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12945136-DS-3 | 25,181,684 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You came to the
hospital for a headache and were found to have an extremely high
blood pressure. You were given IV medications and your blood
pressure improved. You will be discharged on: amlodipine 5mg
daily, labetalol 200mg twice a day, and lisinopril 40mg daily.
Please stop taking your metoprolol.
You became confused while in the hospital. This was most likely
an effect of the benadryl you were given in the ED. Once your
confusion improved, you were ready to be sent home. You were
also started on tamsulosin to help your urinary problems.
Sincerely,
Your medical team at ___ | Mr. ___ is an ___ year-old man with a past medical history
of mild-moderate vascular dementia, poorly controlled
hypertension (hypertensive urgency at several recent outpatient
visits), chronic headache from cervicalgia who presented with
headache and was found to have hypertensive urgency.
# HYPERTENSIVE URGENCY: Mr. ___ presented to the hospital
with a BP of 254/106 with associated with a headache. There were
no signs of end organ damage except for an elevated lactate,
which was thought to be secondary to metformin. He was given IV
labetalol and his BP improved. He was switched to oral agents
and his blood pressure stabilized in the 140s/70s. Hypertensive
urgency was thought to be due to medication noncompliance in the
setting of worsening dementia and possible pseudoephedrine use.
He was discharged on: amlodipine 5mg daily, lisinopril 40mg
daily, and labetalol 200mg BID.
# DELIRIUM: The patient Patient presented to the hospital at
baseline mental state. He was given IV benadryl in the ED and
subsequently became delirious and developed urinary retention.
He was started on olanzapine 2.5mg QHS as well as tamsulosin
(see below) with improvement in delerium prior to discharge to
rehab.
# TYPE B LACTIC ACIDOSIS: Patient's lactate 2.4 on admission,
peaked at 4.1 then downtrended with IV fluids to 2.7. The
patient remained without signs of infection or hypoperfusion.
As such, etiology was though due to type B lactic acidosis from
metformin and decreased oral intake.
# URINARY RETENTION: The patient had baseline benign prostatic
hypertrophy. In the setting of IV Benadryl administered in the
emergency room, the patient developed urinary retention with
bladder scan as high as 900cc. In this setting, the patient was
started on tamsulosin uptitrated to 0.8QHS. He is being
discharged on this medication, which can be downtitrated as an
outpatient as needed.
# DEMENTIA: Mild-moderate by history and exam worsened by
hospital setting. Concern that cognitive deficits and making him
incapable of taking medications appropriately and caring for
self despite family members are helping. The physical therapy
team saw the patient and recommended that he go to rehab.
# HISTORY OF CEREBROVASCULAR ACCIDENT: The patient's blood
pressure was managed per above. He was continued on his home
aspirin and statin for secondary prevention.
# CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was
continued on his home inhalers without complications.
=============================== | 113 | 381 |
14857511-DS-19 | 22,878,471 | Dear Ms. ___,
It was a pleasure caring for you at ___. You came in initially
for dizziness. In the emergency deparment, you were found to
have an abnormal EKG and required monitoring overnight on a
heart monitor. Fortunately, we did not see any heart rhythm
abnormalities on your monitor while you were here. However, you
should see your cardiologist when you leave the hospital to be
sure you are on the right heart medications. We did not find any
concerning causes of your dizziness, and we now feel it is safe
for you to leave the hospital.
While you were here, your potassium was found to be low. We have
given you a prescription for daily potassium supplementation.
You should have your potassium checked midweek. Your PCP ___
follow up the results.
Below are the changes we made to your medications:
START potassium chloride 20meq daily | ___ with PMH of T2DM, HTN, HLD, afib on amiodarone and lovenox,
who presents with presyncopal episode at home, found to have
long QTc, low K, low Mg in ED, now being admitted for concern
for cardiac arrhythmia.
# Presyncopal episode: Symptoms isolate to a single event,
currently resolved. Given presentation, differential includes
orthosasis, hypoglycemia, cardiac arrhythmia, ACS, medication
side effect. Most likely orthostasis given multiple hypertension
medications. Aslo pt, noted to have low FSBG during episode
which likely contributed. Pt appears euvolemic on exam.
Troponins negative x2. Lethal cardiac arrhythmia would have more
likely caused sudden syncope without presyncopal symptoms.
Orthostatics were negative. Fingersticks were well controlled.
No events noted on telemetry. This was most likely a single
isolated event; therefore, no interventions were taken.
# Long QTc: Possibly side effect of amiodarone; however
incidence is extremely low. More likely due to electrolyte
imbalance. Pt was discharged home with K supplementation.
Amiodarone was continued. Her cardiologist was notified of the
incident; adjustment of amiodarone dose left to his or PCP's
discretion. EKG in AM showed improved QTc interval. No events on
telemetry.
# Atrial fibrillation: Continued home amiodarone, BB, CBB,
amiodarone, and lovenox for anticoagulation. NSR on tele.
# T2DM: held home po meds and ISSH while inpatient.
# CAD/CHF: continued home coreg, nifedipine, ASA, and
atorvastatin
# GERD: continued home omeprazole
# Chronic LBP: held home tramadol for potential lightheadedness.
pt has appointment with pain clinic in ___. | 143 | 234 |
12712938-DS-12 | 21,707,137 | -You will be discharged home with ___ & Home IV therapy services
to further assist your transition. Also, wound vac services will
be set up.
For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications or while wound vac is ___ place
-Follow up with UROLOGY for wound check and post-op evaluation
as directed. Follow up with your PCP as directed for further
eval of your abnormal liver functions tests. Follow up with ID
as directed.
-ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-___ scrotum/phallus supported/elevated. Use a
jock-supporter/strap or jockey-type briefs or tight,
tighty-whities to facilitate this; Subsequently you may
transition to loose fitting briefs or boxer-briefs for
support--they should be cotton and/or breathable.
-Do NOT use penis for intercourse/sex until explicitly advised
by your urologist that is may be ok to do so.
-You may want to coordinate your showers with your ___ provider
and the planned dressing changes.
-You may shower, but do NOT bathe, swim or otherwise immerse
your incision.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
-Colace has been prescribed to avoid post-surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops. Colace is a
stool "softener"; it is NOT a laxative
-Resume your home medications, except as noted.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room. | Mr. ___ was admitted to Urology after transfer from OSH to
the ED and taken to the OR for urgent incision and drainage
perineal abscess and scrotal abscess, Fournier's gangrene. No
concerning intraoperative events occurred; please see dictated
operative note for details. The patient received perioperative
antibiotic prophylaxis and was continued on empiric triple
therapy until culture data available. The patient was
transferred to the floor from the PACU ___ stable condition. Pain
was well controlled on PCA and and he was hydrated for urine
output >30cc/hour, and provided with pneumoboots and incentive
spirometry for prophylaxis. The patient ambulated, resumed
appropriate home medications and labs were monitored daily. His
diet was advanced to regular. Our colleagues ___ infectious
disease were consulted for management and he was to discharged
on 1g IV ceftriaxone with Flaggyl 500mg PO TID for a 14-day
course. A PICC line that was placed that was accidently
traumatically pulled out by the patient the day before
discharge, when getting out of bed. A midline was placed ___ the
left arm prior to discharge. He was voiding without difficulty
and discharged ___ stable condition, eating well, ambulating
independently, voiding without difficulty, and with pain control
on oral analgesics.
Wound care specialist evaluated him and he was on veraflo wound
vac for 48hrs before it was removed and a wet-to-dry dressing
applied for discharge home. The date of discharge he was to be
met by ___ for application of a new wound vac device.
On exam, incision was clean, dry, and intact, with no evidence
of hematoma collection or infection. The patient was given
explicit instructions to follow-up ___ clinic ___ approximately 2
weeks time. | 264 | 278 |
15382919-DS-21 | 22,281,682 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted for fatigue and found to have a small heart attack
called an NSTEMI. You underwent a procedure to relieve blockage
in the arteries that supply your heart. You were feeling better
after the procedure. You need to go to rehab to continue to
work on strength and conditioning.
Please see the attached med list for changes made to your
medications. | ___ with hx. afib on coumadin, tachy/brady syndrome s/p dual
chamber ___ (___), CHF, HTN, HLD, T2DM, presenting with
complaints of fatigue. Patient received aspirin and plavix in
the ED and was admitted to cardiology service. In light of
positive troponins patient was started on a heparin drip. The
following summarizes the problems during this hospital stay:
#NSTEMI: Patient appears to have had as NSTEMI given his
positive enzymes. As above, patient was started on a heparin
drip. He complainted of intermittent chest pain on the floor,
so a nitro drip was started which provided relief. Patient was
also started on atorvastatin 80 mg. The patient underwent cath
on hospital day 1 which showed 2 vessel CAD, s/p POBA to 65%
lesion ___ diagonal (down to 35%), as well as evidence of
microvascular disease. On return from cath, patient's heparin
drip was discontinued. He was continued on low dose aspirin,
plavix, as well as atorvastatin and coumadin. Plavix duration
will be one month. Patient was started on low dose isosorbide
mononitrate and his metoprolol was uptitrated for heart-rate
control. The patient remained chest pain free but continued to
have fatigue. Patient was found to have significant
deconditioning by physical therapy and will be going to rehab to
continue to work on strength and conditioning.
# Afib: on coumadin/metoprolol for a CHADS of 3. Patient's INR
was ___ on day of cath so he received 2 units of FFP with 40IV
lasix pre-cath. His coumadin was restarted post-procedure. He
remained on his home dose coumadin with therapeutic INR and
metoprolol was uptitrated, as above.
# sick sinus s/p pacer: dual chamber pacemaker placed in ___,
last interrogated ___. Patient remained on tele without
issues.
# chronic diastolic CHF: preserved EF in ECHO of ___, however
had asymmetric LVH c/w hypertrophic CM, also impaired relaxion.
Patient's home torsemide was held in anticipation of cardiac
cath. He continued to appear mildly volume overloaded
post-procedure and was diuresed with 80mg IV lasix boluses with
improvement in his respiratory and volume status. Repeat ECHO
in house showed preserved EF with evidence of moderate LVH. He
is being discharged to rehab on his recent home diuretic regimen
of torsemide 80 mg daily.
# HTN: uptitrated metoprolol as above, blood pressures remained
in the ___ to low 100s systolic. Patient would likely benefit
from an ACE in the future if blood pressures allow given
underlying diabetes.
# DMII: On orals at home, was covered with ISS in house.
TRANSITIONAL ISSUES
1. Patient will go to rehab to continue to work on strength and
conditioning.
2. Patient should remain on plavix for one month and then
discontinue plavix given risk of bleeding with triple therapy in
the elderly.
3. Patient would benefit from monitoring of volume status and
titration of diuretic regimen as needed.
4. Patient remained full code. | 79 | 488 |
15078112-DS-22 | 29,662,637 | Dear Ms. ___,
It was a pleasure participating in your care here are ___
___ . You came to us with some light
headedness, shortness of breath and a rash. You got a CT scan
upon admission which showed no acute heart or lung problems. We
addressed your light headedness by stopping your diuretic pill,
decreasing your diltiazem to 15mg QID and giving you a small
amount of intravenous fluids. You walked around the nursing
station without difficulty and we monitored the oxygen content
in your blood which remained at 100%. For your rash we stopped
the voriconazole and switched your lasix to torsemide. Your rash
is resolving but itchy so we are treating the itch with Zyrtec
and topical steroid cream for no longer than 2 weeks. A list of
your changed medications are below:
1. Please stop taking voriconazole, we think this my be causing
your rash.
2. Please stop taking your lasix, instead please take torsemide
daily for your leg swelling. Weigh yourself daily and call you
doctor if your weight changes by more than 3 lb.
3. Please apply the topical steroid cream to the itchy areas
twice daily for no longer than two weeks, please do not apply to
the face and use sparingly on the folds of your skin.
4. Please fill the posaconazole prescription but do not start it
until after your next round of chemotherapy.
You are planned for another admission this upcoming ___
___ to have a pheresis catheter placed and start receiving
consolidative chemotherapy. Please follow the line preparation
instructions you previously received, including holding your
lovenox the day prior to the procedure.
Thank you for choosing ___ for
your healthcare needs.
Sincerely,
Your ___ Team | Ms. ___ is a ___ with PMHx of HTN, T2-IDDM, Afib on
enoxaparin, h/o Stage III uterine CA ___ s/p chemo, XRT,
TAHBSO, and recently diagnosed w/ AML s/p 7+3 ___ now in
cytogenetic remission who developed a rash on recent admission
(presumptively DRESS from allopurinol vs Cefepime vs HHV6),
presenting w/ recurrent rash and SOB.
# Rash: Patient presented for recurrance of maculopapular
erythematous rash worse in dependant areas. During last
admission she had this rash that started ___ associated with
fevers, transaminitis, and facial edema. Derm consulted on ___
felt this was DRESS from cefepime or allopurinol. Got 2 doses
solumedrol. HHV6 was also considered as cause of fevers/rash and
simple drug reaction was also in the differential but unclear
which drug caused it. Upon review of medications and rash
started after cefepime, vanco, & vori. Only medication restarted
upon discharge was voriconazole. Only medication changed as OP
was lovenox replaced warfarin. Rash on admission was very
pruritic and widespread. Given history it was decided that it
was unlikely lovenox causing reaction so stopped voriconazole
and switched lasix to torsemide for possible sulfa allergy. HHV6
level was 974 similar to last admission, patient had moderate
peripheral eosinophilia and derm was re-consulted. Decided to
hold off on steroids and rash improved drastically within 72
hours after stopping voriconazole and peripheral eosinophilia
resolved gradually. Voriconazole was added to allergy list.
# Postive BC x1: Patient had one positive blood culture, got
emperic vancomycin from ___ and culture came back as
contaminent bacteria. Vancomycin was stopped and patient
remained well appearing and afebrile.
# Dyspnea on exertion: Patient had lightheadedness and new DOE
at home. CTA ___ ruled out PE and other acute/new pulmonary
process. The patient was not hypoxic and troponins were negative
but her BNP was >1000. She was being diuresed from her last
admission and did not have PND or orthopnea. TTE on ___ was
similar to prior study with EF >55%. Given reassuring evidence
against acute cardiopulmonary process and ambulatory saturation
>98% concern for new pathology was diminished. Patient did not
have recurrence of DOE on admission and thought to possibly be
secondary to over diuresis. . Ambulatory sats 98-100. SOB
resolved on discharge.
#Peripheral Edema / Hypotension: patient presented with mild
hypotension on lasix 40 BID for her residual peripheral edema.
She was switched to torsemide 20mg with continued improvement in
her peripheral edema and resolution of her hypotension after
250cc fluids. She was discharged on 10mg torsemide to be
titrated down and ultimately discontinued once her peripheral
edema resolves.
#Chest Port Erythema: The patient presented with chest erythema
at her previous port site (removed ___ that was flat
confluent and well demarcated likely rash secondary to
bacitracin she applied on the area and exacerbated by the
voriconazole rash. Resolved with discontinuation of both
medications.
#Acute Myeloid leukemia: In hematological CR after 7+3
chemotherapy per bone marrow biopsy from ___. Not eligible for
HSCT due to comorbidities. Planning on consolidation with MiDAC
___ and enrolled in clinical trial ___ Blockade of PD-1
in Conjunction with the Dendritic Cell/AML Vaccine following
chemotherapy induced remission. Planned for readmit on ___
___ for MiDaC consolidation therapy.
#Atrial Fibrillation: CHADS2-VASC of 3. No longer on coumadin
due to difficulty achieving therapeutic INR & contraindicated
for vaccine trial. Home medications continued as prescribed and
discharged on same medications.
#Herpes Simplex Virus 1: continued on acyclovir without acute
event
#Type 2 diabetes Mellitus; home metformin held and continued
home Novolin ___ BID, 9U am 5U pm
#Fungal PNA: Patient with fungal pneumonia on last admission.
Holding anti fungal as above, plan to restart posaconzaole with
next round of chemotherapy.
#Vitamin B12 Deficiency: cont cyanocobalamin | 281 | 611 |
11100330-DS-13 | 26,206,697 | Dear ___,
You were hospitalized due to symptoms of walking difficulty
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high blood pressure
We are changing your medications as follows:
START Atorvastatin 40mg by mouth nightly
START Clopidogrel 75mg by mouth daily indefinitely
Continue Aspirin 81mg until ___ and then STOP aspirin
Please see your medication list for directions regarding your
other medications.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is an ___ right-handed woman with history
notable for Alzheimer's dementia, Grave's disease, HTN, IBS, and
prior right callosal infarct presenting for evaluation of five
days of gait disturbance, found to have acute to subacute
infarct in the pons.
#Pontine Ischemic Infarct: MRI of the brain showed acute to
subacute infarct in the pons. Patient was monitored of
continuous cardiac telemetry and was seen without any
arrhythmia. TTE showed normal EF without any evidence of cardiac
source of embolism or structural abnormalities. A1c was elevated
at 5.9%, indicating pre-diabetes, and LDL was elevated at 135.
The patient was started on DAPT with aspirin and Plavix, with
plan to continue DAPT for 21 days, after which the patient will
continue only Plavix indefinitely (as she was previously taking
aspirin 81mg daily when this event occurred). Atorvastatin was
also added given elevated LDL. Patient's gait disturbance was
seen to be improving but still not back to baseline prior to
discharge, and ___ recommended further rehab and increased
supervision on discharge. Patient was discharged with neurology
follow up. Given the intermittent arterial calcifications seen
on CTA, the patient's age, and the location of the infarct, the
etiology of the stroke was thought to be due to small vessel
disease.
#Hypertension: home anti-HTN medications were held, as the
patient's blood pressure was allowed to be autoregulated in the
setting of ischemic stroke. Her SBP remained at goal at <180
throughout this hospitalization. She was resumed on amlodipine
10 mg daily and lisinopril 20 mg daily rather than her prior
amlodipine-benzapril in favor of being able to titrate
lisinopril further. This can be further increased as needed.
#Alzheimer's dementia: though she has a prior diagnosis of
dementia, the patient did not experience any agitation during
the hospitalization. She is currently scheduled to follow up
with Dr. ___ in the cognitive neurology department.
===== | 254 | 309 |
10540652-DS-18 | 26,814,669 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___!
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were feeling confused
with hallucinations, and insomnia and weakness.
- You also were noted to have decreased food intake, weight
loss, and worsening of your tremors.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital we monitored you and your
blood for your sodium levels which were low when you came in. To
treat this we encouraged you to eat and also not to drink too
much water. Your sodium levels continued to improve.
- We consulted our nutrition team who encouraged you to
continue to eat healthy fats and healthy meals to gain weight so
you can get stronger. We gave you two Ensure drinks per meal to
help you gain some of the weight you have lost.
- We started you on a new medication for your ___
Disease called Sinemet (carbidopa-levodopa) which will help with
your tremors. We discontinued your Ativan.
- We discontinued your Escitalopram as we think this may have
contributed to your low sodium. We started you on a new
medication, Gabapentin to try to help with your anxiety.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications.
- Please continue to eat healthy fats and to try to increase
your caloric intake.
- Please continue to drink Ensures to help gain weight to get
stronger. Do not drink too much water so that you are too full
to eat.
NEW MEDICATIONS
Gabapentin
Carbidopa-Levodopa (___) (Also known as Sinemet)
Please Increase the dose of the Carbidopa-Levodopa as follows:
Week 1 (___) Take half tablet in the morning
Week 2 (___) Take half tablet in the morning, half tablet
at noon
Week 3 (___) Take half tablet in the morning, half tablet
at noon, half
tablet in the early evening
Week 4 (___) Take one tablet in the morning, half tablet
at noon, half
tablet in the early evening
Week 5 (___) Take one tablet in the morning, one tablet at
noon, half
tablet in the early evening
Week 6 (___) Take one tablet in the morning, one tablet at
noon, one
tablet in the early evening and continue on this regimen
CHANGED MEDICATIONS
NONE
STOPPED MEDICATIONS
Escitalopram
Lorazepam
We wish you the best!
Sincerely,
Your ___ Team | Ms ___ is a ___ speaking F with recently
diagnosed ___ disease, anorexia, recent UTI, mastectomy
of left breast (in the ___) who presented to the emergency room
with increasing confusion, insomnia, and hallucinations, found
to
be hyponatremic which improved with fluid restriction now
normalized, started on Carbidopa-Levodopa for ___ also
with deconditioning. She was clinically stablilized and
discharged to rehab. | 416 | 58 |
13158833-DS-19 | 22,888,882 | Dear Mr. ___,
You were admitted for altered mental status. You have dementia
and your behavior is consistent with your dementia. Please see
the recommendations by psychiatry below.
YOU SHOULD FOLLOW UP WITH A NEUROLOGIST IN THE OUTPATIENT
SETTING TO ESTABLISH CARE.
You may have a mild UTI. Please take Cefpodoxime for three more
days starting ___.
RECOMMENDATIONS:
- does not meet ___ criteria
- d/c back to ___
- no indication for ___ placement as patient is not
manic,
psychotic or depressed
- Continue Mirtazapine 7.5mg AM and 15 QHS
- Continue Melatonin 5mg QHS
- Taper Ativan to 0.5mg PO BID ___ and ___, then 0.5mg x1 on
___ and ___ then stop
- Haldol 0.5mg BID prn agitation
- Monitor QTc on Haldol
SNF should get another EKG in about a week to monitor QTc.
All the best,
Dr. ___ | Mr. ___ is a ___ male with a past medical history of
dementia with severe gait disturbances, hyperlipidemia, and
history of multiple falls, who presents from ___ with
behavioral disturbance. He has shown less inhibition and more
sexual aggression. Metabolic causes for his aggression were
pursued. CT head was negative for acute pathology. CBC, BMP,
mag, phos, LFTs were all unremarkable. Utox was negative. TSH,
B12, and folate were all normal. Syphilis test is still pending.
UA was borderline positive and pt was started on Cefpodoxime for
five days for possible UTI. I spoke to the pt and his wife. This
type of behavior is not new and has been waxing and waning for
years. Additionally he has not walked for at least ___ years
and has baseline ___ weakness with severe muscle atrophy thought
to be a combination of possible NPH and spinal stenosis. At this
point, his neuro exam is stable for years, so urgent evaluation
would not be helpful. CT head is stable and his symptoms--though
waxing and waning--also sound fairly stable. | 127 | 175 |
13565328-DS-15 | 28,868,217 | It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service after your Left foot surgery.
You are being discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain heel
weightbearing to your left foot in a post op shoe until your
follow up appointment. You should keep this site elevated
whenever possible (above the level of the heart!). No driving
until cleared by your podiatric surgeon.
PLEASE MONITOR FOR THE FOLLOWING SIGNS:
Watch for signs and symptoms of infection in your foot. These
are:
-a fever greater than 101 degrees Fahrenheit,
-increased redness around your wounds,
-increased pain with swelling,
-pus draining from the incision site.
If you experience any of these signs or symptoms or see active
bleeding at the incision site, please call our office at ___. Then, one of our on-call podiatrists will speak to you
and determine if you need to proceed to the emergency room or
can be scheduled for an urgent clinic appointment.
Also, please call the office in you experience any increased
swelling, redness, or pain in your leg or calf, chest pain,
shortness or breath.
You may experience some nausea but this could be related to your
medication (either antibiotics or pain medication). You should
not take these medications on an empty stomach.
EXERCISE:
-Limit strenuous activity for 6 weeks.
-No heavy lifting greater than 20 pounds for the next ___ days.
-Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub. Shower bags or Reuseable Cast and Wound Protectors
are available at most convenience stores such as ___,
___, ___, and online on ___. Avoid
taking a tub bath, swimming, or soaking in a hot tub for four
weeks after surgery or until cleared by your physician.
WOUND CARE:
Leave surgical dressing intact until next clinic visit. It is
important to keep them dry as noted in the Bathing/Showering
instructions above.
MEDICATIONS:
Unless told otherwise, you should resume taking all of the
medications you were taking at home before surgery.
Antibiotics
If you are prescribed antibiotics, you may feel an upset stomach
or experience nausea from the medication. This does not mean you
are allergic to it. Nausea is a common side effect of many
antibiotics. If you are a woman and you get a yeast infection
after taking an antibiotic, that does not mean you are allergic
to it. Yeast infections are a common side effect of antibiotics.
Symptoms of an antibiotic allergy can be mild and include a flat
rash and itching, hives (raised, red, itchy rashes), lip
swelling, difficulty breathing or swallowing.
If you experience an allergic reactive, please call ___
immediately. If you experience constant discomfort or persistent
diarrhea, please call the office as you may be able to be placed
on a different antibiotic.
If you are receiving intravenous antibiotics through a
peripherally inserted central catheter (___) line, you will
have a nurse visiting your home to set up antibiotic treatments.
This has all been organized for you prior to going home. You may
also have appointments set for you to follow up with the
infectious disease doctors regarding important ___ work to
monitor any toxicities or reactions to the medications.
Pain Medication
Aside from resting and elevating your foot at home, there are
medications we may provide you to help reduce your pain.
Unless instructed to not take them, acetaminophen (Tylenol) and
ibuprofen (Advil, Motrin) should be taken first to help relieve
pain. Acetaminophen can be taken up to 1000 mg every 6 hours
(not to exceed 4000 mg daily). Ibuprofen can be taken up to 800
mg every 6 hours (not to exceed 3200 mg daily).
Narcotic pain medications such as oxycodone, Percocet, Vicodin,
etc. can be constipating and you should increase the fluid and
bulk foods in your diet. If you feel that you are constipated,
do not strain at the toilet. If a laxative is not prescribed for
you, you may use over the counter Metamucil, Milk of Magnesia,
or Miralax daily while taking opioid pain medications. Appetite
suppression may occur shortly after surgery and while taking
these medications but this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for weeks after surgery and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENTS:
Be sure to keep your medical appointments with your surgeon but
also your primary care physician (PCP).
