No clear
infectious etiologies were found with negative blood and urine
cultures. Cortisol and TSH were within normal limits. Among her
medications, metoprolol is the most likely to produce or
exacerbate hypothermia but this was continued without any
recurrence of hypothermia. Patient also had intermittent
hypoglycemia (see below), but it is unclear if this is related
at all. Patient was treated with 6L of warmed IVF as well as
Bair Hugger, with improved temperatures. Her temperatures then
remained stable throughout her hospitalization. Ultimately,
initial episode thought to be related to potential hypoglycemic
episode in setting of mild acute pancreatitis.
# Mild acute pancreatitis
Patient with abdominal pain, n/v, and radiographic signs of mild
pancreatitis, likely caused by alcohol. Lipase is not
significantly elevated, though checked on ___ day of
hospitalization. Her diet was advanced successfully and she
tolerated a regular diet at discharge with resolution of
symptoms. Pancreatitis thought to be secondary to alcohol
ingestion. Patient pre-contemplative regarding her alcohol
abuse, though abstinence was encouraged.
# diarrhea
Unclear etiology but may be gastroenteritis, possibly viral.
C.diff and stool cultures were negative.
# Hypoglycemia
Hypoglycemic episodes noted to BG in the ___, mostly in the
early AM and late ___. Patient never symptomatic. Unclear if
associated with hypothermia as unfortunately BG not measured on
arrival. Hypoglycemia resolves with PO intake. Patient
prescribed glucometer at discharge and instructed to measure
FSBG in the AM and at night and if she has any concerning
symptoms.
# Hyponatremia likely ___ SIADH
Extensive work-up in the past, found to have evidence of
underlying SIADH, though cause is not clear. Patient received 6L
IVF on admission with some decrease in sodium, consistent with
SIADH. Sodium at discharge was 128, which is consistent with
known baseline.
# CV-rhythm:
Patient with known history of afib, presented in an accelerated
junctional rhythm. Maintained on flecainide and metoprolol. Home
apixaban continued. She has upcoming appointment with EP.
# EtOH abuse:
Pt endorses significant EtOH intake, denies hx of withdrawal.
Last drink ___, no evidence of active withdrawal this
admission and patient monitored on CIWA. EtOH level on admission
was 24. Continued on MVI, thiamine and folate. SW consulted and
provided support, though patient was repeatedly resistant to
discussions regarding abstinence and appears to be
pre-contemplative regarding quitting alcohol use.
# Leukopenia
# thrombocytopenia:
Present since ___, has been evaluated by hematology for
pancytopenia, thought to be related to nutritional deficiencies
in setting of roux-en-y. Pt has not been taking nutritional
supplements as recommended. ___ also be component of
myelosuppression ___ EtOH use. HIV negative ___. Home
multivitamins were continued. | 112 | 470 |
11965254-DS-28 | 27,335,468 | Dear ___,
It was a pleasure to take care of you during your
hospitalization at ___. You were admitted for numbness,
tingling, pain, and swelling in your hands. We have ruled out
any electrolyte or mineral deficiency as a cause of these
symptoms. In addition, we ruled out a deep venous thrombosis as
a cause of your hand swelling. We did x-rays of your hand and
wrist to rule out any arthritis causing your symptoms and the
films did not show any. Therefore, at this point we believe your
symptoms are most likely due to carpal tunnel syndrome. The
initial treatment for carpal tunnel syndrome is wrist splinting.
During your hospitalization, the orthopedic technician fitted
you for wrist splints. We would like you to please wear these at
night and as much during the day as possible. We also recommend
that you discuss this with your primary care physician to
determine whether nerve conduction studies would be beneficial.
For your right hand and arm swelling, please keep your arms
elevaed and use hot and cold packs. For pain, please continue
your home regimen for pain. We will give you enough pain
medication to last this week prior to seeing your primary care
physician ___. Finally, for your Crohn's disease we ask
that you please continue to take your home medication until your
next appointment with Dr. ___. | ___ year old female with a past medical history significant for
Crohn's disease with extensive surgical history, who presented
with a one day history of bilateral numbness, swelling,
tingling, and pain in her hands.
Active Issues
# Paresthesias: Cause unclear at discharge. Patient also noted
sensation of swollen fingers. No objective neurologic deficits
identified. The patient's bilateral hand pain and paresthesias
may be due to carpal tunnel syndrome given positive Phalen's
test and known prior history. During her hospitalization other
causes for her symptoms including B12 deficiency, diabetic
neuropathy, severe hypocalcemia, folate deficiency, and thyroid
disorder were ruled out. Lyme serologies pending at discharge.
CRPS felt to be unlikely in the acute setting. Plain films of
her bilateral wrists and hands did not show any degenerative or
otherwise arthritic changes. As she has a history of DVT and had
swelling that was more prominent in the right hand and arm, an
ultrasound was done of the right upper extremity. It did not
show any DVT but did show a small thrombosis at the tip of her
peripheral IV in the cephalic vein. The IV was removed and her
arm swelling decreased. Discussed with radiology and no follow
up imaging was warranted at this time. No indication for
anticoagulation. Discussed with pharmacy, this is not a known
side effect of her JAK2 inhibitor. Patient was given wrist
splints to be worn at night and during the day when possible.
Should follow up with primary care physician regarding whether
nerve conduction studies as an outpatient are warranted re
carpal tunnel.
# Crohn's disease: The patient sees Dr. ___ and has
been on a stable regimen since starting tofacitinib in ___. Of note the patient did notice some darkening of her stool
color and it was found to be guiac positive and flecked with
blood on admission, though nonbloody at discharge. Her
hematocrit on was near her recent baseline at discharge. She did
not have any abdominal pain above her baseline and was treated
with her home medication regimen of PO dilaudid and fentanyl
patch for her pain. Her WBC, LFTs,lipase, and CT abdomen from ED
visit on ___ were all normal.
Chronic Issues
# Anemia, Normocytic:
H/H currently near recent baseline. Patient with recent history
of black stools. No current active signs of bleeding. Guiac
positive. Iron studies showed normal iron and ferritin, slightly
decreased TIBC, TRF, c/w anemia of chronic disease. | 227 | 401 |
11327015-DS-4 | 21,435,446 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted because you felt as though
you were going to pass out. You were monitored in the hospital
and did not have any repeat episodes which was reassuring. Your
heart rate is low however. We stopped a number of your
medications because they can decrease your heart rate. It is
very important that you review your medication list because
there have been some changes. You will follow up with Dr. ___
in clinic. You will also follow up with cardiology and
neurology.
It is very important that you notify your doctors ___ return to
the emergency room if you think you are going to pass out, if
you have chest pain or palpitations. If your heart rate remains
low and if you are symptomatic, you may need a pacemaker.
You will need to get a heart monitor placed after you leave the
hospital. We scheduled you an appointment tomorrow to get this
placed. This is very similar to the heart monitor that you had
on while you were in the hospital. If you cannot make this
appointment, please call ___ to reschedule.
We wish you the best,
Your ___ Team | Mr. ___ is an ___ y/o male with a past medical history of
CAD s/p CABG ___, HTN, AF on Coumadin, DMII, depression,
chronic small vessel disease and recent ischemic stroke ___
who presented with a ___ episode.
# ___: patient had an episode of ___ while
walking up stairs at ___. Initially there was concern that
this was related to a hypoglycemic episode, however his blood
glucose around the event was within normal limits. Patient
denied chest pain, palpitations, loss of consciousness, slurred
speech, vision changes or seizure activity. Orthostatic vital
signs were negative on admission. Troponins were negative x2. He
was noted to be bradycardic in the setting of nodal agents. His
nadolol, digoxin and nicardipine were discontinued. He was
monitored on telemetry. He had no syncopal or ___
episodes while admitted. His TTE did not show evidence of
valvular disease. He worked with physical therapy and was
discharged home with ___. He was discharged off of nadolol,
digoxin and nicardipine. He will have ___ of Hearts placed in
the outpatient setting.
# Bradycardia: patient was monitored on telemetry and within the
first 24 hours of admission he was noted to have bradycardic
episodes with HRs ___ while sleeping and while awake. Patient
was asymptomatic during those episodes. Rhythm was slow AF. His
nadolol, digoxin and nicardipine were discontinued. He remained
on telemetry and was only noted to have episodes while sleeping.
Ultimately his bradycardia was attributed to medication effect
and increased vagal tone while sleeping. He was instructed to
notify his PCP or return to the ED should he have palpitations,
syncope or ___. He will have ___ of Hearts monitor
placed the day after discharge. If patient has recurrent
bradycardic episodes will need to consider pacemaker placement.
# CVA: patient was recently hospitalized with a CVA. He was
evaluated by ___ and was noted to have attention deficits and
slow gait. He was discharged home with ___. He was scheduled to
see a neurologist in the outpatient setting.
# DM: continued home lantus 14U qHS. Discontinued oral
repaglinide. His PCP ___ consider alternative oral agents such
as metformin.
# HTN: continued lisinopril 15 mg daily. Discontinued nadolol,
nicardipine and digoxin. Added amlodipine 5 mg daily.
# AF: patient was on digoxin and nadolol. In the setting of
bradycardic episodes these agents were discontinued. He did not
have episodes of RVR. His warfarin was continued with INR goal
___. He will have ___ of Hearts event monitor placed as an
outpatient.
# CAD: continued aspirin 81 mg daily and continued atorvastatin.
His nadolol was discontinued in the setting of bradycardia.
# Chronic CHF: continued Lasix and spironolactone.
TRANSITIONAL ISSUES
=====================
- discharged home with ___
- DISCONTINUED MEDICATIONS: nadolol, digoxin, nicardipine,
Repaglinide
- NEW MEDICATIONS: amlodipine 5 mg daily
- continue adjusting blood pressure medications as an outpatient
- will have follow up in the cardiology clinic
- recommend INR check on ___ at ___ appointment
- scheduled an appointment on ___ for ___ of Hearts | 203 | 493 |
11664465-DS-16 | 20,290,706 | You were admitted with leg swelling found to be due to a leg
clot and you also had small clots in the lungs. You were started
on blood thinners but had a bleed in your belly so the blood
thinners were stopped and you recieved a filter in your leg to
prvent the clot from travelling and also got medication to that
area to dissolve the clot. You were discharged home in a stable
condition. | HOSPITAL COURSE: ___ w/ GBM s/p resection ___, HTN, DL,
CKDIII who p/w new symptomatic DVT and small PEs; started on
heparin gtt but developed rectus sheath hematoma.
Anticoagulation stopped and patient underwent plcmt of IVC
filter and got DVT thrombolysis via ___ on ___.
# Anemia/Rectus Sheath Hematoma: patient had abdominal pain and
Hct drop on presentation which started after anticoagulation
initiated. She had visible large left flank hematoma also. CT
abdomen pelvis non con showed a rectus sheath hematoma with
intrapelvic muscular bleeding also so anticoagulation stopped.
Hct downtrended
further despite this and she ultimately required 2u RBCs with
appropriate bump on ___. At the time of discharge Hct was
stable.
#DVT/PE: asabove pt was started on heparin gtt but found to have
bleeding so anticoagulation stopped. She is s/p IVC fliter
placed on ___. Lung scan ___
suggested that if PEs present they are small and subsegmental
and if present very low clot burden. She underwent DVT
thrombolysis ___. Given her Hct continued to downtrend slightly
despite discontinuation of anticoagulation it was felt unsafe to
restart anticoagulation and that she was somewhat protected
against further thrombotic events given that it was less likely
she had PEs and if so they were small, she now has the IVCF, and
her DVTs were lysed by ___. Would consider restart
anticoagulation as outpatient, but would proceed cautiously.
Note pt also has thrombocytopenia. ___ will contact her about
scheduling her for an appointment for repeat ultrasound to see
if the DVTs have in fact resolved as an outpatient. Her baseline
CKD also complicates anticoagulation dosing.
#Dyspnea: resolved. V/q showed likely small peripheral PEs, if
any present they are small and subsegmental. Held
anticoagulation as above
# Thrombocytopenia - unclear etiology, slowly downtrending this
admit from low 100s to ___. Ptls much lower in ___ of this
year though unclear why (in mid ___
likely ___ radiation as she also had received TMZ/IMRT earlier
in her course this year). Plts were stable at the time of
discharge.
#Acute Kidney Injury: Improved, back to baseline. Has baseline
CKD III, ___ improved after IVF initially.
#HTN: stable. Contd home amlodipine and valsartan
#Glioblastoma: stable, s/p resection. Pt will follow up with Dr.
___, plan is likely to proceed with temozolomide which had
been planned as an outpatient. | 75 | 375 |
10192095-DS-17 | 29,836,985 | Mr ___ it was a pleasure caring for you during your stay
at ___. You were admitted with new dizziness. Head CT and
brain MRI was done and there are no tumors other than the one
that remains on your scalp. There was also no sign of stroke.
The dizziness is due to a condition called benign paroxysmal
positional vertigo. And your eye movements when we did head
maneuvers confirm this is the cause. You have also experienced
this is in the past. You can continue to take meclizine to
diminish the symptoms. You can also come for therapy if you
choose, call ___. | Mr. ___ is a ___ man with COPD, 60-pack-year
smoking history and extensive stage small cell lung carcinoma,
currently status post four cycles of
platinum/etoposide, presenting with dizziness/vertigo.
#Vertigo, likely BPPV - new onset vertigo x 4 days. Orthostatics
negative. Head CT negative for acute intracranial abnormality.
most consistent with BPPV given positive ___. No
dysmetria w/ cerebellar testing. Intracranial cause such as CVA
or brain mets appears less likely but brain MRI obtained to r/o
and showed ongoing resolution of prior intracranial mets, only
residual is R temporal scalp lesion.
- pt repeatedly declined repeat Epley attempts by providers or
___
- given script for meclizine prn max 25mg TID
- he prefers to f/u w/ his PCP who has performed maneuvers for
him in past. He was given referral to vestibular therapy
although at this time states he declines to attend.
- pt was independent w/ ambulation, gait steady. he was advised
not to drive until vertigo resolves and had a friend/neighbor
take him home from hospital
# Extensive stage small cell lung carcinoma: extensive stage on
diagnosis inc brain mets. Currently C4D7 cis/etoposide recent
imaging shows overall stable disease in chest. Brain MRI
___ showing resolution of prior brain lesions.
Repeat this admission showed ongoing resolution as above.
# HLD: continued home Simvastatin 40 mg PO QPM and Ezetimibe 10
mg PO DAILY
# GERD: continued home Omeprazole 40 mg PO DAILY
# BPH: on Flomax, reports persistent nocturia, advised to
discuss finasteride w/ his PCP, was given urology appointment
but next available not til ___ | 110 | 253 |
14001416-DS-16 | 29,099,098 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were transferred here after you had a
seizure. You seizure was likely caused because you were going
into alcohol withdrawal from not having had any recent alcohol.
While here, you were stable and able to breathe on your own,
however you were noted to have persistent diarrhea. It appears
that your recent diarrheal infection has not been fully treated.
Youshould be treated with an antibiotic called fidaxomycin and
it is extremely important that you take this medication twice
daily for 10 days. DO NOT miss any of these doses.
Please make the following changes to your medication regimen:
TAKE Fidaxomycin 200mg by mouth twice daily for 10 days.
STOP Vancomycin
CONTINUE Keppra 750mg (1 tablet) by mouth twice daily
Please continue home mirtazipine as prescribed. | Ms. ___ is a ___ woman with a history of heavy
alcohol abuse and withdrawal seizures who was transferred to the
ICU following the experience of a generalized 20-minute seizure
at outside hospital necessitating airway protection and
sedation. Found to be C. diff positive with diarrhea.
.
# Seizure, likely secondary to alcohol withdrawal. Confirmed
with partner that patient had been without alcohol for at least
24 hours prior to admission due to a recent hospital admission
for COPD. Lumbar puncture was traumatic, so WBC counts not
suggestive of infection. CT head not suggestive of seziure
focus; report of MRI from outside hospital also not suggestive
of epileptic focus. EEG showed no clear electrographic seizures
or epileptiform discharges. CSF VDRL negative from OSH. She was
sedated with midazolam and then intubated for airway protection;
she quickly was weaned and then self-extubated. She was given
keppra for seizure prophylaxis, and neurology was consulted. She
was given a "banana bag" for vitamin repletion. During her
course in the hospital she did not experience any additional
seizures. Was monitored on a CIWA scale, but did not score.
Patient has a history of seizure disorder NOS, and has been
maintained on Keppra as an outpatient, which was additionally
continued throughout admission per neurology recs.
.
# History of C. diff. colitis: Patient was on a vancomycin taper
as an outpatient. Per PCP, patient was first diagnosed with
c.diff in ___, treated twice with flagyl (incomplete treatment
in ___ as patient had a seizure given flagyl/etoh use), was
started on vanco course with taper on ___ after unrelated
hopsital admission. Followed up with OSH infectious disease
specialist in mid ___ who recommended continuing taper and
trying fidaxomycin should she have another recurrence. Having
diarrhea here which tested c.diff positive, restarted vancomycin
PO and IV flagyl in the unit (flagyl d/c'd on the floor). Ruled
out other etiologies of diarrhea as the toxin assay can often
stay positive even after effective treatment for c. diff (stool
cultures negative for salmonella, shigella, campylobacter,
cryptosporidium or giardia). However, our suspicion for
non-compliance is high and we feel that she likely never
completed a course for her c. diff and therefore has continuing
infection and not recurrence. Patient is being discharged on
full course of fidaxomycin as it is only BID dosing with less
chance of recurrence. She will have ___ and her boyfriend to
help ensure she takes her medication.
.
# Possible urinary tract infection: UA mildly suggestive of
urinary tract infection. Patient received 2g ceftriaxone in ED
for suspected meningitis. Follow up urine culture negative.
Patient was not continued on antibiotics for UTI.
.
# Alcohol abuse: The patient appears, from both physical
appearance and laboratory values, to have chronic malnutrition
from her alcohol use. Social work met with her many times and
her electrolytes were closely monitored and repleted as
necessary. Patient was monitored on a CIWA scale, but was not
scoring.
. | 136 | 481 |
11815740-DS-5 | 28,189,976 | Dear Ms. ___,
You were admitted to the hospital for chest pressure. Your
cardiac tests were reassuring against new or worsening heart
disease - we checked serial EKGs, troponins (an enzyme released
when your heart muscle is damaged), and a stress test. Your
stress test showed no evidence of new disease, but shows a
persistent scarred area from your previous heart attack.
We have made two adjustments to your medications to better treat
your heart disease:
- Changed atenolol to metoprolol
- Started lisinopril
Given the reassuring cardiac tests, we think your chest
discomfort is from coughing and the flu. You should complete a
full course of Tamiflu (oseltamivir) to help fight the
infection.
You should also follow up with your PCP in the next ___ weeks.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | Ms ___ is a ___ year old woman with a history of medically
managed LAD STEMI in ___ with subsequent LAD dissection who
presents with 24 hrs of progressive substernal chest pressure
and found to be positive for influenza A.
#Chest pressure: Likely ___ influenza and coughing given
non-exertional, negative trops x3. Tightness rather than pain
suggests non-MSK. A nuclear stress test showed a fixed perfusion
defect in the LAD territory, which likely represents her prior
ischemic event
--Started Oseltamivir 75 mg Q12H (last day ___
#CAD: history of LAD STEMI treated medically due to complete
occlusion.
--continue ASA, simva 10
--discuss with her rheumatologist/cardiologist higher simva
dose, has been limited in past because of myalgias | 136 | 112 |
17122884-DS-29 | 24,635,465 | Dear Mr. ___,
You were admitted to ___ for treatment of your fever and
cough. You were given Levaquin, an antibiotic, and improved with
this medication. We monitored you to make sure that your
symptoms did not worsen. Please take the Levofloxacin on ___ and
___ to complete your course. Then, start the azithromycin--take
2 tablets on the day you start this, then 1 tablet thereafter.
We hope that you do well at home!
Best wishes,
Your ___ treatment team | PRIMARY ISSUE
Pt is an ___ yo male with h/o COPD, bronchiectasis, recurrent
pneumonias, pulmonary MAC infection in ___, and oropharyngeal
dysphagia who was admitted for signs of sepsis (101.1 F, WBC
22.2 with left shift) with pneumonia as a likely cause.
ACTIVE ISSUES
- Sepsis and pneumonia: In the ED, he was given one dose of PO
levofloxacin, after which he became afebrile and his WBC
decreased to 14.1, and eventually 9.9. Pt's initial CXR showed
bilateral lung hyperinflation with resolving lower lung
opacities, mild blunting of left costophrenic angle but no acute
focal consolidation concerning for pneumonia. A follow up CXR
showed a RLL opacity that could be consistent with PNA. Pt
continued to be hemodynamically stable and afebrile thereafter
on PO levofloxacin. He had a clear UA and no evidence of
meningitis. There was low suspicion for abdominal pathology
given no symptoms except for mild abd discomfort at his right
side.
CHRONIC ISSUES
- COPD: Continued home tiotropium
- CAD/HYPERTENSION: Continued aspirin, atorvastatin, and
metoprolol 50 mg XL.
- GERD: Continued omeprazole 20 mg BID
TRANSITIONAL ISSUES
- Antibiotics: We discussed the issue of prophylactic
antibiotics with Dr. ___, pt's ID doctor. Based on this
discussion, we made the decision to start pt on prophylactic
azithromycin for pneumonia, and scheduled an appointment with
Dr. ___ on ___.
- Code status: pt is DNR, DNI | 79 | 226 |
18810660-DS-27 | 27,790,964 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having fevers and urinary urgency. You were found to
have a urinary tract infection.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with antibiotics for your infection. Your
symptoms improved and you were ready to leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You should continue your antibiotics until you have finished
the prescription, even if you are feeling better.
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
=====================
[] Discharged on cefpodoxime 100mg BID for a 14 day course to
treat urinary tract infection.