Please follow up with your podiatric surgeon, Dr. ___. If a
follow-up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit (Phone
Number: ___. This should be scheduled on the calendar
for one to two weeks after discharge. Our surgeons have
locations in ___, ___, and ___. If
you would prefer one of these locations, please ask the main
office if your surgeon has clinic at any of these other
locations.
Please make sure to follow up with your primary care physician
(PCP) as well regarding your hospital admission within one to
two weeks to review why you were in the hospital, what you
underwent, and if you need any of your regular medications
refilled or adjusted (for example, blood pressure medication).
While your podiatric physician may manage your other medical
conditions while in the hospital, it is important to see your
PCP for further management.
PLEASE FEEL FREE TO CALL THE PODIATRIC SURGERY OFFICE AT ___ WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE.
Thank you for staying with us at ___
Center and we wish you a healthy and speedy recovery! | The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have a left foot abscess and was admitted to the podiatric
surgery service. The patient was taken to the operating room on
___ for L foot incision and drainage with ___ metatarsal
head resection, 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 ___ 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
Heel weightbearing L foot in a post op shoe. 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. | 952 | 240 |
14968931-DS-5 | 26,825,740 | Dear Mr. ___,
You were seen at ___ for your back pain. You were also found
to have clots in your lungs which may be new. You were started
on a blood thinner to prevent your clots from progressing.
You had an MRI done to evaluate your back pain. Although you
have extensive spinal lesions, there is no role for surgery at
this time. You also do not need to wear a back brace at this
time.
Your elbow pain was diagnosed as an elbow fracture. Please
continue to wear your sling, move it as tolerated, and do not
lift anything heavier than 2lbs. Please follow up with your
orthopedic surgery appointment.
You were also noted to have increased calcium. Please avoid
calcium-containing foods and drink plenty of water. You should
have your calcium level checked at your appointment next week.
If you start to develop tremors or altered mental status, please
call your doctor.
Please take all of your medications as directed and follow up
with your outpatient appointments.
Best wishes,
-Your ___ team | Mr. ___ is a ___ yo male with a history of RCC who was
admitted with spinal compression fractures and PEs.
#PE: Previous imaging, including from OSH, is not able to
exclude that PEs are new. ___ be adverse side effect of
axitinib. Pt did not undergo full anticoagulation course
previously because he developed hemoptysis. As the patient's
pulmonary nodules have shrunk, he is less likely to have
recurrent hemoptysis, so the patient was started on a heparin
gtt then switched to lovenox.
#Compression Fractures: Pt has had progression of bony lesions.
___ be contributing to back pain. The patient's pain was
controlled with home lidocaine patch, fentanyl patch, and
oxycodone. The spine service was consulted and had the following
recommendations: Extensive spinal lesions, no indications for
surgery, no need for brace. Radiation oncology was also
consulted and will review previous records, planning to further
discuss treatment options at an outpatient visit.
#Elbow Fracture: Pt has pathologic fracture of elbow. Ortho was
consulted and recs: sling LUE, (range of motion as tolerated)
ROMAT, (weight bearing as tolerated) WBAT, No lifting >2 pounds.
He will have follow up in ___ clinic in 2 weeks.
#Diarrhea: Likely from CT contrast. Less likely from chemo ASE
given that pt has not had this rx before. C Diff negative.
Resovled with Loperamide
#RCC: Dx in ___, s/p radical nephrectomy now on Axitinib.
Pt has had some response but increase in bony lesions.
#Hyponatremia: Likely ___ hypovolemia given diarrhea. Resolved
with IVF.
#Hypercalcemia: Pt has bone lesions and is getting monthly
zometa (last ___. The Ca2+ remained <12 and was managed with
IVF. The patient has follow up on ___ at an outpatient appt;
he should have lytes repeated for this visit. | 173 | 286 |
19819686-DS-15 | 24,226,963 | Dear Ms. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for intermittent fevers. Reason for fevers was not
entirely clear. You had numerous studies and tests and none of
the tests suggested an infectious source. We had a family
meeting to discuss your fevers and the decision was made not to
perform any more studies since it would not change management.
The plan is to send you back to rehab.
Medication changes:
-Please hold coumadin until ___. If INR<3 on ___, may resume
home coumadin dose. | Ms. ___ is an ___ with history of dementia (non-verbal at
baseline) and deep venous thrombosis on Coumadin who presented
with fever of unknown origin. | 96 | 28 |
17336231-DS-14 | 24,061,307 | 1. PO diet: thin liquids, moist, soft solids.
2. All medications crushed with puree such as applesauce or
yogurt.
3. Aspiration precautions including:
a. Chin tuck for all liquids and solids.
b. Alternate bites and sips.
c. Take small sips of liquid, one at a time.
d. Keep foods moist with sauce, butter, gravy, condiments,
etc.
e. Continue to swallow ___ times per bite/sip.
4. Encourage regular oral care. | Patient was admitted for increasing dysphagia and pain. Speech
and swallow evaluated the patient with video swallow and
recommended liquid diet and moist soft diet. GI were consulted
to rule out esophageal injury. They agreed with speech and
swallow recommendations. Their impression was a neurovascular
source
to his persistent dysphagia. As an inpatient the patient was
uncooperative in maintaining the fentanyl patch and removed it
at least once without the nurses knowledge. As the pain
medication are being prescribed by his PCP, he has not been
given any new scripts for narcotic medications. | 100 | 93 |
18900127-DS-7 | 21,169,487 | Dear Dr. ___,
___ was a pleasure taking care of you at ___.
You came to the hospital after vomiting contents from the
intestinal tract. You aspirated some of this material, and had
to be intubated to help you breathe. After a course in the ICU
with intubation, you came to the medical floor. On the floor you
had a small bowel obstruction that got better.
After you leave the hospital:
- follow-up with your doctors that ___ have made appointments
with
- avoid foods that slow GI motility or that cause you
nausea/vomiting as was discussed
Again, it was an honor taking care of you.
Sincerely,
Your ___ Team | SUMMARY:
___ with a history of metastatic urothelial cancer s/p radical
cystectomy with ileal conduit s/p XRT, now on atezolizumab who
presented with respiratory distress s/p elective intubation
following aspiration event post-EGD in the setting of nausea and
guaiac positive feculent emesis. After a prolonged ICU course he
was extubated. His respiratory status continued to improve; he
did have a partial SBO that subsequently resolved. He was
discharged in stable condition to acute rehab.
MICU COURSE (___):
=============
#Shock: Patient was admitted to the MICU with a pressor
requirement not responsive to fluid resuscitation. The etiology
was multifactorial from likely sepsis and hemorrhagic from GI
bleed. He was treated with Vancomycin and zosyn for underlying
infection. As his GI bleed and infection began to resolve he was
weaned off of pressors prior to discharge from the MICU.
#Acute respiratory failure: Dr. ___ voluntary
intubation after an aspiration event during GI endoscopy. He
underwent ARDSnet protocol. He was eventually able to be weaned
from volume control to pressure support. He was eventually
weaned from the vent and extubated prior to discharge from the
MICU.
#Aspiration pneumonitis vs pneumonia: The patient required
intubation and underwent ARDSnet protocol after aspiration. He
became febrile and hypotensive. He was empirically treated with
Vancomycin and zosyn. He was extubated for respiratory support
as described above. His pneumonia resolved with treatment and he
was successfully Extubated prior to leaving the MICU.
#Coffee ground emesis: There was ___ clear evidence of active or
recent GI bleeding on EGD. He was maintained on pantoprazole BID
and Zofran for nausea. His H/H remained stable in the MICU.
# Acute on chronic CKD: Patient developed ___ secondary to
hypoperfusion during shock when he was admitted to the MICU. His
creatinine and urinary output improved throughout his stay while
we maintained a MAP of > 65 with pressors and volume support as
needed.
FLOOR COURSE (___)
=============================
# Hypoxemic respiratory failure: Patient initially had a 2L O2
requirement upon arrival on the floor. Based on exam and imaging
he appeared to be volume overloaded secondary to receiving
volume resuscitation in the ICU. He was diuresed over the course
of several days and his respiratory status improved
significantly. Upon discharge he was on room air.
# Cough: Patient had a persistent non-productive cough. He had
___ other signs of infection or pneumonia, and this was thought
to be represent upper airway cough syndrome vs metastatic
disease in lungs. His cough was managed with guaifenisen,
tessalon perles, fluticasone nasal spray, and oral
antihistamines.
# pSBO
# Abdominal pain: Patient initially presented with feculent
emesis concerning for an acute bowel obstructive event. After
his extubation, he was able to eat small amounts of food.
However on ___ he again developed sharp left-sided abdominal
pain. A KUB was performed which was consistent with an ileus vs
a partial SBO. He was given IV fluids and a glycerin suppository
to move his bowels; subsequently the pSBO resolved and his diet
was ddvanced again.
# Goals of care: Dr. ___ is HCP. Daughters are
involved as well. Goals of care discussion held with palliative
care, Dr. ___ oncologist, and family on ___.
Decision was made to remain full code, and to aim for rehab with
the goal of getting stronger. At that time they would
re-evaluate the benefit of additional chemotherapy.
# Back pain
# ___ pain/radiculopathy: Patient has chronic back pain,
attributed to L5-S1 disc herniation with worsening after
radiation therapy. Patient has expressed that he does not want
opioids if avoidable due to a negative experience with his wife.
Per Dr ___ pain is due to edema ___ XRT and has
responded to NSAIDs in the past. His pain was controlled with
standing APAP, gabapentin 300mg TID, PRN ibuoprofen 200-400mg.
# Gastritis:
# Anemia: Patient initially presented with coffee grounds emesis
and an EGD was performed, which showed gastritis. His hematocrit
remained stable throughout the rest of his admission and he was
continued on omeprazole 40mg BID. He did receive 2u of pRBC
transfusion on ___.
# Positive urine culture: Urine culture taken from urostomy was
positive for pan-sensitive pseudomonas on ___. ___ change in
urostomy output to suggest a true urinary tract infection. Per
discussion with outpatient oncologist Dr. ___ antibiotic
treatment was given.
# Altered mental status: Waxing and waning confusion which seems
to worsen at night, most consistent with delirium. Thought
likely due to poor sleep. He was given seroquel 50mg QHS and he
was able to sleep more consistently; thereafter his mental
status returned to baseline. Seroquel was continued for a
limited duration at the time of discharge, with need for ongoing
to be re-assessed at rehab. QT was WNL at the time of
discharge.
# Urothelial carcinoma: Currently on Atezolizumab (atezolizamab
___ Gemzar/Cisplatin D1,D8,q3wks). Followed by Dr. ___.
CT torso on ___ showed progression of disease with hepatic
metastases and increased size of retroperitoneal
lymphadenopathy. Per Dr ___ currently a candidate for
chemotherapy but would discuss further as outpatient if
patient's functional status improved. | 105 | 829 |
15700332-DS-15 | 21,380,748 | You were admitted to the Acute Care Surgery service for
gallstone pancreatitis and laparoscopic cholecystectomy.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
Please resume all regular home medications. Please take any new
medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. 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. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician as soon as possible. | ___ with hx of HTN, HL p/w epigastric pain found to have
pancreatitis.
# Pancreatitis: Pt presented with significantly elevated lipase
6735 ___s LFTs AST 277 ALT 486 Alk P ___. CT ab/pelvis
prelim showed peripancreatic stranding and free fluid,
consistent with acute pancreatitis. Pt had RUQ u/s showed
Cholelithiasis with multiple small stones and biliary sludge,
but no bile
duct dilatation. On hospital day #1 his lipase, ALT and AST
trended down very quickly making the most likely etiology for
pancreatitis ___ transient obstruction from gallstone. An
increase in ALT is suggestive of pancreatitis (his was 486 on
presentation) per literature a value above 150 strongly suggests
gallstone pancratitis. Patient does drink alcohol (about ___
scotch per night) however he denies excessive drinking and the
fact that the lipase trended down so quickly makes gallstone
pancreatitis from transient obstruction the most likely
etiology. ___ normal. Zyrtec, ibupofen, fluconazole were new meds
that he took over the past few wks and non of them are known to
cause pancreatitis. We calculated pt's ___ score which was 2
(for elevated WBC and AST) which indicated low mortality. He was
given continuous IVF, made NPO and given IV pain meds, zofran
PRN. His vitals remained stable and his lipase and LFTs trended
down. Surgery was consulted and they recommended
cholecystectomy.
.
.
# HTN: initially held PO meds bc he was NPO.
.
# HL: Initially held PO meds bc he was NPO | 256 | 246 |
13889245-DS-21 | 29,055,421 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted to the hospital for acute cholecystitis, or
inflammation in your gallbladder. You had surgery to remove
your gallbladder. You should take the pain medication as
prescribed if you need it.
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 4 weeks. (This is about the weight of a briefcase or a
bag of groceries.) This applies to lifting children, but they
may sit on your lap. You may start some light exercise when you
feel comfortable. You will need to stay out of bathtubs or
swimming pools for a time while your incision is healing. Ask
your doctor when you can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you. You may
have a sore throat because of a tube that was in your throat
during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed. You could have a poor appetite
for a while. Food may seem unappealing. All of these feelings
and reactions are normal and should go away in a short time. If
they do not, tell your surgeon.
YOUR INCISION:
You may gently wash away dried material around your incision.
The glue will come off on its own. Do not scrape or scrub it
off. 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 clothes. If the staining is severe, please
call your surgeon. You may shower. As noted above, ask your
doctor when you may resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription. If you go 48 hours without a
bowel movement, or have pain moving the bowels, call your
surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness". Your pain
should get better day by day. If you find the pain is getting
worse instead of better, please contact your surgeon. You will
receive a prescription for pain medicine to take by mouth. It is
important to take this medicine as directed. Do not take it more
frequently than prescribed. Do not take more medicine at one
time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe. Talk with your surgeon about how long you
will need to take prescription pain medicine. Please don't take
any other pain medicine, including non-prescription pain
medicine, unless your surgeon has said its okay. If you are
experiencing no pain, it is okay to skip a dose of pain
medicine. Remember to use your "cough pillow" for splinting when
you cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain | Ms. ___ was evaluated in the ED by the ___ surgery service.
Her history and examination were concerning for symptomatic
cholelithiasis versus early cholecystitis. She was admitted to
the floor for observation and laparascopic cholecystectomy. Her
LFTs were trended and there was a mild increase in her
bilirbuin, raising concern for obstruction, but this normalized
prior to her surgery.
She was taken to the operating room with the ACS service and
underwent a laparoscopic cholecystectomy, the details of which
are in the operative report. She tolerated the procedure well
and was extubated without incident. Afterward, she was brought
to the PACU for recovery, where she did well and she was
transferred to the surgical floor.
She was hemodynamically stable on the floor. Her vital signs
were monitored routinely and she remained afebrile. She started
a regular diet and tolerated it well. She ambulated and voided
without difficultly. She was transitioned from IV to PO pain
medication. She was discharged in good condition and will call
the ___ clinic to schedule follow up. | 639 | 180 |
13198543-DS-15 | 20,860,458 | General Instructions
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been instructed to hold your Plavix (clopidogrel),
until clearance from Neurosurgery
If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101° F. | Mr. ___ was admitted to the Neurosugery service for
evaluation and surgial planning.
We obtained a medical consult for surgical clearence given his
age and medical history.
He had Carotid dopplers to evaluate his carotid stenosis in the
setting of reported severe stenosis and TIA's. The study showed
less than 40% stenosis, and he was determined to be relatively
safe to undergo a craniotomy for Subdural hematoma evacutation.
We plan to proceed with surgical evacuation of this subdural in
one week given that he has been taking plavix at home.
A physical therapist evaluated the patient and they felt that
the patient needed to be placed in rehab until he returns for
surgery. On ___, pt was stable for discharge to ___
___. He will follow-up accordingly. | 155 | 129 |
16176812-DS-4 | 29,426,518 | Mr. ___,
You were admitted for weakness and fatigue and you were found to
have a urinary tract infection. We treated you with IV fluids
and antibiotics. Your kidney function and weakness improved. You
also had pain in your left knee which was tapped by our
Rheumatologists and showed that you had a gout flare. You were
treated for this with colchicine and an intra-articular steroid
injection. Please see below for information regarding follow up
care and medications to take on discharge.
It was a pleasure taking part in your care.
Your ___ Team | ___ is a ___ yrs male with CKD s/p transplant in
___ who over the past 10 days, after cystoscopy, felt very
weak, lightheaded and nearly syncopized at an outpatient
appointment presenting with UTI.
# Complicated urinary tract infection: Most likely weakness,
hypotension and fatigue are secondary to urinary tract infection
s/p recent cystoscopy. He presented to the ED with dirty UA and
Cr bump to 3.1 from baseline of 1.4-1.8. UCx from outside PCP's
office showed >100,000 CFU of GNRs that are non-lactose
fermenters. He was started on IVF and CTX and then changed to PO
ciprofloxacin (Day #1 ___ after cultures started
speciating. Species and sensitivities were pending at discharge
in Atrius. Other infectious etiologies were ruled out: CXR
clear, blood cx ngtd, stool cultures, CMV viral load and EBV PCR
all were negative.
#Pre-renal azotemia: Most likely was secondary to hypovolemia in
setting of urinary tract infection. Patient was found to be
orthostatic at his PCP's office and his urine cultures showed as
above. He was given IVF and CTX and then was switched to ___
___ for UTI. Cr decreased to his baseline (1.8) and was stable
for 2 days before discharge.
#Crystal proven gout (left knee): patient has history of gout
and is not on any preventative medications currently. In
addition, patient is immunosuppressed. Pt. had monoarticular
swelling of left knee with warmth posed concern for septic
arthritis. Rheumatology consulted and tapped effusion on ___
which showed 43,500 WBCs, 96% PMNs and monosodium urate
crystals. IV Vancomycin 1gm q12 hr initiated while gram stain
was pending, but discontinued as WBCs most likely ___ to gout
flare and gram stain negative. Patient received colchicine 0.6
on ___ and an intraarticular steroid injection done by
Rheumatology on ___. Pain control with Tylenol and
breakthrough with oxycodone.
#Hyponatremia: most likely was due to hypovolemic hyponatremia
w/UTI + pseuodhyponatremia in setting of hyperglycemia. Resolved
with boluses of NS and better glucose control.
#ESRD s/p left renal transplant ___. Baseline Cr 1.4-1.8.
Patient maintains right lower arm fistula. Cr elevated on
admission to 3.1. Cr improved to baseline after treatment of UTI
and IVF. Tacrolimus 4mg BID, cellcept 500 mg BID continued
#Hyperparathyroidism: Cinacalcet increased slightly on this
admission.
#Uncontrolled Diabetes Mellitus Type II. Patient had glucose
into the 400s on admission. Continued Lantus at an increased
dose from 40 to 53 units daily and d/c'd Humalog 12 with meals
and instead put him on ISS while in house with good control.
Continued gabapentin 300mg capsule daily.
#BPH:
Continued home tamsulosin.
#Coronary artery disease. Continued pravastatin 80 mg daily,
metoprolol tartrate 25 QID, increased amlodipine 5 mg to 10mg
daily, continued aspirin 81 daily and withheld chlorthalidone 25
mg daily (in setting ___ and infection).
#Hypertension
BPs recovered following abx and IVF. Increased amlodipine 5 mg
to 10mg daily. Continued metoprolol at fractionated dosing as
met tartrate 25 QID. Withheld chlorthalidone in setting of
___.
#seasonal allergies
Continued fluticasone nasal spray
#GERD: continued home ranitidine
TRANSITIONAL ISSUES
===================
[] Antibiotics: Cipro for 10 day course (Day #1 ___ thru
___.
[]Labs: Outpatient chemistry 10 within 3 days of discharge to
ensure stability of Cr and good control of Ca with new dose of
Cinacalcet. He should continue with twice weekly chem 10 and
tacrolimus levels at rehab ___ and ___. Please fax
labs to: Nephrology - Transplant Team at ___: ___.
and Dr. ___: ___
[] Tacro Goal: ___. Must be a true tacro trough (drawn within 1
hour prior to AM dose).
[]Rehab Consult: Please have nephrology consulted at rehab and
evaluate patient given complex case.
[]Urine Culture: ___ has a Urine culture from ___
pending. Will need to ensure species is sensitive to cipro once
culture finalizes.
[]HTN: Given ___ and hyponatremia, in place of chlorthalidone,
we increased his amlodipine to 10 mg daily on discharge for
better BP control. If needs improved BP control, consider
restarting chlorthalidone with stable Cr and BP >140.
[]Insulin: Lantus regimen was altered during stay for high
glucose. He is currently at 53 units Lantus AM with NO standing
Humalog and ISS. Please continue to monitor blood sugars 4x
daily and adjust as necessary.
[]Hypercalcemia: Patient will be discharged on cinacalcet at 90
mg daily from 60 mg daily
[]Gout Flare: Patient in middle of gout flare. He received 1
dose of colchicine without good effect, and because of
medication interactions, decided to give intraarticular
injection of left knee.
[]Outpatient F/Up: needs outpatient follow up with urologist,
nephrologist, and primary care provider.
[]Bladder Stone: Patient had cystoscopy on ___ showing
non-obstructive bladder stone. Consider outpatient removal, and
analysis for urate crystals. If + for urate crystals, may need
to be placed on urate lowering medications. Please fax results
to Attn Dr. ___: ___
# CODE: Full Code, confirmed
# CONTACT: ___ (wife, HCP) ___ | 91 | 779 |
18717491-DS-10 | 23,008,098 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for ___ weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" a couple weeks. You might
want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You could have a poor appetite for a couple days. Food may
seem unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
o If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mrs. ___ was admitted on ___ under the acute care
surgery service for management of his acute appendicitis. She
was taken to the operating room and underwent a laparoscopic
appendectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. He was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic. | 736 | 171 |
16252323-DS-13 | 23,075,715 | Dear Mr. ___,
You were admitted to the hospital with kidney and lung failure.
While here, you were admitted to the ICU and placed on a
breathing machine. You underwent hemodialysis due to the kidney
failure. You were treated with IV antibiotics for a pneumonia
and also developed two GI bleeds, one that was secondary to
inflammation in your stomach and a second that was related to a
diverticulum in your colon. You were treated with an
acid-blocking medication and bowel rest. You did well in the
ICU and were transferred to the medicine floor for further
management. You had no further bleeding and passed a swallowing
exam so are being trialed on a soft diet. You will continue to
get feeds by the ___ tube until you are stronger and
eating well. You are being discharged to rehab.
The following changes were made to your medications:
1. START omeprazole 40mg by mouth twice daily
2. START finasteride 5mg daily
3. START tamsulosin 0.4 mg qHS
4. STOP aspirin until otherwise instructed by a doctor
5. STOP nifedipine until otherwise instructed by a doctor
6. STOP cyclobenzaprine
7. STOP doxycycline
8. STOP lisinopril
9. START lidocaine patch as needed for pain
Please continue your other medications as prescribed by your
outpatient providers.
You will need to keep the foley catheter in for at least 2 weeks
and will need to see a urologist as an outpatient for further
evaluation of your urinary obstruction. You will also need to
follow up with gastroenterology.
It was a pleasure taking care of you. We wish you a speedy
recovery. | ___ yo M w/ COPD, HTN/HL, CAD, who p/w ___, hypotension tx for
obstructive uropathy w/ foley, urgent HD, with hospital course
complicated by HCA pneumonia and GIB initially ___ gastritis and
subsequently diverticular in nature.
# Hypotension, Adrenal Insufficiency
The patient's hypotension was likely multifactorial and
secondary to a combination of hypovolemia from GI bleed,
infection from pneumonia, and unstable tachycardia. See below
for treatment of each of these problems. The patient also
received stress dose steroids, but was ultimately transitioned
back to his home prednisone as he stabilized. Cardiac enzymes
were not suggestive of MI. The patient was resuscitated fully
and left the MICU slightly hypertensive because he was NPO and
could not take his home nifedipine. While on the medicine
floor, the patient had no episodes of hypotension and did well
on his home metoprolol dose. His home nifedipine was held, but
this can be gradually restarted if his pressures require it.
#Bacterial Pneumonia:
The patient's X-ray on admission showed a RLL opacity. Unclear
if chronic or new, infectious vs. malignant, based on old
records. The patient was treated for HCAP with vancomycin,
cefepime, and levofloxacin, which was tailored back to
vancomycin and levofloxacin as the patient stabilized. He
completed an 8 day course- last day was ___. He continued to
have a 2L oxygen requirement which was attributed to atelectasis
in the setting of deconditioning. He will benefit from continued
physical therapy and incentive spirometry.
# Acute Renal Failure due to Urinary Retention
This was due to obstructive uropathy, given large amount (3L) of
UOP after Foley placement in ED. He was uremic with extensive
electrolyte abnormalities and acidosis. His initial EKG showed
changes consistent w/ his hyperkalemia. The patient's ultrasound
suggested bilateral hydronephrosis. The patient was emergently
hemodialyzed in one two hour session. He did not require further
dialysis. Between the placement of a Foley catheter and the
dialysis, the patient's renal function rapidly improved and his
creatinine was normal by the time he left the ICU. He was
started on finasteride and tamsulosin and foley was kept in
place. Urology recommended foley for at least two weeks with
outpatient follow-up for a voiding trial.
# Etiology of urinary obstruction. Multiple possibilities, the
most concerning of which was cauda equina syndrome. An MRI
showed no cauda equina, so stress dose steroids for possible
cauda equina were stopped. Thought to be caused by benign
prostatic hyperplasia. Urology consult was placed and they
recommended foley for at least two weeks with outpatient
follow-up for a voiding trial. They did not see an indication
for any acute urologic intervention during the hospitalization.