[] Decreased envarsus from 2mg daily to 1.5 mg daily per renal
transplant
[] Pt will have repeat labs including tacrolimus levels ___
___
BRIEF SUMMARY
==============
___ woman with h/o ESRD ___ anti-GBM disease s/p DDRT ___
with high risk CMV status (D+/R-) with course c/b CMV viremia
(has UL97 mutation c/w Ganciclovir resistance, treated with
foscarnet for 2 weeks and then transitioned to letermovir at 480
bid dose), also with hx of MDR E. Coli and VRE UTIs, presented
with fevers, leukocytosis, dysuria with urine culture growing E.
coli concerning for urosepsis. Initially started on linezolid
and cefepime given previous culture data then to linezolid and
ceftriaxone. Pt was clinically improving and remained HDS
throughout hospital course. She was discharged on an oral course
of cefpodoxime 100mg BID (renally adjusted) for total ___CUTE ISSUES:
=============
# UTI
Patient presenting with fever, malaise and increasing urinary
frequency/urgency. Also noted "hot" feeling with urination c/f
dysuria. Found to have elevated WBC to 15. She was started on
cefepime then ceftriaxone and linezolid due to history of E coli
and VRE UTIs. Urine culture grew E coli and she was transitioned
to cefpodoxime 100mg BID per sensitivities.
# ESRD ___ anti-GBM, s/p DDRT ___
# Immunosuppression
Cr is at baseline (1.5-2.0). Renal US with unchanged pelvic
fullness and resistive indices. Tacro level therapeutic on
admission. She was continued on tacrolimus extended release 2mg
daily with goal level of ___. Continued prednisone 5mg daily
(not on anti-metabolite due to CMV history). She was continued
on Bactrim for PCP ___. | 118 | 263 |
14237047-DS-21 | 21,242,502 | Dear Mr. ___,
It was a pleasure participating in your care here at ___
___. You came to us with poor appetite and
faitgue. A CT scan of your abdomen showed that your biliary
stents were clogged. You underwent ERCP with removal of
infectious material from your stents and placement of a new
stent in the common bile duct. Unfortunately, your procedure was
complicated by a small perforation that caused air to leak into
your abdomen. You recovered without further complication and
your appetite has improved every day. Upon discharge you were
eating and drinking adequately and walking independently with
physical therapy.
Please take your medications as prescribed and attend your
follow up appointments as outlines below.
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team | Mr. ___ is a ___ w/ cholangiocarcinoma on Cis/Gem presented
C7D17 for fatigue X 1 week and poor PO intake
# Hepatobiliary obstruction c/b perforation:
Patient is very functional and alert individual at baseline and
presented with poor PO intake and fatigue for 1 week. Initially
thought to have pneumonia, he was found to have biliary
obstruction on CT scan likely the cause of his presenting
symptoms. He as taken for ERCP on ___ and had removal of
puss from biliary tracts with placement of a new stent.
Unfortunately, the procedure was complicated by perforation with
intra-abdominal free air and ascites. He was seen by surgery and
ERCP and was treated with antibiotics and supportive care. His
diet was advanced slowly and he tolerated it well. He completed
a course of cefepime, vanc and ___ and was
narrowed to cipro and flagyl on ___ for a 7 day course upon
discharge. His liver function tests and bilirubin were trending
down / normal on discharge and he was taking good PO and
ambulating independently.
# Pancytopenia:
Patient with new progressive thrombocytopenia and anemia now
also neutropenic. This has never occurred on previous chemo
cycles. DIC & TTP / hemolysis ruled out given normal coags,
elevated fibrinogen and elevated haptoglobin, normal LDH and
absence of rash / abnormal bruising. Initial concern for
gemcitabine induced HUS but renal function normal and no
evidence of hemolysis. Blood observed from rectum on ___, but
on exam found external hemorrhoids likely bleeding in setting of
thrombocytopenia. Otherwise no evidence of blood loss. Likely
chemo induced pancytopenia. This improved daily and was trending
up on discharge.
# Poor PO intake
Patient with poor PO intake since 1 week prior to admission.
Also has been NPO since admission for procedures and
complication of SB perforation. His potassium and phosphorus
were repleted during admission and he was given IVF as needed.
He was started on megastrol 400 QD because of patients continued
concern about his poor apatite and was taking good PO upon
discharge.
# Cholangiocarcinoma: Previously tolerating chemo well. Stable
over the last 3 months until admission on C7D17 of Cisplatin +
Gemcitabine with plan for 8 cycles. His outpatient oncologist
was contacted and his next cycle was held in the setting of
acute illness. He was discharged with close follow up to discuss
continued treatment.
# Diarrhea: Small amount, likely secondary to obstructed biliary
ducts. C-diff negative and resolved upon discharge.
# HTN/HLD: his home aspirin was held given anemia | 128 | 408 |
10386925-DS-32 | 28,592,400 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for abdominal pain. A fluid collection was found which
tracked to your skin. This grew out a bacteria called
Pseudomonas. You are being treated for this with IV and oral
antibiotics. The fluid collection has improved.
You had an episode of low blood pressure and GI bleeding which
led to a stay in the ICU for a few days. An endoscopy showed
some inflammation in your esophagus and stomach and a small tear
but no active bleeding.
A PICC was placed in your left arm for the antibiotics, but this
caused a clot. Thus, this PICC was removed, and one was placed
on the right side.
You should have labs on ___ and then weekly to
ensure stability of your hematocrit and your renal and liver
function.
Please see attached for an updated medication list. | ___ y/o female with extensive medical and recent surgical history
who presents with abdominal pain. On admission the patient
underwent CT of the abdomen and pelvis. There are several
notable findings, including a right flank wound (CT reports area
of abnormal enhancement in the right flank along the oblique
muscles previously described as a phlegmon; now shows interval
increase in size of central fluid and gas collection measuring
up to 1.6 cm of longest axis diameter with associated probable
fistulous tract communicating with the skin -- more likely to be
superinfected metastasis than pure phlegmon). The wound drained,
and patient was treated with antibiotics. She was initially on
a surgical service, but was transferred to oncology service.
Hospitalization complicated by hematemesis and hypotension
requiring brief MICU stay.
#. Right flank purulent mass: Pt had rupture of right flank
collection revealing purulence with CT scan demonstrating
fistulous tract from abdominal wall communicating with the skin.
Although initial culture after rupture was negative, repeat
aspiration overnight revealed Pseudomonas. Based on imaging, it
appears that the mass may be a tumor focus, superinfected, as
opposed to an abscess/phlegmon. ID recommended cefepime and
Flagyl, which will be continued until patient sees outpatient ID
physician ___ in follow up.
#. Cholangiocarcinoma with possible peritoneal carcinomatosis:
Not a surgical candidate. Therapeutic and diagnostic
paracentesis (for cytology) done on ___, but without definitive
evidence of cancer in the peritoneum. Normal CEA and AFP and CA
___. Treatment in future depending on staging and resolution of
acute infection. She will have medical oncology and radiation
oncology outpatient follow up.
# Hypotension: Patient became hypotensive in AM of ___ to
SBP in ___. Transferred to MICU. Responded well to 4L of IVF.
Resolved. Unclear event as precipitant but likely some form of
inflammatory response evident given WBC count elevation vs.
bleeding alone. Could have been related to inflammatory
response from tumor invasion and bleed versus transient biliary
obstruction. No clear infectious source found outside of flank
mass, which was already being treated. Volume depletion or HCT
drop alone could explain hypotension, but pt may have had
transient biliary obstruction (alk phos elevation, relative ___
elevation) which then resolved.
# GI bleed: Patient had hematemesis with hypovolemia. EGD shows
esophagitis and gastritis. Unclear if this is fully responsible
for the GI bleed, but given small volume hematemesis, this is
most likely cause, as opposed to duodenal tumor which was not
visualized and thus would be unlikely to cause hematemesis. GI
did not find much on EGD that would suggest tumor eroding into
dudeonum. Per GI, radiology reviewed films, and no clear
evidence of tumor communicating into duodenum. If pt were to
continue to have unexplained melena, then tumor into duodenum
would seem more likely. High-dose PPI and Carafate were
prescribed. No further GI bleeding after the EDG.
# Mixed cholestatic and hepatocellular transaminitis: Transient
obstruction seems likely given interval biliary dilation seen on
CT, combined with elevated alk phos and ___ + hepatocellular
picture. This may have played a role in the transient SIRS
response requiring ICU transfer.
#. C diff: PCR here was negative. Pt however gets recurrent C
diff with abx. Thus, she is being prophylaxed while on cefepime
with oral vanco 125 mg Q8h
# Worsening ascites: Likely from peritoneal carcinomatosis. Pt
was tapped ___. Then restarted on PO Lasix.
# Edema: Pt with anasarca. Likely from low albumin, >4L
repletion in ICU. ECHO nml.
# Right lung opacification: RLL collapse on CT on ___. Not
short of breath. No urgent need for bronch. Unclear etiology:
? mucous plug versus pleural effusion but effusion only small to
moderate. Per ICU, nothing clear to tap. Aggressive physical and
respiratory therapy.
# Rising INR: Most likely from poor nutrition. PO vitamin K 5
mg x 3 days was planned, but this was stopped ___ after only 1
dose due to LUE line-associated DVT as below.
# PICC-associated UE DVT: Patient had LUE swelling and, based on
UE venous US, an UE DVT. We cannot anticoagulate given bleed, so
removed PICC and placed another on the right side.
# Prophylaxis: Boots. Would hold off on heparin given continued
evidence of low grade GI bleed.
# Hypothyroid: stable. Continued home levothyroxine.
# Goals of care: This was readdressed. If pt were to clinically
decompensate, unlikely to do well given host of comorbidities
and recurrent illnesses. However, pt does want to be full code. | 157 | 746 |
13497866-DS-5 | 21,324,245 | Dear Mr. ___,
You were admitted to ___ after you fell and evaluated by the
trauma service. You suffered multiple broken bones, including
your right clavicle, ribs, spine, right wrist, and right iliac
wing (pelvis). You also required a chest tube because you had a
pneumothorax (when air leaks into the space between your lung
and chest wall) and a abrasion to your scalp. Your injuries were
managed non-operatively. Your wrist fracture was reduced and
placed in a splint and your right arm was placed in a sling due
to your clavicle fracture. You have since been seen by physical
and occupational therapy, who recommend you go home with
outpatient ___ services. Your pain has been well-controlled on
oral pain medications. You are ready to go home to continue your
recovery. Please follow the instructions below:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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.
* Your injury caused right and left-sided 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).
Activity as tolerated:
Restrictions: Right upper extremity non-weight bearing in
splint, OK for ROMAT at elbow and digits, OK for light ADLs with
digits.
OK to start gentle pendulums at the shoulder, no ROM
restrictions at the shoulder or elbow. Sling for comfort as
needed, patient should limit use of sling to avoid shoulder
stiffness. | Mr. ___ is a ___ year old male with no significant PMH, who is
s/p fall from ladder with positive LOC, who was brought to ___
as a trauma evaluation. He was seen by the Trauma service and
had imaging done which showed that he suffered multiple
fractures, including his right clavicle, right ___ ribs,
left ___ rib fx, L1-L3 right transverse process, right iliac
wing, and right distal radius fracture. He also had a right
pneumothorax and is s/p a chest tube insertion. He was admitted
to the Acute Care Surgery/Trauma service for further management
and pain control.
On HD1, his C-Collar was cleared by the primary team. His chest
tube was placed on water seal and his subsequent CXR showed a
stable right pneumothorax. His tertiary exam revealed a swollen
and painful right wrist and left hip pain. Right wrist xray was
ordered which demonstrated a nondisplaced wrist fracture.
Bilateral hip xrays did not show a new fracture, right iliac
wing fracture was seen on xray but already known. The hand
service was consulted for the patient's wrist facture and they
recommended non-operative management with a splint placement,
and NWB of that extremity. He was also seen by the orthopedic
team for his right clavicle fracture. They suggested
conservative management with a sling for comfort and follow up
in clinic.
His chest tube was pulled on HD2 and post-pull CXR showed stable
right apical pneumothorax. The patient remained stable from a
pulmonary standpoint. He was encouraged to use the incentive
spirometer and encouraged to ambulate early. Physical and
occupational therapy was ordered for evaluation and treatment.
After working with the patient, they cleared him to go home with
outpatient ___ on HD3. However, the patient was still noted to be
in considerable pain especially with movement/activity, so pain
medication was adjusted for better pain control. Teaching was
done regarding the importance of pain management in order for
patient to heal and to prevent complications such as pneumonia
or blood clots.
At the time of discharge, the patient was doing well, afebrile,
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without issue, and pain was well-controlled
on oral pain medication. He was discharged on a pain regimen of
acetaminophen, ibuprofen, oxycodone, and lidocaine patch. The
patient and wife received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. His follow up appointments were scheduled
prior to discharge. | 681 | 405 |
15990138-DS-21 | 29,449,054 | You came to the hospital after you were found unresponsive. You
required intubation with a breathing tube and monitoring in the
ICU. This was a complication of ingesting GHB while at the
hotel. Please stop taking GHB and other street drugs to reduce
the risk of this happening in the future. We recommend you see
a primary care doctor in follow-up and establish care with a
psychiatrist.
You were also found to have an aspiration pneumonia while you
were here. Please take the antibiotic, levofloxacin, for 1 more
day (last dose will be on ___.
We wish you the best.
-- Your Medical Team | ___ Mwith GHB intoxication and + amphetamine in urine.
Intubated for airway protection upon arrival to the ED.
Extubated in the ICU doing well on RA. He was loaded with
phenobarbitol for withdrawal and
agitation. After extubation patient was not providing many
details regarding history of events. He said that he is
homeless, had gotten a hotel room w/ his boyfriend. Says that
the night of admission, he was watching a movie w/ his SO and
then didn't want to elaborate further. ___ notable for HTN, no
meds. Endorses marijuana, denies other substances.
His hospital course further complicated by fever, rising WBC,
sinus tachycardia. CXR with evidence of new RLL consolidation.
He was started on Unasyn for c/f aspiration pneumonia.
# ENCEPHALOPATHY
# TOXIC INGESTION
The patient endorses GHB and amphetamine use prior to episode of
unresponsiveness. Toxicology has been consulted and feels that
overall presentation is consistent with GHB ingestion. He has
been loaded with phenytoin. Mental status much improved since
presentation. He was monitored on ___ and scored 0 throughout
his hospital stay. Psych was consulted. Psych felt that from a
mental health perspective, his presentation is most consistent
with meth-use disorder and substance-induced mood disorder.
They recommended outpatient addictions program and outpatient
mental health. He was provided information regarding some free
resources in the community as he does not currently have
insurance. Once he gets insurance (patient needs to call the
health connector) he would be a good candidate for the ___
___ for PCP and mental health.
# Transaminitis (hepatocellular)
LFTs were wnl on admission, since initiation of Unasyn/Augmentin
he has a new, mild transaminitis. Suspect this is most likely
drug side effect. Changed abx to levofloxacin for CAP and
trended LFTs. LFTs worsening on ___ AM, AST and ALT up to ~200
each. Repeated LFTs in the afternoon and they may have plateaued
but not totally clear. Viral hepatitis studies were added-on,
and he was advised to stay for work-up of his hepatocellular
transaminitis. He declined and chose to leave AMA on ___.
# PNA:
The patient developed fever and tachycardia ___ with CXR
showing concern for PNA. He was started on unasyn which was
changed to PO Augmentin. As above, Augmentin stopped due to
transaminitis and switched to levofloxacin.
- Continue levofloxacin for 5 day course ___ - ___
# No Primary Care Physician: SW & CM consulted. Has new PCP
___. scheduled at ___ on ___.
# Homelessness: SW consulted
>30 minutes spent on discharge-related activitiese today. | 106 | 408 |
11604306-DS-17 | 20,554,470 | Dear Mr. ___,
It was a pleasure caring for you during your recent admission to
___. You were admitted for
evaluation of 2 days of fever, runny nose and cough. You were
found to have the flu based on a rapid influenza A test. You
improved clinically with Tamiflu and it was determined you could
be discharged to home. Please complete your final day of twice
daily dosed Tamiflu ___, and beginning ___ please take Tamiflu
75mg once a day for two weeks, ending ___ (this course may be
prolonged by your primary oncologist). In addition, please
complete the final 4 days of your Levaquin at home. You should
follow up with your primary oncologist, Dr. ___, on ___
___ at 12:20PM.
Please hold you home Lisinopril tomorrow, ___, given your
slightly low blood pressure. Address restarting it with your
primary oncologist, Dr. ___, on ___ at your visit.
Should you develop fevers, worsening cough or shortness of
breath, please seek medical care at a clinic or at your nearest
emergency department.
New medications:
Tamiflu 75mg twice a day for ___nding ___
Tamiflu 75mg daily for 14 days beginning ___ and ending
___
Levaquin 750mg daily for ___nding ___
Medications changed:
Please hold your home Lisinopril tomorrow ___ | ASSESSMENT/PLAN: ___ with history of NHL (follicular type) with
recent transformation, on ___ cycle of ___, now with
neutropenic fever and found to be positive for Influenza A. | 209 | 28 |
19301597-DS-25 | 22,425,582 | You were admitted to the hospital with abdominal pain,
nausea/vomiting, and diarrhea. You had a CT scan which showed
some thickening in your intestines, which made us worried about
infection or poor blood supply. You were treated with IV
fluids, pain and nausea medicine, bowel rest, and antibiotics,
and you got significantly better. You were seen by the surgeons.
After all this, it seemed like the most likely diagnosis was an
infection of your intestines caused by a virus. We stopped your
antibiotics, and you continued to improve. You should ___
with your outpatient providers as noted below. | ___ woman w/PMHx CAD s/p MI, afib not on warfarin, PVD,
multiple TIAs, admitted for enteritis NOS (thought likely to be
infectious), improved with conservative therapy, including off
antibiotics. She did develop some mild pulmonary edema from
fluid resuscitation for the enteritis, in the setting of COPD,
both of which improved after diuresis and nebs. She's back to
her baseline and ready for discharge.
On the day of discharge, Ms. ___ was doing well. She had
no issues with shortness of breath or pain or other concerns.
No recent stools or nausea -- appetite is good. She clearly
identifies where she is and the day. She is able to remember
details of our conversation later in the conversation. She
clearly articulates why she was admitted. She does have trouble
remembering yesterday's holiday, but from communicating with her
outpatient provider, it's clear this is baseline. I discuss the
idea of discharge with the patient and physical therapy. I also
spoke with her daughter by phone and we agreed that she will
continue to recover back at her assisted living and that
discharge there today is good.
By PROBLEMS
Enteritis NOS
- unclear etiology but suspect viral etiology
- rapidly improved with IV fluids
- initially was on antibiotics, but these were stopped and she
continued to improve
- no further w/u or tx needed unless it recurs
Shortness of breath due to pulmonary edema in the setting of
recent IVF and possibly undx chronic diastolic heart failure --
in the setting of CAD s/p MI, afib not on warfarin, PVD,
multiple TIAs and COPD
- she does not have a TTE in our system -- this could be
considered as an outpatient if clinically indicated
- here she received furosemide x 1, her home meds and nebs, and
rapidly improved back to her baseline
- continue amiodarone, ASA, lisinopril (restarted on the day of
discharge), metoprolol, simvastatin
Adrenal insufficiency
- continued home prednisone
COPD
- continue home inhalers ___, tiotropium),
received some PRN nebs here, and can get these via MDI as an
outpt
IDDM
- sugars were ok here -- per outpt provider she had ___ fall that
could have been associated with hypoglycemia as an outpt, so
higher sugars are ok -- will use metformin + Humulin ___ as
outpt (no more glipizide)
- she may need titration of this regimen
Hypothyroidism
- levothyroxine
Stable normocytic anemia
- continue ferrous sulfate
- outpatient workup as indicated/guided by outpt providers
GERD
- pantoprazole, sucralfate
Possible dementia, with mild delirium while here
- the patient had intermittent mild confusion early in her
hospital stay, with the daughter reporting some hallucinations
- these cleared, and as noted above, the patient was back to her
baseline on the day of discharge
- her ___ memory problems may be mild dementia -- she
should have a cognitive evaluation done as an outpatient by OT
and then ___ with her PCP
- ___ advised the patient's daughter of this
___
- a very extensive medication list was provided with the patient
- I would recommend that this be scrutinzed carefully when she
is evaluated by her PCP in ___ -- it is likely that many
of the medications can be stopped
- we stopped glipizide while she was here, but I think there are
many other changes that could be made
Goals of care
- the patient arrived with a MOLST that indicated:
A: DNR
B: DNI, but ok to use ___ ventilation (e.g. CPAP)
C. Do transfer to hospital
- no changes were made to this -- her prior MOLST should still
be valid/active
Dispo
- came from assisted living, she worked with ___ and it was
determined she could safely return there
OTHER INACTIVE PMHx
PFO
depression
chronic UTIs
diverticulosis
h/o LGIB
left vertebral artery dissection
s/p distant open appy and cholecystectomy, TAH, sigmoidectomy
for diverticular bleed at ___ ___, bilateral common
iliac stents | 101 | 609 |
18266605-DS-2 | 20,586,690 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital after ___ overdosed on antipsychotic
medications and were found unresponsive. ___ had a very
complicated course that included intubation and a cardiac
arrest. ___ had CPR and your heart restarted. When ___
overdosed, ___ vomited and developed a lung infection that
required IV antibiotics. ___ were also found to have a pulmonary
embolism. ___ were treated with heparin, then lovanox, and
transitioned to apixaban. ___ had diarrhea that was C. Difficile
negative. ___ were extubated and transferred to the general
medicine floor.
___ improved dramatically throughout your course. Your diarrhea,
fevers, and cough resolved. ___ were followed closely by the
infectious disease specialists and decided on antibiotic course
for total of 4 weeks from ___. ___ were switched to an
oral medication, apixaban, to treat your pulmonary embolism. ___
will take this medication for 3 months.
___ were seen by psychiatry after your overdose and per their
recommendations, ___ were discharged to an inpatient psychiatric
facility to undergo treatment for your depression and
suicidality.
We wish ___ the best of health,
Your medical team at ___ | ___ with history of depression presented after intentional
overdose with hypercarbic and hypoxic respiratory failure and
shock with course complicated by PEA arrest in the MICU.
============= | 194 | 26 |
19847287-DS-24 | 21,631,643 | Dear Ms. ___,
You were seen in the hospital for weakness and found to have a
urinary tract infection.
We treated you with antibiotics and you improved. You were also
seen by the physical therapists, who recommend home ___.
As we discussed, please work on your diet by eating smaller,
more frequent meals. Continue the protein supplementation in
your oatmeal. Please try to add an Ensure or Boost type drink
once to twice per day.
Please follow up with your primary care doctor within 2 weeks of
discharge.
Continue taking the antibiotics until the bottle is empty.
It was a pleasure caring from you. We wish you the very best!
- Your ___ Care Team | ___ is a ___ woman with a history of CVAs s/p
CEA, hypothyroidism who presents with weakness and confusion
found to have urinalysis c/w UTI. | 112 | 26 |
16725940-DS-18 | 26,989,058 | Dear Ms. ___,
You were admitted to the hospital with weakness and dark stools.
You were evaluated and found not to have obvious blood in your
stool or evidence of dropping blood levels. Your abdominal pain
did not get any worse throughout your admission. You are now
safe for discharge home with close follow up.
It was a pleasure caring for you - we wish you all the best!
Sincerely,
Your ___ Oncology Team | Ms. ___ is a ___ lady with a PMH significant for
stage IV gastric cancer with bony mets who presents with
weakness and dark stools, guaiac positive, but stools do not
appear to be consistent with melena.
# Weakness: Differential includes infection, anemia, chemo. No
obvious s/s of infection, aside from loose stool. Blood and
urine cultures negative. c. diff negative. Did not require
antibiotics. Her blood counts had been slowly downtrending but
were stable throughout admission. Anemia may be due to chemo,
especially where patient does not seem to have GIB. Remained
afebrile, WBC stable throughout admission
# Dark stool: Not frankly melanotic. Dark brown, no blood, not
black, no tarry quality. Guiaic positive in ED but this is in
the setting of known gastric cancer. Daily HCT was stable
throughout admission. Given Pantoprazole daily, held
prophylactic heparin. Tolerated regular diet, no indication for
endoscopy or colonoscopy during this admission.
# Gastric adenocarcinoma: Known bony mets. Currently on
Ramucirumab/Taxol. Treatment complicated by cytopenia,
proteinuria, and peripheral neuropathy. Most recent treatment
may be contributing to her profound weakness. Discharge
treatment plan per outpatient team
# HTN: Continued home lisinopril and amlodipine
# Neuropathy: Continued home gabapentin
# Pernicious anemia: Receives monthly B12 injections
TRANSITIONAL ISSUES
#Patient was guaiac positive, though did not have any evidence
of BRBPR or melena this admission. continue to trend H&H to
monitor for any acute or continued bloodloss
#Patient having diarrhea during this admission, c. diff negative
#no changes in medications, except patient written for
simethicone as needed for gas pain
#EMERGENCY CONTACT HCP:
Husband (___) ___
#CODE: Full (confirmed) | 72 | 273 |
13151494-DS-19 | 23,047,563 | Please call your surgeon or return to the Emergency Department
if you develop a fever greater than ___ F, shaking chills, chest
pain, difficulty breathing, pain with breathing, cough, a rapid
heartbeat, dizziness, severe abdominal pain, pain unrelieved by
your pain medication, a change in the nature or severity of your
pain, severe nausea, vomiting, abdominal bloating, severe
diarrhea, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness, swelling from your
incisions, or any other symptoms which are concerning to you. To
avoid dehydration, remember to sip small amounts of fluid
frequently throughout the day to reach a goal of approximately
___ mL per day. Please note the following signs of dehydration:
dry mouth, rapid heartbeat, feeling dizzy or faint, dark colored
urine, infrequent urination.
Medication Instructions:
Please refer to the medication list provided with your discharge
paperwork for detailed instruction regarding your home and newly
prescribed medications. You can start all your home medication
after discharge.
your ___ Team
Thank you, | ___ POD#6 from laparoscopic cholecystectomy who presents with
generalized fatigue and fevers at home. The patient underwent
laparoscopic cholecystectomy on ___ for chronic
cholecystitis; procedure was uncomplicated but notable for
chronic inflammation and numerous gallstones. There was some
oozing from the liver bed after removal of the gallbladder and 4
pieces of surgicel were placed in the gallbladder fossa with
hemostasis achieved. She presented to ___ on ___ with
acute onset shortness of breath and malaise. She was found to be
dehydrated (lactate of 2) with a leukocytosis of 14. CTA torso
showed no acute thoracic processes to explain the subjective
shortness of breath, and patient was breathing comfortably on
room air. However, imaging was concerning for an abscess in the
gallbladder fossa. However, after further review by the surgical
and radiology teams, it was determined that the air-containing
collection was reflective of Surgicel in the gallbladder fossa,
with a small 3x3cm collection, likely seroma or residual
hematoma. The CT also noted an incidental finding of a 3.4cm
subcarinal lymph node that was evaluated by IP who recommend an
interval CT in one month. The patient was admitted to the
surgical service, rehydrated and started on antibiotics. Her
symptoms improved and her leukocytosis was down trending and she
was discharged home on a course of oral antibiotics. | 164 | 217 |
13678565-DS-19 | 28,932,989 | You were re-admitted to the inpatient general surgery unit from
the ED after your total thyroidectomy for a neck washout. You
have adequate pain control and have tolerated a regular diet and
may return home to continue your recovery. Please continue your
previous instructions regarding thyroid hormone replacement and
calcium supplement, please take as prescribed. Monitor for signs
and symptoms of low Calcium such as numbness or tingling around
mouth/fingertips or muscle cramps in your legs. If you
experience any of these signs or symptoms please call Dr.
___ for advice or if you have severe symptoms go
to the emergency room.
Please resume all regular home medications, unless specifically
advised not to take a particular medication and take any new
medications as prescribed. You will be given a prescription for
narcotic pain medication, take as prescribed. It is recommended
that you take a stool softener such as Colace while taking oral
narcotic pain medication to prevent constipation. You may also
take acetaminophen (Tylenol) as directed, but do not exceed 4000
mg in one day. Please get plenty of rest, continue to walk
several times per day, and drink adequate amounts of fluids.
Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site. You may shower and wash incisions with a mild
soap and warm water. Avoid swimming and baths until cleared by
your surgeon. Gently pat the area dry. You have a neck incision
with steri-strips in place, do not remove, they will fall off on
their own.
Thank you for allowing us to participate in your care. | Patient was taken to the OR for neck washout on ___. Postop,
she had no cuff leak. ENT was consulted and noted edema in the
airway and recommended steroids. She was given dexamethasone and
diuresed in the ICU. She was extubated on ___ and monitored
in the ICU. She had a sore throat which improved. At time of
discharge she was tolerating a regular diet. | 272 | 65 |
18637603-DS-7 | 21,611,915 | Dear Ms. ___,
It has been a pleasure being a part of your care during your
admission to ___. You were
admitted for an infection of your foot ulcer. You were taken to
the operating room with the Podiatry team, and your ulcer was
debrided. You were also found to have an infection ___ your
bloodstream, which was likely from the bacteria ___ your foot
ulcer that got into your blood. You were treated with IV and PO
antibiotics, which will continue for a minimum of 6 weeks
(earliest end date: ___. You had a PICC line placed,
basically a more permanent IV, ___ order to receive these
antibiotics even when you leave the hospital.
Your right leg was still very swollen and red after you went to
the operating room, and you had an ultrasound which showed that
there were no pockets of fluid or infectious collections that we
were missing.
Also, because you had bacteria ___ your blood, we wanted to make
sure that no bacteria were sitting on your heart valves. You had
an echocardiogram, which showed no evidence of this condition.
___ terms of your falls, you previously had a negative workup for
cardiac or neurological causes of your falls. It is likely the
combinations of medications that you are on, as well as your
diabetic neuropathy that is causing you to be unsteady on your
feet. Your Gabapentin and Amitriptyline were subsequently both
decreased ___ dose. Your Lasix (Furosemide) was also discontinued
this admission ___ an attempt to reduce your lightheadedness.
Please weigh yourself everyday. ___ your MD if your weight goes
up more than 3 lbs.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team | Ms. ___ was admitted for right foot osteomyelitis that failed
outpatient antibiotic treatment after a previous debridement.
#OSTEOMYELITIS: She was started empirically on Vancomycin,
Ciprofloxacin, and Metronidazole for concern of a polymicrobial
infection. She was taken to the operating room with podiatry for
a debridement. Wound cultures grew out MSSA and mixed bacterial
flora. Vancomycin was discontinued and nafcillin started. Her
___ seemed persistently edematous and erythematous
post-debridement, and she had a ___ soft tissue US which
demonstrated no evidence of abscess or fluid collection. (She
had already had a ___ on presentation, which was negative
for DVT.)
# BACTEREMIA: The patient was found to be bacteremic, with blood
cultures growing MSSA. Given that MSSA was also isolated from
her wound culture, she was transitioned to Nafcillin IV from
Vancomycin. Considering her bacteremia, she also had a TTE which
showed no evidence of endocarditis. | 284 | 143 |
14439178-DS-7 | 29,191,977 | Dear Mr. ___,
You were admitted to the hospital because you were having
abdominal pain and you also had diabetic ketoacidosis (DKA)
because of very high blood sugars. You were also found to have a
possible pneumonia and urinary tract infection.
While you were here you were initially admitted to the ICU to
receive insulin through a continuous IV infusion and for close
monitoring. You were eventually transitioned to insulin shots
once your blood sugars improved and you were moved to the
medicine floor for treatment of a pneumonia. During your stay,
your abdominal pain worsened and a CT showed injury to your
bowel and you had to go to the OR to undergo exploratory
laparotomy and had a portion of your intestine removed.
You have now had return of bowel function, are tolerating a
regular diet and are ready to be discharged home. Please follow
the discharge instructions below:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
When you go home, please continue taking all your medications as
prescribed and follow up with your doctors as listed below.
We wish you the best!
Your ___ Care Team | ___ w/ hx of DMI, hepatitis C, homelessness, substance use
disorder on methadone, current IVDU, PTSD, chronic diarrhea and
multiple recent admissions to ___ for DKA with AMA discharges
who presented with abdominal pain and DKA. He was initially
admitted to the ICU requiring and insulin drip, and was
subsequently cared for on the medical floor. Also found to have
pneumonia and possible UTI, treated with course of antibiotics.
The pt's abdominal pain worsened acutely and CT imaging showed
extensive pneumatosis and small bowel necrosis. He was taken to
the OR on ___ for small bowel resection and transferred to
the surgical service for post operative care.
TRANSITIONAL ISSUES
=====================
[] Repeat CXR in ___ wks
[] Hepatology f/u as outpt for hepatitis C
ICU COURSE
=============
The patient was admitted to the ICU initially for DKA requiring
insulin drip. On admission he also complained of abdominal pain
with CT A&P showing wall thickening and edema of the large and
small bowel. Serial abdominal exams did not reveal any
peritoneal signs and his symptoms improved after several days,
so these findings were attributed to trauma from a recent
assault prior to admission. The patient was transferred to the
medicine floor after anion gap closed and he was transitioned to
subcutaneous insulin (see medical floor course below).
However while on the medicine service, the pt developed acute
worsening of abdominal exam on ___ and a repeat abdominal CT
showed extensive pneumatosis and small bowel necrosis. He was
taken emergently to the OR for small bowel resection and
transferred back to the surgical service for post operative
care.
MEDICINE COURSE (BY PROBLEM)
==============================
ACUTE/ACTIVE ISSUES
====================
# DMI
# DKA
The patient presented with DKA, in the setting of reportedly
missing insulin for 16 days due to poor access. The pt did not
report that it was cost prohibitive, however was simply unable
to obtain. The patient was initially stared on insulin drip in
the ICU and was subsequently transitioned to subcutaneous
insulin after gap closed and acidosis resolved. ___ diabetes
team was consulted and titrated long acting, prandial, and
sliding scale insulin accordingly.
# Small bowel necrosis
Acute worsening of abdominal pain on ___ ___hest
revealing for pneumatosis and small bowel necrosis. Underwent
small bowel resection that day and was continued on antibiotics.
# LLL PNA
A CXR from admission showed a LLL consolidation, concerning
aspiration vs PNA. At the time, he also endorsed mild cough with
scant sputum production. Given his recent hospitalizations,
including an admission in the ___ ICU, the patient was deemed to
have multidrug resistant risk factors, so was covered broadly
with vancomycin and zosyn with a 7 day course (___).
# Substance Use
# Chronic pain
The patient has a long history of IV drug use, on methadone. He
reported active IV drug use 1 week prior to admission, via
heroine injection to the antecubital fossa. He previously was
prescribed 60mg methadone daily at ___. ___
clinic, however had not been seen there since ___. More
recently he was receiving methadone at ___,
and then admitted to getting methadone of unknown quantity on
the streets after leaving against medical advice. The addiction
psych team was consulted and assisted in narcotic prescription
management. Due to somnolence, the patient was given a decreased
dose of 30mg methadone daily. He was continue ___ home lyrica,
as well as Tylenol and naproxen for chronic pain.
# Klebsiella UTI vs asymptomatic bacteruria
MDR klebsiella was also found to growing in urine from a sample
taken on admission. The patient denied symptoms, so most likely
represents asymptomatic bacteruria. He was already receiving
antibiotics for a PNA as discussed above.
# Dysphagia
Throughout admission, the patient complained of chest pain and
difficulty swallowing. His EKG was unchanged and a barium
swallow study did not reveal any evidence for aspiration or
obstruction. His symptoms were managed with Maalox and Carafate.
CHRONIC/STABLE PROBLEMS
========================
# Anxiety
# Depression
The patient was continued on home duloxetine and received
hydroxazine as needed.
# Chronic diarrhea
The patient has also had longstanding of diarrhea for > ___ years
due to unknown etiology. A cdiff test was negative on admission.
His chronic diarrhea could have been due to pancreatic
insufficiency as he is prescribed creon as a home medication.
The patient was continued on home loperamide, creon, and
diphenoxylate-atropine while here, in addition to a short course
of zinc supplement.
# HCV
There were no signs of acute decompensated liver failure this
admission.
# Coagulopathy
Likely nutritional given lack of significant underlying liver
dysfunction. The patient was given IV vitamin K for 3 days with
improvement in INR.
# Gram positive rod bacteremia
Blood cultures grew gram positive rods from admission, speciated
as bacillus. Felt to be a skin contaminant. An echo was done
which was negative for vegetations.
CORE
======
# CODE: Full
# CONTACT: None
On ___, the patient was transferred to the surgical floor.
Neuro: The patient remained alert and oriented. He was on a
ketamine drip for pain and this was discontinued. Addiction
Psychiatry was consulted and the patient was started on
methadone and oxycodone which was weaned and ultimately stopped.
He was continued on acetaminophen, ibuprofen and Pregabalin.
CV: The patient remained stable from a cardiac standpoint. Vital
signs were routinely monitored
PULM: The patient remained stable on room air with no acute
respiratory distress.
Good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization.
GI/GU/FEN: Patient's NGT was removed and diet was advanced from
sips to clears and ultimately to regular which he tolerated
well. The patient had diarrhea and a c.diff was checked which
was negative. The diarrhea was attributed to the patient's
history of chronic diarrhea due to pancreatic insufficiency.
The patient was restarted on creon, loperamide and lomotil.
The patient had urinary retention, required straight
catheterization and Urology was consulted and recommended foley
placement for 7 days. He was started on Flomax, the foley was
removed and the patient voided without issue.
HEME: The patient's blood counts were closely watched for signs
of bleeding. On ___, he received 1U PRBC for hematocrit of
20.7, hemoglobin 6.3 and HCT/HGB increased appropriately.
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.
On ___, the patient was noted to have some drainage from
his midline surgical abdominal wound and wicks and a pravena was
placed. Pravena was removed on ___ and the wound was
healing well w/ no s/s infection.
On ___, the patient left the hospital before discharge
paperwork or prescriptions could be provided. His discharge
paperwork and prescriptions were faxed to his pharmacy. The
patient was doing well, afebrile and hemodynamically stable.
The patient was tolerating a diet, able to ambulate to his
wheelchair, 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. | 467 | 1,131 |
19103554-DS-14 | 24,008,609 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
chest pain, shortness of breath or any other concerns.
******WEIGHT-BEARING*******
weight bearing as tolerated
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
No chemical anticoagulation. Please ambulate.
******FOLLOW-UP**********
Please follow up with ___ in 14 days for
evaluation. Call ___ to schedule appointment upon
discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
WBAT
Treatments Frequency:
home safety evaluation | The patient was admitted to the Orthopaedic Trauma Service for
right hip contusion. Pain was controlled with PO pain meds. The
patient worked with ___ on mobility and steadily improved.
Weight bearing status: weight bearing as tolerated.
The patient was discharged in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will not require
chemical DVT prophylaxis and should be out of bed and
ambulatory. All questions were answered prior to discharge and
the patient expressed readiness for discharge. | 147 | 85 |
11382944-DS-2 | 22,363,657 | Dear ___,
___ were admitted for management of eye inflammation, vision
changes and headache. Our evaluation showed that these two
complaints are likely unrelated.
A variety of tests were sent to try to determine the cause of
your eye inflammation. The results of these tests were negative
or still pending at the time of discharge. In the meantime,
please continue using the eye drops provided by your
Ophthalmologist. Your vision changes ___ be due to problems with
your retina. Your headache does not seem to have been due to
increased pressure inside your head, and rather seems to be a
migraine type headache.
Screening labs also showed that your Thyroid medication may need
to be adjusted. Please discuss this matter with your Primary
Care Provider.
Follow up with Neurology (Dr. ___ - ___ has been
scheduled. Follow up with Ophthalmology (Dr. ___ - ___ will be arranged. If ___ do not hear from Ophthalmology
within three business days, please call the clinic.
Please call ___ registration at ___ to update your
patient information.
It was a pleasure being part of your care team.
___ Neurology | Patient was admitted with uveitis, concern for papilledema and
headache with high pressure features. Workup for uveitis
included a variety of screens for autoimmune, autoinflammatory
or infectious conditions. All of these were negative or pending
at the time of discharge. She was continued on Prednisone eye
drops to treat inflammation. Upon repeat evaluation by
Ophthalmology, no papilledema was noted. Instead retinal cysts
were identified and the patient will follow up with a retina
specialist, appointment pending. MRI was unremarkable with the
exception of a large left occipital vein coursing close to the
left vertebral artery. No further workup of this was pursued
during this admission. Lumbar puncture was performed. Opening
pressure was 19cm H2O, which was not consistent with elevated
intracranial pressure. Basic CSF studies were reassuring.
Infectious and inflammatory CSF studies were pending at the time
of discharge. Follow up with Neurology was scheduled. TSH was
elevated at 5.2. TSH, T3/Free T4 were repeated prior to
discharge, but were pending. Adjustment to Levothyroxine may be
indicated on the basis of these results. | 179 | 173 |
18305217-DS-11 | 22,255,712 | DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with a diagnosis of small
bowel obstruction. Your management included conservative
measures such as bowel rest and intravenous fluids, and serial
abdominal exams. You did not require antibiotics. You did not
require surgery for this condition. You were able to tolerate
regular diet and fluids at the time of your discharge. Please
follow instructions outlined below to ensure good recovery.
ANTIBIOTICS:
Please complete the full course of antibiotics as instructed. DO
NOT stop taking antibiotics if your symptoms resolve before the
end of the prescribed course. Take antibiotics with food to
avoid nausea.
ACTIVITY:
You may resume regular activity. You may climb stairs. You may
start some light exercise when you feel comfortable. You may
resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you. You might have trouble
concentrating or difficulty sleeping. You might feel somewhat
depressed. You could have a poor appetite for a while. Food may
seem unappealing. All of these feelings and reactions are normal
and should go away in a short time.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
oxycodone, Percocet or codeine. 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 primary care doctor and the surgery office to schedule an
appointment. Drink plenty of fluids. If you develop diarrhea,
stop taking laxatives. If it does not go away, or is severe and
you feel ill, please call your surgeon.
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 to the hospital on ___ for management of
partial small bowel obstruction. She was made NPO with IV
fluids. NGT was not placed. Urinalysis on admission revealed a
urinary tract infection, and she was started on oral
ciprofloxacin for treatment.
Her diet was advanced to clears on hospital day 2, when she was
having flatus. On hospital day 3 she was advanced to regular
diet with marked improvement of her abdominal exam. She
ambulated without assistance. She was discharged from the
hospital with plan to follow up with outpatient primary care
provider. | 337 | 95 |
10758378-DS-7 | 25,098,108 | You were admitted to the hospital because of difficulty walking
and concern for seizure activity. You EEG did not show seizure
activity and your walking was back to normal by the following
day. You are back to baseline so you are safe to go home.
Please take it easy this weekend, drink plenty of fluids and get
plenty of rest. You may return to your normal activities on
___. Please call Dr. ___ first thing ___
morning to touch base and see when he would like to follow up
with you next. Please return to the nearest emergency room for
any persistent worsening of your symptoms or new concerns for
seizure.
There was some confusion regarding the dose of your home
medications upon your admission to the hospital. We recommend
that you make an up to date list of your current home
medications, including doses and how many times a day you take
each medication, and keep a copy of this in your purse or wallet
to help prevent this confusion from happening in the future. | Patient was admitted from outpatient Neurology Clinic for EEG
monitoring in the setting of ataxia/unsteady gait. She was
unsure of exact medication dosing upon admisison and so got less
medication than usual (what we had in our system- only 100mg
Vimpat, and only 50mg of Lamictal). Despite this, there was no
seizure activity and her preliminary EEG read was at her
baseline: "IMPRESSION: This is an abnormal continuous EMU
monitoring study because of sleep related paroxysmal interictal
epileptic activity that appears to be generalized. There were
however no sustained events during this recording session." The
EEG read from the last 12 hours of admission is pending at the
time of discharge. The morning following admission, ___,
she felt completely better and her walking was back to baseline.
She remained neurologically at her baseline and received the
extra dose of medications when her correct dosage was figured
out (Vimpat 200mg BID and Lamictal 100mg qAM and 125mg qPM).
She was discharged on all of her home medications and will touch
base with her outpatient neurologist Dr. ___ thing on
___ morning ___. | 182 | 188 |
14269536-DS-20 | 25,530,842 | Ms ___,
You were admitted for respiratory failure / shortness of breath.
This was caused by a combination of Pneumonia, COPD
exacerbation, Heart failure, likely from a past heart attack.