# Acute Blood Loss Anemia due to Diverticulosis with Bleeding:
The patient was was initially given DDAVP 0.4mcg/kg over 10
mins. a PPI drip, and resuscitation with fluids. The patient
underwent endoscopy, which showed gastritis, gastric ulcer,
duodenitis. He was then started on PPI BID. His H pylori
serology was equivocal, stool antigen was ultimately negative.
He was called out to the floor but returned to the ICU following
additional episodes of hypotension and bright red blood per
rectum. He required transfusions of red blood cells (4 units).
His CTA abdomen was negative, but his colonoscopy showed
left-sided diverticulosis which was believed to be the etiology
of his bleed. He will require GI follow up (scheduled) with Dr.
___ for repeat EGD given concern for gastric metaplasia
in the setting of his gastritis.
# Severe Malnutrition/aspiration risk:
On second to last day of patient's initial ICU stay, the patient
coughed up a large pill that was stuck in his posterior throat.
He was made NPO, his medications were switched to IV. On ___,
S/S team felt the patient was high risk for aspiration so he
remained NPO, failing multiple trials until ___ when he passed a
video swallow and was started on a nectar thick liquids, pureed
solids diet. After completion of GI studies and resolution of
the bleed, patient was given tube feeds for nutrition. These
will need to be continued while his swallowing mechanism is
still improving and nutritional status poor. We would recommend
nutrition to follow him and perform calorie counts to help
decide when to discontinue tubefeeds. Would recommend monitoring
for refeeding syndrome given severe malnutrition and several
days w/o food in setting of GI bleed.
# LUE weakness:
On ___, the patient was seen not using his left arm.
Neurological exam showed biceps and triceps weakness, with no
obvious sign of shoulder dislocation. Strength in hand was ___,
though patient had some swelling of dorsum of left hand. UE
ultrasound was scheduled, but patient refused that test on ___.
Neurology was called. They recommended soft cervical collar and
MRI spine. MR ___ performed on ___, which showed
degenerative changes, posterior disc bulge throughout w/ severe
spinal stenosis. He may benefit from neurology follow up as an
outpatient.
# Possible air embolism:
Shortly after the patient's HD line was removed, he had
hypotension and destauration. This was thought to be secondary
to an air embolism. The patient was placed on his left lateral
decubitus. An echo was obtained that did not suggest right heart
strain or pulmonary embolism. The patient's condition slowly
improved until he only needed 2L nasal cannula. This can
continue to be weaned as tolerated.
# Intraatrial septal aneurysm:
Incidental finding on echocardiography. Following discussion
with Cardiology and Neurology, the patient may be placed on
aspirin once he is out of the window of his acute GI bleed.
# CAD:
Echo w/ EF 55%, no wall motion abnormality, though notable for
interatrial septal aneurysm. Per cardiology and neurology
recommended aspirin and statin. We have been holding aspirin
given his recent bleed but this can be restarted if hcts remain
stable and no signs of further bleed. He was continued on his
metoprolol and restarted on his statin on discharge.
# Polymyalgia Rheumatica:
He briefly received stress dose steroids as above, but then was
switched tot methylpred 4mg iv daily. On discharge he was
restarted on his home prednisone 5 mg daily.
The patient will need to establish care with a PCP and is
interested in doing so at the ___. He will need to follow up
with urology and GI as detailed in the discharge instructions.
He had extensive code status discussions during this
hospitalization and he decided to be DNR/DNI. His health care
proxy is son ___ ___. | 267 | 1,063 |
16996620-DS-15 | 27,046,081 | Surgery/ Procedures:
You had a cerebral angiogram which showed no aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
You had a VP shunt placed for hydrocephalus.
Your shunt is a ___ Strata Valve which is programmable.
This will need to be readjusted after all MRIs or exposure to
large magnets. Your shunt is programmed to 1.0 ****
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.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on a medication called Nimodipine.
This medication is used to help prevent cerebral vasospasm
(narrowing of blood vessels in the brain).
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. 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:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ yo M sudden onset WHOL and neck pain while at Martial Arts
class. CT reveals SAH. CTA negative for anerysm. R EVD placed
for hydrocephalus. Confirmed placement by CT head. Intubated in
ICU for airway protection. Patient taken to angio suite for a
diagnostic angiogram which was negative. He was transferred back
to the ICU where he was monitored carefully. On ___ he was
extubated and his SBP was liberalized to 180. He maintained in
the ICU and his exam was stable. On ___ his EVD was raised to
20. TCDs were performed and were negative for vasospasm.
On ___, patient was intact on exam, but reported headaches.
Oxycodone was increased. EVD was clamped at 20 and reopened for
increased ICPs. He remained stable on exam. TCDs were performed.
On ___, patient was febrile and a workup was sent. A UA was
positive and started on Cipro. Patient's exam remained stable
with plan for repeat imaging tomorrow.
On ___, ICPs were intermittently in the low 20's and a CT head
was obtaine dwhich showed the catheter was at the tip of the
ventricle. Extra staples were also palced at the catheter site
for bleeding that was noted with good effect.
On ___, he underwent a diagnostic angiogram which showed mild
vasospasm but no aneurysm or vascular malformation. He
subsequently underwent a Right VP shunt without complication.
On ___, he was off the clevidipine gtt and his SBP was
liberalized.
On ___, his exam remained neurologically intact and he was
deemed fit for transfer to the SDU and orders were written.
On ___, the patient remained neurologically intact. His sodium
was 129 this morning. His salt tabs were increased from 1g to 2g
every 8 hours. He was placed on a 1L fluid restriction.
On ___, the patient remained neurologically stable. His
morning Na was 132. His K was 3.2 and he received 20mEq of oral
Potassium repletion. Around 12PM, the patient was unable to
state his location and was lethargic yet arousable. He underwent
a STAT CTA which showed mild-to-moderate ACA vasospasm. He
remained in the Neuroscience Step-down unit with neuro checks
every 2 hours. He also continued on NS at 100cc/hr and his SBP
goal was changed to 130-180. He underwent lower extremity
non-invasive vascular studies which showed no DVT. His repeat K
was 3.5 and his evening serum Na level was 131. His neurologic
examination returned to normal at 3PM.
On ___, his K and NA were stable. Patient remained stable
___. On ___ the patient was medically cleared for discharge
and awaited rehab placement.
On ___ Patient remained neurologically stable. Na remained
stable. Awaiting rehab placement
On ___ Patient was discharged to rehab in stable condition. He
was given instructions for follow up. He was afebrile and
tolerating a PO diet. | 384 | 462 |
17502499-DS-13 | 23,319,708 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for chest pain.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You had a small heart attack.
- You felt better after a blood transfusion.
- You went for a cardiac cath, which is a study to evaluate the
blood vessels in your heart. This showed no new blockages in
your heart. No new stents were placed.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with history of CAD, LAD stent
placed ___, hypertension, newly diagnosed metastatic
prostate cancer who presented with chest pain several days after
discharge from LAD stenting. He underwent cardiac cath on ___
which was unchanged from prior. He was discharged with plan for
outpatient stress test. | 123 | 54 |
11586698-DS-9 | 21,912,089 | Dear Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with shortness of breath and fever very likely
an exacerbation of your Wegener's disease. You improved with
prednisone, which is important to take 60mg daily for the next 7
days, then 40mg daily. Please complete the course of antibiotics
as well as use your nebulizer. Finally, a new protective
antibiotic, bactrim, has been prescribed to protect you from
infection while you are taking prednisone. You have appointments
described below. | ___ year old man with longstanding polyarteritis granulomatosis
on azathioprine, recently tapered off prednisone, presenting
with one week of worsening respiratory and constitutional
symptoms.
# Fever, hypoxia and malaise: Most likely a flare of
polyarteritis since it matches prior episodes and responded
rapidly to prednisone. Given the degree of systemic symptoms
(fevers, tachycardia, malaise), he was admitted for observation
and empiric pneumonia coverage awaiting complete workup with
pulmonology and rheumatology. There was no evidence of
extrapulmonary disease- no hematuria, no joint effusions though
he had some hand swelling likely due to prednisone. He was
continued on maintenance azathioprine, covered empirically for
pneumonia trigger with levofloxacin though imaging was
unrevealing (Chest CT with expected ground glass, sinuses within
normal limits). ANCA was negative. Rheum and pulmonary
coordinated discharge prednisone taper 60mg daily for 7 days, to
be adjusted by rheum/pulm as outpatient. He was started on
bactrim ppx given possibly prolonged steroid taper. Discharge
amb sats were 93% room air.
# Social Issues: He described an unsafe home environment,
including ongoing conflict with his wife. Social work met with
him and arranged a plan where he would stay with his daughter
when needed. Counseling provided. He was recommended to stay
home from work for a week due to shortness of breath.
CHRONIC ISSUES
# HTN: Continue lisinopril, amlodipine.
# GERD: Cont omeprazole
# Insomnia: Cont prn zolpidem | 85 | 221 |
13219691-DS-21 | 20,148,606 | Dear Ms ___,
You were admitted to the Neurology Service at ___
___ after presenting with difficulty
speaking. You were found to have a stroke in the part of your
brain that controls the muscles on the upper left side of your
body. You were restarted on aspirin and a statin. The cause of
your stroke was unclear at the time of discharge. Additional
testing will likely be undertaken as an outpatient when you see
Dr ___ in follow-up.
Please note that it is very important that you continue to take
aspirin every day once you leave the hospital. You should take
the statin every day as well to help lower your cholesterol. | Ms. ___ was admitted to the ___ Stroke Service after
presenting with difficulty speaking. CT/A head and neck was
normal. MRI showed a "late acute-early subacute" infarction
involving the right frontal lobar precentral gyrus, the insular
cortex and adjacent subcortical areas. She was started on
aspirin 325 mg and restarted on atorvastatin. She had an echo
that was unremarkable. ESR and CRP were unremarkable.
Anticardiolipin antibody testing was pending at the time of
discharge. The etiology of her stroke remained unclear. She
will likely undergo further testing when she sees Dr ___ in
follow-up as an outpatient. | 116 | 103 |
17641905-DS-15 | 22,229,903 | You were evaluated at ___ for
your difficulty with memory, cognition, and performing your
work. As these symptoms were concerning for stroke, we
evaluated you first with a CT scan and then an MRI which
demonstrated no abnormality concerning for hemorrhage, mass, or
stroke. We also performed an EEG which demonstrated no evidence
for sub-clinical seizure activity. As a result of these
negative studies and normal blood work, your symptoms are most
likely due to a phenomenon known as Transient Global Amnesia,
which has resolved.
As you do have some vascular risk factors including high blood
pressure, pre-diabetes, and a smoking history, we recommend a
baby aspirin (81mg daily) which will protect against any future
stroke. | ___ is a ___ year-old right-handed woman with past
medical history including hypertension, nicotine dependence,
prediabetes, anxiety and hypothyroidism who presented to the ED
___ with acute short-term memory loss and confusion. She was
admitted to the neurology general wards service for further
management.
Initially, there was concern for stroke or seizure. For concern
for stroke, pt underwent an MRI and CTA of head and neck which
were unremarkable. She was started on aspirin as well. For
concern for seizure, she underwent an EEG which was also
unremarkable.
Symptoms completely resolved about 12 hours after admission. As
her episode manifested as short-term memory loss and confusion
after an emotional precipitant, she was diagnosed with transiet
global amnesia. On day of discharge, pt was at baseline mental
status and had an unremarkable general and neurologic
examination.
Otherwise, pt had a urine culture and TSH level checked in the
hospital. Urine culture was unremarkable and TSH was WNL. She
was continued on her home HCTZ, levothyroxine, and paxil while
in the hospital. Physical therapy also worked with patient who
determined she had no needs.
At time of discharge, she was feeling well. She will follow-up
with neurology closely as an outpatient.
==========================
TRANSITIONS OF CARE
==========================
- EEG, MRI, and CT/CTA were all unremarkable.
- Symptoms began in setting of stress and over 12 hours
resolved, most consistent with TGA. | 120 | 220 |
16020425-DS-25 | 23,868,678 | ===================================
WHY DID YOU COME TO THE HOSPITAL?
===================================
You came to the hospital due to nausea, vomiting, diarrhea.
================================
WHAT HAPPENED AT THE HOSPITAL?
================================
We discussed with your husband that ever since you had the
stroke, you hadn't recovered as expected, and decided it was
best to transition to hospice care.
====================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
=====================================================
-You will be transitioned to home hospice care.
It was a pleasure taking care of you during your stay.
Sincerely,
Your ___ medical team | ___ female with complex PMHx including hx of L ICA
stroke in ___ (thought to be cardiembolic iso low EF c/b
persistent R-sided paralysis), dysphagia on TFs, aphasia, HFrEF
(EF 25%), HTN, type 2 DM, hypothyroidism who presented to the
emergency department on with nausea, vomiting, and diarrhea, and
a transient episode of hypotension in the emergency department
during an episode vomiting. She was stabilized in the medical
ICU before being transferred to the general medicine floor.
Soon after transfer, a goals of care discussion was held between
the care team and the patient's family. After extensive
discussion with the patient's husband regarding the patient's
wishes for her care, the decision was made to place the patient
on comfort measures only as part of hospice care. All
unnecessary treatment and interventions were stopped except
those that would optimize the patient's comfort. She was
discharged and then re-admitted to inpatient hospice. | 76 | 151 |
14131135-DS-16 | 22,809,724 | Dear Ms. ___:
It was a pleasure taking care of you during your hospitalization
at ___. You had come in with coughing up small amounts of
blood. You were evaluated with imaging and the interventional
pulmonologist who found no concerning sources for your bleeding.
Your blood levels remained normal and you were on room air with
no further coughing up blood the next day. We believe that the
reason you had this was due to radiation causing some irritation
in your lung. If you have any significant blood with couging
(greater that 2 tablespoons) or trouble breathing, please come
back to the emergency room immediately.
We have scheduled follow up appointments for your with your
doctors. ___ have made no changes to your medications.
We wish you all the best!! | ___ yr old female with hx of ___ metastatic to brain who is
admitted with recurrent hemoptysis.
# Recurrent hemoptysis - Patient had tea spoon full of
hemoptysis. Did not have remarkable worsening of pulmonary
nodules or PE, may be due to ongoing post-radiation
inflammation/friable mucosa. Recently completed course of
steroids but no significant pneumonitis on CT thus not resumed.
IP saw patient and concluded on outpatient follow up for bronch
scheduled by IP.
# ___ with brain metastases - L hilar soft tissue overall
stable, increase in RUL nodule. Currently on supportive cares
due to side effects from prior treatment
# Chronic atypical chest pain - related to underlying disease,
continued on oxycodone
# Ductal carcinoma of the breast: biopsy proven, ER/PR positive.
Per oncologist does not affect her overall survival from ___,
specific therapy deferred.
# Peripheral artery disease: s/p L common illiac kissing stents
placement in ___, no symptoms of claudication currently. ASA 81
was continued.
# Smoking Cessation: <1 ppd currently. Pt reports that she uses
nicotine patches at home. Encouraged nicotine patch in-house.
# Depression: stable. Continued on home fluoxetine and
mirtazapine.
# Panic attacks: stable. Continued on home lorazepam prn.
# Hyperlipidemia: stable. Continued on lovastatin.
# Insomnia: Stable. Continued on home ambien prn. | 127 | 210 |
17292606-DS-33 | 26,193,341 | Dear,Mr ___
You were admitted to the hospital because pain around your left
side and fullness of your abdomen
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You have blood work and imaging to look for signs of infection
in your abdomen and none was found.
- You were found to have alot of stool on your intestines and
were given medications to help you go to the bath
- You were found to have cocaine in your urine which can cause
damage to your kidney
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never do cocaine again or you will damage your kidney
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Obtain a blood pressure machine and measure your blood
pressure at home
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | Mr. ___ is a ___ man with past medical history of
ESRD ___ hypertensive nephropathy s/p DDRT transplant in ___,
complicated by active ___ with advanced transplant
glomerulopathy
s/p steroid pulse, IVIG, and rituximab, h/o BPD, depression,
PTSD, TBI, and seizure disorder presented with abdominal pain
and
found to have ___ which improved with fluids.
TRANSITION ISSUES
=================
[] CT abdomen with incidental 2.2 cm rounded density in the
right lower lobe - follow-up CT in 3 months recommended, a
PET-CT, or tissue sampling is recommended.
[] Given concern for cocaine use, would benefit from appt with
transplant social worker for substance use disorder.
[] BP Were elevated and home medications were restarted after
inital concern for orthostatic hypotension. Please continue to
monitor BP in the outpatient setting and consider adding
Amlopdine to Anti-hypertensive regimen if BP continues to be
elevated
[] Decreased Tacro from 4mg BID to 3mg BID given elevated Tacro
trough. Please followup as outpatient and adjust as needed
[] Patient reported taking olanzapine however, he had not filled
a script in the past couple of months. Did not refill given
patient reported already having medication at home. Please
clarify as outpatient. | 181 | 184 |
14292518-DS-18 | 24,928,111 | Dear Ms ___,
It was a pleasure caring for you at the ___
___. You were admitted on ___ initially to the
intensive care unit for 2 days, and later to the regular
medicine floor with severe headaches and fevers. On arriving to
us, your lab tests showed signs of infection in your blood, as
well as abnormal platelet counts and liver function, which taken
together with your history of hiking and gardening, strongly
suggested a tick-borne infection. We sent further testing to
determine the precise cause of this infection, and all of these
are still pending. In the meantime, we continued you on the
Doxycycline antibiotic that was started at ___ before you
were transferred to us; this covers many tick-borne illnesses,
and you seemed to improve with this medication. We also had to
give you fluids and platelet transfusion in order to get the
lumbar puncture, the test we did by drawing some fluid through a
needle inserted in your lower back. This test showed no
infection in the fluid surrounding your spinal cord and brain.
You developed some fluids in your lung, which gave you some
shortness of breath and we gave you some medications to help
remove some of the fluid, and that also seemed to help with your
breathing. Please continue the Doxycycline antibiotic till
___ for a total of ___nd please follow up with
our Infectious Diseases team (as detailed below). Please also
schedule an appointment with your PCP for review and further
management of your symptoms. | Ms. ___ is an ___ year old woman with no significant past
medical history who presents with severe headaches, fevers and
confusion.
# Headaches and fevers: On arrival to the ED, patient met SIRS
criteria with leukopenia and fever to ___. Her admission labs
were notable for leukopenia to 1.2, platelets of 50, as well as
potassium of 3.2 which was repleted. Blood cultures, and type &
cross were sent. Monospot test was negative. Urine and Chest
x-ray were unremarkable to suggest UTI or PNA respectively as a
cause of her fevers.
With systolic blood pressures to the ___, she was transferred to
the MICU, where she received 5L of normal saline and maintained
her blood pressure with good urine output throughout the rest of
her course. Suspected source on arrival included meninigitis, or
tick borne illness such as anaplasma or ehrlichiosis. She
received 5L She was started empirically on broad spectrum
meningitis prophylaxis with high dose ceftriaxone, vancomycin,
and acylcovir, and doxycycline given inability to perform a
lumbar puncture in the setting of thrombocytopenia. She was able
to get an LP after receiving platelets. Her rapid improvement in
headache and negative LP makes bacterial meningitis very
unlikely. Her hx of hiking, leukopenia, thrombocytopenia, and
tranasminits, with headache and myalgia, suggest anaplasma or
erhlichosis as a potential etiology or other tick borne illness.
She was empirically treated with doxycycline 100mg PO BID for ___nd improved back to baseline.
# Elevated transaminases: pt with elevated transaminases without
any other stigmata of liver disease, coags were normal
indicating intact synthetic function. Transaminases downtrending
with doxycycline. This is most likely ___ tick-borne illness
(other causes could be DILI or drug induced hepatitis, but
patient not on other medications), no risk factors for HCV, and
mild shock liver (less likely). We did not check a RUQ u/s or
hepatitis serologies given the more likely relation to tick
borne infection.
# Leukopenia/ thrombocytopenia - pt with new leukopenia with
calculated ANC of 1190 and thromboyctopenia. Differential
included bone marrow suppresion in the settting of sepsis as
above, but this was quite soon. Other differential includes
malignancy and DIC, but fibrinogen normal and coags relatively
normal, and smear unremarkable. Hematology was consulted and
felt this was likely ___ tick-borne illness.
# TRALI/TACO- She received 2 units of platelets and 45 minutes
after the second unit became acutely short of breath with
audible wheezing. She received IV furosemide and nebulizers and
improved. This was most likely TACO in the setting of massive
volume resuscitation and platelet infusion. We also notified the
blood bank and sent off the appropriate labs for this, but less
likely acute reaction given time course.
TRANSITIONAL ISSUES
====================
- Code status: Full code.
- Emergency contact: husband ___ ( ___.
- Studies pending on discharge: Blood cultures, Lyme Ab, Babesia
Ab, Anaplasma Ab, HSV PCR, C. difficile toxin assay
- ECHO read became available at discharge; patient will follow
up with PCP for further discussion and evaluation of findings | 252 | 487 |
14153619-DS-7 | 20,184,343 | Discharge Instructions
Spinal Fusion
Surgery
- Your incision is closed with staples. You will need staple
removal ___ days after surgery. Please call clinic to schedule
appointment.
- Do not apply any lotions or creams to the site.
- Please keep your incision dry until removal of your staples.
- Please avoid swimming for two weeks after staple removal.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
- You must wear your brace at all times when out of bed. You
may apply your brace sitting at the edge of the bed. You do not
need to sleep with it on.
- You must wear your brace while showering.
- 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.
- Do NOT smoke. Smoking can affect your healing and fusion.
Medications
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- New weakness or changes in sensation in your arms or legs. | #L3, L4 Fractures, lumbar stenosis
___ is an ___ year old female with known L3-L4
radiculopathy who presented to the ED on ___ with worsening
lower extremity pain and weakness for ___ days. Patient had MRI
done in ED, and initially fractures were thought to be chronic
in nature, therefore patient was recommended to follow up in the
clinic. On second review of MRI by radiology, it was determined
that fractures were acute, therefore patient was placed in a LSO
brace and admitted and taken to the OR for L3-5 laminectomy and
fusion on ___. Patient tolerated the procedure well and a
Hemovac drain was left in place, which was removed on POD#3.
Please refer to formal op report in OMR for further intra
operative details. Patient was extubated in the OR and
transferred to the PACU for post op care where she remained
stable and was later transferred to the floor. Her routine
post-op xrays showed stable hardware placement. Her foley was
d/c'd and she mobilized out of bed in her brace. ___ evaluated
her and recommended rehab. She remained stable and was
discharged to rehab on POD#6.
#Anxiety
Patient takes Ativan and trazodone at home for anxiety and
sleep. Her Ativan was held initially while she came out of
anesthesia. On the night of POD0 she experienced a panic attack
with associated shortness of breath, nausea, and abdominal pain.
EKG was normal. She was given ativan and Zofran and her home
medications were resumed. Her nausea, SOB and anxiety improved.
Due to her recent psych admission and acute panic attack psych
was consulted to ensure her symptoms were managed appropriately
post-operatively. It was recommended to continue her home meds
and add PRN Ativan to her standing Ativan for anxiety.
#Anemia
On ___, the patient's H/H was ___ and she felt lightheaded.
She was transfused 1 PRBCs, after which her H/H came up
appropriately to 9.7/31.4. H/H continued to uptrend and was
stable at the time of discharge.
#Disposition
___ evaluated the patient and recommended discharge to rehab.
Rehab Stay expected to be less than 30 days. | 299 | 346 |
16755391-DS-17 | 21,625,822 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted with a headache and fevers and
were found to have meningitis caused by the ___ Virus
(which causes mononucleosis).
You will continue to shed the EBV virus for the next several
months, however you can go back to work after you are feeling
better.
Transitional Issues:
Pending labs: Blood cultures ___, CSF Spinal fluid
viral culture ___, fluid culture ___. HCV viral Load;
Lyme serology
Medications started:
1. Acetaminophen, do not take more than 2g in 24 hours
2. Oxycodone 5mg- do not take prior to driving or operating
machinery
.
Follow-up needed for:
1. Check your liver function tests and platelets to make sure
they are still stable
2. Have splenomegaly on exam, avoid contact sports. Your PCP
___ let you know when you can participate in sports again | Pt is a ___ yo healthy M w/ PMH of lyme disease (treated) who
presents with headache and photophobia due to aseptic meningitis
and EBV infection.
#EBV meningitis- patient has no known sick contacts so it is
unclear how he received this infection. He was diagnosed by LP
on ___ which showed a 40 WBC and a lymphocyte predominance. He
was admitted to the hospital for fevers and pain control. He was
started on empiric acylovir to cover for HSV, as that could not
be ruled out. When his HSV PCR came back negative this
treatment was stopped. His headache was controlled with
actemainophen and oxycodone. The patient was informed of the
time course of EBV, and that this ___ not completely resolve for
a few weeks.
-If his headache continues to be worse when sitting up or moving
(1 week from now), ___ need to consider a blood patch for a
post-LP headache
#EBV hepatitis- patient had elevated LFTs, which were stable
around the time of discharge in the 300s. A RUQ U/S performed
during this admission did not show any abnormalities of blood
flow, ascites or evidence of hepatomegaly.
-He will need to have his LFTs checked at his appointment to
ensure they are downtrending
#Thrombocytopenia- the patient was noted to ahve
thrombocytopenia during this stay with Plts in the 90K range,
and stable. He had no petichiae or ecchymosis at the time of
discharge. On exam he had a palpable spleen and RUQ u/s
measured his spleen at 14cm in the longest axis. He was
counseled on the signs of petichiae and to call his PCP if these
are noted. He was also counseled on not engaging in contact
sports while he has splenomegaly as he is at risk for splenic
rupture.
-He will need to have his Plt count checked at this follow-up
appointment
Transitional IssuesPending labs: Blood cultures ___,
CSF Spinal fluid viral culture ___, fluid culture ___. HCV
viral Load; Lyme serology
Medications started:
1. Acetaminophen, do not take more than 2g in 24 hours
2. Oxycodone 5mg- do not take prior to driving or operating
machinery
. | 141 | 355 |
14832532-DS-16 | 22,286,203 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for a blood stream infection
that likely started in your bladder. You were treated with IV
antibiotics and will complete a course of oral antibiotics on
discharge.