You were placed on a breathing machine until you were able to
breathe effectively on your own. You were given antibiotics for
pneumonia. You were given oral steroids for a COPD
exacerbation. You were given diuretic medications for heart
failure to help you clear excess fluid in the lungs.
You were also found to have a blood clot in your lungs. You were
started on blood thinners to treat the blood clot. You will need
to continue the blood thinner for at least 3 months.
It is important that you follow up with a cardiologist to
discuss your heart disease. | ___ old woman with history of COPD, CHF, NIDDM, alcohol and
tobacco abuse, and schizoaffective disorder who presented with
shortness of breath, was intubated for hypercarbic respiratory
failure, s/p extubation ___, finished HCAP course ___, and
returned to the ICU with hypoxemia, found to have PE and now
back on treatment for HCAP due to fever. | 131 | 57 |
19024917-DS-20 | 29,604,310 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. You were admitted
after a fall at your nursing home. This might have been from
confusion, as some elderly people can get confused at night or
with certain medications. You had a CT scan of your head that
show no new bleeding or new strokes. You did not have any falls
while in the hospital.
You also had one blood test that showed concern for a blood
infection and you were given antibiotics. However, further
testing showed that this was probably a contaminant and not a
real infection, and antibiotics were stopped.
Your family was concerned about your rapid decline in your
cognitive thinking and functioning over the past few months.
Unfortunately, we were not able to find any further reasoning
for this, but we recommend you continue to work with your
outpatient doctors and consider seeing a neurologist again.
If you have fevers, worsening confusion, problems breathing, or
anything that concerns you or your family, please seek medical
attention.
All the best,
Your ___ Care Team | Mr. ___ is a ___ year old man with history of prostate
cancer s/p XRT and hormonal therapy in ___, vestibular
neuritis, hyperparathyroidism, Paget's disease, hearing loss,
dementia and cognitive decline over the past ___ months, who
presented after a fall with head strike at his nursing home. He
was monitored without evidence of infection or cardiac etiology
for fall, and was discharged back to his SNF.
#Acute on chronic Encephalopathy:
#Rapidly declining cognitive status:
#Dementia:
From review of ___ records, patient's rapid cognitive decline
began in ___. Before then he was functional, driving and
conversant. Since then he has had trouble walking and expressing
himself, although does appear to comprehend. From ___ chart
review, he had MRI/MRA head, CT head, EEG, and broad autoimmune
workup in two different hospitalizations in ___ that were
unrevealing of the etiology. There was concern that his decline
started after a course of steroids given for vestibular neuritis
in ___, but this has not been well described and patient did
not improve with cessation of steroids. There may be a component
of vascular dementia, as he does seem to have the focal deficit
of expression but can comprehend. We recommend he continue to
see an outpatient neurologist (son is continuing to think about
this decision as unsure if it is helpful) and that occupational,
physical and speech therapy would with him frequently to provide
the best chance of rehabilitation.
#Fall:
Patient presented after a fall from his bed, reportedly in the
setting of agitation. Patient have been experiencing sundowning,
leading him to fall, or could have been presyncope in the
setting of medication side effect (on tamsulosin at home). He
sustained an abrasion to his forehead, but otherwise had no
acute injuries. His CT scan was negative for any acute
intracranial processes or bleed. He had an echocardiogram that
was unrevealing for an etiology of presyncope or syncope that
could have led to a fall. He had no falls while in the hospital,
and as above would encourage OT, ___ and frequent orientation.
#Pancytopenia:
On day 3 of his hospitalization, his CBC was notable for all
three cell lines being decreased from admission and baseline. He
received no medications to trigger this, and did not appear to
be actively infected. His counts remained stable, but would
recommend repeating a CBC ___ to ensure resolution vs further
workup.
#Coag-negative staph positive blood culture, likely contaminant:
Patient had 1 blood culture that grew coag-negative staph. He
was temporarily started on vancomycin. The other blood cultures
had no growth at time of discharge, he was afebrile and well
appearing, and this was determined to be a likely contaminant.
#Elevated lactate:
Patient admitted with a lactate of 5, improved to 2 with IVF. He
had no signs of active infection, and suspect this may have been
due to poor PO intake and any muscle breakdown after his fall.
#Medication reconciliation:
Patient was still on medications started at the ___
hospitalization in ___, that were supposed to be discontinued
in early ___. These medications were discontinued and should
NOT be restarted upon return to his nursing home: fleet enema
(can cause marked electrolyte abnormalities), indomethacin (can
worsen confusion in the elderly), melatonin (not needed),
tamsulosin (can cause presyncope, syncope, hypotension, or
confusion in the elderly), omeprazole (no longer an indication
for this).
#Code status:
The patient's son/HCP expressed very clearly that he is full
code, but would not want to be on "life support" for a prolonged
period of time. | 179 | 569 |
18082015-DS-9 | 29,815,898 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain probably related to an infection in your
appendix based on your clinical exam as well as CT scan imaging.
Your pain decreased with antibiotics. The risks and benefits of
surgery were discussed and medical treatment with antibiotic
therapy was determined appropriate. You are now doing better,
tolerating a regular diet, and ready to be discharged to home to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
Service on ___ with right lower quadrant/epigastric pain
for 3 days. Denies associated fever, chills, nausea, vomiting,
or change in bowels. CT abdomen pelvis was consistent with acute
appendicitis. Risks and benefits of operative versus medical
management with antibiotics was discussed and the patient opted
for medical mangagment. He was made NPO, given IV antibiotics,
and admitted to the floor for monitoring.
On HD2 he remained afebrile, hemodynamically stable, and
abdominal pain improved. White blood cell count was 10.0 from
7.7. His diet was progressively advanced to regular with good
tolerability with normal bowel function.
He was discharged to home on HD2 to complete a 10 day course of
antibiotics. 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. | 260 | 178 |
17387734-DS-19 | 27,183,049 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of chest pain. You underwent a cardiac cath
that showed restenosis or recurrent blockage of one of your
coronary arteries. Since this is the fourth time this occurs
during the last year, you were referred to cardiac surgery for a
redo CABG.
Please make sure to take all your medications and keep up with
your appointments. Also, please make sure you call an ambulance
if you experience worsening pain.
Please call the echo lab on ___ morning at ___ to
find out what time your echo is. | ___ yo male with CABG (___) with persistent angina s/p
multiple stents (most recent ___ who persists with
worsening chest pain over the past 2 weeks, accompanied by
non-specific ischemic EKG changes but no elevation of cardiac
enzymes.
# UNSTABLE ANGINA: Patient with extensive coronary history, s/p
CABG complicated by recurrent symptoms s/p multiple PCIs
(___). Appears to have stable EKG changes,
however missing posterior/LCx perfusion areas that could be
suspiscious for ischemia. Has 2 sets of negative cardiac
enzymes, but with persistent pain. Has had chronic angina since
CABG, but symptoms had been gradually worsening over the past 2
weeks prior to admission. Patient reported recent negative
stress test done by cardiologist 3 weeks prior, however this did
not necessaily mean that he is perfusing his heart well; could
be low perfusion globally. Unclear if this is actually cardiac
pain in nature given it's chronic presentation without evidence
of infarct or resolution in the pain. He was continued on a
heparin gtt until cardiac cath. He had evidence of refractory
restenosis of the LAD that will require definitive treatment
with repeat CABG. CT surgery consulted during admission and
reccommended surgical work-up and readmission in a few weeks. He
continued medical management with statin, metoprolol, asa 325
and plavix given recent DES in ___. Started amlodipine,
# H/O GI BLEED: Patient had a history of GI bleeding. No
evidence of any bleeding during admission. Denies melena or
hematochezia. Continued home pantoprazole.
TRANSITIONAL ISSUES
-patient will continue on plavix to prevent thrombosis of
multiple stents
-plan for appointment with Dr. ___ surgery) next
week
-started on amlodipine 2.5mg daily | 111 | 270 |
19336651-DS-23 | 29,736,608 | Please call your doctor or nurse practitioner if you experience
the following:
*You experience shakiness, nervousness, sweating, irritability,
confusion, lightheadedness, dizziness, hunger and nausea,
sleepiness, weakness and fatigue, as these may be signs of
hypogycemia.
*You experience frequent urination, increased thirst, blurred
vision, fatigue, headache, confusion, coma, abdominal pain, as
these may be signs of hypergylyemia.
*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 is 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. | Patient was admitted to the ___ service 3 days prior to
his completion pancreatectomy for findings of elevated glucose
on pre-admission testing. On admission to the hospital, his
glucose level was 284. ___ was consulted to assist with
preoperative and postoperative management of glucose. He was
started on Lantus 10 and insulin sliding scale preoperatively.
He underwent a robotic completion pancreatectomy and splenectomy
on ___. Please see operative report for further details of
the operation. On POD1, he was started on clears and his foley
was removed. However on POD2, he developed abdominal distention
and diet was reduced to sips. On POD4, his abdominal distention
began to resolve and his diet was readvanced up to a regular
diabetic diet. Dilaudid PCA was discontinued on POD4 and he was
switched to oral pain meds and restarted on his home
medications, except for metformin. Throughout the postoperative
period, ___ continued to follow patient for blood glucose
control. At time of discharge, patient's blood glucose was well
relatively well controlled (FSG: 127-222). He was discharged on
18U of Lantus at bedtime and an insulin sliding scale. The
nutritionalists also worked very closely with the patient
regarding diabetic, post-whipple diets and further diet
education. Patient will be followed in the outpatient setting by
the ___ for glucose control and nutrition adivice. He
will have close follow-up with Dr. ___ as well with Dr.
___ pancreas). At time of discharge, patient was
tolerating a regular diabetic diet, self-administering insulin,
ambulating, and having normal bowel movement. | 195 | 251 |
12426769-DS-11 | 21,184,369 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with liver failure after a
tylenol overdose. Your liver function improved and it is safe to
discharge you to continue treatment for your depression.
You will follow up with your primary care doctor regarding your
liver health after psychiatric treatment. You do not need to be
seen in the liver clinic.
Please make the following changes to your medications:
# STOP lamicatal, adderall and ativan. Your medications will be
adjusted by the psychiatrists.
# START daily potassium supplementation for one week until labs
normalize.
# START thiamine and folic acid supplementation
Please have labs checked by twice weekly to monitor electrolytes
and liver function for 2 WEEKS then transition to once weekly
lab checks until liver function tests completely normalize. | ___ y/o F with PMHx significant for depression with prior SA
(with various pills), who was admitted with Tylenol overdose.
.
. | 132 | 22 |
17575759-DS-2 | 25,235,534 | Ms. ___,
You were admitted to the hospital because of blocakages limiting
circulation to your intestines. You underwent surgery to fix
these blockages. After this first surgery, you had to go back
to the OR several times because of complications you were
having. Your circulation improved. While you were
hospitalized, you received a blood transfusion. Your appetite
was poor and you were not able to take in enough calories on
your own, so you were seen frequently by a nutritionist and a
speech and swallow therapist. A tube was placed through your
nostrils into your stomach to give you calories in addition to
the small amount of food you ate. You became delirious as many
people do while in the hospital during an illness. You are
getting better and ready to be discharged to rehab.
Please follow the below instructions carefully and call us with
any questions. ___. | Ms. ___ arrived to the hospital on ___ after an episode
of acute onset abdominal pain ___. CTA A/P demonstrated
complete occlusion of proximal segment of SMA 3.___s
a more distal segment of SMA of 6 cm w minimal reconstitution of
flow in between likely secondary to collaterals. No gross
evidence of bowel ischemia visualized. Diagnosis of acute
mesenteric ischemia was made. She underwent exploratory
laparotomy and had 15 cm of necrotic jejunum resected. She was
left in discontinuity with an abthera vac placed on the open
abdomen. She was taken back ___ POD#1 and POD#3 from initial
operation for washout, but was unable to be closed. She was
diuresed and taken back on POD#5 but was still unable to be
closed secondary to edema. Diuresis was continued, and she was
transfused with RBCs as needed for low hematocrit. On ___
she was primarily reconnected and her abdomen was closed. She
was extubated but reintubated for failure to clear secretions.
She was extubated a second time on ___ and remained
extubated for the duration of her stay. She had multiple guaiac
positive stools, thus her anticoagulation was discontinued and
will remain off per attending vascular surgeon Dr. ___. A
dobhoff tube was placed for nutrition. She was discharged to
rehab with dobhoff tube in place. Please see below for her
course by system.
Neuro: The patient was sedated while intubation but off sedation
when extubated; pain was initially managed with IV dilaudid and
then transitioned to oral medications once tolerating a diet and
cleared by speech and swallow.
CV: The patient's vital signs were routinely monitored, and she
was treated with blood transfusions and pressors as needed to
keep her hemodynamically stable.
Pulmonary: The patient remained stable from a pulmonary
standpoint; when intubated her vent settings were monitored and
when originally extubated she was closely monitored. When it was
noted that she was failing to clear secretions she was
re-intubated. There were no signs of aspiration. Once
extubated the second time her respiratory status remained
stable. Good pulmonary toilet and incentive spirometry were
encouraged throughout hospitalization when extubated.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___, the
NGT was removed, and a speech and swallow eval recommended
puree'd diet with thickened liquids. Due to poor oral intake, a
dobhoff feeding tube was placed. Patient's intake and output
were closely monitored. The dobhoff was pulled by the patient on
___ and not replaced. PO intake has gotten better but still
well below the appropriate.
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, and she was transfused with packed RBCs as needed.
Due to multiple guaiac positive stools, her anticoagulation was
discontinued.
The patient was discharged to a rehab facility that accepts
patients with dobhoff feeding tubes on ___ | 157 | 498 |
10901084-DS-25 | 25,004,448 | You were admitted to the hospital with abdominal pain and poor
tolerance to food. You were placed on bowel rest and given
intravenous fluids. The abdominal pain recurred when you resumed
food and you again were placed on bowel rest. Because of this,
you were taken to the operating room where you underwent an
exploratory laparotomy and lysis of adhesions. You have resumed
a diet without abdominal pain. A small area of your abdominal
wound is open and VAC dressing was placed to help facilitate
closure. Your vital signs have been stable and you are
preparing for discharge with the following instructions:
You were admitted to the hospital with abdominal pain and poor
tolerance to food. You were placed on bowel rest and given
intravenous fluids. The abdominal pain recurred when you resumed
food and you again were placed on bowel rest. Because of this,
you were taken to the operating room where you underwent an
exploratory laparotomy and lysis of adhesions. You have resumed
a diet without abdominal pain. A small area of your abdominal
wound is open and VAC dressing was placed to help facilitate
closure. Your vital signs have been stable and you are
preparing for discharge with the following instructions:
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 6 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.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
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 r 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.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. 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.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please 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 from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | ___ year old male admitted to the hospital with abdominal pain.
Upon admission the patient was made NPO, given intravenous
fluids, and underwent a cat scan which showed dilated proximal
small bowel loops with air-fluid levels, compatible with a
small bowel obstruction. This finding showed progression of the
bowel obstruction from the prior imaging. Based on these
findings, the patient was placed on bowel rest. He was placed on
a heparin drip because of his history of LV thrombus.
Coagulation studies were monitored and adjustments in the rate
were made according to protocol. After return of bowel function,
the patient resumed clear liquids and slowly advanced to a
regular diet. He again experienced a recurrence of abdominal
pain and was made NPO. He underwent an MRE which showed a
persistent mechanical small-bowel obstruction. Based on these
findings, the decision was made to take the patient to the
operating room. He underwent cardiac clearance and was taken to
the operating room on HD #7 where he underwent an exploratory
laparotomy, extensive lysis of adhesions, and jejunal resection
x 2. His operative course was stable with a 75cc blood loss.
The patient was extubated after the procedure and monitored in
the recovery room.
The patient did well in the PACU. He was alert and oriented x3.
His pain was well controlled and his urine output was
appropriate. After a brief stay in the PACU he was safely
transferred to the floor where his vital signs remained stable.
On ___, pod 1, a heparin drip was restarted which was
subsequently kept at a therapeutic range by trending ptt's every
6 hours. His wbc was slightly elevated which was attributed to
the normal stress incurred during the procedure. His Cr was 1.5
which was attributed to him being slightly volume down. He
received appropriate Iv fluids and his Cr trending down to his
baseline level. He received metoprolol IV while we were awaiting
return of bowel function. The patients pain remained well
controlled and he was able to ambulate early and often after
surgery. The patient started on a clear liquid diet on ___
as he was passing flatus. The patient reported some difficulty
tolerating the full liquid diet at first but had no episodes of
nausea, vomiting, or change in physical exam of his abdomen.
Some erythema around his wound was noted on ___ and some
staples were removed to express any fluid that had accumulated
in his wound. The wound was probed and cultures were sent. On
the following day, more staples were removed and the track was
further probed to express any remaining fluid. The wound was
packed with a wet to dry gauze dressing that was changed twice a
day. At this point, the patient was starting to tolerate a full
liquid diet better. On ___, the patient was transitioned to
po pain meds, which enabled us to discontinue the heparin drip
and start his home dose of apixaban. Further, he was
transitioned to a regular diet and put on a bowel regimen. He
tolerated this transition well. On ___, a wound vac was
placed in his surgical midline wound to aid in healing. His
wound healed nicely and the wound vac was discontinued on
___ and he was transitioned back to bid dressing changes
prior to his discharge to his rehab facility. At the end of his
hospital course, the patients vital signs were stable, he is
ambulatory independently, his pain is well controlled, he was
tolerating a regular diet, and his surgical site is healing
appropriately. He was provided with the appropriate discharge
instructions and an appointment for follow up. | 1,011 | 613 |
16663465-DS-42 | 23,713,853 | Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for nausea and dark vomiting.
What was done for me while I was in the hospital?
- We gave you anti-nausea medication and checked your labs to
make sure you weren't bleeding.
- Your labs were stable, so you did not need to get endoscopy.
- We slowly advanced your diet back to regular.
What should I do when I leave the hospital?
- Go to your follow-up appointments.
- Take all your medications correctly.
- Do not drink alcohol.
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ year-old man with T1DM complicated by ESRD s/p
DDRT in ___, neuropathy, gastroparesis, HFrEF borderline, a
fib, HTN, hypothyroidism, cirrhosis (likely EtOH +/- HBV) who
presented for evaluation of nausea and dark emesis, with ongoing
nausea/abdominal pain but stable hemoglobin and hemodynamics
without any observed hematemesis since presentation, discharged
with plan for GI follow up.
# Vomiting, possible hematemesis
Patient reported dark/red emesis about an hour after drinking
___ glasses of red wine 4 days ago along with nausea and
abdominal pain. He reported that he had stopped drinking for
several weeks prior to that. It is unclear if this was truly
hematemesis, given that the dark emesis may have been the red
wine in the setting of gastroparesis. We also considered ___
___ tear vs. gastritis from ETOH use. He was hemodynamically
stable with stable Hgb since ED presentation on ___, with a
negative stool guiac. He was initially started on ceftriaxone,
octreotide, and IV PPI BID. Octreotide was stopped in the ED per
GI. He was admitted due to not being able to tolerate PO. On the
floor his blood counts remained stable so EGD was deferred. He
was able to tolerate a normal diet so we discharged him to home
with his home resources restarted. His home apixaban, BP meds,
diuretic, and beta blocker were held due to concern for
bleeding, but were resumed on discharge. He was prescribed PO
cipro for 4 days to complete a 7 day abx course for infection
prophylaxis in a cirrhotic patient. He will require a follow up
with the hepatology department to possibly pursue outpatient
endoscopy.
# ABDOMINAL PAIN
# NAUSEA
# INABILITY TO TOLERATE PO
The patient presented with nausea/emesis as above, likely
secondary to gastroparesis and gastritis secondary to EtOH. KUB
showed a non-specific bowel gas pattern, but the patient had a
non-bloody, non-melenic BM on day of presentation so there was
low suspicion for obstruction. Lactate was not significantly
elevated and lipase was normal. RUQUS was unremarkable without
ascites or biliary obstruction. There was a mild elevation in
Tbili to 2.2 but no transaminitis or elevated INR to suggest
alcoholic hepatitis. UA was without evidence of infection. He
was given Compazine prn and his diet was advanced to a full DM
diet before discharge.
# TYPE I DIABETES:
Patient has significant microvascular complications. There was
no evidence of DKA during the admission. He was noted to have
large glucose and some ketones on UA, but he had identical UA on
admission in ___ when he had very similar presentation. He
was continued on his home diabetes regimen.
# URINARY RETENTION
Patient had urinary retention in the ED, initially requiring
foley for 849cc of urine. The etiology is unclear, and it seems
this has been a problem on prior admissions as well. The foley
was pulled in the ED, with pre-void bladder scan of 300cc and
post-void with 100cc. On the floor, patient was able to urinate
without issue throughout the hospitalization.
# ESRD ___ TYPE I DIABETES, s/p DDRT ___:
Cr at baseline on admission. He was continued on mycophenolate
mofetil 500mg BID and tacro 1 mg BID. Tacro level was 16. Per
renal transplant, the level is inaccurately high due to timing
of the trough <12 hrs after last dose. They recommended
rechecking the tacro level as an outpatient within the next
week.
CHRONIC PROBLEMS:
=========================
# ATRIAL FIBRILLATION:
Held apixaban due to c/f GI bleed. Restarted on discharge.
# CIRRHOSIS:
# HEPATITIS B: Patient has Child's class A cirrhosis, cirrhosis
likely ___ HBV + EtOH. No signs of decompensation during this
hospitalization and probability of variceal bleeding is very
low. Held home diuretics overnight given question of GIB and dry
appearing on exam, but was continued on discharge. We also
continued lamivudine for HBV.
# EtOH USE: Reports 3 glasses of red wine on Father's Day.
Otherwise, last drink was several weeks ago prior to last
admission in ___. No evidence of withdrawal during admission.
# HFmrEF: Last LVEF in ___ 40-45%. Restarted diuretics on
discharge.
#HTN: Anti-hypertensives were initially held in setting of
concern for GIB but restarted on discharge.
#THROMBOCYTOPENIA: Chronic, stable. Likely due to cirrhosis,
MMF.
#HYPOTHYROIDISM: Continued levothyroxine 25mcg daily
#HLD: Continued atorvastatin 40mg qHS | 108 | 693 |
14266063-DS-4 | 20,521,528 | Dear Mr. ___,
Why you were here?