Medication Changes:
Ciprofloxacin 500 mg PO/NG Q12H ___
Mycophenolate Mofetil 500 mg PO BID
Tacrolimus 1 mg PO Q12H
Please go to transplant clinic to have usual labs drawn in 10
days. | ASSESSMENT AND PLAN: ___ yo F with ESRD s/p kidney transplant on
immunosuppression presenting with multiple days of N/V, diarrhea
and chills found to have gram negative bacteremia likely urinary
source.
#Pyelonephritis: The patient presented with several days of
fever, nausea and vomiting of unclear etiology. She did not
have any pain, nor did she have any tenderness on exam. Labs on
presentation were notable for a white cell count of 13.1. She
was started on ciprofloxacin and flagyl for presumed
gastrointestinal source. One of two sets of blood cultures from
the day of admission grew gram negative rods which were later
speciated to be eschericia coli. Urine cultures were difficult
to obtain as patient often had liquid stool mixed with urine.
Urine cultures done on ___ had <10,000 microorganisms. She
continued to spike fevers during the first 3 days of admission
and so was switched to meropenem for broader coverage including
pseudomonas. On ___ an ultrasound was performed of the
transplanted kidney which showed no evidence of abscess with
normal renal transplant waveforms. The patient improved
clinically but continued to have a rising white blood cell count
so a CT abdomen with contrast was performed to rule out abscess.
The CT showed heterogeneous enhancement of the transplanted
kidney with loss of corticomedullary differentiation concerning
for pyelonephritis. The patient improved clinically and was
switched to Ciprofloxacin on discharge. She will follow up with
renal and ___ after discharge.
#Diarrhea: Patient complained of diarrhea intermittently during
her hospitalization. A clostridium difficile test was ordered
but canceled by the lab because of the consistency of the stool.
The diarrhea was ultimately atributed to high levels of
mycophenoate.
# Acute kidney injury- Patient presented with creatinine of 2.2
on admission. This was likely prerenal in the setting of 5 days
of nausea, vomiting, diarreha and decreased PO intake. She was
hydrated with IVF during admission and creatinine was trended.
Creatinine on discharge 1.1.
# Renal transplant: Patient is s/p hx LRRT in ___. She was
admitted to the renal service. She was continued on
immunosuppressive medications: prednisone, tacrolimus, and
mycophenolate. Tacrolimus levels were checked daily and
adjusted accordingly. Creatinine was elevated on admission as
described above, but trended down with IV hydration to baseline.
The CT scan showed heterogeneous enhancement of the
transplanted kidney with loss of corticomedullary
differentiation concerning for pyelonephritis. The patient was
treated with antibiotics as above and will follow up with
nephrology on discharge.
Chronic Issues:
# Diabetes Mellitus type 1 - Patient was continued on home
lantus with a sliding scale.
# Hypertension - Patient was continued on metoprolol.
Furosemide was held due to volume depletion secondary to
diarrhea, vomiting and decresaed PO intake. Furosemide was
restarted on discharge.
# Hyperlipidemia: Continued on atorvastatin. | 74 | 491 |
12124616-DS-8 | 27,631,081 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had dizziness and lightheadedness.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received brain imaging (CT scan and MRI) that did not show
any concerning finding.
- You received IV fluids with improvement in lightheadedness and
dizziness.
- Your blood sugar was found to be poorly controlled.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and ___
with your appointments as listed below.
We wish you a speedy recovery!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with a past medical history of HTN, HLD,
DM, who presented with lightheadedness, nausea/vomiting and
question of altered mental status. Imaging studies did not
reveal acute intracranial process. Patient was found to have
positive orthostatic vitals. Lightheadedness improved with IV
fluids.
DISCHARGE Cr 1.4
DISCHARGE K 4.8
DISCHARGE Na 141
DISCHARGE H/H 8.9/30.4
#CODE: presumed full
#CONTACT: ___ number: ___ | 111 | 60 |
10288579-DS-9 | 29,234,985 | Dear Mr. ___,
You were admitted for acute pancreatitis. We believe this was a
result of your alcohol use. You were treated with bowel rest,
intravenous fluids, and pain medication - in addition to the
placement of a nasojejunal tube for enteral feeding. This
intervention resulted in resolution of your symptoms. We advise
you ABSTAIN from alcohol use to avoid future episodes of
pancreatitis. You also should maintain a LOW FAT diet and
exercise regularly.
Please ___ with your primary care physician, ___.
Also you should ___ with the gastroenterology specialists.
Thank you for allowing us to be part of your medical care.
Sincerely,
Your ___ Care Team | ___ with PMH significant for anxiety disorder and irritable
bowel syndrome presenting with abdominal pain due to
alcohol-induced acute, uncomplicated pancreatitis.
# Acute uncomplicated pancreatitis - Patient endorseD ___ years of
heavy drinking and within past week prior to admission had been
on ___ break and drinking ___ shots of vodka daily. Lipase
was elevated at 1498 on admission, and he was also found to have
a triglyceride level of 1274. RUQ US showed no cholelithiasis
but the pancreas and biliary system could not be adequately
visualized due to body habitus. GI was consulted and felt likely
alcoholic pancreatitis. Patient was treated with bowel rest and
IVF. Triglycerides downtrended to 667 then 277. No signs or
symptoms of complications. Had some dyspnea thought to be due to
bilateral pleural effusions seen on CXR which resolved over the
course of his admission without need for diuresis. On ___ an
NJT tube was inserted and he was started on tube feeds after it
was advanced to the post-pyloric region (jejunal). He also
underwent an abdominal CT which showed acute pancreatitis with
peripancreatic fluid collections extending to the pararenal
spaces, paracolic gutters, and extending into the pelvis, but no
complications. Over several days his tube feeds were
downtitrated, his diet advanced and he improved. He is
discharged with PCP and GI ___. He is to maintain a low
fat diet, per nutrition. He is to avoid all alcohol.
# Alcohol use - Patient reports ___ years of drinking ___ times a
week, about ___ drinks a week. No history of trouble with the
law due to drinking. CIWA scales were ___ and not concerning for
alcohol withdrawal. He was given MVI, folate and thiamine.
Social work was consulted to address his alcohol use and gave
contact information for SA recovery resources. He should abstain
from alcohol.
# Anxiety disorder - Patient states that he has anxiety and
reported taking clonazepam daily. Clonazepam was held initially
due to his being on a CIWA scale with diazepam written; however
clonazepam was restarted on ___, and the patient did not
experience alcohol withdrawal. During his hospitalization, the
patient continued taking his fluoxetine but refused his
buspirone most of the time. | 103 | 363 |
10730662-DS-10 | 23,746,410 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came here from ___
after having worsening fatigue at home. You were found to have
low a red blood cell count that was causing your weakness. It
was not clear what caused this bleeding, but was likely from
your GI tract. You were given blood transfusions to increase the
red blood cells in your body, which led to an improvement in
your energy status. You were monitored closely and you did not
have any further bleeding.
You were also found to have an infection in your urine for which
you were given a full course of antibiotics.
Your medications were adjusted while you were here. Please see
the attached sheet for an updated list and follow up with your
primary care doctor to make further changes.
Please follow-up with the appointments listed below and take
your medications as instructed below. It is very important that
you stop drinking alcohol to prevent any further damage to your
pancreas and liver.
Wishing you the best,
Your ___ Care team | ___ history chronic pancreatitis with known pseudocyst and
chronic abdominal pain, s/p selective angiography of bleeding
splenic artery pseudoaneurysm with embolization at OSH earlier
this month, chronic EtOH abuse, presents from OSH for recurrent
GI bleed with anemia and Hct drop. Patient required ICU level of
care, received 1U packed red blood cells. Endoscopy did not show
acute signs of bleeding, therefore possible re-bleed into
pancreatic pseudocyst. Patient's hematocrit remained stable
without further bleeding. Patient tolerated full solid diet and
was discharged to home with plan to follow up with Dr. ___
(___) for potential ___. | 181 | 96 |
17243626-DS-9 | 22,654,770 | Dear Mr. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital for management
of your severe heart failure. Unfortunately, your heart was not
pumping blood well enough to meet the demands of your body.
Several therapies were tried. You underwent a cardiac
catheterization procedure to examine your heart, and this showed
that your coronary arteries did not have any blockages, but you
did have some elevated pressures in your heart. We gave you
medicine to remove the excess fluid from your body. We also
added several other medications to treat your heart failure.
During your stay, you required an IV medication called lasix to
assist your heart's ability to pump blood. We then transitioned
you to another similar medication called torsemide, which you
took by mouth. You responded well to this medication and the
swelling in your legs and shortness of breath improved
significantly.
We have arranged for you to have an appointment with your new
PCP, ___, and a cardiologist, Dr. ___.
Please feel free to contact his office or contact the hospital
sooner if you have any questions or other important issues.
Thank you for letting us participate in your care.
Sincerely,
Your ___ Team | ___ with obesity who presents with progressively worsening
DOE, orthopnea, and leg swelling x 1 month precipitated by
recent URI presenting with new onset heart failure.
# Hypertensive emergency: Patient presented with SBPs in the
160s to 170s on admission with evidence of end organ damage
(CHF, pulmonary edema). We successfully treated the patient with
several antihypertensive medications: isordil, hydralazine,
captopril, carvedilol, and torsemide and his SBPs were
maintained in the 110s-130s. We further evaluated the cause of
his hypertension with renal ultrasound, which did not reveal any
evidence of renal artery stenosis. We also obtained a
renin/aldosterone level which will need to be followed-up as an
outpatient.
# New onset heart failure with reduced ejection fraction, ___
IV: Patient presented with new 3-pillow orthopnea, worsening DOE
x 1 month, and leg swelling with bedside ultrasound showing a
depressed EF ~20% without pericardial effusion. Labs showed
downtrending troponins (0.02 to 0.01) and a proBNP: 5351. We
started him on captopril 50 mg daily and torsemide 40 mg daily
and he tolerated it well. On discharge, we lowered his torsemide
dose to 20mg daily and converted his captopril to lisinopril.
Patient underwent cardiac catheterization which revealed
severely elevated R and L sided filling pressures with
borderline cardiac index 2.27, but no obstructive CAD.
# Dilated cardiomyopathy: TTE revealed a dilated left ventricle
with severe global systolic dysfunction with low cardiac output.
CXR showed mild cardiomegaly with hilar congestion and mild
pulmonary edema. EKG revealed LAE and LVH. Patient with no known
PMH, and therefore no known risk factors associated with
ischemic cause, though patient does have obesity and HTN. Based
on cardiac catheterization results showing no CAD, an ischemic
precipitant is unlikely. On the differential for dilated CM
include infection (previous URI with fevers, now resolved as
trops downtrending), most likely given ___ titers
positive, though no cardiac biopsy performed so unclear if this
is the primary causative agent. Other etiologies may include
toxin-mediated vs hypertensive emergency vs tachycardia-mediated
cardiomyopathy vs ischemia. Other less likely etiologies OSA vs
inflammatory vs autoimmune. Workup was notable for negative HIV,
___ negative, TSH 1.2, CMV IgG positive but IgM negative,
___ titer positive.
# Tachycardia: Patient presented with HRs 110s - 120s with EKG
showing sinus tachycardia. Likely compensatory in the setting of
reduced ejection fraction/fall in cardiac output by increasing
sympathetic outflow. Other less likely causes include infection
vs PE vs hypovolemia vs anxiety. In the event the cause is
ischemia, we treated cautiously with beta blockade.
# Transaminitis: Mildly elevated ALT on admission. Etiology
unclear. Patient reported drinking alcohol occasionally. We
continued to monitor his LFTs, which continued to downtrend over
the course of his hospitalization and therefore no further
workup was pursued.
# DM2: HbA1c: 6.3. Newly diagnosed. Patient will need outpatient
___.
# HPL: HDL: 30, CHOL/HD: 6.5 LDLcalc: 141. We started him on
atorvastatin daily.
=========================== | 210 | 470 |
16200045-DS-11 | 26,350,545 | Dear Mr. ___,
You were admitted to ___ on ___ with findings of fluid
overload in your lungs and your legs, and were treated for acute
heart failure with IV diuretics. We monitored your weight and
your urine output with the IV medications. Your leg ultrasound
and your urine studies did not show any other reasons for your
swelling. We transitioned you to an oral diuretic, to be taken
twice a day.
Please follow up with your primary care physician and Dr. ___.
We encourage you to limit your water intake to about 2 L in a
day and to eat a low sodium diet. Please also weigh yourself
every morning, call MD if weight goes up more than 3 lbs.
It was a pleasure taking care of you
Your ___ Care Team | ___ year old man with CAD s/p CABG ___ and ___ BMS D1,
HFrEF (EF 35-40%), severe AS s/p redo TAVR ___, CVA, HTN,
DM1, recent VF arrest s/p ICD, discharged from ___ on
___, presents from rehab with acute on chronic systolic
heart failure exacerbation.
# CORONARIES: recent BMS D1, patent LIMA-LAD SVG-OM1
# PUMP: EF 35-40%
# RHYTHM: Sinus rhythm, atrial paced
# Acute on Chronic Systolic Heart Failure. Patient was
discharged from prior admission on Lasix 20mg PO but was not
given at rehab per patient and his wife for unclear reasons. He
presented this admission with classic CHF findings including
scrotal/leg swelling, PND, orthopnea, and dyspnea. Patient
symptomatically improved with Lasix 20 IV at ___ and his
discharge weight was 79.9 kg. Patient was continued on
increasing doses of IV lasix dosing, and transitioned to oral 80
mg PO Lasix BID. Prior to discharge, he was noted to have
orthostasis, so his AM dose of Lasix was switched to 40mg and
his Losartan was switched back to 25mg daily. His ___ dopplers as
well as urine studies did not show other etiologies of lower
extremity swelling. Repeat Echocardiogram confirmed EF <40%,
with mild ?paravalvular aortic regurgitation now seen. Overall,
the left ventricle was found to be less vigorous with Severe PA
systolic hypertension. Patient adhered to 2 g Na diet and 1.5L
fluid restriction. Patient was continued on home Eplerenone 25
mg daily, Losartan 25 mg daily, with addition of Isosorbide
Mononitrate 30 mg daily.
#Hypertension: Isosorbide Mononitrate (Extended Release) 30 mg
PO DAILY added ___ with continued Losartan Potassium 25 mg
PO/NG DAILY and Eplerenone 25 mg PO DAILY.
# CAD. s/p CABG and recent PCI BMS D1 (diagonal) ___ after
VT arrest: Patient denied any recent chest pain. He had a
troponin elevation peaking at 0.10, likely in setting of CHF
exacerbation and acute kidney injury, rather than type 1 MI. His
recent VF arrest likely due to acute coronary lesion s/p BMS D1.
He was loaded on amiodarone for this with 400mg BID. His
amiodarone was decreased to maintenance 400 mg daily, and then
down to 200 mg daily. He was continued on ASA 81, Plavix 75,
metoprolol XL 100, atorvastatin 80.
# s/p Vfib arrest: Patient was admitted on ___, transferred
from outside hospital s/p CPR and 2 rounds epi, amiodarone,
completed cooling protocol after ROSC. Between his history of
myocardial infarction and subsequent scar, and LV dysfunction,
he carries the substrate for sudden cardiac death without a
clear, reversible cause. It is very unclear whether ischemia
from his diagonal branch precipitated arrest. He had an ICD
placed on prior admission ___ for secondary prevention of
sudden cardiac death
# ___. Cr from 1.2 on discharge to 1.5 on admission. This was
likely due to CHF exacerbation and volume overload leading to
decreased intravascular volume. Discharge Creatinine: 1.4.
# DM1: Patient on home glargine with Humalog ISS (normally
Apidra at home), modified sliding scale to account for likely
lower insulin needs in-house. He was seen by ___ Diabetes
specialists in house for help with managing morning relative
hypoglycemia. He was continued on Lantus 22 units QAM + HISS
started w/ BG >70. Patient had follow up outpatient for diabetes
management.
#Anemia: Noted in prior admission, with stable currently Hgb
8.3-9, normal MCV
# Recent spine surgery: Pain was controlled mainly with tylenol.
Physical therapy recommended home with ___ services to optimize
functional status.
# BPH. Home finasteride and tamsulosin continued.
# Peripheral neuropathy: Home gabapentin continued | 132 | 584 |
17775194-DS-8 | 27,583,978 | Lumbar Decompression Without Fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace, this brace is to be worn when you are
walking.You may take it off when sitting in a chair or lying in
bed.
Wound Care: Remove the dressing in 2 days.If
the incision is draining cover it with a new sterile dressing.If
it is dry then you can leave the incision open to the air.Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline X-rays and answer any questions.We may at that
time start physical therapy.
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
If the incision is draining cover it with a new sterile
dressing.If it is dry then you can leave the incision open to
the air.Once the incision is completely dry (usually ___ days
after the operation) you may take a shower.Do not soak the
incision in a bath or pool.If the incision starts draining at
anytime after surgery,do not get the incision wet.Cover it with
a sterile dressing and call the office | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as tolerated.
Mr. ___ refused to d/c his foley and would like to do a void
trial at rehab. Physical therapy and Occupational therapy were
consulted for mobilization OOB to ambulate and ADL's.Hospital
course was otherwise unremarkable.On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet. | 637 | 129 |
18377889-DS-25 | 26,828,586 | Ms. ___,
You were admitted with a clogged feeding tube, which was
replaced on ___ via upper endoscopy procedure. You were
restarted at tube feeds and you were monitored until tube feeds
were at goal.
It was a pleasure taking care of you,
Your ___ team | ___ h/o roux-en-Y (___) (complicated by jejuno-jejunosotmy
anastomotic stricture, adhesions/SBO, afferent limb syndrome)
likely requiring revision surgery, malnutrition s/p NJ tube
___, and chronic pain presented with clogged NJ tube.
1. Clogged NJ tube w/ severe malnutrition and malabsorption h/o
roux-en-Y, jejuno-jejunosotmy anastomotic stricture,
adhesions/SBO, afferent limb syndrome
-NJ tube clogged and removed by GI. s/p EGD ___ with
replacement of NJ tube. Continue copper gluconate
(nonformulary), ascorbic acid, folic acid, thiamine, and
multivitamins in setting of malnutrition. Patient will need
surgical revision once her nutritional status is improved. Tube
feeds were advanced and she was discharged on Levity 1.5
@80mL/hour cycled for 15 hours per day with free water flush
100mL Q6 hours. Patient should flush tube Q1-2 hours with warm
water (30mL) during the day when not in use to prevent clogging.
2. Acute on chronic Abdominal pain and distention
-Although she does not have clinical signs of obstruction (no
nausea/vomiting and passing gas/bowel movements) she has
evidence of worse obstruction of the afferent limb. Continue
pain regimen: methadone 40mg BID, oxycodone 20mg BID PRN,
oxycodone 30mg BID PRN (as per home regimen managed by her PCP).
Simethicone and acetaminophen. Also started bowel regimen in
setting of high dose narcotics.
3. Lower extremity edema
-As per previous discharge summary this has been a chronic and
ongoing process that has been, "extensively worked up in the
past and was thought to have chronic lower extremity edema
likely in the setting of malnutrition and hypoalbuminemia."
Right lower extremity venous ultrasound negative for DVT.
Continue compression stockings.
4. Acute on chronic normocytic anemia
-Stable. Continued ferrous sulfate.
CHRONIC MEDICAL PROBLEMS
1. Vitamin D deficiency: continue vitamin D
>30 minutes spent on discharge planning | 44 | 287 |
17377519-DS-9 | 24,946,047 | Dr. ___,
___ was a pleasure taking care of you at ___
___. You were admitted with macrophage activation
syndrome and treated with steroids and continued Anakinra, which
you tolerated well. You were followed by rheumatology and
hematology-oncology. You had a bone marrow biopsy that was
consistent with macrophage activation syndrome.
New Medications:
START prednisone 80 mg BID
START Anakinra (Kineret) Kineret 100 mg/0.67 mL Sub-Q Syringe
BID
START atovaquone 750 mg/5mL solution BID with meals
STOP Bactrim
STOP Colchicine
Please follow up with Dr. ___ ___ or ___.
Please have labs drawn every two days. Dr. ___ will
write this script for you. | ___ yo F recently diagnosed with Adult Onset Still's now
presenting with likely macrophage activating syndrome.
# Adult Onset Still's complicated by Macrophage Activating
Syndrome (MAS): Patient diagnosed with Adult Onset Still's in
___, she had been unsuccessfully trying to taper her
steroids. She presented from her rheumatologist with concern
for MAS. Typical lab abnormalities in MAS are thrombocytopenia,
elevated AST, low WBC and low fibrinogen. Her labs are
consistent with MAS with thrombocytopenia (PLT 49) and increased
aspartate aminotransferase levels (AST 579). Her white count
was normal on presentation (6.7) but dropped to 2.3 on ___
with 10% neutrophils. Her fibrinogen was also normal at 229
mg/dl but dropped to 125 mg/dl on ___. On physical exam, she
had petechia consistent with low platelet count. She also
developed a reticular rash on her trunk and upper extremities.
The patient was followed by rheumatology and her primary
rheumatologist Dr. ___. She was also seen by
hematology/oncology who performed a bone marrow biopsy, which
was consistent with macrophage activation syndrome. CMV IgG and
IgM and monospot were negative making infection unlikely.
Further, she recently had a complete infectious workup and
tested negative for Hep B, Hep C, mycoplasma, schistosoma,
parasite smear, HIV, anaplasma, lyme, RPR, CMV, EBV and negative
PPD.
She was treated with 5 days of 1000 mg of IV methylprednisolone.
Anakinra was initially held and then restarted at QHS and then
BID per rheumatolgoy. On ___, she was transitioned to 125 mg
IV BID of solumedrol. The patient was monitored with telemetry
and daily tumor lysis labs. There was no evidence of tumor lysis
and she tolerated the treatment well. She was switched to
Atovaquone from Bactrim for prophylaxis after developing a rash;
this is unlikely due to the Bactrim however because of the
timing of rash onset. On the day of discharge, her LFTs
continued to trend down and her WBC count increased to 3.3 with
62% PMNs. She was discharged on prednisone 80mg BID and
Anakinra (Kineret) Kineret 100 mg/0.67 mL BID. She will follow
up with her rheumatologist and have labs drawn every other day
for monitoring.
# Hypothyroid: Chronic.
- continued synthroid ___ mcg daily | 98 | 379 |
15459380-DS-15 | 26,021,885 | You were admitted to the hospital with confusion and agitation.
You had a lumbar puncture that was normal, but due to agitation
you were admitted to the ICU and intubated. You have made a
dramatic improvement in your thinking and physical strength. We
think that your confusion was due to a viral illness,
medications and a small stroke and perhaps also from untreated
sleep apnea. We expect that your confusion will continue to
improve slowly.
You had a stroke because your blood was not thinned
appropriately. It is very important that you remain on Coumadin
and that your INR remain above 2 at all times! | ___ h/o chronic diastolic CHF, DM, Afib on Coumadin, and CKD was
admitted to the ICU ___ for severe agitation and acute
encephalopathy. He was febrile raising concern for meningitis
and started on empiric ceftriaxone, vancomycin, and acyclovir
but LP
___ with WBC 2 and vancomycin and ceftriaxone and ___ HSV
negative and acyclovir stopped. He was intubated ___ for the LP
and unable to extubate until ___ due to persistent agitation and
transferred out of ICU ___.
1. Acute encephalopathy with agitation
He had a complete work up including several infectious workups,
LP, CXR, CT, and EEG. Toxicology did not feel that this was due
to his chronic medications. MRI showed subcentimeter acute to
early subacute infarct of left frontal cortex/subcortex.
OUtpatient notes also comment on alcohol use, but tox screen
negative for ethanol.
It is likely that his encephalopathy is multifactorial in nature
- from sedating medications that are renally cleared
(gabapentin, baclofen) when he has renal impairment, infection
(fevers, but all cx negative, so ? viral syndrome) untreated
sleep apnea, and small stroke. His mental status continued to
improve on the floor and he had no further episodes of
agitation. He was AOx3, but occasionally tangential.
2. ___ h/o CKD III
-Baseline Cr 1.6-2.0 that peaked at 4.0 during this admission.
___ likely due to dehydration/prerenal in setting of bumex with
limited PO intake. Creatinine returned to his baseline of 1.9 on
discharge.
3. Atrial fibrillation on Coumadin: Was previously on apixaban,
but during last admission changed to Coumadin as he has CKD. He
was continued on Coumadin here, and INR on discharge is 2.
Coumadin had been held because of supratherapeutic INR,
restarted on ___ at his home dose of 2.5 mg daily. He should
have INR rechecked on ___ to confirm it is above 2.
4. Subacute stroke
Seen by neurology; felt to be thromboembolic stroke (he had a
period of subtherapeutic anticoagulation when taken off apixaban
and restarted on Coumadin). He should be bridged with IV
heparin prior to any procedure given risk of recurrent stroke.
He also has some chronic microhemorrhages seen on imaging,
unchanged from prior. Per neurology attending note: "His
CHADS2VASC score for risk of recurrent
embolic stroke is 6, with a 9.7% per year stroke rate, CHADS
score is 5, 12.5% risk of stroke per year. HASBLED score is 2,
and if microhemorrhage is considered, it is 3 with a 5.8% bleed
risk per year, or 3.73 major bleeds per 100 patient years.
Overall his stroke risk is considerable and would continue
Coumadin". He should f/u with ___, ___ neurologist,
after discharge.
5. Chronic diastolic heart failure h/o HTN
-ECHO ___ EF >55%. Due to recent admission for acute on chronic
heart failure exacerbation bumex was continued upon admission to
ICU and then stopped due to ___.