You came in after a fall
What we did while you were here?
We found out that you had pancreatic cancer.
You have an infection in your liver that is related to your
pancreatic cancer. We cannot treat the infection.
We are now focusing in your comfort and will have you go home
with hospice.
What to do when you go home?
If any questions come up please contact the hospice help line.
It was a pleasure taking care of you.
Your ___ Team | ASSESSMENT AND PLAN: ___ yo M with T2DM not on insulin,
presenting with progressive weakness and weight loss, with new
diagnosis of pancreatic adenocarcinoma now with cholangitis that
cannot be intervened upon. Patient transitioned to CMO and
discharged home on hospice.
#Goals of care
Patient with metastatic pancreatic adenocarcinoma, there are no
options for treatment. Patient transitioned to CMO and will be
discharged home on hospice.
#Metastatic pancreatic adenocarcinoma
#Elevated transaminases
#Weight loss
S/p biopsy of metastatic site (liver) with pathology consistent
with adenocarcinoma. CEA and Ca ___ markedly elevated. Heme/onc
consulted, patient not a candidate for chemotherapy in setting
of cholangitis.
#Sepsis secondary to cholangitis
#L intrahepatic duct compression
Patient with fever to 102, leukocytosis, tachycardia and rising
bilirubin. Fevers may be secondary to multiple thrombi, tumor
fever or L intrahepatic duct compression ___ to tumor burden.
Not a candidate for ERCP given location of intrahepatic duct
compression. Initially on Ceftriaxone/Flagyl (___),
antibiotics broadened given sepsis to Vanc/Flagyl/Cefepime
(___). ___ unable to offer drainage of intrahepatic duct
given concern for seeding bacteria into additional ducts and
poor functional reserve of liver. Will discharge with
Cipro/Flagyl for ___an be discontinued at any time
if they are causing patient discomfort.
#Multiple subsegmental PEs
#Tachycardia
Patient with CTA chest on ___ with multiple subsegmental PEs,
splenic vein thrombus and L femoral vein thrombus. Likely
etiology of tachycardia. Trop <.01 and BNP 365,TTE with no e/o
RH strain. Anticoagulation with heparin gtt, transitioned to
lovenox BID. Discontinued prior to discharge.
#Occluded or severely attenuated left portal vein
Patient with occlusion of L portal vein on MRCP with multiple
left upper quadrant collateral vessels. Discussed with radiology
likely secondary to tumor burden not thrombus given no e/o vein
expansion or hypoattenuation.
#Rib fractures: Pain on the left side, with extensive bruising.
Reduced inspiratory capacity. Pain well controlled with Tylenol,
Ibuprofen, Lidocaine patch, Morphine Sulfate Liquid 5mg Q6prn.
#Hypercalcemia: Could be related to malignancy, or dehydration.
PTH is low so unlikely to be primary hyperparathyroidism. PTHrP
within normal limits. 25 Vit D is 22. S/p pamidronate on ___.
#Wt loss
#Aspiration risk
Patient disinterested in eating. Evaluated by speech and
swallow, patient at risk for aspiration, recommended NPO.
Discussed with family, it is within patient's GOC to continue
eating with accepted aspiration risk.
#Elevated INR:
#Anemia and thrombocytopenia
Likely secondary to malignancy/dilution. Likely liver
dysfunction in setting of extensive mets. S/p Vit K x 3 days
with no improvement.
#DM:
Initiated on Lantus 10u QHS. Discontinued at time of discharge. | 81 | 400 |
17782789-DS-25 | 23,280,865 | Dear Ms,
It was a pleasure caring for you at the ___
___. You were admitted for pain in your chest and
abdomen. We perfored blood tests and an EKG that showed there
are no new problems with your heart. We also preformed an
ultrasound of your abdomen that showed no problems with your
liver or pancreas. Given your pain has completely resolved, we
feel you are safe to return home. We will email your
Cardiologist, Dr ___, to let him know you were in the
hosptial. He may want to perform a stress test as an outpatiet.
We made no changes to your medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Primary Reason for Admission: ___ year old woman with systolic
CHF (EF 40-45% ___, h/o previous pulmonary embolus, PVD,
hypertension, hyperlipidemia presents with self limited
abdominal pain admitted to ___ for sets and a stress test.
. | 119 | 37 |
13478814-DS-33 | 25,708,366 | HOSPITAL SUMMARY
You were admitted to the hospital after having watery diarrhea
and 3 episodes of passing out at home. We diagnosed you with a
urinary tract infection for which we are giving you
ciprofloxacin, an antibiotic. We also found that you had an
infection of your colon caused by the bacteria, Clostridium
difficile, for which we are giving you a different antibiotic,
vancomycin. We believe the reason for your passing out is due
to dehydration from your diarrhea.
WHAT TO DO AT HOME
1. You will need to take ciprofloxacin until ___ or when
you run out of your prescription.
2. You will need to take vancomycin while you are taking
ciprofloxacin and continue for 2 weeks after you finish
ciprofloxacin. Therefore you will take vancomycin every 6 hours
until ___.
3. Please weigh yourself every morning after you wake up and go
to the bathroom but before you get dressed. If your weight goes
up by more than 3 pounds in 1 day or 5 pounds in 2 days, please
call your doctor and let them know.
4. Please note that there was a change in your regular
medications. In particular the brand of your mycophenolate was
changed. We changed it from CellCept to Myfortic. We have sent
the new prescriptions to your pharmacy so that you will receive
the right medication. | SUMMARY
Ms. ___ is a ___ lady with a PMH notable for type 1
diabetes, ESRD status post DDDRT (___) and PAKT (___)
complicated by acute pancreas rejection (___), CAD s/p CABG
and PCI to RCA, seizure disorder, and hypertension, who
presented with 2 days of watery diarrhea and 3 episodes of
syncope. The etiology of her syncope was thought to be due to
dehydration from diarrhea. She had an unremarkable TTE, which
showed normal EF (53%) with regional wall motion abnormality in
the RCA territory, no significant change from prior. She was
found to have C. difficile colitis which improved with
vancomycin p.o. The patient's CellCept was switched to Myfortic
360 mg p.o. twice daily to help improve diarrhea. She was also
found to have a UTI due to pansensitive Pseudomonas, for which
she was initially treated with meropenem and subsequently
ciprofloxacin for 7 days total, last day ___.
TRANSITIONAL ISSUES
[ ] UTI: complete ciprofloxacin 500 mg BID for 7 day course,
initially treated with meropenem, last day ___.
[ ] C. Difficile Colitis: complete vancomycin 125 mg PO Q6H 2
weeks after stopping ciprofloxacin, last doses ___.
[ ] Follow Up: Transplant ID will arrange follow up with them in
clinic.
[ ] Medication Changes: Switched Cellcept to Myfortic 360 mg PO
BID. | 229 | 210 |
10266518-DS-5 | 28,290,870 | * You were admitted to the hospital with an infection in your
right sternoclavicular joint which required debridement and
subsequent dressing changes. You will eventually need the
Plastic surgeons to close the area but in the mean time you will
need IV antibiotics and VAC dressing changes.
* A PICC line was placed for antibiotics and the Infectious
Disease service will determine the course but it's likely ___
weeks. You will need to be hospitalized during that time.
* Continue to eat well and stay well hydrated to help with
healing.
* Get out of bed and walk frequently
* The narcotic medications can cause constipation so make sure
that you take a stool softener or laxative to stay regular.
* You will need to be followed closely by the Plastic Surgery
service and Dr. ___. | Mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
managemnent of his right sternoclavicular osteo. He was hydrated
with IV fluids and also evaluated by the Infectious Disease
service for appropriate antibiotic coverage. Vancomycin was
initiated on ___ after blood cultures from OSH grew GPC in
clusters whih eventually MSSA.
He was taken to the Operating Room on ___ where he
underwent resection of the right sternoclavicular joint. The
wound was eventually VAC'd and began to clean up well. The
tissue cultures were + MSSA. He eventually had a left SL power
PICC line placed on ___ for ___ weeks of antibiotic therapy
with Vancomycin. That was the preferred drug as he developed
neutropenia and a rash after treatment with Ceftriaxone during
his earlier admission. He had a cardiac echo which ruled out any
valvular vegetations.
His Vancomycin dose was adjusted on multiple occasions and his
trough was 19.7 which reflrcted 1500 mg Q 8 hrs. The ID service
recommended decreasing the dose to 1250 mg Q 8 hrs. A trough was
done on ___ AM which was 19.6 with a goal of ___.
The final ID plan is for ___ week course of iv vancomycin 1250mg
q8.
Start date: ___
End date: ___ vs ___
Pt should have cbc+diff, basic, lfts, esr, crp and vanc levels
weekly.
Access: 44cm left SL power picc placed ___.
ID follow up during admission to the ___.
On discharge from the ___, he should have ___ clinic follow
up with ___ on ___ at 3pm to discuss
treatment options for Hepatitis C.
He also had some problems with opiate withdrawal on admission,
eventually becoming tachycardic and having muscle cramps as well
as GI upset. He was placed on ___ protocol and his daily
Methadone dose was increased to 20 mg QD. He was given oral
Dilaudid on a prn basis and his symptoms resolved.
The Plastic surgeons feel that the wound needs to improve prior
to surgery and for that reason he was transferred to rehab on
___ where he can get his antibiotics and continue with VAC
dressing changes. He will follow up in the Plastic Surgery
Clinic on ___. | 133 | 367 |
18586624-DS-20 | 26,854,128 | Instructions After Orthopedic 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.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take lovenox for 2 weeks to help prevent the formation
of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after
surgery. Let water run over the incision and do not vigorously
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: weight bearing as
tolerated at all times in both legs
Physical Therapy:
WBAT in BLE. ROMAT. No hip precautions.
Treatments Frequency:
Daily dry sterile dressing to left hip wound site | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemiarthroplasty which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to ___ 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
WBAT LLE, and will be discharged on lovenox x2 weeks for DVT
prophylaxis. The patient will follow up in two weeks 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. | 488 | 256 |
17793825-DS-15 | 20,703,905 | Mr. ___,
You were admitted due to fever after receiving a platelet
transfusion. You had persistent fevers therefore and was found
to have a pneumonia (lung infection) and a stomach infection.
You were placed on IV antibiotics and when your counts improved
your symptoms improved as well. | Mr. ___ is a ___ male with FLT3+ AML
most recently s/p cycle ___ MiDAC consolidation, presenting
originally with FN now extended stay to work up lung findings on
CT chest.
#pulmonary nodules: originally noted for RUL mass on ___ with
persistent FN work up, never had signs/symptoms of respiratory
distress or symptoms including no hypoxia cough. question
malignancy vs opportunistic infection, initiated treatment dose
antifungal with posaconazole and significant improvement in
fever
trend. repeat CT chest to evaluate mass on ___ noted
persistent
mass of similar size with new disseminated nodules scattered
throughout with some cavitation. reconsulted ID for
recommendations.
-r/o TB with 3 sputum cultures--smear neg, quant gold neg
-send AFB b culture NTD
-resent fungal markers
-f/u toxo studies
-underwent bronch on ___ and tolerated well
-GPC growing on bronch, will treat with cefpodoxime x14d per ID
(___) and f/u with sensitivities outpatient
-patient remains clinically stable with count recovery and no
signs/symptoms of infection, plan to d/c home after bronch if
remains this way and will f/u with results outpatient, ID
scheduled outpatient as well. plan to continue posaconazole for
extended period of time per ID recs.
#Febrile Neutropenia: Neutropenia resolved. afebrile >1 week.
Most likely source of fever was mucositis/esophagitis and
questionably lung opportunistic infection as above. peeled off
___ with count recovery and symptomatic improvement,
remains on antifungal coverage per ID.
#Thrombocytopenia: resolved. Due to chemotherapy. He requires
HLA match platelets. He last received 1 unit of HLA matched
platelets on ___. He was on Promacta *NF* (eltrombopag)
100mg oral DAILY, held since ___ with count recovery, will
resume during nadir of next chemotherapy cycle.
#Anemia and Neutrapenia: Improving, likely secondary to recent
consolidation therapy. Showing signs of counts recovery with
evidence of monocytosis. He has no evidence of circulating
peripheral blasts. In regards to his anemia, he has not required
PRBCS since ___. Transfuse if hgb <7 and/or active bleeding
#AML FLT3+: s/p 7+3 midostaurin, in remission. Admitted for C1
MiDAC consolidation (day 6 - ___ s/p neulasta on ___.
-premedication with Tylenol/Benadryl for plts transfusion
#Hyperbilirubinemia: resolved, continue to monitor and trend
#Electrolyte Imbalances: Improved but ongoing hypophosphatemia,
now on BID repletion's adjust prn.
#Prior PICC associated upper extremity clots: Holding
anticoagulation given thrombocytopenia. Repeat upper extremity
ultrasounds on the right shows unchanged deep vein thrombosis in
the right basilic vein, unclear if need to continue anticoag
treatment or not, will discuss with primary attending when
counts
more robust and post bronch
#POC Hematoma: Improved. Evaluated by venous access, reconsulted
venous access to assess site
#GERD: On an oral PPI
#Iron Overload: Holding deferasirox during chemotherapy
#T2DM: holding metformin, low dose sliding scale
#FEN: IVF/Replete PRN/Regular low-bacteria diet
#ACCESS: Port
#PROPHYLAXIS:
-Pain: discontinued dilaudid
-Bowel: Colace/Senna as needed
-GI: Protonix PO since ___
-DVT: holding lovenox due to bronch
#CODE: Full code
#EMERGENCY CONTACT: ___ ___
#DISPO:home f/u ___ in clinic or sooner if issues arise,
pulm/ID f/u to be set outpatient | 46 | 454 |
19877091-DS-19 | 23,067,854 | Dear Ms. ___,
You came in with low sodium levels. We think this was due to
drinking too much water at home. When you go home you should
make sure not to drink more than 1.5L of fluid a day. You should
also make sure to eat enough salt. Ensure supplements can also
help increase sodium levels.
You also had a cough, which is most likely due to bronchitis.
You can continue taking cough medication as needed.
It will be very important to have your sodium levels checked on
___. We are sending you a prescription that you can
take to the lab.
It was a pleasure taking care of you, and we are happy that
you're feeling better! | Ms. ___ is an ___ female with a past medical history of
hypertension and breast cancer s/p mastectomy, who presented to
the ED with elevated blood pressure and was found to be
hyponatremic. | 115 | 33 |
19156989-DS-16 | 25,557,503 | Ms. ___,
You were hospitalized because of your shortness of breath and
were found to have a flair of your COPD, perhaps set off by a
beginning pneumonia. You received antibiotics, breathing
treatment, oral steroids. Your breathing improved. You were
weaned off of the supplementary oxygen and your oxygenation when
walking improved.
New Medications:
Please take levoquin 750mg Daily for 2 more days
Please take prednisone 40mg Daily for 2 more days
Please take all of your prescribed medications as they are
prescribed to you (i.e spiriva every day not just when you have
trouble breathing) to help prevent further COPD flairs. | Primary Admitting:
___ yo F with COPD, HTN, HL presented with cough and dyspnea and
was found to have a COPD exacerbation complicated by a potential
early PNA. | 97 | 27 |
16053379-DS-12 | 28,977,988 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted due to abdominal pain and very
high potassium. Your pain is most likely due to stretching of
your belly from the fluid you had accumulated. Your potassium
was high, probably due to an interaction between potassium
supplements and a high potassium diet with spironolactone. It is
very important you do not take potassium supplements, and to
avoid foods that are high in potassium (or at least use caution)
while you are on this medication.
Please STOP your furosemide and spironolactone until you see Dr.
___ on ___, and please have your labs checked then. | ___ yo male with a pmh of HIV and HCV cirrhosis complicated by
refractory ascites, esophageal (grade 1) and rectal varices, who
presented to clinic with positional abdominal pain and malaise.
# Hyperkalemia: Due to exogenous intake in setting of recently
starting spironolactone. On presentation to the ED he was
hyperkalemic to 8.1, with a creatinine of 1.8 from a normal
baseline. He had been having occasional leg cramps at home,
thought that he was low in potassium, so he took OTC potassium
supplements. He drinks a large glass of carrot juice in the
morning, and he was also recently switched to spironolactone. He
was treated with kayexalate, insulin and dextrose, bicarb, and
calcium gluconate. His EKG showed peaked t-waves and slightly
long QRS. His potassium and EKG improved with the above
measures. He was strongly advised against further potassium
supplements, educated on low potassium foods, and advised to
tell Dr. ___ time he is considering other OTC or
homeopathic medications.
***Please check electrolytes at/before next visit
# Position Abdominal pain: Labs and exam unrevealing for source.
He had an US in the ED of his abdomen that showed his known
portal vein thrombosis, but no other acute intra-abdominal
process. His pain is largely positional (sitting up or laying on
his side) and improves with movement. He has never had the pain
while active. IT was felt this was mostly peritoneal/MSK
stretching due to his organomegaly as well as the recent
drainage of his very distended abdomen (now much smaller than
before). He was comfortable and without pain by time of
discharge with outpatient followup.
# Acute Kidney Inury: Likely due to dehydration and
overdiuresis. Patient appeared very dry on exam and FENA 0.8%
consistent with pre-renal etiology. Volume down given recent
paracentesis and diuretic change. Patient improved with fluid
challenge and was advised to STOP furosemide and spironolactone
followup with outpatient hepatology and lab checks this week.
***Please check electrolytes at/before next visit
***Consider restarting furosemide and spironolactone,
potentially at reduced doses.
# Hepatitis C cirrhosis: Complicated by portal hypertension,
diuretic refractory ascites, and gastrointestinal varices in the
esophagus (grade 1 in ___ and the rectum (large on
sigmoidoscopy in ___, and portal vein thrombosis on
warfarin. On the transplant list at ___. Currently requiring a
tap every month. No acute decompensation, and diuretics held as
above. Held Nadolol 40mg
# HIV: Most recent CD4 89 on ___. Continued home HAART
regimen and acyclovir. | 108 | 402 |
16209832-DS-17 | 22,011,184 | Dear Ms. ___,
You came to ___ because your blood pressure was very low and
you were feeling lightheaded. Please see more details listed
below about what happened while you were in the hospital and
your instructions for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
-We STOPPED your blood pressure medication called lisinopril.
-We monitored your blood pressure and it was normal.
-You had blood work done which was all normal.
-You had some tests done, including blood work and an
electrocardiogram, that showed that you did not have a heart
attack.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
-Do not restart your lisinopril until your primary care doctor
says you should restart it.
-Do not drive or take a bath when you are home alone because of
your pseudoseizures
-Follow up with your PCP within ONE WEEK to check on your blood
pressure | Key Information for Outpatient ___ y/o female with
PMHx of neurofibromatosis type 1, HTN, HLD, pseudoseizure,
anxiety who presents from outpatient ___ clinic for chest
pain, syncope, hypotension, found to have orthostatic
hypotension which improved with fluids and also holding
lisinopril.
ACTIVE ISSUES
=================
#Syncope
#Hypotension
Patient with several episodes of syncope in the past couple
weeks coinciding with recent initiation of lisinopril. This had
been started at rehab due to report of symptomatic blood
pressures 200s/100s over 2 days (preceded and followed by
normotension); she had previously been on atenolol and losartan.
Telemetry did not alarm; EKG was normal. Her orthostatic vital
signs were positive on ___ am but improved with PO fluids.
Suspect syncopal episodes from over-medication and dehydration.
Lisinopril was discontinued and she was encouraged to drink
fluids. Prazosin was also held during the hospitalization in
case of contribution. She was not familiar with this medicine.
#Anxiety
#Psychogenic nonepileptiform seizures. Patient had a witness
episode of pseudoseizure overnight ___. Vitals remained
stable and patient was A&Ox3 after the episode. During hand drop
test the patients hand did not fall on her face. She had no aura
or postical phase. She is following up with neurology as an
outpatient. Continued home escitalopram, prazosin, lamotrigine.
Home clonazepam held secondary to presyncope.
#Chest pain. She had reassuring EKG and neg trops x2. ___ be GI
related vs anxiety. Continued on famotidine.
CHRONIC ISSUES
==================
#GERD. Continued famotidine 20mg.
#HLD. Continued home simvastatin.
TRANSITIONAL ISSUES
======================
HELD MEDICATIONS: Lisinopril, clonazepam, prazosin.
[ ] Consider restarting low-dose anti-hypertensive if blood
pressure remain elevated in the outpatient setting.
[ ] Consider restarting prazosin as outpatient. Presumed that
she is taking it for off-label use for PTSD.
#Full code
#Health care proxy/emergency contact: Husband ___.
___, h: ___ | 164 | 283 |
14245674-DS-9 | 26,738,151 | Please call the Dr. ___ office at ___ for fever,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, incisional redness, drainage or bleeding,
inability to tolerate food, fluids or medications, yellowing of
skin or eyes, inanbility to pas gas or other concerning
symptoms.
No lifting greater than 10 pounds
No driving if taking narcotic pain medication
Continue all home medications as ordered. | She was taken to the OR on ___ for repair of umbilical
hernia for incarcerated umbilical hernia. Surgeon was Dr.
___. Please refer to operative note for details.
Postop, she did well. Vital signs were stable. Sips were started
on postop day 1 and diet was advanced over subsequent days. She
was passing flatus, but did not have a BM. Colace and Senna were
ordered.
Abdominal incision (periumbilical incision)appeared intact
without redness or drainage. Abdomen was soft. She used minimal
pain medication (morphine initially then oxycodone).
___ was consulted and felt that she was safe for home without
assistive devices. Previous ___ services were ok to resume. She
was ambulating independently. ___ services were offered, but she
refused services.
She was discharged to home in stable condition. | 59 | 128 |
14486034-DS-13 | 25,679,860 | Please call the Transplant Office ___ if you have any
of the following: temperature of 101 or greater, shaking chills,
nausea, vomiting, inability to eat/drink or take any of your
medications, chest pain, urinary frequency, urine cloudy/bloody
or foul smelling, or pain with urination, decreased urine
output, weight gain of 3 pounds in a day | She was admitted to the Transplant Service. EKG was without
acute changes. Serial troponins were all less than 0.01. She was
started on Protonix and Reglan. Chest discomfort was attributed
to GERD symptoms.
UA, urine and blood cultures were sent. UA was positive.
Ceftriaxone was started for UTI. She remained afebrile and
denied dysuria. She felt well enough to go home. Nephrology saw
her as well. Cefpodoxime was recommended for 1 week.
Of note, Prograf level was not a true trough level as she had
taken Prograf late the preceding night.
She was discharged to home. | 55 | 97 |
17436868-DS-14 | 26,254,956 | Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
after a fall sustaining a left temporal bone fracture and a
small head bleed. You were seen by the Ear, Nose, and Throat
specialists who evaluated the decreased hearing in your left
ear. You ear exam showed blood and air bubbles behind the ear
drum. Your hearing should gradually improve as this injury
continues to heal. Please continue to put ear drop in as
prescribed to prevent infection. Please call and schedule a
follow up appointment to have your ear and your hearing
re-tested in 3 weeks. You were seen by the neurosurgery service
for the head bleed and you should continue to follow the
"traumatic brain injury" instructions. Please call and schedule
an appointment in the concussion clinic in 4 weeks if you
continue to have post-concussive symptoms.
You are now ready to be discharged to home with the following
discharge instructions.
**IF YOU DEVELOP FACIAL NERVE WEAKNESS YOU NEED TO RETURN TO THE
EMERGENCY DEPARTMENT IMMEDIATELY FOR EVALUATION.**
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.
Sincerely,
Your ___ Team | Ms. ___ was admitted after sustaining a fall after
reportedly being pushed down by a security guard at a local
event. She was admitted to the Acute Care Surgery service and
was found to have a contusion on the occiput, a left left
temporal bone longitudinal fracture, left mastoid air cell
opacification, and a small subarachnoid hemorrhage around the
left temporal lobe. No other injuries were found. She was
evaluated by the neurosurgery service and non-surgical
management was recommended. Given her injuries and reportedly
decreased hearing on the left side, she was seen by the Ear,
Nose, and Throat specialists who evaluated the decreased hearing
and directed the patient to follow up in the outpatient clinic.
After two days of observation with decreasing size of the
hemorrhage in the cranium and improving hearing in the setting
of stable vitals, the patient was discharged with direction to
follow up with Dr. ___ to schedule a follow up
appointment in approximately 3 weeks with an audiogram.
Active Issues:
================
# Contusion of occiput, Temporal bone fracture, TBI: Patient was
evaluated by the neurosurgery service and was found to have a
normal neurological exam short of hearing loss on the left.
Given the small size of her SAH, her improvement on re-imaging
and improvement of her symptoms, decision was made for patient
to follow up with the concussion clinic as needed.
# Decreased hearing on left side: Patient was evaluated by ENT
and a plan for followup in outpatinet setting was planned. At
time of discharge the patient reported improving hearing on the
left side.
Chronic Issues:
================
NA
Transitional Issues:
======================
# Follow up with your PCP
# ___ up with Dr. ___ to schedule a follow up
appointment in approximately 3 weeks for an audiogram.
# Follow up with Concussion Clinic as needed.
# Medication Changes:
NEW Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
NEW Ciprofloxacin 0.3% Ophth Soln 3 DROP LEFT EAR TID | 392 | 325 |
15404950-DS-25 | 26,522,997 | Dear Ms. ___,
You were admitted to the hospital for a rash and facial
swelling. Your rash ultimately was felt to be most likely due to
partially treated psoriasis (however could not rule out drug
reaction) - the pathology did not show evidence of
life-threatening rashes such as SJS or DRESS. You also had a lot
of facial swelling during your hospitalization, which Allergy
saw you for and recommended continued doses of IV Benadryl and
the rest of your Mast Cell Activation Syndrome medications.
Finally, you developed neck pain and a bit of discharge from
your T-tube, which IP did a bronchoscopy for on ___.
Ultimately, you were stable for discharge.
What to do at home:
-Take all of your medications as prescribed below
-Go to all of your appointments as scheduled below
We wish you the best,
Your ___ Care Team | Ms. ___ is a ___ woman with a complex PMH of class III
obesity, Ehlers-Danlos Syndrome, Tracheobronchomalacia s/p
T-tube placement, PE on Lovenox, severe OSA, mast cell
activation syndrome, GERD, psoriasis, eczema, borderline PD, and
anxiety, admitted for new onset rash and facial swelling -
overall felt to be due to a psoriasis flare as well as MCAS
flare.
# Rash
# Psoriasis flare
Dermatology was consutled, who recommended high dose steroids
with a slow taper. There was initial concern for drug reaction
or DRESS, however pathology was most suggestive of psoriasis
(and not SJS/TEN, DRESS, drug reaction, or mast cell
activation). Was treated with Methylprednisolone 150mg daily x3
days and then transitioned to 150mg PO Prednisone daily (with
taper plan of decreased Prednisone by 20mg q3 days). She was
also started on NF Otezla while inpatient, as per Dermatology
recommendations. She was otherwise continued on her outpatient
Dermatology topicals of Triamcinolone and Clomitrazole. Given
pathology could not definitively rule out drug reaction, her
Chantix was discontinued (as this was started ~1 month prior to
the worsening rash) - per Derm, PCP could consider restarting as
an outpatient once her current flare settles out. Finally, she
was started of PCP ___ 1500mg daily x21 days given
prolonged steroid use.
# Dyspnea
# Community Associated Pneumonia
# Tracheobronchomalacia
# Recurrent idiopathic angioedema w/ multiple episodes of acute
respiratory failure requiring intubation
Follows with Dr. ___ in IP, who was already planning for an
outpatient bronchoscopy. As such, had a bronchoscopy on ___ to
consider T-tube adjustment as well as to obtain bronchial
washings. On admission, was noted to have a possible right lung
base pneumonia and as such was treated with IV Ceftriaxone x5
days for CAP. Of note, attempted to provide atypical coverage
however had an anaphylactic reaction to Doxycycline and has been
unable to tolerate Azithromycin or Levaquin - nonetheless, her
urine legionella returned negative. Strep pneumo and MRSA
negative as well. Was otherwise continued on her home
Guaifenesin ER 1200mg q12 hrs, home nebulizers of Albuterol q2
PRN, Acetylcysteine BID PRN, 3% NaCl BID, and 7% NaCl BID.
Finally, patient had a bedside laryngoscopy on ___ that showed
granulation tissue but no obstruction.
# ___ Syndrome
# Facial swelling
# Acute on Chronic Mast Cell Activation Syndrome
Has port in place for home IV benadryl. Was otherwise continued
on her current MCAS regimen: Cetirizine 10 mg QID, Ranitidine
150 mg BID, Famotidine 20mg BID, Omeprazole 20mg BID. She also
received 50mg IV Benadryl PRN (often received ___ doses per day;
at home takes ___ doses per day per Allergy). Allergy was
consulted, who recommended this continued regimen - they are
currently considering continuous Benadryl infusions as an
outpatient.
# Neck pain
Patient noticed new and worsening neck pain and swelling, as
well as new mild yellow discharge around her trach. CT Neck w/
contrast without evidence abscess or gas. Rising leukocytosis
concerning for possible tracheitis, though patient remains
afebrile with minimal sputum production and no new oxygen
requirement. Overall, she received a course of antibiotics for
CAP early in her hospitalization - but given her clinical
stability, was not restarted on antibiotics given upcoming
bronch. Her bronchoscopy on ___ demonstrated granulation tissue
that was subsequently debrided and she had a t-tube revision as
well.
# Anxiety
# Borderline PD
# Chronic Pain
Pt follows previously with Psychiatry at ___, currently on
waiting list to establish with new outpatient psychiatrist. Has
been felt that her anxiety may be contributing to her dyspnea.
As per her hospitalization plan, continued her home Clonazepam
0.5mg BID PRN and Oxycodone 10mg q4 PRN, started Quetiapine
100mg QHS and 50mg BID. Obtained frequent ECGs for QTc
monitoring. Otherwise increased her home Trazodone to 150mg QHS
for insomnia as per below while she is on high dose steroids.
# Insomnia
Patient noted that since admission she was having worsened
insomnia, likely in the setting of high dose steroids. As such,
increased Trazodone to 150mg QHS and added Ramelteon, which was
helpful. She was otherwise continued on Seroquel 100mg QHS as
per her hospitalization plan. At discharge, was continued on an
increased dose of her home Trazodone to 150mg QHS.
# H/o adrenal insufficiency
Has history of adrenal insufficiency. Patient refused to take
steroids as recommended until Cortisol obtained given her fear
for adrenal crisis. As such, obtained a Cortisol which was low
at 1.0 - however this is expected given she was on a steroid
taper since ___. Per Endocrinology, recommend outpatient
Ednocrinology follow up once current Prednisone taper is
completed for further evaluation.
# Pulmonary vascular congestion
Noted on CXR to have new pulmonary vascular congestion (since
___ that was more prominent on ___ CXRs. Last TTE in
___ was extremely limited, and as such obtained repeat TTE
that was without obvious abnormalities. | 137 | 783 |
18673777-DS-17 | 25,618,492 | Dear Mr. ___,
It was a pleasure to be part of your care at ___.
You were admitted to the hospital because you were concerned
that your left leg appeared more swollen than usual.
You received imaging of your lungs which showed that you might
have accumulated some fluid in your lungs. The fluid in your
legs and lungs is likely accumulating because of your heart
failure, which could have been worsened by the fact that your
heart doesn't beat regularly (you have an arrhythmia called
atrial fibrillation).
You received medication to help you remove that extra fluid by
urinating. You also were changed to a new medication to help
treat your heart arrhythmia. Your home statin medication was
increased.
If you experience any increased leg swelling, difficulty
breathing or chest pain please contact your doctor. Please weigh
yourself everyday, and if your weight increases by 3lb in one
day, please call your primary care physician.
MEDICATIONS TO TAKE:
Aspirin 81mg daily
Atorvastatin 80 mg daily (increased from 40mg daily)
Digoxin 0.25mg daily
Glipizide 5 mg daily
Haloperidol 2 mg every night
Metformin 1000 twice daily
Rivaroxaban 20mg daily
Torsemide 20 mg daily
Bicalutamide 50 mg oral DAILY
NEW MEDICATIONS TO TAKE:
Spironolactone 25mg daily
Metoprolol Succinate 12.5 twice a day
Lisinopril 10 mg daily
It was a pleasure to be part of your care,
Your ___ Team | Mr. ___ is a ___ with h/o HFrEF (LVEF 35% ___, CAD s/p
PCI (___), Afib s/p ablation in ___, COPD, prostate cancer and
possibly schizoaffective disorder or paranoia secondary to
neurocognitive decline who presents for left ___ swelling and
pain, found to have volume overload. Of note he was recently
admitted for volume overload but left AMA before he could become
euvolemic.
# CORONARIES: CABG/PCI: PCI ___
# PUMP: HFrEF (LVEF 35% ___
# RHYTHM: Afib s/p ablation in ___
#HFrEF: Pt presenting with left lower leg pain likely in context
of heart failure. Pt had elevated BNP on admission and CXR
showed mild pulmonary edema. CHF exacerbation ikely ___
medication nonadherence. Other etiologies include arrhythmia,
ischemia unlikely precipitant given negative troponins. Preload:
Pt was diuresed with IV lasix and started on a lasix drip. He
then was transitioned to oral torsemide and is being discharged
on torsemide 20 mg daily. He is also being discharged on 10
lisinopril daily for afterload reduction. NHBK: Metoprolol at
12.5 mg BID, spironolactone 25 mg daily.
#History CAD: Patient s/p PCI in ___. Pt was admitted with a
mild trop elevation and an EKG with no changes. Pt had ECHO last
admission that showed slight decline in EF at 35%. Pt's
atorvastatin was increased to 80 mg QD, he continued with
aspirin. Consider stress test as outpatient as patient refused
as inpatient.
#Atrial fibrillation: Was on diltiazem and digoxin at home. Pt
was transitioned to Metoprolol 12.5 Q12H, continued on digoxin
0.25 QD and rivoraxaban.
#Venous stasis dermatitis. Pt was diuresed as above and received
compression stockings. Pt used sarna lotion.
#Hx prostate cancer. Pt received home bicalutamide 50 mg oral
DAILY on discharge
#Psychiatric History or paranoia. Patient was seen by psychiatry
on his prior hospital admissions, and per their notes, he was
noted to have a primary psychiatric condition such as
schizoaffective vs. paranoia secondary to a neurocognitive
condition. During last admission he had bouts of agitation,
which were accompanied by paranoia, delusions, and auditory
hallucinations. His paranoia and delusions contributed to his
refusal of medications while in the hospital. However, during
this hospitalization he was compliant with medications/and
treatment. His repeated hospitalization due to decompensated CHF
are due to medical non adherence due to paranoia above. Patient
refused home services. Family is very involved including son and
ex-wife. At some point in future, family may need to seek
guardianship but this was not addressed during this
hospitalization as patient was competent. Pt received home ___
Haldol daily.
TRANSITIONAL ISSUES
=====================
[] Consider stress test - pt refused as an inpatient.
[] Please check Chem 10 at primary care appointment when on
torsemide 20 daily to ensure that CrCl >50. If <50, will need to
decrease rivaroxaban to 15 daily
STOPPED MEDICATIONS
Diltiazem
NEW MEDICATIONS
Metoprolol 12.5 BID
Spironolactone 25 mg daily
CHANGED MEDICATIONS
Atorvastatin 80 mg QD
Upon discharge: 70.2kg and Cr 1.2
CODE: Full
CONTACT: ___ ex wife ___ | 213 | 489 |
15521468-DS-22 | 25,303,455 | You were admitted to the vascular surgery service with right
hand pain and color changes in your fingers concerning for
ischemia. A CT angiogram showed extensive atherosclerotic
calcifications in your hand distal to the wrist. You were
anticoagulated with a heparin drip, and transitioned to oral
coumadin (warfarin) to take as an outpatient. Your INR
(coumadin level) is now therapeutic, between 2.0-3.0 and you are
ready to return home. You will be on coumadin for the next
three months to treat a likely arterial embolic event. You
should follow your INR very closely with your primary doctor,
and adjust the coumadin dose as needed. Coumadin puts you at an
increased risk of bleeding, so please be vigilant in monitoring
these INR leves as well as any signs/symptoms of bleeding.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Patient was admitted to the vascular surgery service on ___
with pain and discoloration of her right ___ digit. A CTA was
obtained which was significant for:
Patent flow from the aortic arch, right brachiocephalic artery
to the
radial and ulnar arteries at the level of the wrist, without
occlusion or high
grade stenosis. Multifocal moderate to severe narrowing of the
distal ulnar
artery. Assessment of patency of the arteries distal to the
wrist within the hand
is markedly limited due to extensive atherosclerotic
calcifications and the
small caliber of these arteries.
Due to concern for arterial embolic disease, she was started on
a heparin drip. Because she had a history of GI bleed ___
dieulafoy's lesion, a GI consult was obtained to determine risk
of anticoagulation. On ___, she was started on coumadin, 5 mg,
and also received 5 mg on ___. She was started on high dose
omeprazole, and on ___, GI performed an EGD. They did not see
any bleeding or nidus for bleed, however, they were unable to
perform a full evaluation ___ food in the stomach. GI
determined that the area of her previous bleed appeared stable,
and she would be safe to anticoagulate with a goal INR of
2.0-3.0 while on omeprazole 40 mg daily. She was deemed
appropriate for discharge on ___, and will follow up with Dr.
___ INR and coumadin dosing. | 148 | 235 |
18435448-DS-12 | 20,505,288 | You presented with abdominal pain, nausea, and vomiting. There
was no evidence of pancreatitis on your lab work. Your symptoms
improved with a bowel regimen and subsequent passage of stool.
.
Of note, one of you blood cultures grew out a bacteria; however,
this was felt to be unlikely to represent a true infection.
Additional blood cultures are still pending. If you note any
fevers or chills, you should return to ___ ER or seek
immediate medical attention, as this may represent true
bacterial infection in the bloodstream.
.
On the day of discharge, we recommended that you continue to
stay in the hospital to optimize your pain control and bowel
regimen based on your subjective complaints. However, you
refused to stay and wanted to leave against medical advice, and
you acknowledge and accepted the risks of such a discharge.
.
Please see your physicians as listed below.
.
Please take your medications as listed.
. | Pt is a ___ y/o M w/ PMHx of recurrent pancreatitis, pancreatic
pseudocyst, CAD, DM, obesity, as well as recent admission
___ for biliary obstruction treated with ERCP with sphx and
stent placement, back with recurrent RUQ abdominal.
# RUQ Abdominal Pain, N/V: Most likely etiology felt to be ileus
seen on imaging. Labs significant for mild bilirubin elevation
and transaminitis; however, these were improved from his recent
discharge labs, making ongoing biliary obstruction less likely.
Surgery, both Acute Surgical and Hepatobiliary, were consulted.
Symptoms improved with aggressive bowel regimen. Of note, pt
will likely have a degree of persistent chronic abdominal pain
given known pancreatic pseudocyst.
# Positive Blood Culture: Felt to likely represent contaminant.
He was initially placed on IV Vancomycin, until 2 out of 4
bottles of blood cultures obtained on ___ returned positive
for CoNS only. He did not have any fevers. He does not have an
indwelling catheter or port. He has additional surveillance
cultures (2 sets ordered prior to initiation of IV Vancomycin, 2
sets ordered after stopping IV Vancomycin) that show no growth
to date.
.
# Recurrent Pancreatitis / Pancreatic Pseudocyst: No e/o acute
pancreatitis on admission lab work. However, pt does have lesion
seen on recent CT pancreas protocol, which could not rule out
malignant cystic lesion. Pt also reports signicificant weight
loss over the past 6 months. CA ___ WNL on recent admission.
Surgery evaluated and plans for surgical removal of pseudocyst
in the near future.
.
# LLE pain: Patient complained of LLE pain in the calf. He did
not have any erythema or swelling. ___ was obtained, with
prelim read negative for DVT. He was able to ambulate
comfortably. He should follow-up with his outpatient providers.
.
# DM2, poorly controlled, with complications: He was continued
on his home regimen of Lantus and Humalog.
.
# CAD: continued home ASA, BB
# OSA: Non-compliant with CPAP. O2 sat's were monitored during
hospitalization.
.
# AMA Discharge
Of note, on the day of discharge, we recommended to the patient
that he continue to remain inpatient due to his complaint of
constipation and persistent abdominal pain, as well as pending
surveillance blood cultures. He reported significant anger and
frustration with his abdominal pain. He felt that his pain was
not being treated and he also felt that the Hepatobiliary
Surgery team did not have a well defined plan in place for
surgical management of his pseudocyst. Patient also reporting
that only IV dilaudid adequately controlled his pain and rated
his pain a "12 out of 10." Despite his subjective complaints,
his physical exam was benign and he appeared comfortable on
exam. He had also had a bowel movement within the past 48
hours. Explained to the patient that given his subjective
complaints, would prefer to keep him inpatient to optimize pain
control and management of his constipation, however, he declined
to stay unless IV dilaudid was provided. Given that he appeared
clinically well, he was discharged to home AMA. He agreed to
accept prescriptions for a bowel regimen. He declined an offer
for additional PO opioids, as he felt that new script for opioid
would violate his outpatient opioid contract with his PCP. I
explained that I could provide a short-term supply of PRN opioid
for breakthrough pain and that I would contact his PCP to
explain, but patient declined this offer. He acknowledged and
accepted the risks of AMA discharge.
. | 152 | 586 |
18019166-DS-11 | 21,869,494 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
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 heparin daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- 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
Physical Therapy:
WBAT RLE
Treatment Frequency:
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 change dressing on ___
Can replace with DSG (preferably waterproof - gauze and
tegederm) and may change daily. If no drainage after post-op
day 7, may leave open to air | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right TFN, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on heparin 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. | 340 | 253 |
14321214-DS-12 | 29,581,150 | 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. | ___ who was restrained driver in rollover MVA going
approximately 40mph. EKG prior to arrival c/f ST elevation. Upon
arrival patient complains of pain "everywhere." On arrival to
the ED, the patient was GCS 15, eFAST negative and pan-scan and
CT head showed no acute findings. We admitted the patient
overnight for pain control. We decided to keep the C collar in
place, repeat EKG which was WNL, and manage the patients pain.
On discharge on HD#1, the patient was ambulating without
assistance, out of bed, voiding normally, eating a regular diet
and pain controlled with ibuprofen, Tylenol and discharged home
with a prescription for oxy as needed. | 218 | 109 |
15765578-DS-20 | 22,207,745 | Ms. ___, you were admitted to our service because you had
worsening chest pains and shortness of breath. We received a
report that stated that your stress test results were
concerning. While with us, we performed a cardiac
catheterization that showed some occlusions in your vessels, but
none that warranted intervention. We decided that medical
management would be most appropriate for your care. We are
sending you home in stable condition. | The patient was admitted with chest pain and shortness of
breath. She had received an exercise stress test at the outside
hospital, which showed worrisome findings. The patient was
transferred to our service, where she received a cardiac
catheterization. The findings did not warrant intervention, and
the decision was made to optimize medical management. The
patient was monitored and discharged in stable condition. | 71 | 64 |
12468016-DS-45 | 28,888,729 | Dear Mr. ___,
You were admitted to the hospital after you were having
increased diarrhea and abdominal pain at home. We were
concerned about a Chrons flare and treated you with steroids.
Your pain and frequency of bowel movements seemed to improve.
The sigmoidoscopy did not reveal evidence of inflammation. Your
steroid regimen was adjusted. You should continue taking the
steroids after discharge and taper by 5mg every 10 days as
directed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you and getting to know you
while you were in the hospital. Wishing you a complete
recovery!
-Your ___ care team- | ___ smoker with Crohn's s/p total colectomy and splenectomy on
prednisone and Vedalizumab, history of c diff presenting with
lower abdominal pain concerning for an acute Crohn's flare.
Sigmoidocopy did not reveal signs of acute inflammation.
Patient treated with steroid burst and transitioned to PO
steroid taper. On discharge bowel movements were reduced to his
baseline of ___ BM/day and pain was well controlled.