His bumex dose at home was 2 mg po bid; he was restarted at 1 mg
a day, and did not complain of PND/orthopnea. No ___ swelling.
Weight on discharge is 119.75 kg and dry weight according to
last discharge summary is 125.7 kg. Would gradually increase
bumex dose to his home dose of 2 mg po bid as his weight
increases.
6. Gout: continue allopurinol and colchicine; dose of
allopurinol decreased to 150 mg po daily given his renal
insufficiency, and colchicine dose decreased to .3 mg po daily
given renal insufficiency.
7. GERD: omeprazole held in the hospital and patient without
complaints; I have restarted this as a PRN agent.
8. BPH: continue tamsulosin
9. DM: He is on bid glargine at home, 10 units in the morning,
32 units at night. He was initially on sliding scale insulin
here, but then glargine restarted - now on glargine 12 units in
the morning, and will start him on glargine 6 units at night. I
suspect he may be better servied with 70/30 insulin bid. A1C
here 9.3 indicating poor control at home. Rehab should
uptitrate glargine or consider 70/30 insulin bid
5. Vitamin D deficiency: continue vitamin D
6. Chronic pain: Had intermittent neck and back pain, but
appeared comfortable for the most part; I stopped baclofen given
that it could worsen his encephalopathy; he will continue on
gabapentin, but this dose also decreasd from prior given his
encephalopathy; continue prn Tylenol, lidocaine patch. Tylenol
#3 held as well; tramadol that he took at home was continued for
pain. | 109 | 755 |
14704505-DS-19 | 20,864,737 | You came to the hospital with abdominal pain and were found to
have evidence of liver disease without clear explanation. We
performed several tests most importantly a biopsy of your liver
to assess for autoimmune conditions that can cause chronic liver
disease. You will follow up in clinic with Dr. ___ at ___ who
is a liver specialist. He will discuss the results of your liver
biopsy with you and decide on further tests and/or treatments as
needed.
We also performed an endoscopy of your feeding tube (esophagus)
and small intestine. This is a routine test we perform in any
patients with chronic liver disease or cirrhosis. We found
inflammation in your feeding tube or esophagitis which may
explain some of the pain that you've been experiencing. We have
started you on an acid blocker called omeprazole or prilosec
which you should take daily first thing in the morning for the
next 8 weeks. | ___ female without significant medical history who
presents with one week of worsening jaundice and prandial
epigastric pain found to have elevated transaminitis with
bilirubin to 13, now improving.
1. Jaundice, Hyperbilirubinemia, abnormal LFTs, Epigastric pain,
Splenomegaly - MRCP with evidence of cirrhosis primarily in the
left lobe, and anterior right lobe, with mild dilatation of
central intrahepatic portal ducts. Also with evidence of portal
hypertension including splenomegaly. Serologic work-up has been
negative for viral etiologies or autoimmune hepatitis. ___ have
a biliary stricture or obstruction leading to more focal atrophy
of her liver. S/p liver biopsy on ___.
[ ] will need f/u with Dr. ___ in 2 weeks (see below)
2. EGD on ___ notable for esophagitis for which she has been
started on omeprazole 20mg bid for 8 weeks.
3. Epigastric pain - had significant pain during liver biopsy
yesterday complicated by severe HTN. ___ will see her in f/u but
they are not concerned about procedural complications at this
time. the pain is in same location as the pain she presented
with. Her epigastric pain worsened significantly after liver
biopsy; discussed with ___ no concern for post procedural
complication given. She was discharged on a limited amount of
oxycodone to help manage her pain at home.
3. Hypertension: No prior h/o HTN but hypertensive to 170's on
admission and was started on captopril which has been titrated
up to 37.5 tid. She was converted to lisinopril on discharge.
Discussed with her at length the need to find a PCP and for her
to have ongoing medication titration. She had an episode of
dizziness when she received her blood pressure medication and
oxycodone at the same time.
Transitional Issues: EGD with grade 1 varices, no need for
treatment at this time. Should have repeat EGD in ___ years. | 154 | 315 |
11261194-DS-10 | 27,585,003 | Dear Mr. ___,
You were hospitalized due to symptoms of headache, neck pain and
word finding difficulties resulting from a CAROTID ARTERY CLOT
AND DISSECTION CAUSING TRANSIENT ISCHEMIC ATTACK. This is a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot due to a tear in the lining of
the artery wall. This caused brief decreased oxygen to your
brain. The clot is still in the blood vessel. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Coronary artery disease, prior heart attacks
- Hyperlipidemia (high cholesterol)
- Pre-diabetes (HgA1c 5.8%)
- High blood pressure
We are changing your medications as follows:
- start simvastatin 20 mg nightly, your primary care doctor ___
increase this if you tolerate it
- start lovenox (enoxaparin) and continue until you see your
primary care doctor
- please start warfarin 5 mg daily on ___, 2 days prior to your
primary care doctor appointment on ___
You have had some neck pain and headache during your admission
that is related to the clot in your neck. Your tooth pain may be
related to this as well however if you have had the tooth pain
for a long time it may be related to a primary dental issue.
Please make an appointment to see your dentist. Make sure your
dentist knows you are receiving anticoagulation.
It is very important that you take your medications as
prescribed given your risk for bleeding and ischemic stroke.
Please avoid heavy lifting (greater than 15 lb), strenuous
physical activity and neck manipulation. Avoid NSAIDs (advil) as
much as possible while receiving anticoagulation.
You will have a repeat MRI in 3 months to make sure that this
dissection is healing. It is important to ___ in neurology
clinic to get clearance to stop taking the blood thinner.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ man with hypertension,
hyperlipidemia non-compliant with statin therapy, coronary
artery disease non-compliant with aspirin therapy and poor PCP
follow up who presented with 2 weeks of left sided headache,
neck pain and intermittent word finding difficulties. He had a
non focal examination on presentation with some mild left neck
and head pain and initial word finding difficulty that resolved
on day 1 of admission. He was admitted to the neurology service
and was found to have left ICA narrowing to complete occlusion
on CTA s/p left ICA dissection. Suspect TIA as well given word
finding difficulties. His TIA was likely related to occlusion of
his ICA secondary to dissection. He underwent a brain MRI which
showed no evidence of acute infarct on MRI. He was started on IV
heparin and warfarin was initiated however patient remained
subtherapeutic INR 1 on 5 mg warfarin so he was transitioned to
___ with plan to continue this until follow up with PCP who
could then bridge to warfarin. He complained of left sided
headache, neck pain and tooth pain which was managed with
Tylenol and tramadol. He had no deficits on exam on day of
discharge.
His stroke risk factors include the following:
- Coronary artery disease, prior heart attacks
- Hyperlipidemia (LDL 166); simvastatin 20 mg initiated with
plan to increase if tolerated
- Pre-diabetes (HgA1c 5.8%)
- Hypertension
Transitional issues
[ ] New PCP appointment with nurse practitioner at the office of
Dr. ___ phone number
___, fax number ___, Address ___, scheduled for ___ @ 1pm; office called and
provided with summary of hospitalization on ___
[ ] Patient discharged on ___ with plan for PCP to start
warfarin, INR goal ___, which should be continued until
neurology follow up in 3 months
[ ] continue simvastatin 20 mg, increase if tolerated as
outpatient
for LDL 166
[ ] avoid NSAIDs while on anticoagulation if possible
[ ] avoid heavy lifting (greater than 15 lb), strenuous physical
activity and neck manipulation until ___
[ ] needs outpatient follow up with dentist to evaluate for
primary dental problem as etiology of left sided tooth pain
although may be related to dissection
[ ] Polycythemia noted during hospitalization, continue to
monitor
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - (x) No
4. LDL documented? (x) Yes (LDL = 166) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - started low
dose to monitor toleranace() No [if LDL >70, reason not given:
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 507 | 607 |
16020526-DS-3 | 24,432,097 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
You came to us from ___ after experiencing nausea, vomiting,
abdominal pain. We did imaging with a CT scan that showed
increased stool burden without other concerning findings. Your
symptoms improved with a bowel regimen, indicating that you were
constipated. We started you on a bowel regimen that will need to
be continued at ___. Additionally, it was noted by your
outpatient psychiatrist that you previously had nausea with
fluvoxamine. We recommend that the NP at ___ consider
tapering you off of this to see if this additionally improves
your nausea.
Your sisters also mentioned that you had been more sleepy and
less interactive after starting haldol at ___. We were
worried about potential side effects of this medication, and
asked our psychiatrists for assistance. They agreed that it is
likely that the haldol caused side effects, and we have listed
it as an allergy. You showed improvement off of this medication,
further consistent with this side effect.
We spoke with your sister regarding your left shin infection.
You should see a care provider next week to ensure resolution of
the infection and to have your blood work checked.
It was a pleasure meeting you. We wish you all the best!
- Your ___ care team | Mr. ___ is a ___ male with a past medical history of
presumed behavioral variant frontotemporal dementia who
presented with vomiting and abdominal distention during recent
admission to ___ for SI and aggressiveness, also with
LLE purulent cellulitis and leukocytosis, on ___. Course
at ___ notable for initiation of Haloperidol which we suspect
may have caused ___ symptoms leading to decreased
verbal output and recent decline.
# Frontotemporal dementia, suspected behavioral variant
# Recent paucity of speech - likely EPS ___ Haloperidol
Patient carries diagnosis of FTD from ___ neurology, although
records unavailable for us to review, with manifestations
including increased appetite as well as insistence on repeated
ICS. Patient had worsening output of language since starting
haloperidol, with increased somnolence. Exam was notable for
some Parkinsonian features including rigidity and masked facies.
Psychiatry consulted for assistance, who recommended stopping
haloperidol and documenting this as an allergy, given concern
for typical antipsychotic causing EPS. Should he be agitated,
recommendation for seroquel 25 mg TID: PRN, while he was in
house he required minimal doses of this medication. Patient's
recent decline was also discussed with patient's outpatient
cognitive neurologist, who notes that the typical FTD
progression is in the ___ year range and therefore EPS seemed
most likely to be cause 1 week decline. Patient improved with
cessation of Haldol and was noted to have improved mood, and was
increasingly interactive with improved speech in terms of
hypophonia and paucity of words.
# Abdominal pain
# Nausea
# Constipation
He initially presented with vomiting and abdominal distension,
CT A/P with distended and ___ small bowel with multiple
___ levels suggestive of a low grade obstruction or ileus.
ACS evaluated and thought he did not have SBO. Started
aggressive bowel regimen with improvement in symptoms. Had
recurrence of nausea on ___ and was given tap water enema x1
with improvement once again. Started lactulose on ___ for
improved bowel regimen. Please continue bowel regimen with
docusate/senna/Bisacodyl and lactulose to titrate BMs to
distension and symptom improvement.
Of note, per sister- patient noted to have nausea with
fluvoxamine in the past and was tapered off of this and started
on fluoxetine instead with improvement in symptoms. If
persistent nausea in spite of regular BMs and improved abdominal
distension, would consider stopping fluvoxamine again in favor
of fluoxetine.
# Leukocytosis/LLE purulent cellulitis:
Patient with LLE cellulitis previously treated with keflex,
however appeared purulent and was worsening on keflex.
Antibiotics switched to TMP/SMX on ___ with improvement in
appearance. Plan for 4 additional days on discharge to complete
10 day course. Leukocytosis resolved after switching
antibiotics. Otherwise, infectious work up was negative. There
was initial concern for questionable infiltrate on CXR which
resolved on repeat the subsequent day; as patient had no
respiratory symptoms, suspicion for pneumonia low.
# Creatinine elevation:
Patient with Cr 1.0--> 1.3 on ___ after starting Bactrim; also
in setting of patient having multiple bowel movements and being
on furosemide. Appears that patient never had indication for
furosemide hence this medication was stopped. Cr remained stable
around 1.3/1.4 and appeared most consistent with impaired Cr
clearance ___ Bactrim. Recommend BMP check after completion of
abx course to ensure resolution. | 215 | 523 |
16587125-DS-18 | 25,304,792 | Mr. ___,
It was a pleasure taking care of you at ___
___. You were transferred here from ___
for evaluation of shortness of breath and low oxygen levels. We
did not find any evidence of a clot in your lungs. Your
shortness of breath was likely a combination of inflammation in
your lungs and also increased fluid in your lungs. We gave you
medicine to remove excess fluid and your breathing improved. | ___ yo male with PMH notable for asthma, DMII, morbid obesity who
presents from ___ for evaluation of hypoxia.
Active issues:
# Hypoxia: Likely secondary to COPD exacerbation; may have
component of fluid overload as BNP can be falsely low in
obesity. Pulmonary HTN also possible ___ chronic hypoxia.
Patient was gently diuresed with improvement in O2 sat back to
baseline (88%RA). Patient has O2 at home which he uses
occasionally for symptomatic relief. Additionally, uses
albuterol PRN and flovent. Encouraged to continue with
inhalers/O2 as needed.
Chronic issues:
# OSA: Stable. On CPAP
# DM II: Holding oral meds. Maintained on ISS during admission.
# HTN: On combination meds that are NF. Given individual meds
for BP control
# Depression/Anxiety: Stable. Continued home effexor, lamictal,
clonazepam PRN | 72 | 129 |
11372911-DS-8 | 22,133,672 | Dear Mr ___,
You were admitted to the hospital with severe constipation. This
was probably related to pain medications. You improved with
stool softeners. Your abdominal pain resolved prior to
discharge. You also had some fluid in your lungs from heart
failure, so we gave you extra diuretic. However, you developed
CDiff diarrhea and became hypovolemic, so we have held your
diuretics.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ hx of ___ mitral regurgitation, systolic
CHF, history of coronary artery disease, status post PROMUS
stenting of the LAD and RCA, chronic left bundle-branch block,
status post pacemaker implantation in ___, and atrial
fibrillation who presents with abdominal pain and fecal
impaction.
# Abdominal pain:
Patient describes lower abdominal to diffuse cramping sensation,
coming and going. Found to have fecal impaction on CT as well as
note of gallbladder sludge and perinephric fat stranding.
Elevated LFTs, ALP (normal bili) and elevate lipase w/ note of
sludge on CT c/f possible cholecystitis/choledocolithiasis, but
exam not consistent and LFT abnormalities stable from prior.
Considered intermittent obstruction with sludge/microlithiasis,
but no recurrent abdominal pain. Lactate 2.5 c/f possible
ischemia in setting of Afib, but overall course not consistent,
and lactate normalized. Pain resolved after constipation
resolved. Unfortunately, following aggressive bowel regimen,
patient developed diarrhea. CDIFF sent and positive. Started on
PO vancomycin ___, plan for 14 day course. Patient had
persistent poor appetite throughout his inpatient course,
although no recurrent abdominal pain, nausea/vomiting. Repeat
KUB And RUQ ultrasound largely unrevealing. Will follow up
outpatient for ongoing evaluation.
# Constipation:
Likely ___ opioids in setting of shoulder injury. S/p fecal
disimpaction in ___ and having BMs here. TSH, calcium, total
protein, albumin unrevealing for cause of constipation. Later
developed diarrhea, as above, and treated for CDIFF. ___ need
bowel regimen in future.
# Acute Kidney Injury:
Patient with CKD and baseline creat 1.7-2.0. Creatinine at ~2
since prior discharge. Rising creatinine since ___ thought
likely ___ poor PO intake. Volume repleted w/ IVF on admission
as appeared hypovolemic but later developed pulmonary edema so
gently diuresed. Patient then again became hypovolemic in
setting of diarrhea and persistent poor PO intake. FENa from
___ was 0.33% c/w pre-renal azotemia and poor po intake. Renal
ultrasound was negative for obstruction. SPEP/UPEP neg, but
albuminuria noted. 250cc IVF given on ___. Diuretics held and
continued to encourage PO intake. He will need continued
monitoring of I/Os, electrolytes, and creatinine. He would
benefit from outpatient f/u with nephrology.
# CHF:
EF 30%. No e/o decompensated CHF by exam on admission, however,
after IVF repletion on day of admission, he developed SOB
despite starting home dose lasix. Lungs were clear on exam, but
noted to have elevated JVP, pro-BNP elevated (4,533) and CXR
with note of pulmonary edema c/w acute systolic heart failure.
Received add'l 20mg IV Furosemide ___ and 5mg torsemide ___
with improvement. However, in setting of diarrhea and subsequent
poor oral intake, noted to be somewhat hypovolemic. Held
diuretics starting on ___ and not resumed at discharge. He
will need to be monitored closely, as diuretics will need to be
resumed once oral intake normalizes as he will be at high risk
for decompensated heart failure. He was continued on carvedilol,
although dose reduced to 12.5mg BID given SBPs ___. He will
also f/u outpatient with cardiology for consideration of cardiac
resynchronization.
# Transaminitis:
ALT 53 AST 60* ALP 207 TB 0.9 LIPASE 186. Patient w/ note of LFT
abnl during previous admission. Congestive hepatopathy and ETOH
considered on ddx. LFTs not significantly changed from prior.
Viral serologies negative. HIV negative. Congestive hepatopathy
+/- obstructive lesion, although nothing noted on non-con CT and
RUQ ultrasound with sludge but no cholecystitis. Improved to
stable on repeat labs. Rosuvastatin held esp with concomittent
increasing creatinine. Will need continued monitoring at f/u
with PCP.
# Severe MR:
Patient being evaluated for MVR. Follow up outpatient for CT
surgery evaluation.
# CAD:
H/o known CAD s/p Promus stenting of the LAD and RCA in ___,
and stable cardiac cath in ___. Continued ASA. Rosuvastatin
held in setting of elevated LFTs and ___. Should f/u with PCP
with repeat LFTs. Consider resuming statin outpatient with close
monitoring. (Rosuvastatin would need to be renally dosed).
# Atrial fibrillation:
CHADS2 of ___. Not anticoagulated per discussion of risks and
benefits with patient, family and PCP. Paced. On ASA 325mg. Rate
controlled w/ carvedilol. Will need outpatient f/u for device
interrogation.
# Anemia, Thrombocytopenia:
___ ~ HCT 30. Ferritin, folate, B12 WNL. Hep C and HIV neg.
SPEP/UPEP neg. H/o heavy ETOH use in past, concerning for ETOH
related marrow toxicity. Seen by hem/onc inpatient during last
admission, at which point considered outpatient f/u for BM
biopsy. Patient should f/u outpatient for further evaluation.
# Depression:
Patient and family endorsed depressed mood since death of wife ~
one year ago. Concern that insominia, decreased appetite and
anhedonia were possibly related. TSH, B12, calcium WNL.
Apparently had discussed and declined medical management prior.
Started low dose mirtazapine inpatient on ___ with no
subsequent adverse effects. Can be further uptitrated as needed.
Would benefit from outpatient social work. Will f/u with PCP
outpatient for ongoing management.
TRANSITIONAL ISSUES:
#CODE STATUS: Full
#CONTACT: ___, ___ ___, ___
- complete 14 days of treatment for CDIFF, D1: ___.
- Please check I/O and weights daily and report results to Dr
___ at ___
- will need to resume diuretics
- check BMP ___ and fax labs to: Fax:
___ | 75 | 846 |
15130765-DS-20 | 23,156,617 | Dear ___,
___ were admitted to ___ on ___ with shortness of breath.
___ were diagnosed with an exacerbation of your heart failure
from excessive fluid retention. ___ were treated with diuretics
to remove this excess fluid and your shortness of breath
subsequently improved significantly.
___ also experienced a flare of your gout during your stay. This
was treated with a medication called 'prednisone' which ___ will
continue for several days outside of the hospital.
Continue to take all of the medications in your blister packs
EXCEPT for glipizide (small white round tablet with 'WPI 845' on
one side) which is in BOTH the morning and bedtime blister
segments.
Medications which are NOT contained within the blister pack but
which ___ should continue to take separately are AMLODIPINE,
ALLOPURINOL, RENAGEL, TORSEMIDE and PREDNISONE.
On ___, please REDUCE the dose of Novolog (mealtime) insulin
by 3 units compared to the sliding scale given to ___ at
discharge. At that time, please also reduce the dose of Levemir
that ___ take each evening from 30 units to 20 units.
Please weight yourself every morning and call your doctor
immediately if your weight goes up by more than 3 lbs. It was a
pleasure to take care of ___ during your stay.
Sincerely,
Your ___ Team | ___ year old female with past medical history significant for AF,
___, near-ESRD, who presented to ___ with several days of SOB
and new orthopnea, found to be in decompensated CHF.
# Acute Decompensated Diastolic CHF: Patient presented with new
orthopnea, SOB, and oxygen requirement in conjunction with
elevated BNP and radiographic evidence of overload all
consistent with CHF exacerbation. She underwent diuresis with
decrease in weight from 76.2kg at admission to 74.7kg at
discharge. Patient was discharge on Torsemide 40mg PO qday.
# Discharge Disposition: The medical team *strongly* recommended
that the patient be discharged to acute rehabilitation facility,
citing reasons of decreased mobility due to deconditioning and
her acute gout flare, high fall risk, and fluctutating insulin
requirements in the setting of being treated with prednisone for
her gout flare. After a thorough discussion of the risks and
benefits of being discharged home with services instead of to a
rehab facility, the patient and her son opted for discharge home
with services. The patient was deemed to have medical decision
making capacity and was subsequently discharged home.
# Mild Hyperkalemia: Serum potassium noted to peak at 5.8 on
___, most likely secondary to mild ___ on CKD secondary to
diuresis. Her losartan was held and she was placed on a
potassium restricted diet with improvement in her potassium to
5.0 on ___. Her home irbesartan was resumed at discharge.
# Gout: Continued on home allopurinol during her entire hospital
stay. Patient with complaint of bilateral (L > R) foot pain on
___, with tenderness to palpation of dorsum of midfoot
bilaterally as well as the soles of the feet. Initially without
swelling or erythema, however this developed on ___ (affecting
the first MTP on the left foot and lateral aspect of the right
foot). Pain was controlled with tramadol 50mg Q6H PRN.
Prednisone 40mg qday was started on ___ and tapered to 30mg
qday on ___ after improvement in symptoms. She will complete 4
additional days of prednisone 20mg as an outpatient before
stopping this medication.
# T2DM: Last A1c: 8.3. Takes Levamir 20 units at bedtime as well
as an hISS and glipizide. Required uptitration of her insulin
sliding scale and long-acting insulin on ___ after starting
prednisone. Oral hypoglycemic (glipizide) was held while
inpatient and at discharge. This may be resumed at her follow up
appointment with her PCP if clinically indicated. Patient was
given instructions to reduce her insulin sliding scale by 3
units on ___ as she will take her last dose of prednisone on
___. Also instructed to reduce her dose of Levemir from 30
units to 20 units at that time.
# Pyuria vs UTI: Patient with history of asymptomatic
bacteriuria and previous UTI with pan-sensitive Klebsiella. On
this admission, she reported having dysuria for about a week. UA
w/ 116 WBC and few bacteria so she received 3 days of
ceftriaxone, completing this on ___. Urine culture was
ultimately negative.
===== TRANSITIONAL ISSUES =====
# CHF:
- Cardiology follow up within 3 weeks (scheduled for patient)
- Discharged on torsemide 40mg PO qday
- Discharge weight of 74.7kg
# T2DM:
- Held home glipizide at discharge given increased insulin dose
while on prednisone for gout and recent ___ on CKD. Please
resume at follow up appointment if needed.
- PCP follow up on ___: Please ensure patient's insulin
regimen remains appropriate given that she will be completing
her last dose of prednisone on that day.
# Acute Gout Flare
- Patient will complete a 7 day course of prednisone on ___.
# Dry weight: 74.7 kg
# CODE: Full code
# CONTACT: Patient, Daughter ___ (___) | 205 | 589 |
12200381-DS-9 | 27,944,373 | You were admitted after a fall. You had a CT scan of your head
that was unremarkable. You were acutely confused and you
improved. You were treated for a skin infection (cellulitis)
that developed after an IV was placed on your arm, but there is
no evidence of active infection.
TRANSITIONAL ISSUES:
[]treatment of constipation (no BM for >4d prior to admission,
resceived miralax, dulcolax on ___
[]referral to movement disorders specialist and a cognitive
neurologist for evaluation of possible memory disorder and
tremor | Mr. ___ is an ___ with PMH of AS s/p valve repair,
orthostatic hypotension, multiple falls at home, who presents
with agitation and AMS who was intubated in the ED for CT scans,
now s/p extubation with waxing and waning mental status.
# ICU Course ___: Pt was quite sedated on arrival. Waxing
and waning mental status currently. Lack of sleep likely
contributing to worsening mental status this morning. No clear
source of infection given UA clean and no clear infiltrate on
initial CXR. No evidence of acute intracranial process, though
pt with lytic lesions on prelim CT imaging. However, on further
Attending review these are unlikely to be malignancy related
(sclerotic). Hypercarbic respiratory failure: Resolved and he
was extubated on ___ without difficulty and was breathing on
room air.
# Metabolic Encephalopathy/Delerium: Multifactorial secondary to
ICU stay, disturbance of sleep wake cycle, and possibly related
to benzodiazepines. He was reoriented, and discontinued on his
lorazepam since this was thought to be contributing to this
picture. He was transferred to the medical floor and with time
his mental status gradually improved and he is now AOX3,
interactive and appropriate. His nephew, HCP noted significant
improvement over the course of the hospitalization. He was seen
by both the neuro and psych consultants per the HCP's request
and at this time he is not requiring neuroleptic medication to
control behavior, but seroquel was advised as PRN in case of
significant agitation.
# Anxiety: Continued on home sertraline. However, as above,
discontinued benzodiazepine given likely contributing to
delirium
# Mutliple falls: Most likely mechanical. Severe cervical
spondylosis thought to be contributing. Pt had planned neurology
evaluation as an outpatient. ___ was consulted and recommended
rehab.