Chronic issues:
# Hyponatremia: thoought to be related to hypovolemia. Resolved
to 131 on discharge
# Chronic dCHF: ECHO in ___ with hyperdynamic LVEF (EF>75%),
with normal free wall contractility. The patient remains volume
overloaded and bp remains stable. He was continued on home
diuretics and ACEi
# Gold Class IV COPD / Hypoxia: Patient was stable on home O2
requirement of 3.5L NC. He was also treated with home meds
Advair, Tiotroprium and duo nebs PRN
# PE/DVT: Suntheraputic INR on admission. History of DVT in
right popliteal vein ___. provoked DVT in RUE in ___
secondary to a line. Coumadin stopped s/p GI bleeding incident
this ___, with PE in ___ prompting reinitiation of
coumadin. INR goal ___. Patient restarted on home dose of
warfarin daily. Lovenox to bridge for 24 hours until INR is at
goal x 24 hours.
# Depression: Stable. Continued home Duloxetine 60mg daily and
Risperidone qHS
# OSA: Stable. continued home CPAP
TRANSITIONAL ISSUES:
-Patient has hematoma on dorsum of right foot which should be
continued to be monitored. Please compress with ACE wrap per
podiatry recommendations. Podiatry would like to see patient
within 1 week after discharge for further surveillance.
-___ start 20 mg steroids taper by 5 mg every 10 days
-f/u with GI ___. Please schedule patient for next Vedalizumab
infusion.
-Please continue to monitor platlets
-Please schedule patient for next Vedalizumab infusion.
-Please monitor INR daily. INR goal ___. Plan to bridge with
lovenox for 24 hours after achieving theraputic INR. recheck
INR on ___ can stop coumadin once INR therapuetic (___) x 24
hours
-Prednisone taper:
___: 20mg daily
___ 15mg daily
___ 10mg daily
___ 5mg daily | 116 | 353 |
18123331-DS-23 | 26,540,752 | You were admitted to this hospital due to concerns for acute on
chronic heart failure exacerbation based on presentation with
complaints of dyspnea and findings on examination consistent
with that of pulmonary edema.
You will be discharged home with a new medication with
metoprolol 12.5 mg once daily.
Please keep all scheduled follow-up appointments as described
below. | Mrs. ___ is a ___ year-old lady with a history of AS s/p
TAVR, CAD, RA, DVT/PE on rivaroxaban and metastatic breast
cancer complicated by loculated pleural effusions s/p R TPC and
lymphangitic involvement who presents with worsening dyspnea. | 56 | 39 |
17708869-DS-5 | 29,632,629 | You were admitted to the hospital due to obstruction of your
urinary tract, which was causing kidney failure. You had
nephrostomy tubes placed to drain the urine, which helped to
improve your kidney function. You also developed atrial
fibrillation with fast heart rates and low blood pressures,
which improved with changes to your medications, IV fluids, and
improved oral intake. | ___ year old male with atrial fibrillation, recurrent UTIs on
suppressive bactrim, locally advanced rectal cancer status
status post palliative diverting colostomy, prior hydronephrosis
treated with R ureteral stent that was complicated by recurrent
UTIs necessitating stent removal, being treated with
pembrolizumab (first dose ___ by Dr. ___ at
___, presenting with worsening ___, now s/p bilateral
PCN tubes with initially persistent renal failure that is now
improving
#Post-renal obstructive ___ - improving
#Hydronephrosis s/p bilateral PCN
#Metabolic acidosis - improved
PCN tubes placed on ___, with initially bloody urine now more
clear. Per urology, right draining considerably less d/t
atrophic collection system, may be able to remove in the future.
___ slowly improving since ___ (4.7 ->2.1, and still
improving). Has ___ follow-up in 12 weeks for tube change, and
has instructions and ___ for tube care. Will have labs next week
with oncology follow-up appointment.
#History of right apical clot.
Had been on edoxaban at home, but stopped in setting of renal
failure. Was on renally dosed lovenox during admission, but due
to improvement in renal failure was able to be restarted on
edoxaban at discharge.
#Afib/RVR, likely tachy-brady
#Baseline hypotension
Upon admission digoxin was held, metoprolol was reduced
significantly due to renal failure and sinus with low-normal and
mildly bradycardic rates. Around ___ he had some periods of
afib/RVR with associated hypotension. this occurred in the
setting of lower PO intake and improved with fluids.
Subsequently the patient's PO intake improved somewhat and the
RVR did not recur. Systolic BPs remained in the ___, which
appears to be his baseline and is asymptomatic. Digoxin was not
restarted prior to discharge.
#Anemia
Chronic multifactorial normocytic anemia that has been
intermittently transfusion dependent as an outpatient, often
worse during acute illness. Suspected to be related to
malignancy, renal failure, chemotherapy, and some acute/chronic
blood loss through ostomy and neph tubes. No evidence of
bleeding in days preceding discharge and hemoglobin relatively
stable. Received 3 units of RBCs while inpatient. Will have
labs in outpatient follow-up
#Rectal cancer with invasion into bladder
#Known colovesicular fistula
Patient will follow-up closely with oncology next week and will
resume pembro. He receives prophylactic Bactrim at baseline,
which was switched to cipro during the admission due to his
renal failure, but switched back to Bactrim at discharge.
# Depression
Continued Mirtazapine
# Chronic severe protein calorie malnutrition
Nutrition provided recommendations. patient restarted on
multivitamin and supplements. His PO intake improved during the
admission with treatment of his obstruction and renal failure.
#Intermittent abdominal pain and hiccups - treated effectively
with dicyclomine and baclofen
==================================== | 60 | 418 |
12770482-DS-10 | 26,025,624 | Dear Mr. ___,
You were admitted to ___ for a
severe headache. We were concerned for a possible bleed or
infection in your brain, given the severity of your pain. We
performed imaging of your brain and looked at the fluid in your
spinal cord (lumbar puncture). We did not see any evidence for
an infection or bleed in your brain. Please follow up with your
primary care doctor if you experience any more headaches.
It was a pleasure taking care of you,
Your ___ Team | Mr. ___ is a ___ year old man with history of STEMI s/p DES
and HTN who presented with sudden-onset headache X 1 day, likely
secondary to tension headache after ruled-out for subarachnoid
hemorrhage and CNS infection.
#HEADACHE: Mr. ___ presented with an undifferentiated
sudden-onset ___ headache, most concerning for SAH v. CNS
infection v. a migraine or tension headache. Meningitis seems
less likely given absence of leukocytosis, fever or other
systemic signs of infection. He had a CTA of the Head that was
normal without masses or hemorrhage and an LP without evidence
of SAH or meningitis. His headache was managed with
acetaminophen and home pain medications. His headache improved
and he was discharged with plans to follow-up in the outpatient
setting.
#CAD: STEMI w/ DES placed in LAD on ASA and clopidogrel.
Continued home regime.
#HTN: Mr. ___ remained normotensive throughout admission.
Lisinopril initially given at reduced dose but restarted home
dose prior to discharge.
#DMII: Last AIc 6.8. Diabetic diet, gentle ISS used for
inpatient glycemic control.
***TRANSITIONAL ISSUES***
#HEADACHE: Mr. ___ is being discharged with plans for
outpatient clinic follow-up to ensure headaches are fully
resolved.
#HTN: Mr. ___ blood pressure remained well-controlled on
his home Lisinopril. | 84 | 197 |
10729844-DS-16 | 23,077,276 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing
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 lovonox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
weight bearing as tolerated
Treatments Frequency:
dressing changes PRN | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an acetabluar fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF, 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 rehabilitaion ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the RLE extremity, and will be discharged on lovonox 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. | 191 | 250 |
16196316-DS-15 | 21,378,082 | Dear Ms. ___,
You were admitted with severe throat pain and mouth ulcers. Your
antibiotics were changed and you began to improve. Please
complete your antibiotic course and make sure to follow up with
your primary care doctor within one week to ensure you continue
to improve.
You can continue to take ibuprofen (Motrin/Advil) with food and
cough drops to help soothe your throat. Please avoid sharp foods
until your mouth feels better. | ___ with hearing loss s/p cochlear implant presenting with acute
pharyngitis and failed outpatient therapy with ongoing
difficulty tolerating PO.
# Acute pharyngitis: Admitted with bandemia though no overt
leukocytosis. With subjective fevers at home, and sore throat
preceded oral ulcers. Most likely viral process given chronicity
and slow improvement, however given Centour criteria will
complete course of antibiotics. Initially given PCN as
outpatient, transitioned to Unasyn and then to amox-clav
suspension. Tolerating it well upon discharge with improvement
in symptoms. No cough. HIV Ab sent and negative, VL pending at
discharge. GC/C throat pending, RPR pending. Monospot negative.
Primary HSV infection was also considered, however visible ulcer
healing and unlikely to provide good lab sample.
- follow up with PCP within one week
- complete abx
- f/u pending labs - per patient request will contact her via
secure email given difficulty with phone conversations | 73 | 143 |
12995867-DS-7 | 20,838,252 | Ms. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted with shortness of breath and a
congestive heart failure exacerbation. You were treated with
diuretic medications to remove fluids from your body. You
breathing improved. We started you on a new medication called
lasix.
Please take your medications as prescribed and follow up with
your doctors as ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ with rheumatic heart disease (mild AS, mild AI, mild-mod MR,
TR), dCHF, afib s/p cardioversion on amiodarone, HTN, HLD who
presents with dyspnea likely ___ to acute on chronic diastolic
CHF exacerbation.
# acute on chronic diastolic CHF - Recent echo in ___ with
normal EF. Patient's history and exam consistent with volume
overload. Patient was recently started on a prednisone taper
which may have contributed to fluid retention. Patient reported
being complaint with low sodium diet and taking all her
medications as prescribed. There were no localizing s/s of
infection. Patient was diuresed with 20 mg IV lasix boluses. She
was transitioned to 10 mg of torsemide however diuresed too much
to this dose and developed mild ___. Ultimately she was
transitioned to 10 mg po lasix. She was also switched from
metoprolol to carvedilol for improved blood pressure control.
Patient was euvolemic at time of discharge. Discharge weight was
62.3 kg.
# atrial fibrillation - Patient noted to have new dx of Afib
during previous admission. On that time she was started on an
amiodarone load. She was initially given xarelto given her
CHADS of 3 however given rectus sheath and pelvic hematomas she
was discharged off anticoagulation. On presentation, she was in
SR with frequent ectopy. She was completed her amiodarone load
and was transitioned to amiodarone 200 mg daily at time of
discharge. She will need to discuss further with her PCP and
cardiologist when it is safe to start anticoagulation.
#HTN: Patient had difficult to control HTN on 4 agents at home
prior to last admission. However due to transient hypotension,
she was discharged home on reduced dose of anti-hypertensives.
SBP 160's on admission. Her losartan was increased from 50 to 75
mg daily, and she was switched from metoprolol to carvedilol
12.5 mg BID. She was continued on her home felodipine. Blood
pressures were improved at time of discharge.
#leukocytosis: Pt with wbc 13.5 on presentation with no signs or
symptoms of active infection. She completed her previously
prescribed course of keflex for UTI. It was felt that her
leukocytosis was most likely ___eing treated for UTI with 7-day course of keflex, currently
day 6. Leukocytosis likely secondary to PO prednisone course.
- continue to monitor for signs of infection
- prednisone taper: 20mg daily ___, 10mg daily ___
#Skin rash: Skin bx shows evidence of hypersensitivity reaction.
Has been started on topical clobetasol and hydrocortisone per
___ clinic, with sarna lotion and hydroxyzine prn
pruritis. Patient could not tolerate hydroxyzine due to
oversedation. Rash does not appear to be improving despite
discontinuation of lisinopril and therefore was recently started
on a prednisone taper. She was continued on her previously
prescribed course. She is scheduled to follow up with
dermatology.
# s/p fall: Patient had mechanical fall at home which resulted
in bruising to her face. She had a CT head and Cspine which
showed no acute process. She was evaluated by physical therapy
and discharged home with ___.
#HLD: continued lovastatin
#OA: Continued home acetaminophen 650mg BID prn pain.
Transitional Issues:
- follow up volume status. diuretic regimen may need further
adjustment
- repeat electrolytes at follow up appointment on ___
- discuss if and when it is safe to start anticoagulation for
atrial fibrillation
- follow up blood pressure, medications may need further
adjustment
- follow up with dermatology regarding rash
- blood culture pending at time of discharge
- patient full code during this admission
- contact: ___ (husband) ___ | 81 | 579 |
14306557-DS-18 | 27,318,875 | Dear Ms. ___,
It was a pleasure to take care of you. You came to ___ for
fevers and were found to have a very resistant strain of
bacteria both in the blood and in the urine. We placed you on
antibiotics and treated both infections. We also found that your
infection had involved the aortic valve (one of the heart
valves). As a result, you now have a condition called aortic
regurgitation. You will be followed by cardiology for this. You
received your ___ cycle of decitabine on this admission. This
was complicated by a GI bleed which we treated supportively with
medications and blood products. We attempted to do a bone marrow
biopsy on the day prior to your discharge, but we were
unsuccessful at obtaining an adequate sample. Dr. ___
decide if she would like to try again as an outpatient. At time
of discharge, your counts were low, but stable.
Please do not drive or drink alcohol while taking oxycodone. | ACTIVE ISSUES
# AML with preceding polycythemia ___ and secondary
myelofibrosis: Pt is s/p matched unrelated nonmyeloablative stem
cell transplant with pre-conditioning on Flu/Bu/ATG (D0
___. Pt was given Cycle 7 of Decitabine (Day 1, ___
on this admission. She was continued on atovaquone, acyclovir,
and ciprofloxacin for neutropenia prophylaxis. Her counts
remained low throughout the admission, but platelets stabilized
around C7D32. Patient is being discharged with close follow-up
with Dr. ___ transfusions as an outpatient, if necessary.
# VRE bacteremia/endocarditis: Pt has a history of multiple
complicated infections including VRE bacteremia resistant to
daptomycin. BCx on this admission grew VRE sensitive to
linezolid. As such, the pt's initial central line was pulled by
___ on ___. She underwent several initial TTEs w/o evidence of
vegetation. Given repeat positive blood cultures, pt had TEE on
___ which showed aortic valve endocarditis and severe AR.
The pt's case was discussed at length with the patient,
cardiology, cardiac surgery and infectious disease. It was
decided that the pt had a very high ___ mortality at
30%. Pt was without evidence of interval prolongation on EKG
throughout hospitalization. Given that she did not meet valve
replacement criteria on this admission, the pt was medically
optimized. The pt was continued on IV linezolid for 6 weeks from
the first negative culture ___ to ___. A repeat TEE on
___ showed no evidence of abscess or discrete vegetations. Upon
discharge, the patient will have follow-up with Dr. ___
cardiology. At that visit, the possibility of TAVR for
compassionate use should be discussed.
# Aortic regurgitation: ___ VRE endocarditis occurring on this
hospitalization. Lisinopril was initially continued for
afterload reduction in order to best reduce regurgitant flow. Pt
had low normal blood pressures, however, during this
hospitalization. As such, her lisinopril was held. Throughout
the hospitalization, the pt was without signs of CHF. She was
able to ambulate with minimal dyspnea on exertion, which the pt
stated was near her chronic baseline. Her dry weight was
recorded at 210 lbs on this admission. Pts weight upon
discharge was 212.2 lbs.
# GI Bleed: Following administration of decitabine, pt was noted
to have repeated dark melanotic stools in addition to an acute
worsening of her chronic anemia without appropriate increase to
pRBCs or plt products. Pt has a hx of GI bleeding related to
treatments with decitabine. Her most recent EGD was in ___
which was negative for source. She was started on IV protonix
and supportively transfused. GI bleeding resolved with
maintainance of plts > 50. The pt remained hemodynamically
stable throughout her hospital course.
# Lightheadedness: During hospital course, the pt began to
describe new lightheadeness with position changes. Her
orthostatic vital signs were normal and her vital signs remained
within normal limits without signs of hypoperfusion. She was
without visual changes, numbness/tingling or weakness of
extremities, or other neurologic deficit on exam. As the pt's
symptoms were somewhat concerning for centrally caused vertigo
in the setting of new aortic valve endocarditis, and MRI brain
was done, which returned negative for evidence of embolic event
or other neurologic lesion. To rule out a significant cardiac
change, a repeat TTE was obtained on ___, which showed
preserved LVEF, moderate to severe AR, and trivial pericardial
effusion. A steroid taper had been initiated during
hospitalization, which corresponded with pt's new symptoms.
Given that she had been chronically on steroids, it was thought
that her symptoms were ___ adrenal insufficiency. As such, she
was placed on higer dose steroids at 10 mg PO with resolution of
symptoms. Her chronic prednisone was reduced to 9 mg at time of
discharge. The patient should continue to taper her steroids by
1 mg per week, down to 5 mg PO QD.
# Enterobacter UTI: On admission, pt reported urinary
"pressure." Her UA was unremarkable but urine culture grew
nearly pansensitive enterobacter. Repeat urine culture growing
citrobacter sensitive to macrobid. Pt received 5 day course of
macrobid with repeat urine cultures negative x 3. Despite what
was thought to be adequate treatment for her UTI, she continued
to have fevers while also on linezolid for her VRE bacteremia.
It was, therefore, thought that the pt could have possible
ongoing UTI, and she was subsequently started on a course of
meropenem. She completed the course with resolution of symptoms.
Urology was consulted for ongoing urinary pressure and
determined that pt was having residual dysuria in the setting of
recently treated UTI. On ___gain noted similar
urinary pressure. Urine culture again grew out citerobacter
sensitive to meropenem. She was, therefore, started on meropenem
and completed a 5 day course on ___. Her symptoms of urinary
pressure resolved shortly thereafter.
# Vascular access: Pt has limited vasculature access options
given complicated medical co-morbidities and multiple
hospitalizations. The pt had a previous central line removed ___
ongoing bacteremia and a new right internal jugular central line
placed on this admission. A permanent tunneled line was
considered during hospitalization. Once the patient completed a
full 6 week treatment course with linezolid for her
endocarditis, the decision was made to proceed with placement of
a new line. A tunneled line was placed on ___ without
complication.
# Upper extremity DVT: Pt has a history of non-occlusive left
brachial vein thrombus in ___ which resolved with course of
heparin while inpatient. On ___, pt was found to have
thrombus in the R internal jugular vein. Given persistent clot
and increased right upper arm swelling, she was placed on
chronic Lovenox at 60 mg twice per day. On this admission, pt
complained of worsening left arm swelling. Left arm
non-invasive ultrasound revealed no visible thrombus in right
upper extremity, however the R IJ was adequately visualized
given the presence of R IJ line (unable to remove line for study
given high risk of inability to place additional line as stated
above). The pt's Lovenox was temporarily discontinued in the
setting of worsening thrombocytopenia and GI bleed related to
cycle 7 of decitabine. At time of discharge, the pt's Lovenox
continued to be held due to ongoing thrombocytopenia and should
be restarted at the discretion of Dr. ___ as an outpatient.
# EBV infection: EBV Viral load was sent on ___ and returned
elevated. A repeat EBV PCR was sent on ___ and ___
which returned undetectable on assay.
# Diarrhea: Pt noted to have several episodes of diarrhea in
hospital course. Multiple C. diffs tests and stool studies were
sent and returned negative. Likely related to antibiotics and
other ongoing medications.
# Sore throat/cough: Patient developed dry non-productive cough
and sore throat during admission without sinus congestion or
nasal discharge. At that time, pt was already on linezolid and
meropenem for her bacteremia and UTI. Patient refused
respiratory viral swab. CT chest and sinus were unchanged from
prior with no clear active infectious process. She completed a
course of azithromycin for atypical coverage with resolution of
symptoms.
CHRONIC ISSUES
# Pulmonary MALToma: Pt had previously received intermittent
Rituxan infusions, last given on ___. CT Chest on
admission revealed stable nodules with no evidence of MALT
lymphoma progression.
# Chronic GVHD/skin: No evidence of active GVHD during
hospitalization. She was continued on her physiologic prednisone
dosing, given adrenal insufficiency.
# Chronic venous stasis: Pt has hx of chronic lower extremity
edema likely ___ venous insufficiency. Pt without evidence of
edema on admission and as such, her torsemide was discontinued.
# DM type II, on insulin: Pt had several episodes of
hypoglycemia on admission. As such, her insulin regimen was
adjusted appropriately. At discharge, she was sent home on
glargine 10U with breakfast and NPH 10 U with breakfast plus a
humalog ISS.
# Sinus tachycardia: Pt without evidence of ongoing sinus
tachycardia. As such, her diltiazem was discontinued.
# Hearing loss: Stable. Monitor and consider audiogram as
outpatient.
# Vertigo: Stable. Continued on meclizine.
# Insomnia: Stable. Continued trazadone and lorazepam as needed | 163 | 1,309 |
18807164-DS-28 | 28,688,010 | Dear Mr. ___,
You were admitted to the hospital for:
- chronic cough despite multiple rounds of antibiotics
- a rise in your creatinine indicating damage to you kidney,
this was likely caused by your Lasix and medications you took
for gout
While you were in the hospital:
- you were evaluated by the Infectious Disease and Pulmonology
Teams
- the Renal Transplant Team helped monitor your
immunosuppressive medications, your Pograf dose was changed to
0.5mg every twelve hours
- you received IV antibiotics for a lung infection
- you started using acapella flutter valve to help your lung
function
- we gave you IV fluids which helped your kidney function
improve
Now that you are going home:
- Please arrange Pulmonary follow-up (___) with repeat
chest CT in ___ wks (___), if opacities remain would
recommend bronchoscopy
- Your primary care doctor ___ arrange a video speech
and swallow study to ensure you are not swallowing into your
lungs
- Take levofloxacin for two more days
- ___ not take NSAIDS, ibuprofen at any time
- Please ensure tacrolimus level and creatinine checked on
___ at ___, Please fax to ___
ATTN: Dr. ___
- ___ not take Lasix until told to by a doctor
It was a pleasure taking care of you!
Your ___ Inpatient Team | ___ retired ___ of ___ with a h/o
liver/kidney transplant ___ on MMF/tacro immunosuppression who
presented with ___ and a 6 month productive cough s/p multiple
outpatient antibiotic courses, found to have ___ iso NSAIDs for
gout flare and radiographic multifocal infiltrates on CT
imaging.