#Tremors and Memory difficulty: noted gradual decline over
months, but no prior h/o Dementia and prior neuro-psych testing
in ___ without significant abnormality per family. Neuro
consult suspected possible ___ Body Dementia, but nephew (HCP)
who is geriatric psychiatrist felt this would be unlikely given
limited prior history of memory or mood problems. Nevertheless
he should be referred to outpatient neurology for further
assessment and repeat neuro-psych testing.
#He received several days of keflex/bactrim for local
redness/phlebitis following PIV placement in his L arm, that was
then removed. He no longer requires antibiotics on discharge.
#CONSTIPATION: Patient reported >4d of constipation prior to
discharge. Bowel regimen increased with use of mirlax and
dulcolax on ___. Please monitor closley and assess for
obstipation and need for enema, etc. | 81 | 419 |
11826223-DS-6 | 21,721,197 | Dear Mr. ___,
You were admitted for symptoms of fluid overload. You were found
to have congestive heart failure. You have been started on
medications which will help you to feel better and also to help
improve your heart over time. However, it will be very important
for you to take all of your medications as prescribed and follow
up closely with your physicians. If you gain 3 lbs, please call
your MD.
___ was a pleasure taking care of you and we wish you all the
best.
YOU MUST EAT A LOW SALT DIET. THE FOLLOWING FOODS ARE HIGH IN
SALT: FAST FOOD, CANNED FOOD, BACON, AMONG OTHERS. | ___ male with T2DM, HLD presenting with symptoms consistent
with acute presentation of sCHF, new diagnosis on this
admission.
#) ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE (LVEF 20% ___:
Also valvular dysfunction (MR, TR), but this may be secondary to
annular dilation. This is new onset on this admission. Was not
previously on diuretics. Cath showed LMCA 40% distal stenosis,
LAD with 50% stenosis, LCX 100% occluded. Nevertheless, his
systolic dysfunction was felt to be out of proportion to his
CAD. Contributing etiology differential includes silent infarct
(has DM), metabolic (ex. EtOH), infectious (postviral DCM). He
was started on furosemide 80mg, metoprolol, lisinopril, and ASA.
Discharge weight was 77.8 kg.
#) LOWER EXTREMITY SWELLING: Given recent ortho procedure,
tachycardia, dyspnea, considered DVT, but LENIs showed no
evidence of DVT
CHRONIC ISSUES
--------------
#) OSA: Continued home CPAP.
#) HLD: Continue simvastatin 40mg daily
#) T2DM: Transitioned to HISS while in house, but switched back
to oral agenst (glyburide, metformin) upon discharge
#) BPH: Continued home doxazosin, finasteride
#CODE: Full code
#CONTACT: wife, ___, ___
#DISCHARGE WEIGHT: 77.8 kg | 107 | 175 |
15413946-DS-3 | 23,674,211 | Dear Mr. ___,
You were admitted to ___ because you were having abdominal
pain, which was concerning for an infected gallbladder. You had
an ERCP on ___, where a stone was removed. The next day you
went to the OR to have your gallbladder removed
laparoscopically. You have since been tolerating a regular diet,
ambulating, and your pain has been well-controlled. You are
ready to be discharged home to continue your recovery. Please
follow the instructions below:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mr ___ is a ___ years old morbidly obese male with history of
lap sleeve gastrectomy ___ years ago, who presented to ___
___ with RUQ pain and a RUQ US revealed stones and sludge in
a mildly distended gallbladder and he was transferred to the
___ for further management. The patient was admitted to the
Acute Care Surgery service and was made NPO with IV fluids and
IV antibiotics.
On HD2, the patient had transaminitis and he underwent ERCP with
sphincterotomy and single gallstone removal. The patient was
then taken to the operating room on HD3 and underwent
laparoscopic cholecystectomy with IOC. This procedure went well
(reader please refer to note for further details). After
remaining stable in the PACU, the patient was transferred to the
surgical floor.
Pain was managed with acetaminophen and ibuprofen. Diet was
advanced to regular which the patient tolerated well. The
patient voided without problem. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge on ___, 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. He will follow up in ___ clinic. | 749 | 252 |
13187640-DS-15 | 22,175,894 | Dear Mr. ___,
Why was I admitted to the hospital?
- You were admitted to the ___
because you had fevers and low blood pressures concerning for a
serious infection. You were treated with antibiotics and given
medications to support your blood pressures. You were tested for
malaria due to your recent travels to ___, which came
back positive. You were treated for three days with a drug
called Malarone. We monitored your blood everyday for parasites,
and it looks like the antibiotic worked to get rid of it.
- You had fluid removed from your chest and abdomen that were
felt to be from the tuberculosis. These were tested for other
infections in addition to TB which did not grow any other
bacteria.
- You were also tested for Dengue Fever since you just traveled
to ___ which was still being processed when you were
discharged from the hospital.
- You were found to be a carrier for hepatitis B, which is a
virus that infects the liver and can cause problems with liver
function over time.
- You were continued on treatment for your tuberculosis.
What should I do after discharge?
- Follow up with your primary care physician ___ 7 days of
discharge
- Your drain will stay in place until draining less than 10 cc
per day for two days in a row. When this happens, please call
___ to arrange an appointment with Interventional
Radiology to have them remove the drain
- Follow up with the doctor that treats your tuberculosis and
take your medications as directed
- Follow up with infectious disease to discuss possibly treating
your hepatitis B
- Follow up with Hematology for your history of elevated calcium
Thank you for allowing us to take care of you.
Sincerely,
Your ___ Care Team | SUMMARY:
--------------------
Mr. ___ is a ___ year old man with a recent history of
multiple admissions for disseminated tuberculosis involving the
lung, mediastinum, spine, lymph nodes, peritoneum (miliary,
lymphadenitis, Potts, scrofuloderma) and skin, also with
multiple
abdominal fluid collections, who has been on RIPE since ___
and presented to the ___ ED on ___ in septic shock found to
be positive for malaria (plasmodium falciparum) parasitemia who
has successfully completed treatment.
==============
ACTIVE ISSUES:
==============
# Septic shock ___ malaria (plasmodium falciparum)
Patient presented with hypotension in the setting of fevers and
episode of emesis. Due to requiring pressors he was admitted to
the medical ICU. He was started on broad spectrum antibiotics
for concern for bacterial infection, with large concern of
infected abscesses in his abdomen and chest. These were drained
by ___ and a JP drain was placed in his left para-renal abscess.
He received 2 L of IVF in ED, and lactate was 2.0. He was worked
up for possible distributive shock secondary to possible
bacterial infection, disseminated TB, or parasitic infection
given his recent travel status to ___. He was given broad
spectrum coverage with vancomycin and zosyn and his blood
evaluated for parasites in a smear. It was found on Plasmodium
falciparum PCR that he was positive for malaria, for which he
was treated with a 3 day course of 1000mg-400mg malarone, his
vancomycin and zosyn were discontinued. He had nocturnal fevers
for the first 24 hours of his antimalarial treatment requiring 6
L of IVF boluses. Hemolysis labs during these episodes revealed
no findings of acute hemolysis except for increasing bilirubin.
His parasite load decreased from 2.0% ___ to 0.2% ___, then
subsequently NEG. He did not require further pressors and was
downgraded to the floor. His drain cultures showed no growth on
cultures with negative gram stains. In addition, blood and urine
cultures were collected with showed no growth to date. He was
successfully treated with 3 days of Malarone with improvement in
his vitals, labs, and with resolution of parasitemia on
peripheral smear. His dengue fever antibodies, blood culture,
and fluid collection cultures were pending at discharge. He will
have ___ at home that monitor his drain output. When these drop
below 10 cc per day for 2 days, he should follow up in
___ clinic and have the drain removed.
#Disseminated TB
Patient has known complicated TB that was being treated as an
outpatient with rifampin, isoniazid, and pyrazinamide. He was on
a course that would be continued for a total of ___ months. His
CT on admission demonstrated new intra-abdominal collections
concerning for progression of his TB disease. He had his chest
wall collection and left pararenal abscess drained and cultured,
which showed no growth to date at time of discharge. He will
follow up with Dr. ___ at ___
after discharge.
# Hepatitis B
He arrived at ___ with a mild transaminitis and Tbili of
1.9-2.0. His liver functions were trended while he was in the
MICU and his transaminitis improved. His Tbili began to climb in
the context of malarial fevers and possible hemolysis, peaking
at 3.8 on ___. He was transferred to the general medicine floor
as his total bilirubin began to decline, he had declining
parasitemia, his fevers had resolved, and he was hemodynamically
stable. HBV viral load 2.2 He had hepatitis B viral studies sent
including cAb, eAb, and eAg which were pending at discharge. He
will follow up with Infectious Diseases as an outpatient to
discuss further treatment.
# Acute on chronic hemolytic anemia ___ malaria
Admitted with Hb of 12.2 trending down. He was also noted to
have elevated AST and T.bili, consistent with hemolysis from
malaria. His AST and T.bili normalized on the day of discharge.
Discharge hemoglobin was stable at 8.3.
# Acute thrombocytopenia
Platelets on admission 245 with nadir of 98. Likely due to
sepsis in the setting of TB and active malarial infection, as
patients platelets rebounded with treatment of his infection.
His discharge platelet count was 206.
# Hypoglycemia
Patient with intermittent hypoglycemia with BGs in ___ of
unclear etiology. Patient was given amps of dextrose. He was
evaluate for adrenal insufficiency, which showed a normal AM
cortisol of 18.1. His blood sugars improved without further
intervention.
===============
CHRONIC ISSUES:
===============
# Hypotension
Patient with SBPs in ___ at baseline. Patient returned to this
after his brief MICU stay for septic shock.
# Hx of hypercalcemia with light chain proteinemia
Patient reportedly with possible MGUS, although not clear in our
records. He was normocalcemic during his admission with normal
renal function. We will schedule follow up with
Hematology/Oncology as an outpatient for further workup.
===================== | 292 | 761 |
18028277-DS-10 | 27,988,731 | You were admitted with cellulitis associated with your toe
wounds. You were treated with antibiotics and you improved. You
were seen by podiatry and they felt your wounds were improving.
You were provided with a surgical shoe to help protect your toes
from injury. You are being discharged with close PCP and
___ followup. | This is a ___ with untreated HIV, homelessness, IV drug use
(notes state methamphetamine and heroin, but patient denies
history of use), alcohol use, neuropathy, depression, and
frostbite injury this past winter with resultant dry gangrene of
the toes on the right foot complicated by slow healing, who
presents with worsening pain, redness, and swelling of the right
foot and toes, consistent with cellulitis. Cellulitis improved
with antibiotic therapy (IV, transitioned to PO at discharge).
# Cellulitis
# Dry gangrene related to frostbite injury: He has been seen by
podiatry. The overall impression is that there is some
cellulitis proximal to the areas of necrosis but that the
"digits appear relatively stable at this time and appear to show
signs of healing in comparison to prior evaluations."
Inflammatory markers/CRP are lower than last admission.
- Continued dressing changes to right foot - he has been doing
this at home and has been doing a fairly good job
- Complete course of doxycycline 100 BID x5 days and Augmentin
875 BID x5 days
- Per podiatry he can remain weightbearing as tolerated.
Obtained a boot for him.
- Podiatry and PCP followup scheduled prior to discharge
# Untreated HIV infection
# History of cervical adenopathy: He tells me that he has been
considering resuming HAART therapy but has not yet done so. His
last CD4 count in ___ was 228. Of note he has a history of
cervical adenopathy of unclear etiology (was thought to be a
manifestation of potential syphilis status post treatment). I
have been unable to examine him very thoroughly but have not
appreciated any adenopathy on limited exam.
- F/u CD4
- Continued home at___
- I counseled him extensively about follow up with PCP and
___ of HAART
# Possible drug abuse at risk for multidrug withdrawal syndrome:
He denied any drug use recently or in the past, though his chart
is strewn with references to intravenous drug use. Urine
toxicology positive only for amphetamines. No signs of
withdrawal symptoms here.
# Homelessness: This appears to be a chronic issue, which is
almost certainly contributing to his recurrent admissions and
slow wound healing. He has recently been living with his mother,
which I think is a stabilizing factor for him. He was seen by
social work here.
# Metabolic disarray with hypok, hypomg - likely lab error
# Possible malnutrition - likely lab error
# Mild hyperkalemia after supplementation: Initial laboratory
evidence of fairly advanced malnutrition, but markedly improved
on repeat with rising K after supplementation overall suggestive
of laboratory error (possibly drawn off of vein getting IVF). He
is at risk for malnutrition given social situation, chronic
wound, and HIV infection and I was initially concerned by
admission albumin of 1.6, but repeat albumin came back at 3.3
suggesting spurious initial value.
- Continued home thiamine, folate, multivitamin
# History of syphilis: He had a positive RPR in ___ and was
treated. His repeat RPR in ___ was negative.
# Pancytopenia: Resolved. Likely spurious lab values (perhaps
drawn off of line getting IVF). B12 and folate checked, WNL.
>30 minutes spent coordinating discharge home | 54 | 505 |
13737842-DS-18 | 26,071,872 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were in AFib with RVR and had
several days-weeks of heart failure symptoms.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received several cardioversions for your atrial
fibrillation, and were started on amiodarone. You converted to
sinus rhythm, but unfortunately the amiodarone needed to be
discontinued because you had a prolonged QTc.
- You were initially in the CCU requiring support for low blood
pressure and to help your heart squeeze. This was able to be
weaned and we restarted you on medications for your heart
failure, including metoprolol. You should restart your Lasix
upon returning home
- Your blood pressure remained low during your hospitalization,
so we started you on a medication called midodrine to help keep
your blood pressure up.
- You had several long pauses when changing from atrial
fibrillation back to normal rhythm that concerned us; for this
reason, you had a pacemaker/ICD placed to decrease the frequency
of these pauses. This device also reduces your risk of a fatal
arrhythmia from your heart failure.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You can take off your dressing when you get home tonight. You
can take a shower as early as tomorrow ___. Be gentle around
the incision site. Do not scrub or irritate the area. Wash
gently with soap and water letting water run down over the wound
and pat dry gently with a clean towel.
- Your weight at discharge is 141 pounds. Please weigh yourself
today at home and use this as your new baseline.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
- If you experience chest pain, SOB, persistent lightheadedness
or dizziness, fatigue, malaise, significant lower extremity
swelling, or severe palpitations, you should report to your
local emergency department immediately.
Thank you for allowing us to be involved in your care, we wish
you all the best!
- Your ___ Healthcare Team | SUMMARY:
=====================
Mr. ___ is a ___ year old man with a history of HFrEF (EF
___ NiCM, MR, recent diagnosis of AF who presented with
HFrEF exacerbation secondary to AF with RVR, found to be in
cardiogenic shock. Cardioversion was attempted 5 times but was
unsuccessful each time. His HFrEF was managed and was
subsequently called out to the floor, where he underwent
placement of an ICD w/ his-bundle pacing wire for long
conversion pauses. Despite recommendations for ablation while
inpatient, he deferred this to an outpatient procedure,
understanding the risks of prolonging the amount of time in afib
w/ RVR.
TRANSITIONAL ISSUES
===================
[ ] Follow up with Dr. ___ on ___ to discuss medication
changes and future ablation. Please obtain BMP for potassium
monitoring given issues with hyperkalemia while inpatient and
INR for warfarin monitoring.
[ ] Plan for TTE in 3 months after optimization of volume status
and BNP to assess if candidate for intervention
Discharge Cr: 1.3
Discharge Weight: 141 lbs
Discharge K: 5.1
Discharge INR: 2.0 | 366 | 166 |
13187640-DS-13 | 29,056,756 | Dear Mr. ___,
You were admitted to ___ with worsened draining abscess on
your chest, back, neck, and underarms. We did CT scans and MRIs
which showed abscesses ___ your spine and back as well. We found
you to have a tuberculosis infection and you were started on
antibiotics. You will need antibiotics for a long period of
time. Some of these antibiotics can cause visual abnormalities
and we recommend follow up with the eye doctors ___. We
also found a mass ___ your lung for which you will need a
follow-up imaging for ___ ___ weeks. You also tested positive for
a hepatitis B infection. You will need weekly monitoring of your
liver function for this.
Wishing you the best,
Your ___ Team | Mr. ___ is a ___ year old ___ gentleman with
innumerable cutaneous abscesses ___ the sternum, back,
supraclavicular area and axillae , weight loss, pulmonary
nodules, and LLL mass, found to have disseminated TB.
# Disseminated tuberculosis - progressive pulmonary and
extrapulmonary TB
# Tuberculous scrofuloderma and lymphadenitis
# Likely TB involving the Thoracic Spine (see MRI read)
Patient originally presented for multiple draining purulent
wounds located on back, axilla and chest, first noted ___ years
ago, and now progressive. He presented with fatigue, poor PO
intake, unintentional weight loss, and night sweats, with
increasing pain and drainage at the site of these wounds. Skin
biopsy ___ microbiology shows +AFB. Concentrated sputum AFB
stain, positive ___ and ___. c/w pulmonary and
extra-pulmonary TB. MTB sputum consistent with TB. S/p spinal
drainage and vertebral biopsy w/ drain, now removed. Spinal
abscess drainage +AFB, otherwise no ___ negative. Vertebral
bx tissue w/ negative AFB.
Mr ___ symptoms improved substantially and wounds were
addressed by acute care surgery. Recommendation is I/D as needed
for abscess formation w/frequent dressing changes. Given high
degree of anticipated nursing care for wounds and risk for
superinfection it was felt he would be best cared for ___ long
term care and was discharged to ___.
-- Wound care (adaptic /AquaCelAg/Sofsorb for now)
-- See transitional issues below as there are many
# Cutaneous abscesses:
Patient was treated for bacterial superinfection of his
tuberculous skin abscesses, first with broad spectrum
antibiotics, then he was narrowed to Keflex. He completes his
course on ___.
# Chronic hepatitis B infection - Chronic hepatitis B infection
with normal LFTs and low viral load. Consistent with likely
immune-controlled hepatitis B and would therefore not start
treatment. He is HIV and hepatitis C negative. Ferritin was
>1000, however felt that likely related to severity of
infection. Should have iron studies rechecked and if lack of
resolution would evaluate for cirrhosis and screen accordingly.
-- HBcore Ab Positive / HBsAb Negative / HBsAg Positive/HepBe Ab
positive/HepBe negative
-- HBV viral load low (35)
-- Will need follow up PCP/ID to determine frequency of Hep B VL
screening
-- Outpatient RUQ ultrasound and LFTs for evaluation of
progressive liver disease / cirrhosis.
# Question pulmonary masses: CT chest reads
"Focal areas of confluent airspace opacity ___ the left lower
lobe superior
subsegment and medial basal subsegment may represent
postobstructive pneumonia
given the presence of air bronchograms, or less likely primary
pulmonary
masses"
This finding was discussed with pulmonary specialists, who felt
that the finding was likely due to pulmonary tuberculosis, and
recommended checking a repeat CT ___ ___ weeks to evaluate for
underlying primary pulmonary mass, and further workup depending
on that scan. Patient and family were counseled on this
finding.
==========
NOT ACTIVE
==========
# Hyponatremia - Likely etiology ___. Resolved.
# Anemia, slightly microcytic - no active bleeding. Ferritin >
1000 indicating adequate storage and not iron deficiency. ACD
likely.
#Thromboyctosis: Elevated platelets ___ the 500s. Likely reactive
___ the setting of underlying infection.
# R shoulder pain - Improving. Had limited ROM d/t pain ___ the
axillae and likely some referred pain from pathology ___ T spine
per MRI. Pain well controlled w/standing APAP and prn Oxycodone.
# Sinus Tachycardia: Resolved w/treatment. Likely secondary to
hypovolemia due to persistent poor PO intake. Also tachycardic
to the 130s-140s when febrile.
*****TRANSITIONAL ISSUES*****
# CODE: Full
# HCP: Daughter, ___ ___
# Started on RIPE w/pyridoxine on ___, end date to be
determined 6 to 9 months
# Weekly LFTs; fax labs to ___ clinic ___ (LAST
CHECKED ___
# Keflex ___ q6mg until ___
# ___ ID will not establish formal follow up as being
discharged to ___ and they have ID Department, however (see
below)
# Cleared by ophthalmology prior to initiation of RIPE HOWEVER
will need o/p follow up. This appointment is pending
# Pulmonary recommendation of repeat CT chest ___ weeks to see
if mass has resolved/improved
# Will need to be on precautions until negative sputum. This
sputum sample should be taken on ___.
# Repeat iron studies following substantial treatment of TB.
Given Chronic Hep B and high ferritin would perform RUQ and
liver function tests to evaluate for cirrhosis to guide needs
for screening if indicated.
# If any focal abscesses (currently has one ___ the L clavicular
area) not spontaneously draining, will need ___ | 122 | 722 |
12179037-DS-9 | 29,322,553 | Ms. ___,
You were admitted to the hospital because you were having
abdominal pain and nausea. While in the hospital we gave you
medications to control your pain. We also did imaging of your
abdomen to identify the source of your pain. An abdomen MRI
showed a right adnexal mass, in close proximity to you right
ovary. We consulted the Gynecology service who recommended
outpatient follow up in their clinic (see below details of the
appointment. Please follow up with your PCP as soon as possible
and return to the ED if you experience any symptoms that concern
you.
Your ___ team | Ms ___ was admitted to the hospital on ___ for
management of her abdominal pain. A CT scan of her abdomen and
pelvis showed a pelvic mass in close proximity to her ovary but
was non-diagnostic for the origin of the mass, a US showed a 4.4
cm right adnexal lesion which appears adjacent to, but separate
from the right ovary. Therefore, the patient was admitted to the
___ service for pain management and further workup. An MRI was
done which showed: "a 6.3 x 3.4 x 5.4 cm right adnexal mass, in
close proximity to the right ovary, is suggestive of a fibrous
tumor such as fibroma or fibrothecoma. ___ tumor is less
likely".
Gynecology service was consulted again on the floor and they
recommended an outpatient follow up. the patient was discharged
on ___. | 100 | 139 |
18280519-DS-36 | 25,868,135 | Please take the levaquin until it is all gone
You can use miconazole as needed for your groin irritation. Keep
the area dry and clean and do not use scented soaps or vaginal
douches. | # Bronchitis
# Hypoxia (resolved)
# hemoptysis (resolved)
# Chest pain/pressure
Pt with multiple underlying pulmonary issues including OSA,
COPD,
asthma, now presenting with hemoptysis and c/f PNA (?patchiness
in RML). Symptoms did not improve with outpt doxy. CTA was
negative. IP team evaluated with recommendation for 5 days PO
antibiotics as outpt for likely bronchitis as no infiltrate was
seen on CT chest.
- transitioned from doxy (GI upset) to levaquin on d/c.
- encourage acapella use in setting of infection
- advised to follow up with PCP
- ___ NGD2 but still pending on day of discharge
- UCx showing MMF
# Migraines: seems consistent with her chronic daily headaches.
Neurology evaluated and will follow up as outpatient.
- received abortive therapy with Phenergan, torodol and Benadryl
on ___
- verapamil dose needs verification
#Asthma/COPD on home O2. She tolerated down titration of O2 to
2L
-continued home breo, nebs
-continued ipratropium albuterol
-continued mometasone
-continued home montelukast
#Epilepsy: Continued home topamax, zonesimide
#Chronic back pain:
-continued lyrica
#Depression/anxiety:
-continued paroxetine, diazepam, trazadone for sleep
-Ativan Po x1 now for anxiety.
-SW consult given patient expresses concerns about getting
transporation to medical appointments and is perseverating on
issues with her husband
___:
-Receives monthly IVIG (due on thurs per pt)
#Hypothyroidism:
-continued home levothyroxine
#GERD:
-continued PPI
Transitional Issues
[ ] verapamil dose needs verification - unclear if 80 mg qhs or
40 mg BID
[ ] Pt to complete course of levaquin as outpatient for
bronchitis
[ ] Blood cultures still pending on day of discharge (NGD2).
Will call pt if growth on Day 3+.
[ ] prescribed miconazole for rash around introitus
[ ] restarting home Lasix on d/c. held I/s/o possible infection.
>30 min spent on discharge planning including face to face time. | 33 | 267 |
14279228-DS-15 | 27,357,078 | You were admitted to the hospital after you a sustained a fall
out of bed. You sustained a sternal fracture and right sided
rib fractures. Your pain has been controlled with pain
medication. You are ambulatory and ready for discharge home
with the following instructions:
Your injury caused right rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
In addition to the above recommendations:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered. | ___ year old female who was seen in the emergency room on ___
after a fall from bed in which she reported right rib and chest
wall pain. Imaging was done which showed a sternal fracture and
right sided rib fractures. The patient was discharged from the
hospital with analgesia. She returned to the hospital 24 hours
later with increased sternal pain. A chest x-ray was done which
showed a minimally displaced sternal fracture which was stable.
The patient's pain regimen was re-evaluated and resumed. A
tertiary survey was completed and no new injuries were
identified. The patient's vital signs remained stable and she
was afebrile. She was ambulatory without assistance. The
patient was discharged home on HD # 2 in stable condition. An
appointment for follow-up was made in the acute care clinic.
The patient was instructed to follow-up with her primary care
provider and with the her endocrinologist, Dr. ___.
**************
E-mail to Dr. ___ thyroid finding on CT chest and
follow-up | 452 | 175 |
14957565-DS-26 | 25,526,644 | Discharge Instructions:
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 aspirin 81mg a day for anticogulation for 2 weeks.
Please follow-up with your primary care physician regarding
anticoagulation in the future.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated, left lower extremity
Physical Therapy:
Weight bearing as tolerated
Knee range of motion as tolerated
Unlocked ___ for comfort
Treatments Frequency:
Dry dressing until no drainage
Leave sutures in until discharge | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left knee pain and retained foreign bodies (glass) and
was admitted to the orthopedic surgery service. In the ED, she
had a left knee bedside washout and removal of foreign bodies.
On imaging, there were concerns for air in the knee joint and
arthrotomy, so the patient was taken to the operating room on
___ for left knee irrigation and debridement, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with home ___ was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on aspirin for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 161 | 278 |
16195602-DS-4 | 25,636,913 | Dear Mr. ___,
You were admitted with headaches. You were found to have spinal
fluid with many white blood cells, which may indicate infection
or inflammation. Your initial tests, for bacterial infection,
herpes simplex virus, and HIV, are negative. There are more
specialized tests that are still pending. You will have a follow
up appointment with Neurology to discuss the results of these
tests - if any test is positive, you will be contacted about
starting treatment.
You have been diagnosed with seizures with loss of
consciousness. Due to your impaired consciousness, you should
not drive for 6 months after your last event, by law. You should
not participate in activities in which you could be injured if
you lost consciousness, such as but not limited to swimming,
bathing, cooking or using knifes, especially when unsupervised.
It was a pleasure caring for you during this hospitalization. | Mr. ___ is a ___ ___ left handed man with hx of HTN,
Chronic diarrhea (? lisinopril side effect), hx of +50 P/Y
smoking quit in ___, colon polyp, lung nodule (2mm, 3mm,
detected in ___, remained stable in ___, remote hx of IVDU,
presented with progressive headache started about 3 days prior
to admission, and got worse over 2 days. LP showed >500 WBC with
lymphocytic predominance. The patient's symptoms improved
spontaneously, and his headache was almost completely gone at
the time of discharge. His current diagnosis is viral
meningitis.
#Neurology: inflammatory/infectious CSF, but neuro exam normal
so that makes TB and leptomeningeal carcinomatosis less likely.
Diagnosis viral meningitis.
- HIV negative, HSV negative
- serum cryptococcus, quantiferon gold, Lyme, Anaplasma, ___, RPR pending upon discharge (tests ordered based on ID
Consult recommendations)
- MRI with and without contrast: normal, no leptomeningeal
enhancement
- Empiric bacterial meningitis and HSV medications discontinued
- Started Keppra 750 bid for concern for seizure witnessed by
outside physician
- EEG normal
- droplet precautions discontinued
Seizure semiology: left hand shaking spread to the right arm | 143 | 172 |
14128850-DS-6 | 28,375,820 | Dear Ms. ___,
It was a pleasure taking part in your care. You were admitted to
the hospital after a fall from your bed and a fracture in your
right leg. You underwent a number of tests, and you were also
found to have a urinary tract infection and a kidney injury. You
were treated with antibiotics which treated the urinary
infection, fluids which improved your kidneys, and you underwent
surgery with the orthopedic surgeons to fix your broken right
leg.
.
You were also found to have an enlargement of your aorta, the
blood vessel carrying blood away from the heart. You were seen
by the vascular surgery team, who recommended you follow up with
them in their clinic, but noted that the risks of surgery would
outweigh the possible benefit, and therefore they would not do
surgery.
.
Please continue to take your medications as prescribed. Please
follow up with the appointments as listed below. Should you have
any new or concerning symptoms, please seek medical attention
urgently.
.
We wish you the best!
- Your ___ care team | ___ w/pmh dementia, COPD, CHF, HTN presenting with right leg
pain after a fall out of bed and found to have a right femur
fracture, UTI and incidental large descending thoracic aortic
aneurysm.
.
# Closed displaced femur fracture
# Osteoporosis
Patient is s/p intermedullary nail to R femur without
complication on ___. Some worsening anemia after surgery but
stabilized with Hgb of 8.4 on discharge. ___ recommended acute
rehab. Patient may benefit from outpatient endocrine follow up
given osteoporosis and fracture, and consider starting calcium
and more frequent vitamin D as outpatient. Lovenox 40mg daily
prophylaxis for 4 weeks.
.
#Thoracic aortic aneurysm
This was seen incidentally on imaging. Vascular followed while
patient was in the hospital, and stated that she would not be
operative candidate given comorbidities. Was not active during
admission. Plan to follow up in a couple weeks in ___
clinic. We continued patient's beta blocker.
.
#Anemia
Occurred in setting from likely bleed from fracture as well as
from surgery. Stable prior to discharge
.
# Pyuria
# Leukocytosis
Patient presented with elevated WBC and pyuria, without
significant symptoms. Urine culture showed pan-sensitive
proteus, and patient was
Patient denies dysuria, unclear if true UTI.
.
# ___ vs CKD
Cr 1.2 on admission. Improved to 0.9 with light hydration.
Likely in setting of hypovolemia and UTI.
. | 173 | 204 |
11286186-DS-24 | 20,831,815 | Dear ___ were hospitalized because ___ had a seizure. A CT scan of
your brain was normal. Dr. ___ while ___ were
in the hospital, and she felt ___ were back to your usual self.
There have been no recent changes in your psychiatric medication
regimen, or in ___ seizure medications. Your VNS device was
interrogated, and it was shown to be functioning normally.
We decided it would be best for ___ to be discharged home since
___ were at your baseline, and ___ agreed. Your home nursing
services will be resumed in the morning to continue to help with
your medications. ___ will call ___ with
an appointment to see her within the next few months.
It was a pleasure taking care of ___ and we wish ___ the best!
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ yo woman with history of refractory
complex
partial epilepsy on LTG and ZNS (follows with Dr. ___
who
presents with seizure. Initial exam notable for decreased
attentiveness which was thought to be worse from her baseline.
She was seen by Dr. ___ in the hospital, who said she
was at her cognitive baseline. She thought that her visiting
nurse had inadvertently given her an extra dose of medication,
and that she remembered falling out of bed but not much else.
Generally, her seizures involve movement of complex confusional
behavior, has fallen from being confused, but rarely falls from
secondary generalization. There were no medication changes in
her psychiatric regimen or her seizure regimen recently. An
X-ray in the ER showed mild fecal loading within the large bowel
without significant distention. She should be continued on her
bowel regimen.
Her VNS was interrogated while in the hospital, and it was shown
to be functioning properly. ___ was deemed stable for
discharge with no medication changes. She should follow up with
Dr. ___ ___ we contacted the office
to schedule a follow up appointment. | 133 | 186 |
17851933-DS-12 | 23,979,954 | You were admitted to ___ and
underwent Open reduction and internal fixation of scaphoid,
triquetral-lunate pinning & hamate-capitate pinning. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
* 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.
* 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.
*You can ambulate as tolerated while in TLSO brace at all times.
you can take TLSO brace off while in bed.
* | The patient presented to the ED on ___ after scooter
accident, Trauma team seen and examined the patient. The patient
has been admitted to the regular floor. left writs x-ray showed
perilunate dissociation, scaphoid waist fracture, lunate/distal
radius avulsion fractures. CT spin was conclusive for T12 ship
fracture. Neursurgery and plastic surgery teams have been
consulted, TLSO for the spine and ORIF of scaphoid,
triquetral-lunate pinning & hamate-capitate pinning have been
recommended by the teams respectively. Given findings, the
patient was taken to the operating room for ORIF. There were no
adverse events in the operating room; please see the operative
note for details. Patient was extubated, taken to the PACU
until stable, then transferred to the ward for observation. The
patient was alert and oriented throughout hospitalization; pain
was well managed with oxycodone and Tylenol.
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. | 175 | 185 |
18193563-DS-6 | 21,678,616 | Dear Mr. ___,
It was our pleasure to care for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
Your podiatrist referred you to the hospital because he was
concerned that your foot ulcer was infected.
WHAT DID WE DO IN THE HOSPITAL?
- We gave you antibiotics to treat a possible infection of your
foot ulcer.
- You underwent a procedure called an angiogram of your right
leg, where the arteries of the leg are evaluated for blockages.
A blockage in one of the arteries was opened with a stent.
WHAT SHOULD YOU DO WHEN YOU LEAVE?
- Please continue your antibiotics (last day: ___.
- Please continue taking your other medications, especially the
aspirin and Plavix (clopidogrel) that help keep the stent in
your right leg open.
- Continue working with physical therapy to improve your
mobility.
- Weigh yourself every morning, and call your doctor if your
weight goes up by more than 3 lbs in one day or 7 lbs in 3 days.
We wish you all the best!
- Your ___ Care Team | ___ with history of CAD status post CABG (___), HFpEF (LVEF
>55% in ___, HTN, insulin-dependent T2DM complicated by
neuropathy and nephropathy/CKD, OSA, PAD, and recent admission
for MSSA bacteremia and LLE osteomyelitis who presents from
___ clinic with worsening of RLE diabetic foot infection.
He was treated with antibiotics and underwent RLE angiogram with
balloon angioplasty and placement of drug-eluting stent in the
right anterior tibial artery. His hospital course was
complicated by ___ thought to be contrast-induced nephropathy.
ACUTE ISSUES
============
#Diabetic foot infection:
#Peripheral arterial disease s/p POBA and DES to anterior tibial
artery:
Patient has a history of multiple chronic diabetic ulcers on his
right foot. He presented from ___ clinic after his
outpatient podiatrist noted clinical worsening of the ulcers,
concerning for infection. On admission, patient's lactate was
elevated, but he was afebrile and hemodynamically stable (and
remained so throughout his hospital course); two of his lesions
were purulent without crepitus. XR and MRI of the right foot did
not demonstrate evidence of osteomyelitis. He was treated with
antibiotics for a planned 14-day total course; per patient
report, he has a history of MRSA infection of the left foot, so
he was covered for MRSA. He was discharged on doxycycline 100mg
q12h and Augmentin 500mg q12h (renally-dosed, day 1: ___,
planned end ___. Patient was also evaluated for peripheral
artery disease given the chronic, non-healing nature of his foot
wounds. A non-invasive arterial study of his lower extremities
showed bilateral tibial artery disease, and he underwent right
lower extremity angiogram status post POBA and DES x1 to the
mid-segment of the anterior tibial artery by Dr. ___. He
was started on ASA 81mg daily and Plavix 75mg daily with
recommendations to continue DAPT for 12 months. Patient was
regularly seen by Podiatry while in-house for dressing changes
and Santyl debridement.
#Acute kidney injury on CKD
Patient presented with ___ (Cr 1.9) on admission from a
baseline of ~1.1-1.4. His kidney function improved with
initiation of antibiotics. However, after RLE angiogram, he
developed recurrent ___ with peak Cr of 2.1, thought to be
contrast-induced nephropathy in the setting of receiving 160 mL
of contrast +/- overdiuresis with IV Lasix due to subjective
dyspnea thought secondary to volume overload. He was switched
from PO Bactrim to PO doxycycline in the event that the Cr
increase was induced by Bactrim (although no evidence of
eosinophilia or WBC casts on spun urine to raise concern for
AIN). Renal ultrasound showed no hydronephrosis. His Cr was
downtrending and near-baseline by the time of discharge. His WT
had remained stable off diuretic as well, with only mild ___
edema. NOTE: patient's diuretics (home furosemide and HCTZ) were
held in the setting of this ___. He can restart furosemide 40mg
every other day and HCTZ 50mg daily once his Cr stabilizes. His
home valsartan 320mg daily was also initially held for his ___
but was restarted on discharge for HTN iso CKD and DM; please
continue to monitor his kidney function.
#HTN
Patient's blood pressures were noted to be in the 160's
systolics in the setting of holding home furosemide and HCTZ
given his ___. He was continued on home amlodipine 10mg daily
and isosorbide mononitrate 90mg daily. His home valsartan 320mg
daily was initially held for infection and ___ but restarted on
discharge. Please continue to monitor his blood pressures. He
can restart his home diuretics once his Cr normalizes (as above)
and as dictated by high BP trends.
#Right posterior forearm swelling
Patient noted a blister-like area of swelling on his posterior
forearm without erythema, TTP, or purulence, thought to be
induced by pressure on the arm. An ultrasound was performed and
demonstrated no fluid collection or abscess. Please continue to
monitor the area as it is adjacent to a healed incision, and
patient is at risk for infections.
#Otorrhea
Pt reported clear, painless ear drainage on the day of
discharge. On exam, some e/o middle ear effusion w/o erythema,
visible drainage debris or perforation. Possibly may be
secondary to resolved otits media (though no antecedent pain).
Less likely chronic suppurative otitis media in absence of
debris. Recommended continued monitoring clinically as pt had
already being treated with more than adequate treatment as a
typical duration of treatment for a mild OM infection is ___
days. | 166 | 704 |
11673775-DS-19 | 21,988,880 | You were admitted to ___
because you had a heart attack or NSTEMI. The cath found you had
severe 3 vessel CAD however you declined any intervention.
Continue all your current medications with the following
changes:
-continue steroid taper for gout flare
-hold lisinopril and hydrocholorthiazide until seen by Dr. ___ antibiotic for pneumonia
-start atorvastatin 80mg every night, this replaces your
pravastatin
-start isosorbide 30mg daily
-increased labetalol to 200mg twice a day
Please refer to cardiac rehab information sheet. You will need
to make an appointment to see them so that you can safety
exercise post heart attack
We have made changes to your medication list, so please make
sure to take your medications as directed. You will also need to
have close follow up with your heart doctor and your primary
care doctor.
It was a pleasure to take care of you. We wish you the best with
your health!
Your ___ Cardiac Care Team | Assessment/Plan: ___ year old man who presented with chest pain
and ruled in for NSTEMI now s/p coronary angiogram revealing
severe 3 vessel disease.
#NSTEMI/unstable angina: Cath revealed severe 3 vessel
disease, but patient declining CABG. Patient offered PCI but
after discussion of risks and benefits with Dr. ___ Dr.
___ is deferring for now. Risk for potential fatal MI without
PCI or CABG conveyed.
-___ discontinued today
-continue statin, ASA
-Imdur 30mg started this am
-Labetolol 200mg BID (from 100mg BID)
-Ace Inhibitor dc'd due to CKI with cre 2.1
-start nitro SL PRN
-follow up cardiac rehab
-follow up with Dr. ___
#Hypercholesterolemia: ___ Total 135, Triglycerides 126, HDL
40, LDL 70
-Continue heart healthy diet post cath
-Continue Atorva 80mg
#Pneumonia: chest xray on admission with patchy left basilar
opacity concerning for pneumonia; has productive cough and
elevated WBC on admit; presumed community acquired pneumonia,
comorbid renal disease.
respiratory fluoroquinolone per IDSA recommendations; follow up
chest xray yesterday showed "Low lung volumes causing
bronchovascular crowding and atelectasis. Allowing for this
difference, left lung base very sparse opacities are likely
unchanged."
-Levofloxacin 750mg q48 hours for 5 doses
-continue tessalon pearls for cough
#chronic kidney injury: followed by Dr. ___
creatinine 2.2 with GFR 28
Stable
-renal dose medications
-Hold Lisinopril
-get creatinine checked outpatient in 48 hours
-follow up with renal on ___
#Pseudo Gout: Concern for worsening kidney function if pain
treated with Colchine. Pain is preventing weight bearing. Some
relief with cold compresses. Rheumatology consult suggests treat
gout flare, uric acid 7.7, ESR pending, CRP 145.0. family does
not want to aspiration. ankle xray showed no fracture, ? sift
tissue swelling or infectious process involving bone and soft
tissue, ? follow up MRI, however patient declined and Dr. ___
___ not feel that MRI is warranted at this time as patient's
symptoms are already improved with steroid taper
-Cold compresses and Tylenol PRN
-continue prednisone taper 40mg x days, 30mg x 2 days, 20mg x 2
days and 10mg x 2 days
#Hypertension: stable
-Discontinued Lisinopril and HCTZ
-Monitor BP closely up titrate Amlodipine if needed
-continue amlodipine
-Labetolol increased from 100mg bid to ___ bid
#Hypomagnesaemia: Mg ___ yesterday)
-follow up magnesium outpatient in 48 hours
#hypothyroidism: TSH normal in ___
-continue levothyroxine
#Insomnia: Slept well last night after Ramelton; No sleep night
prior d/t ankle pain and cough
-Codiene qhs prn cough
-Ramelton 8mg po qhs prn insomnia
#asthma: currently stable
-PRN atrovent neb
#Disp: Dc home with wife and ___ | 148 | 395 |
13406560-DS-12 | 20,205,059 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | ___ with active IV drug abuse and asthma presenting with left
flank pain and found to have bilateral renal infarcts and LV
thrombus versus vegetation.
# ENDOCARDITIS WITH SEPTIC EMBOLI. Etiology would be from recent
and continued IV drug abuse including ___, heroin, and
methamphetamines. She had renal infarcts and large LV thrombus.
Patient claims she only had 1-time ___ use, but outside
medical records state otherwise, including ___
admission ___ where she was in respiratory distress and
found to have used multiple IV drugs in her hospital room and
later left AMA. She was treated with vancomycin while blood
cultures were pending (no blood cultures were drawn at ___
___ prior to administration of vancomycin). TEE showed
large mobile ovoid mass in apex, LV thrombus vs vegetation.
Cardiology and Cardiac Surgery were consulted, who agreed with
antibiotics and anticoagulation. Possible set of events was
endocarditis from IV drug use, with emboli to LAD causing MI,
then LV hypokinesis leading to development of large LV thrombus.
CT head was initially negative for septic emboli, so heparin gtt
was started. Two hours later, she had acute stroke and heparin
gtt was stopped.
# CODE STROKE. Two hours after heparin gtt was started, she
developed acute facial droop, slurred speech, and left
hemiparesis. Code Stroke was called. CT head showed no bleeding,
but MRI was consistent with multifocal septic emboli. Heparin
gtt was stopped. She was transferred to CCU for closer
monitoring.
# LEUKOCYTOSIS. WBC 33 at OSH, 29 on admission here. Some
component attributable to multiple recent solumedrol doses for
asthma exacerbations at OSH, however cannot exclude infection
given endocarditis question on OSH CT scan.
- send Cdiff given recent levofloxacin use, no current diarrhea
but she has abdominal pain
# LEFT FLANK PAIN. Probably from bilateral renal infarcts,
consistent with L>R infarcts seen on OSH CT. ___ have had a
fracture given onset of pain directly after mechanical fall with
abdomen/flank region hitting desk. Some of it may be
drug-seeking behavior given known IV and opiate abuse history.
She was treated with dilaudid IV PRN and lidocaine patch.
# TRANSAMINITIS. ALT>AST in low 100's in 2:1 pattern. She has
had abnormal LFTs in the past per ___ records. She
has multiple risk factors for liver disease including alcohol
and IV drug use. HIV was negative.
- Hep B, Hep C serologies
# ACTIVE IV DRUG ABUSE. Patient declined this to me on exam, but
records show clearly she continues to abuse IV drugs, and was
found with them recently in her hospital room at ___ three
days prior to her presentation at ___. Serum tox screen was
negative on admission here. Urine positive for opiates only (has
received narcotics for pain control). Social Work consulted.
# ASTHMA. History of asthma and mild wheezes on exam.
Asymptomatic. She was treated with nebulizers. | 121 | 468 |
15455517-DS-53 | 24,039,290 | Dear Mr. ___,
You were admitted to ___ after
being found unresponsive with very low blood sugar. A breathing
tube was placed and we found that you had damage to your brain
due to low blood sugar. This was complicated by seizures and we
started you on seizure medications. Because you are still unable
to protect your airway we placed tracheostomy and PEG tube on
___. You also developed a pneumonia while here, and you
will need to finish a course of antibiotics at your facility.
You will need to follow up with neurlogy as scheduled. | Primary Reason for Admission: This is a ___ y/o man with poorly
controlled HTN, DM1, and HD dependent ESRD who was found down
and unresponsive at home on the day of admission with FSBG of
30.
. | 95 | 36 |
11869131-DS-2 | 24,166,056 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers medications.
- 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 325mg of aspirin daily for 6 weeks.
ACTIVITY AND WEIGHT BEARING:
- You may be weight bearing as tolerated on your right lower
extremity.
- Please do not remove or alter the external fixator in any way.
Physical Therapy:
WBAT RLE. | The patient was admitted to the orthopaedic surgery service on
___ with R knee dislocation. Patient was taken to the
operating room and underwent closed reduction of R knee
dislocation with external fixator placement. Patient tolerated
the procedure without difficulty and was transferred to the
PACU, then the floor in stable condition. Please see operative
report for full details.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT RLE in exfix at all times. Throughout the
hospitalization, patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by IV
morphine and oxycodone and was subsequently transitioned to PO
dilaudid with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's HCT remained stable throughout the
hospitalization. He did not receive any blood transfusions
while in the hospital.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received aspirin during this stay, and
was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with his exfix on, voiding without
assistance, and pain was well controlled. The extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on aspirin for
DVT prophylaxis for 6 weeks post-operatively. All questions
were answered prior to discharge and the patient expressed
readiness for discharge. | 97 | 315 |
19319186-DS-18 | 25,894,732 | Please call Dr. ___ office at ___ for fever
of 101 or greater, chills, nausea, vomiting, diarrhea,
constipation, increased abdominal pain, pain not controlled by
your pain medication, swelling of the abdomen or ankles,
yellowing of the skin or eyes, inability to tolerate food,
fluids or medications, the drain insertion site has redness,
drainage or bleeding, or any other concerning symptoms.
You may shower. Allow water to run over the drain. no
lotion or powder to the biliary drain insertion site.
The PTBD drain will remain capped at this time.
Change the gauze dressing daily and prn
You will be sent home with an empty drain bag in the event that
you are instructed to open your PTBD
No driving if taking narcotic pain medication (tramadol). No
No tub baths or swimming | ___ female with history of type 1 choledochal cyst, pancreatic
divisum s/p robot-assisted laparoscopic bile duct excision, RNY
hepaticojejunostomy (___), c/b HJ stricture requiring
balloon dilation and PTBD placement (___) who
presents to the ED with abdominal pain at her drain site and
chills. On ___, ___ found nearly completely occluded PTBD and
the catheter was exchanged. Post procedure, she had some nausea
that resolved and LFTs decreased with alk phos decreasing from
1414 to 666. She remained afebrile. The PTBD was capped and her
abdominal discomfort was minor at the PTBD insertion site.
Creatinine was increased to 1.4 from baseline of 0.7. One liter
of IV fluid was given with creatinine decrease to 1.6 on ___.
She was encouraged to drink at least 2 liters of fluid per day.
She was given a script for a chem 10 to be drawn on ___
___ at her local lab. Diet was advanced and tolerated. She was
discharged to home on Augmentin that was filled by ___ on
___. | 129 | 172 |
16192713-DS-6 | 29,086,328 | Dear Mr. ___,
You were admitted to ___ after
falling down 4 stairs and having a right clavicle fracture,
right ___ rib fractures. You are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
Rib Fractures:
* Your injury caused 8 ribs 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). | ___ with known right sided rib fractures and clavicle fracture
on right after fall on transfer from OSH. Patient was admitted
to the ACS service for polytrauma. Patient received pan-scan to
evaluate for fractures causing SOB, tachycardia, and tachypnea.
CT head demonstrated no intracranial abnormalities, CT Chest
demonstrated Right ___ rib fractures and a comminuted
fracture of the mid third of the right clavicle with inferiorly
displaced butterfly fragments, and hip x-rays demonstrated no
fractures.
Patient remained stable after scans, SOB and tachycardia
improved with better pain control, and vital signs normalized.
Patient was admitted to ACS service for pain control and oxygen
support. Chronic pain service was consulted to assist with pain
control given patient's history of opioid use. A combination of
Lidocaine patch, Cyclobenzaprine 5 mg PO/NG TID, Acetaminophen
1000 mg PO/NG Q6H, OxyCODONE (Immediate Release) 20 mg PO/NG
Q4H:PRN Pain, and Gabapentin 900 mg PO/NG TID appeared to
control the patient's pain. Incentive spirometry was encouraged
early on. The patient worked with physical therapy and was
cleared for discharge home.
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. | 284 | 221 |
10015860-DS-21 | 25,103,777 | Dear Mr. ___,
You were admitted to ___ with fevers. You had bacteria in your
blood and were treated with intravenous antibiotics. We
suspected the source of this infection to be from your
hemodialysis line which was removed. We replaced your
hemodialysis line. You underwent echocardiograms of your heart
which found a bacteria in one of your heart valves. You will
need antibiotics for several weeks with your hemodialysis
sessions. It was a pleasure caring for you.
Wishing you the best,
Your ___ Team | ___ is a ___ with DMII c/b ESRD on HD MWF p/w 2 days
of fevers and positive blood cultures with MRSA, now s/p HD
port removal and identification of aortic valve vegetation.
# MRSA BACTEREMIA LIKELY DUE TO LINE INFECTION
# MRSA ENDOCARDITIS OF AORTIC VALVE
Patient presented from his ___ facility on ___ after
episode of fevers, rigors, found to have high grade MRSA
bacteremia (positive culture at rehab ___ 1 of 4 cultures on
___ with MRSA). Likely etiology is line sepsis from infected
tunneled HD catheter and this was removed on ___. TTE was done
which was suboptimal quality but did not show any vegetations.
TEE on ___ndocarditis with mod vegetation on AV
cusp. No paravalvular abscess seen. Repeat surveillance blood
cultures were negative. New tunneled hemodialysis line was
placed ___. Plan is to treat with 6 weeks of vancomycin dosed
with HD through ___. Will follow-up in ___ clinic.
#ESRD on HD MWF
#Hyperkalemia
Patient was initiated on HD during his last hospitalization
___. Renal failure is secondary to diabetic nephropathy.
Still makes urine. He was given a line holiday and missed
dialysis session on ___ and ___. CMP checked daily, hyperK+
and hypervolemia treated with insulin/dextrose and 100 mg Lasix
and insulin/dextrose PRN. HD tunneled line was replaced on
___. He was kept on strict low K+ diet, strict ___ mL fluid
restriction and continued on home nephro caps, calcitriol,
calcium carbonate and Vitamin D. Last dialysis session on ___.
His home Lisinopril was held and then restarted on discharge.