#Cough
#Community Acquired Pneumonia : 6mo cough with poor response to
abx in ___ and again in ___. Presented on day 5 of 10 days of
doxycycline. CXR concerning for RUL opacity and chest CT showing
multifocal pneumonia. Given inadequate response to outpatient
antibiotics possibility of simple recurrence of community
acquired pneumonia in immunosuprressed patient vs silent chronic
recurrent aspiration vs unlikely inflammatory process such as
COP. ID and pulm teams were consulted, full fungal diagnostics
pending at time of discharge. TB was indeterminate with poor
mitogen stimulation result, in this context viewed as
unconcerning. Would recommend completion of aspiration studies
as outpatient. He will complete antibiotic course with
levofloxacin ___ for seven day course of abx (received
ceftriaxone and azithromycin while in hospital ___ given
procalcitionin consistent with bacterial infection. Albuterol
and advair should be continued as well as acappella valve BID.
# Acute Kindey Injury on Chronic Kidney Disease
# Status post kidney and liver transplantation in ___:
Crt 3.3 on admission versus baseline 1.8-2.5. Suspect pre-renal
injury at presentation due to combination of NSAIDs, hemodynamic
changes, diuretics. Review of biopsy from ___ at time of
transplant notes already moderate IFTA and significant donor
vascular disease. DSA screen negative, renal ultrasound was
unremarkable and urine protein/creatinine 0.1, BK virus screen
negative. Patient's mycophenlate was continued, prograf was
decreased to 0.5mg Q12hrs given trough goal of 4.0 He will have
levels checked ___ and faxed to Dr. ___.
CHRONIC ISSUES
# Hyperkalemia: managed with Florinef 0.1 mg once daily, would
be hesitant to resume prior Lasix given recent acute kidney
injury.
#HTN: Continued home carvedilol and amlodipine with holding
parameters.
#BPH: Continued home doxazosin
#HLD: Continued home fenofibrate
#Iron deficiency anemia: may resume repletion as outpatient
#DM2: may resume home regimen as outpatient, insulin regimen was
reduced in hospital initially in setting ___
TRANSITIONAL ISSUES
- Please arrange Pulmonary follow-up (___) with repeat
chest CT in ___ wks (___), if opacities remain would
recommend bronchoscopy
- would obtain video speech and swallow to ensure no silent
aspiration
- would consider Outpatient GERD evaluation, including pH probe
- follow-up pending serum fungal markers
- complete antibiotic course with levofloxacin (last day
- continue flutter valve BID
- patient should avoid NSAIDs at all times, even with gout
flares
- please ensure tacrolimus level and creatinie checked on
___ at ___, Please fax to ___
ATTN: Dr. ___ MEDICATIONS: holding lasix, no known cardiac history
CHANGED MEDICATIONS: Prograf changed to 0.5mg q12hrs | 211 | 448 |
19909671-DS-21 | 20,359,453 | Dear Mr. ___,
You were admitted to the medical intensive care unit at ___
___ for shortness of breath and
chest pain caused by low red blood cell count secondary to
bleeding from a duodenal (intestinal) ulcer.
For your low red blood cell count, you were treated with red
blood cell transfusions. For your ulcer, the gastroenterologist
performed an esophagogastroduodenscopy (EGD) and cauterized and
injected medicine to help constrict the vessel to help prevent
future bleeding. We monitored your hemoglobin levels and they
were stable.
To minimize your risk of developing more ulcers, it is important
for you to stop taking NSAIDs such as ibuprofen and aleve and to
also refrain from alcohol use. These two things can exacerbate
ulcers. Also, you were positive for H. pylori antibody which
indicates an infection of H. pylori in your intestines which
will also be contributing to ulcer formation. For this, you will
be treated with two antibiotics as well as your acid suppressing
medication. One of these medications (clarithromycin) has the
potential to interact with your statin. If you experience any
muscle pains, stop taking your statin and call your PCP right
away.
We are discharging you home. Please follow up with your PCP ___.
___ on ___. At that appointment, she will
work with you to coordinate follow-up imaging for your
pneumonia. In terms of your aortic stenosis, the ___ team
will be coordinating your appointments.
It was a pleasure taking care of you,
Your ___ Healthcare Team | ___ w/ PMH of severe aortic stenosis present with shortness of
breath, melena and significant hemoglobin drop (12.4 on ___ to
6.0 on ___ and developed Type II NSTEMI. He was admitted to
the MICU for monitoring (___).
# GI Bleed: Pt presented with melena and a Hgb drop of
12.4->6.0) in the setting of new and significant NSAID use and
drinking one bottle of wine daily. He received 4 units of PRBCs
and underwent an EGD in the MICU on ___. Unfortunately he
became hypotensive at the onset of sedation and the procedure
was aborted. Later that day he developed T-wave inversion on EKG
with a rise in troponin. Cardiology was consulted and believed
that this was secondary to demand ischemia in the setting of an
acute GI bleed. He was transfused another unit of blood to keep
the Hgb above 9.0. He was maintained on PPI BID per GI on
transfer out of the MICU. ___ ___ he had another melanotic
bowel movment which prompted ___ AM EGD. EGD showed bleeding
ulcer in duodenum, which was cauterized and injected with
epinephrine. He was transferred to medicine for monitoring. On
the medical floor, his hemoglobin was stable, 8.9-9.9 with
discharge hemoglobin 9.3 g/dL. He no longer had melanotic
stools. Per GI recommendations, he received Pantoprazole 40 mg
PO Q12H. He was also instructed to discontinue NSAID and alcohol
use. H. pylori IgG test was positive by ___ ___, for
which he was started on a 14 day course of clarithromycin and
amoxicillin in addition to his BID PPI. Per GI and At___
cardiology recommendations, his aspirin dose was downtitrated
and he was restarted on Aspirin 81 mg daily on ___.
# Community acquired pneumonia: CXR showed bilateral opacities
with a recent 5 day course of levofloxacin. He was treated with
ceftriaxone and azithromycin for 1 day. Since he was clinically
asymptomatic with no cough or fever, did not continue to treat.
He is recommended to have repeat imaging in 4 weeks to confirm
resolution.
# Type II NSTEMI: Active angina with lateral ST depressions,
likely demand ischemia in the setting of anemia vs hypotension
during EGD attempt. Troponin rise on ___ to 0.28 and CK-MB 19.
Trop rose to 0.38 but downtrended ___. CK-MB downtrended ___
to 11.
# Severe aortic stenosis: Patient underwent evaluation by
cardiac surgery on ___ and was deemed a moderate risk for TAVR
surgery. He will have further workup as an outpatient for TAVR
per At___ attending. Medicine spoke with and confirmed that ___
___ will be coordinating his follow up care for the AVR. GI
recs that work up for TAVR that requires anticoagulation be
completed after two weeks (after ___
# Leukocytosis: Initially WBC of 13.3 with predominance of
PMNs, felt to be reactive. CXR showed bilateral opacities with
recent completion of a 5 day course of levofloxacin ending on
___. He was afebrile and without cough, and upon transfer out of
the MICU, his WBC had resolved.
#HTN: He was normo- to hypertensive throughout admission. He was
restarted on amlodipine 10 mg PO daily and carvedilol 6.25 PO
BID with instructions to restart home lisinopril and
chlorthalidone in outpatient setting.
=====================
TRANSITIONAL ISSUES
=====================
# Medication changes. Started on pantoprazole 40 mg PO Q12H.
Downtitrated aspirin 325 mg to 81 mg daily. Atorvastatin
downtitrated to 20 mg daily while on macrolide therapy; please
consider uptitrating after completion of antibiotic course.
Chlorthalidone and lisinopril temporarily halted in the setting
of acute GI bleed; will be restarted individually as outpatient.
# Antibiotic course. Will require amoxicillin 1 g BID and
clarithromycin 500 mg BID x14 days (end ___ for treatment
of H. pylori. Please monitor for signs of rhabdomyolysis while
on concurrent macrolide and statin therapy.
# Repeat EGD. EGD ___ showed irregular Z-line, with concern
for ___, needs EGD follow up
# Repeat imaging (CXR, MRI abdomen, CT chest). Please f/u CXR in
4 weeks after resolution of pneumonia. CT ABD/Pelvis showed
lesion along the greater curveature of the stomach concerning
for possible GIST; please order 3 month followup MRI. Incidental
pulmonary nodule 3 mm at left lung base: High risk patient
(extensive smoking history), please follow-up at 12 months and
if no change, no further imaging needed.
# Severe aortic stenosis. Will be contacted by ___ team for
outpatient work-up.
# Communication/HCP: ___ ___
# Code: Full, confirmed | 243 | 725 |
15418459-DS-16 | 28,448,078 | Dear Mr. ___,
You were admitted to the hospital with confusion and diarrhea
and were found to have an infection in your colon called C
difficile. You were treated with antibiotics and are improving.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | ___ w/ cognitive impairment, gait instability, HTN, depression,
urinary incontinence, hearing loss, IBS-D, NPH s/p VP shunt, and
CLL (not on therapy) who is presenting from assisted living with
confusion, somnolence, and diarrhea found to have severe C
difficile infection.
#Diarrhea
#C difficile infection
#Leukocytosis
Presents from assisted living with encephalopathy. At baseline
he is sometimes disoriented, but alert and appropriate and very
hard of hearing. CT abdomen in ___ showed mild colitis and
at ___ CDiff PCR and toxin both positive. Of note, he received
ciprofloxacin for UTI in late ___. No prior history of CDI.
He was stated on oral vancomycin and his leukocytosis improved
back to his baseline of ___. He will complete a 10d course of
oral vancomycin (___). His ___ blood culture was NGTD at
discharge and UCx was negative.
#Encephalopathy
#Hearing loss
Presented with confusion most c/w delirium due to infection.
Shunt series and CTH on admission unremarkable. No focal neuro
deficits. His hearing loss contributed to his confusion and also
inability to participate in mental status exam. Once his hearing
aid was put in place his confusion and ability to communicate
with staff improved.
___
Presented with Cr 2.3 from baseline 1.1. Initially improved with
IVF and treatment of diarrhea to 1.0, then increased to 1.3 on
___ (though with downtrending BUN) and then with encouragement
of PO intake Cr went back down to 1.1. His lisinopil was held
and will be resumed on discharge. Cr at discharge 1.1.
#Transaminitis
Mild transaminitis on admission, similar to ___. HCV
negative. HBsAg neg, HBsAb neg, HBcAb neg. Transferrin sat 34%.
Admission CT done at ___ comments on normal appearing liver
in report. Pending at discharge: Hepatitis EBV/CMV serologies.
Workup should be continued as an outpatient.
#CLL
Recently seen by Dr. ___ felt no indication for
therapy
at this time (no B symptoms, no evidence of lymphadenopathy, no
evidence of splenomegaly, no evidence of frequent infections,
and a lymphocyte doubling time on the order of 3 or more years).
Dr. ___ was notified of admission. He was continued on
home acyclovir ppx.
CHRONIC ISSUES
#Depression: Continued venlafaxine, buspirone
#Fecal incontinence: holding home eluxadoline and Imodium given
CDI -- resume once oral vancomycin course is complete
#HTN: held lisinopril, resume on discharge
#CV: ASA 81
>30 minutes spent on discharge planning including face-to-face
patient counseling and coordination of care. | 43 | 373 |
13647967-DS-22 | 20,581,441 | You were admitted to the hospital with an exacerbation of your
heart failure because your Lasix was not taken as prescribed and
your diet contained a lot of salt while on vacation. Initially,
you were diuresed with IV Lasix and required supplemental
oxygen. Over 24 hrs, your symptoms improved and you were weaned
from the oxygen. You also had a fever, which resolved after
several hrs. No source of infection was found.
Please weigh yourself everyday at the same time and using the
same scale. Report a weight gain of ___ lbs over several days to
your cardiologist. Follow a low salt diet. ___ services were
suggested to help you monitor your weight, diet and medications,
but you declined these services at this time.
You also developed an abnormal heart rhythm called atrial
fibrillation. This rhythm can increase your risk of a stroke.
Because of this, you were started on a blood thinner called
warfarin. You will need frequent blood checks to make sure that
you are on the correct dose of warfarin. Your dose may change
depending on the results of this blood test (called an INR).
Please obtain blood work on ___ to check
your INR level and Tacrolimus level, and kidney function.
Continue to take your home medications.Your Aspirin was
decreased to 81 mg a day. Your Tacrolimus dose was changed to 3
mg twice a day for now. You had a Tacrolimus level pending at
the time of discharge. You will be called at home with that
result. | ___ PMH CKD s/p renal transplant, DM2, CAD, p/w 3 days onset of
dyspnea in the setting of medication non-compliance and dietary
indiscrestion, transferred to the CCU for presumed CHF
exacerbation. | 253 | 31 |
19253812-DS-8 | 28,629,186 | Dear Ms ___,
You were admitted to the hospital with chest tightness and
shortness of breath with exertion that we believe was likely due
to a blood clot in your lungs, called a "pulmonary embolus."
You were started on treatment for this with a medication called
___ ("Eliquis"), which you will need to take twice daily
every day for at least 6 months. Do not stop this medication
until you told to do so by your Oncologist (Dr. ___. As we
discussed, ___ increases your risk of bleeding, so please
seek immediate medical attention if you develop blood in your
stool, dark black tarry stool ("melena"), or vomiting blood.
Because you have started this medication that can increase your
risk of bleeding, we would advise that you STOP taking aspirin.
For your upset stomach, we recommend that you continue to work
with your primary care doctor and your primary GI doctor to
hopefully get this feeling better. You have an appointment
scheduled with Dr. ___ in the ___ GI clinic on this
___ at 09:20 AM.
For the burning sensation in your legs, we recommend that you
discuss this again with your primary care doctor for further
evaluation and potential treatment.
It was a pleasure caring for you while you were in the hospital,
and we wish you a full and speedy recovery.
Sincerely,
The ___ Medicine Team | # LLL Subsegmental PE: suspect precipitated by her recent plane
flight of ~4 hours from ___, no other clear inciting factors
- low-risk PE: hemodynamically stable and satting well on RA,
trop negative, BNP wnl, and no evidence of right heart strain on
CTA chest
- initially was started on heparin gtt, discussed with her
primary oncology team (Atrius - Dr. ___ Dr. ___, who
advised DOAC over lovenox
- started ___
--10 mg BID x7 days ___ - ___
--5 mg BID after that ___ - )
--Advised patient to stop taking PRN aspirin (uses for
abdominal pain) in setting of starting systemic anticoagulation
--Dr. ___ treating PE for 6 months, but we would
ultimately defer to Dr. ___ final decision on when to stop
anticoagulation based on patient's cancer status at that time.
# Breast Cancer
- Continued home anastrozole
# Chronic Abdominal Pain: Followed by GI at ___. Here with
multiple chronic abdominal complaints. Overall stable and she
was tolerating PO with benign abdominal exam.
- Continued home remeron, PPI, and miralax
- Follow-up with outpatient GI is already scheduled, has appt on
___ at 0920 w/ Dr. ___
# Chronic blurry vision: stable
- can continue outpatient Ophthalmology f/u if appropriate
# Chronic burning pain in b/l distal LEs (below the knees):
stable
- sounds like a symmetric polyneuropathy
- consider further evaluation and trial of symptomatic treatment
as outpatient
.
.
.
.
================================ | 227 | 221 |
11381989-DS-20 | 24,584,644 | Dear Ms. ___,
You were hospitalized due to a headache resulting from an acute
subarachnoid hemorrhage, a condition where a blood vessel
providing oxygen and nutrients to the brain ruptures and spills
blood into the area around your brain. 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 blood and irritation can
result in a variety of symptoms.
Stroke can have many different causes. We think that your brain
bleed was the result of a condition called Cerebral Amyloid
Angiopathy, which means that you have proteins (Amyloid) that
deposit in the small blood vessels in your brain and weakens the
walls. This means that the blood vessels are more likely to
rupture. We think this is the case because your brain imaging
showed evidence of old bleeds in various areas, which can happen
when you have this condition.
Since you had bleeding around your brain, you should stop taking
your anticoagulation (Eliquis) for 2 weeks. You should follow up
with your PCP, who will get a CT scan of your head to make sure
the bleeding has resolved. At that time, if the bleeding has
resorbed, it is ok for you to start the Eliquis again at a low
dose. Your PCP ___ give you more instructions about this.
We are changing your medications as follows:
- STOP taking Eliquis. Follow up with your PCP before
restarting.
- We are starting you on a bowel regimen to prevent you from
straining when you go to the bathroom. This includes senna,
Colace, and MiraLAX. If you are having loose stools stop taking
these medications. You can take the senna and Colace regularly
to keep your stools soft. You can take MiraLAX when you are
still constipated and need additional support. Please follow-up
with your primary care provider for the optimal bowel regimen.
- START taking amlodipine 5mg. Your blood pressure was elevated
while you were in the hospital. It is very important to control
your blood pressure as you recently had a brain bleed. Please
take all your blood pressure medicines as prescribed. If you
want to buy a home blood pressure automatic monitor to check
your pressures at home, you can do so. If your blood pressure
remains consistently above 160 systolic (the top number), please
call your primary care doctor.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Thank you for letting us be part of your care.
We wish you the best,
Your ___ Neurology Team | Ms. ___ is an ___ year old woman with HTN and AFib on
Eliquis/metoprolol/dofetilide who was admitted to the Neurology
stroke service with sudden-onset headache and small convexal
Subarachnoid Hemorrhage. This was most likely secondary to
underlying Cerebral Amyloid Angiopathy, with multiple small
punctate hemorrhages seen on outside hospital imaging GRE
sequences, corroborated by second read at ___. She was also
found to have 2 small aneurysms on CTA. She was evaluated by
Neurosurgery but no intervention was recommended. In the
hospital, she had a headache that improved during her stay, and
her exam was notable for mild left pronation without drift but
was otherwise unrevealing. Workup for a cardioembolic source of
multiple small strokes was unrevealing; a TTE did not show any
evidence of either intracardiac thrombus and blood cultures did
not grow any organisms.
Neurosurgery saw the patient and did not feel surgical
intervention was warranted given the small volume of the bleed.
They also did not think the small aneurysms required clipping or
any further imaging or follow-up. Nimodipine was started but
then held for mild hypotension and since it was a small convexal
bleed.
Her Eliquis was held while she was in the hospital. We will plan
to hold it for 14 days from the date of hemorrhage (___). At
that time, she should have a non-contrast CT scan of her head,
to be arranged by her PCP. At that time, if the blood has
resorbed, she can restart Eliquis 2.5mg BID. This plan has been
discussed with her PCP. She will also require close control of
her HTN. Her blood pressure was elevated in-house, requiring
addition of amlodipine to her existing regimen of Lisinopril and
metoprolol. All antiplatelet agents should be held.
Of note, she has difficult to control AFib on metoprolol and
dofetilide. Her PCP and cardiologist were in discussion about
possible Watchman placement. If successful, this would obviate
the need for future anticoagulation but will need to be pursued
further as an outpatient.
Her deficits improved greatly prior to discharge and were
notable only for mild left pronation on pronator drift testing.
She will not continue rehab at a ___ center as she has no
significant residual deficits.
- STOP taking Eliquis. Follow up with your PCP before
restarting.
- We are starting you on a bowel regimen to prevent you from
straining when you go to the bathroom. This includes senna,
Colace, and MiraLAX. If you are having loose stools stop taking
these medications. You can take the senna and Colace regularly
to keep your stools soft. You can take MiraLAX when you are
still constipated and needs additional support. Please follow-up
with your primary care provider for the optimal bowel regimen.
- start taking Amlodipine 5mg. | 525 | 453 |
16237334-DS-3 | 24,342,221 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | This patient came in as an EU Critical. He was evaluated by
trauma surgery in the trauma bay and found priliminarly to have
an isolated head injury. Upon evaluation and examination of the
patient off sedation we documented a GCS of five. Patient was
admitted to the Trauma ICU. He remained intubated and throughout
the night, his exam improved. MRI head was performed which
confirmed ___. He had an increase in temperature and he was
cooled. On ___, his exam improved. C-spine imaging and brachial
plexus imaging were normal. Cooling was stopped and he was
started on precedex.
On ___, he continued to move all extremities and follow simple
commands L>R. He was extubated successfully. A speech and
swallow evaluation was ordered. On ___, patient was alert to
self, month, and year. He followed commands well on the L side,
the RUE and RLE had minimal movement. Speech and swallow
evaluated the patient and he was cleared for a ground solid and
nectar thick liquid diet. ___ was also consulted. Transfer orders
to the floor were written.
On ___ and ___, Mr. ___ remained stable on the floor and
___ continued to consult. Rehab was recommended and screening
begun.
Mr. ___ was discharge to a rehabilitation facility on ___.
At the time of discharge, he was afebrile, hemodynamically and
neurologically stable. Per discharge instructions, he should
follow up with Dr. ___ Neurosurgery. Also, he will need
an outpatient EMG for further assessment of a right brachial
plexus injury. | 486 | 252 |
18478093-DS-28 | 27,575,771 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
the ICU with sepsis and were treated with antibiotics (which you
completed during the admission). You had an ERCP which
visualized your stents, however they unfortunately could not be
removed. You then had an additional stent placed and drainage by
Interventional Radiology, in addition to paracentesis which
removed fluid from your abdomen. Due to low blood pressure after
this procedure, you were briefly transfered to the Intensive
Care Unit as a precaution.
Blood cultures taken from after the procedure were then found to
be growing ___ species, and you were started on an
anti-fungal medication. This medication needs to be given
intravenously, and you had a PICC line placed prior to
discharge.
On this admission, we also gradually worked to take of excess
fluid that you had accumulated during your recent
hospitalizations. You have multiple follow-up appointments
scheduled, which are listed below.
Please note that we have stopped your rifaximin, you should not
take this drug after discharge. We have also increased the dose
of your lasix from 20 to 40 daily and started you on a
medication called Ursodiol which will help your liver drain.
Thank you for allowing us to participate in your care. | ___ with locally advanced pancreatic adenocarcinoma (s/p
chemo/XRT, recently s/p C5 Gemcitabine), DM, CAD, Afib on
dabigatran, acromegaly, DVT ___, and recurrent biliary
sepsis, admitted for abdominal pain and hypotension, found to
have Klebsiella bacteremia, s/p ___ PTC and stent placement, now
with Candidemia. | 208 | 44 |
Subsets and Splits