#s/p right toe amputation
Healing well, no signs of infection. Podiatry curbsided and had
a very low suspicion for infection, but recommened x-ray to
ensure no signs of osteo, though patient declined. CRP ~11.
#DIABETES MELLITUS II
Previously followed by ___. Most recent A1C 6.6%. Continued
home glargine and Humalog SS.
#HYPERTENSION
SBP 140-150s. Continued on Lisinopril on discharge.
#HLD: Continued on atorvastatin 20mg QHS and ASA 81mg daily
#ANEMIA
Hb 11.3, bl ___. Unclear why higher than usual, maybe some
component of hemoconcentration in setting of fever and
bacteremia. Iron studies from ___ suggestive of anemia of
chronic inflammation; B12 normal. Anemia likely due to ESRD.
EPO 10,000units q14 days per renal recs.
TRANSITIONAL ISSUES
===================
- Continue vancomycin with hemodialysis sessions (end date ___
for a total of 6 weeks.
- Weekly CBC/diff, vanc levels at least every other week, and
CRP every ___ weeks, and surveillance blood cultures at the end
of his course. PLEASE DRAW DURING HD SESSIONS, ALL LAB RESULTS
SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___
- ___ clinic follow-up, likely surveillance culture after abx | 82 | 435 |
19225366-DS-21 | 28,973,757 | Dear Ms. ___,
You were admitted to the hospital with shortness of breath.
We diagnosed you with a COPD exacerbation, gave you nebulizer
treatments, and your breathing improved.
You are being discharged back to a shelter and we are delivering
all of your medications (a 1 month supply of most of them)
directly to you before you leave the hospital.
Please follow up with your doctors as listed below, especially
your PCP ___ you only have a 7 day supply of
methadone and your appointment with him is 7 days after
discharge.
It was a pleasure taking care of your,
Your ___ team | ___ with PMH of chronic bronchitis, DM2, HTN, chronic pain on
methadone, homelessness p/w SOB and cough, likely secondary to
COPD exacerbation, now improving.
# Cough:
# SOB:
# Likely COPD w/acute exacerbation:
Patient p/w cough and SOB, likely exacerbation of undiagnosed
COPD in setting of significant smoking history, with CT evidence
of diffuse bronchial wall thickening suggestive of small airways
inflammation. Possible trigger viral URI. No e/o PE. LLL opacity
on imaging
likely atelectasis, with no fevers or leukocytosis to suggest
PNA. She was treated with prednisone 40mg daily x 5d (through
___ and standing duonebs. She received one dose of
levofloxacin and was transitioned to azithromycin to complete a
5d course (through ___, QTC 413 on ___. Her symptoms improved,
and she remained on RA. Non-ambulatory at baseline
(wheelchair-bound from chronic pain), but was maneuvering to and
from her wheelchair independently at discharge. She was
discharged on her home albuterol PRN with addition of Spiriva
for COPD maintenance. She would likely benefit from outpatient
PFTs and pulmonary f/u. Smoking cessation was encouraged.
# Diabetes mellitus:
# Peripheral neuropathy:
A1c 10.2 on ___ with peripheral neuropathy. Previously
prescribed ___ 20u QHS in addition to metformin, which she
was taking only intermittently prior to presentation in setting
of homelessness. Fingersticks were elevated to the 300s this
admission in setting of steroid administration. After discussion
with her PCP, ___ was increased to 30u QHS and home metformin
- held while in house - was continued at discharge. She was
provided with a glucometer on discharge, but unfortunately test
strips are not covered by her insurance. She was encouraged to
buy test strips over the counter and check fingersticks daily;
her PCP was made aware and will work to obtain insurance
coverage for strips going forward.
# Chronic pain:
# Arthritis:
Continued home gabapentin and methadone 10mg BID (dose confirmed
with PCP). She was given a 7d supply of methadone on discharge
to bridge her to her PCP ___ (scheduled for ___.
# Anxiety:
Continued home clonidine BID PRN (previously prescribed).
Patient frequently requested benzodiazepenes, which were
avoided.
# HLD:
Continued home atorvastatin 80mg daily.
# HTN:
Continued home lisinopril 20mg daily on discharge.
# Housing instability:
Patient intermittently housed at shelters, complicated by need
for wheelchair accessibility and patient's desire to keep her
cat with her. SW was consulted and investigated options for
discharge. Unfortunately, no shelters will allow patient to keep
her cat with her unless the animal is certified as a service
companion. Patient was discharged to a shelter, where a social
worker had previously been helping her to arrange long-term
housing. All medications were delivered to the bedside prior to
discharge.
TRANSITIONAL ISSUES
- Continue azithromycin and prednisone through ___
- Would likely benefit from pulmonary referral and PFTs
- F/u DM; likely will require insulin titration
- Ensure follow-up with Dr. ___ close management of
multiple co-morbidities; Dr. ___ this patient very well
- medical and psychosocial concerns alike.
- Please continue to assist the patient with finding housing
- Please assist the patient with getting ownership of her cat
back from shelter; the animal is extremely important to her.
Patient is medically stable for discharge today. Greater than 30
minutes were spent on discharge planning and counseling. | 102 | 517 |
10417172-DS-28 | 21,610,606 | Dear Ms. ___,
You were admitted to ___.
WHY YOU WERE ADMITTED TO THE HOSPITAL:
=======================================
- You were having abdominal pain and vomiting not controlled by
your medicines at home.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
==============================================
- Your symptoms were treated with nausea and pain medicines.
- You had a CT scan that did not show any bowel obstructions.
- You had an endoscopy that showed some retained food and no
ulcers.
- You were started on Bactrim for a UTI.
WHAT YOU NEED TO DO WHEN YOU GO HOME:
======================================
- Please take Bactrim twice a day for total 3 days (take last
dose in the morning on ___
- Please follow up with your primary care doctor on ___ ___.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | Brief Hospital Course
======================================
Ms. ___ is a ___ ___ retired ___ with a history of RnY gastric
bypass c/b short gut syndrome (on TPN via tunneled central line)
who was admitted for acute on chronic abd pain, nausea, and
vomiting. CT showed no evidence of obstruction or other acute
pathology. EGD showed no ulcers but did reveal a bezoar that
have been contributing to symptoms. Patient gradually improved
and was discharged home at baseline with close f/u.
Active Issues
======================================
#Abdominal Pain:
#Nausea:
#Short gut syndrome:
#Slow Transit:
Patient presented with 24 hours of nausea and vomiting, similar
to prior episodes. CT showed no evidence of obstruction,
infection, or other acute pathology. EGD on ___ demonstrated
large bezoar in jejunal limb, thought to be blind limb, that may
have led to her symptoms. She displayed evidence of slow
transit, with residual fecal matter on CT and retained food at
EJ anastomosis on EGD. Slow transit may be secondary to opioid
use for abdominal pain, and was not treated given patient's
history of short gut syndrome. EGD was also negative for
anastomotic ulcer. Patient's pain was managed with home
buprenorphine and morphine. Nausea was controlled with standing
promethazine and prn ondansetron, prochlorperazine and
lorazepam. By the time of discharge, her pain and nausea had
improved to baseline.
#Hypotension: One episode of hypotension with BP ___.
Patient was asymptomatic and lacked any localizing signs of
infection. Improved with IVF bolus.
#Uncomplicated UTI: Experienced dysuria and urgency. UCx grew
coagulase negative Staph. Started on Bactrim DS BID on ___ for 3
day course.
#Nutrition: Continued on home TPN
#Anxiety: Continued on home mirtazapine and started on zolpidem
10 mg QHS.
#History of DVT: Continued on home Enoxaparin Sodium 80 mg SC
Q12H for history of provoked DVT. Note dose is higher than
standard 1mg/kg due to c/f prior treatment failure. Has
Hematology f/u soon.
#Chronic anemia: Stable this admission. Due to iron infusions as
outpatient.
___ Edema: Home Lasix held, no edema.
Transitional Issues
======================================
- Continue Bactrim DS BID through ___
- No other medication changes made this admission
- Note: patient was recommended to initiate care as outpatient
with gastroenterology but declined at this time.
- GI recommended small bowel follow through to ascertain if
bezoar is in blind limb vs. jejunoileal limb; patient declined
test as inpatient but amenable to doing test as outpatient.
- Has Hematology follow-up scheduled to discuss enoxaparin
dosing and iron infusions for chronic anemia
CONTACT: ___ (Wife) Phone: ___
CODE STATUS: DNR/DNI | 132 | 400 |
10919141-DS-33 | 20,814,714 | Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with right wrist and
leg pain. Further testing showed that you had an infection of
your right shin. There was no fractures in any bones. Your
skin infection improved with antibiotics. You are now being
discharged, but will need to continue taking antibiotics.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck!
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old female with history of hypertension,
hyperlipidemia, atrial fibrillation on apixaban, type 2 diabetes
c/b neuropathy with diabetic foot ulcers, chronic diastolic CHF,
and CKD Stage III who presents with right leg wound.
# Right anterior shin cellulitis
# Stable bilateral foot ulcers
# Possible fever
Admitted with right shin ulcer, pain, erythema c/w cellulitis.
Foot ulcers appearing epithelized and non-infected. Low
suspicion for DVT given she is on chronic apixaban. Patient
with low-grade fevers initially that then resolved with further
antibiotics. Podiatry was consulted and recommended no surgical
therapy. She was placed on IV vancomycin, transitioned to PO
doxycycline and amoxicillin for total 10 day course. She will
need to follow up with Podiatry on ___.
# Immobility
# Mechanical Falls:
Usually, at baseline able to walk with a walker but recently has
been unsteady, unable to get out of a seated position, and prone
to falls (3 falls in last couple weeks). Head CT, C-spine CT
without clear pathology. ___ evaluated patient and
recommended rehab. She will continue work with ___ at rehab.
# Wrist pain: patient endorsed wrist pain after fall, X-ray
showing no evidence of fracture or deformity. She was provided
with acetaminophen and lidocaine ointment for pain.
# Acute kidney injury: patient has labile creatinine, with
elevation to 1.9 one day prior to discharge. She was given IV
fluids with improvement to Cr 1.6.
# Diabetes
# Hypoglycemia: patient hypoglycemic to ___ during admission, so
insulin glargine dosing was decreased from 22 units at night to
16 units. Dosing of insulin will likely need to be uptitrated
again at rehab, and attention should be paid to this.
CHRONIC ISSUES
======================
# HTN/HLD: on lisinopril, torsemide, atorvastatin, which were
continued
# Atrial fibrillation: continued home apixaban
# History of breast cancer: continued home tamoxifen
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will need to follow up with Podiatry on
___. Dosing of insulin will likely need to be uptitrated again
at rehab, and attention should be paid to this. She will
continue work with ___ at rehab.
# CODE STATUS: DNR/DNI, but ok to hospitalize
# Contact: niece ___
Phone number: ___
Cell phone: ___ | 99 | 360 |
13495822-DS-9 | 27,200,232 | Dear Ms. ___,
It was a pleasure participating in your care. You were admitted
to ___ for shortness of breath. We saw on chest X-ray that you
had small fluid collections on both lungs. We sampled the fluid
on the right lung and performed a number of other tests to see
what was causing it. At this time we believe it is from
congestive heart failure.
For your shortness of breath, we also treated you with
antibiotics for a community acquired pneumonia. Please continue
this medicine (Levofloxacin) for one more day.
When you were admitted, some of your blood tests (troponin) were
concerning for damage to your heart. We monitored the projection
of this blood test and at this time believe this is not due to a
heart attack, but rather poor clearance of this chemical by your
kidneys.
Going forward, we have started you on the medicine Metoprolol to
try to prevent worsening heart failure. We also started you on
an aspirin daily. You can also try to keep yourself out of the
hospital with heart failure exacerbations by limiting your
intake of sodium to no more than 2 grams daily. | Ms. ___ is an ___ year-old female with history of DM,
HTN, and CKD who presented to ___ with 1 week of
increasing SOB and non-productive cough.
#Systolic CHF: New diagnosis. Previous ECHO at ___
in ___ showed normal LV function and EF 60%. ECHO here ___
showed EF 40-45% and mild to moderate systolic dysfunction. Her
NTBNP was 7000, she had bilateral transudative pleural effusions
(did not meet any of Lyte's critera) and a pleural fluid pro BNP
of 16000+. She was not diuresed as she was not grossly
overloaded and her diagnostic pleural effusion was in fact
partly therapeutic. She may need to be started on a diuretic as
an outpatient but was relatively euvolemic on exam so were not
started here. Discharge weight: 48kg.
-started metoprolol 50 XL daily
-cont'd Bumex
-cont'd asa 81
# Type 2 NSTEMI (demand): Elevated troponin to
0.26-->0.23-->0.20 with flat MB. Patient denies history of chest
pain. Has been experiencing cough symptoms and shortness of
breath over past week. DVT workup was negative. She initially
got heparin gtt x24hrs after transfered from ___ when there
was concern for Type 1 NSTEMI, but her ECGs were not consistent
with this and so it was stopped. She was initially started on
asa 325mg but changed to 81mg prior to discharge.
(ECG: Sinus rhythm. Diffuse low voltage. Right bundle-branch
block. Left anterior
fascicular block.)
- cont asa 81mg daily
- outpt f/u & workup
# ?Community Acquired Pneumonia: CXR and CT initially concerning
for RLL PNA at OSH and patient was started on oral Levofloxacin
q48 (renally dosed). Urine legionella negative. Strep pneumo Ag
still pending. She received nearly 5 days of oral Levoquin for
CAP to ensure coverage if pneumonia was playing a part in her
dyspnea. However, it is most likely that she was not infected
since her only symptom was cough and dyspnea with no fever or
leukocytosis.
- f/u s. pneumo ag
- finish course of levoquin x1 more day.
# Bilateral pleural effusions: Consistent with CHF.
Transudative, elevated proBNP.
See above. She had a right-sided thoracentesis on ___ and 250cc
was collected.
# CKD: Cr 2.0 on admission and ranged 1.8-2.0 (baseline
2.1-2.5).
- Cont home bumex (bumetanide)= loop diuretic
# Glaucoma
- Continued home eyedrops
# Emergency Contact: ___ (son) ___ | 190 | 391 |
10696809-DS-22 | 20,070,381 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
You were here because your blood sugar was found to be very low
and your heart was beating very slow.
While your were here, your insulin was decreased so your sugars
would not get too low. We also stopped one of your medications
(propranolol/metoprolol) which can prevent you from feeling the
signs of low blood sugar.
When you leave, it is important to take your medications as
prescribed. Make sure to check your sugar at least 4 times
daily, with a value first thing in the morning and before every
meal. If you have any feelings of dizziness, feeling "foggy," or
shaky, check your blood sugar immediately.
****Before you give yourself insulin in the morning, please
check your sugar levels. If your sugar is below 100 in the
morning, please eat something and check again. If your sugar is
above 100 at that time, you may give yourself the long acting
insulin (lantus) that we prescribed you. If your sugar is above
350, please contact your primary care physician about your
insulin regimen****
Also, make sure to look for any signs of bleeding, including
bright red blood in your stool or dark, tarry stools. Come bake
to the ER immediately if you notice this.
We wish you the best of luck!
Your ___ Care Team | BRIEF SUMMARY:
==============
___ male with HCV cirrhosis c/b HCC with presumed right
lung metastasis, hepatic hydrothorax, esophageal varices, and
hepatic encephalopathy, also with CAD and CKD p/w altered mental
status and hypoglycemia. His insulin regimen was lower and he
was discharged at baseline mental status. | 221 | 44 |
16142938-DS-8 | 25,832,005 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall sustaining a fracture in your left scapula also
known as the shoulder bone or shoulder blade. You were seen and
evaluated by the orthopedic surgeon who recommend non-operative
management with a sling for comfort. You can use your left arm
as tolerated. You were seen by the physical therapist who
recommend you are discharged from the hospital to rehab.
You are now doing better and ready to be discharged to rehab to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | Ms. ___ is a ___ yo F who has presents with left shoulder pain
and an xray taken at her sernior living facility revealed a
fracture of the superior scapular body and spine. She denies
recent fall or trauma but did have a fall in ___ with a
left rotator cuff injury. Orthopedic surgery was consulted and
after reviewing imaging and physical exam, recommended
non-operative management with a sling and weightbearing and
mobility as tolerated. She was admitted to the trauma service
for pain control and care planning. Pain was managed with oral
Tylenol and a lidocaine patch. She tolerated a regular diet
without difficulty. The patient voided without problem. During
this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. The patient was discharged to a
rehabilitation center to further assist with her mobility. A
follow-up appointment was made with the Orthopedic service. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 291 | 223 |
14827045-DS-2 | 21,912,949 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came into the hospital because you
were concerned about swelling in your legs and your drinking.
While you were here, we found that your liver enzymes were
elevated meaning your liver was irritated and inflammed. We
think that th emost likely cause of this is alcoholic hepatitis.
We talked about the importance of abstaining from alcohol to
prevent downstream complications from heavy drinking, including
cirrhosis. We also talked about immediate health benefits
including improvement in your blood pressure and weight. We are
excited that you are taking this important step in your life to
stay healthy.
You should look out for withdrawal symptoms from alcohol
including nausea, tremors and shaking, hearing or seeing things
that aren't there, and feeling things on your skin. If you feel
these, call your doctor for further advice.
The lower extremity swelling that you experienced we think is
most likely related to poor nutrition since you had been
drinking a lot. We gave you compression stockings to help get
rid of some of the swelling.
We started you an anti-depressant called prozac. We also changed
your blood pressure medication, atenolol, to once daily because
your blood pressure was very well controlled while in the
hospital.
We wish you all the best,
Your primary medicine team | ___ yo M w/ PMHx of alcohol abuse, depression/anxiety, HTN p/w
worsening ___ edema found to have transaminitis consistent with
alcoholic hepatitis.
# alcoholic hepatitis - Supported by elevation of AST>ALT and
radiographic evidence of steatosis. Clinical history also
supportive as he was drinking over a bottle of wine per day for
a year or two. LFTs downtrending during hospitalization.
Encouraged pt to abstain from alcohol use, which he is highly
motivated to do.
# lower extremity edema - Has a normal albumin with intact
synthetic function as evidenced by normal INR and no protein on
UA indicating that underlying liver disease and nephrotic
syndrome. Was not pitting on exam. Given compression stockings
with improvement.
# alcohol abuse - Pt endorses a desire to quit alcohol all
together. He was seen by social work in the ED and with
continued counseling on the floor, he remained motivated to
change. He was given serveral community resources to help him
remain sober. He was maintained on CIWA scale but did not score.
He was not discharged with any valium but instructed on the
warning signs of withdrawal including nausea, tremors, visual
and tactile hallucinations.
# macrocytic anemia - Likely from bone marrow suppression
secondary to chronic alcohol abuse. Nutritionally supported with
a multivitamin with minerals, thiamine, and folate.
# HTN - Atenolol downtitrated to once daily given normotensive
during admission. Would consider switching from atenolol since
beta-blockers aren't recommended as first line therapy in
hypertensive patients without co-morbidities like CAD or atrial
fibrillation. Further, beta-blockers probably aren't helping his
depression.
# depression/axiety - Started on prozac, will follow-up as
outpatient with PCP.
# subclinical hypothyroidism - Elevated TSH with normal free T4.
TSH checked secondary to peripheral edema that pt was
complaining of. Deferred starting any thyroid replacement
therapy.
TRANSITIONAL ISSUES:
* consider transitioning off atenolol to different
anti-hypertensive
* re-assess mood, started on prozac ___
* has subclinical hypothyroidism - can consider anti-TPO
antibodies for further evaluation | 226 | 329 |
17436646-DS-22 | 26,001,376 | Dear ___ was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you felt weak
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital, you had build up of urine in
your bladder
- Tests showed your kidney function was not working properly,
but it was fixed with fluids
- Some of your medications were changed. We increased your
amlodipine (blood pressure medication) and held your lisinopril
and hydrochlorthiazide (other blood pressure medications).
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team | Summary:
Ms. ___ is an ___ year-old female who presented with 1 week of
worsening abdominal pain, weakness, and was found to have ___
concerning for pre-renal etiology and obstructive etiology. | 128 | 32 |
15573773-DS-52 | 27,949,308 | You were admitted to the hospital with a bloodstream infection.
You also were found to have a pneumonia. You were treated with
IV antibiotics and IV fluids. You were seen by the infectious
disease service. You will need to continue to take antibiotics
after you leave the hospital. | ___ with T2 paraplegia, restrictive ventilatory defect on 2L
home O2, ___, neuromuscular weakness, impaired secretion
clearance, and multiple recent hospitalizations for pneumonia
and UTI requiring pressors in the ICU (___)
presenting with dyspnea.
# SEPTIC SHOCK / STENOTROPHOOMAS BACTEREMIA / PNEUMONIA: She
presented with dyspnea and was found to have an increased
respiratory rate and hypotensive with labs showing leukocytosis.
CXR was concerning for possible LLL pneumonia. Influenza DFA
was negative for influenza. She was started on
vancomycin/cefepime for HCAP (___). Oseltamivir and azithromycin
were also started initially but were discontinued with negative
influenza and legionella testing. Her blood culture grew
Stenotrophomonas and she was started on bactrim. Surveillance
cultures were obtained and are no growth but not finalized at
the time of discharge. Her sputum grew MRSA and she was
initially treated with vancomycin although this was later
stopped as it was sensitive to bactrim. Her indwelling tunneled
line was removed. Her urine grew Klebsiella ESBL although this
was thought to represent colonization as her urinalysis was more
bland. She will complete a 2 week course of bactrim from the
time the line is removed/first negative culture.
.
TOXIC / METABOLIC ENCEPHALOPATHY: She was inattentive and
lacked proper orientation on exam. This was likely due to her
acute medical illness. TSH was within normal limits. Sedating
medications (trazadone, benzodiazepine) were initially held. Her
condition improved and she was felt to be at baseline at the
time of discharge.
.
# POLYSUBSTANCE ABUSE: Urine toxicology screen was positive for
cocaine and methadone. There was some concern in the ICU that
her visitors were supplying her narcotics. She was initially
monitored with a 1:1 sitter and psychiatry as consulted. When
her mental status improved she admitted to taking methadone at
home for her chronic pain. This is not a prescribed medication
and she reported getting it from a friend. She had been
previously prescribed narcotics by her PCP but was in violation
of her narcotics contract so this was stopped in ___. She was
noted to have increased anxiety and abdominal pain during her
hospital stay that could be seen in narcotics withdrawal. We
discussed that she consider a substance abuse treatment program
to wean her off narcotics and so that a better treatment plan
could be developed. Social work met with her to discuss
resources. She was not interested at this time.
.
# CHRONIC NEUROPATHIC PAIN: She has a history of spinal cord
injury and chronic neuropathic pain. She was continued on her
home pain control regimen of gabapentin, baclofen, lidocaine
patch and tylenol. The patient ask her ICU and floor providers
for narcotics. She did not receive narcotics during the
hospitalization as her pain was chronic and there was no plan in
place to continue narcotics as an outpatient. She will follow
up with ___ pain clinic and has an appointment within one week
of discharge.
.
# ANEMIA: She was transfused one unit of blood for anemia and
her hematocrit responded appropriately.
.
#ANXIETY: The clonazepam was initially held due to her toxic
metaboic encephalopathy. This was later restarted as her mental
status improved and up-titrated to her home dose. :
.
CHRONIC ISSUES:
# GI: continued home sucralfate and omeprazole
# Hypothyroidism: continued home levothyroxine
# Code: Full confirmed
# Communication: husband ___ ___, best friend /
PCA ___ ___
.
TRANSITIONAL ISSUES:
-blood cultures are pending but not finalized at discharge | 50 | 576 |
15623486-DS-4 | 20,434,826 | You were admitted for evaluation of abdominal pain and
inflammation of your colon seen on CT scan. You were seen by
our GI team. We ruled out infection in your colon. The cause
of your inflammation in unclear, but possibly related to low
blood supply or as a result of your liver disease. We recommend
close follow up in our GI clinic for ongoing care.
We also found that you have failure of your liver called
cirrhosis. It is very important that you abstain from any
alcohol. We recommend close follow up our liver doctors for
this.
You have been given a limited increase in your morphine. It is
very important that you speak to your pain doctor about this and
follow up closely in that clinic. DO not drive or drink alcohol
on this medication.
You were also started on medication called Lasix to help reduce
fluid in your legs and abdomen. As we discussed, if you feel
dizzy or lightheaded, drink fluids and talk with your primary
care doctor since this medication can increase risk of
dehydration.
For the stye on your left eyelid, would encourage warm
compresses on the face for about 15 minutes four times per day,
in order to facilitate drainage. Massage and gentle wiping of
the affected eyelid after the warm compress can also aid in
drainage. There is little evidence that treatment with topical
antibiotics and/or glucocorticoids promotes healing. Your
primary care doctor can re-assess later this week and if not
improving, can consider whether steroids should be used. | Ms. ___ is a ___ woman with a history of type 1
diabetes, prior alcohol use disorder, chronic pancreatitis
status post pancreatic necrosectomy, status post
cholecystectomy, neuropathy, recent colectomy, who presented
with abdominal pain and imaging findings concerning for
recurrent colitis.
# Abdominal pain:
# Colitis, NOS:
# Recent hemicolectomy with wound dehiscence:
# Chronic pancreatitis:
She has had prior colectomy for unclear reasons and presented
with abdominal pain. CT showed signs of recurrent colitis based
on imaging (moderate wall thickening throughout remnant colon
with mild stranding, compatible with colitis). Unlikely to be
ischemic per surgery. Infectious etiology was considered but C
difficile was negative. She had similar presentation in ___
and had extensive work up at that time, including flex sig with
normal biopsy. Hemicolectomy specimen from ___ did not show
IBD. Her CRP and ESR was normal. Doppler US was negative for
significant vascular disease. She was treated supportively with
bowel rest, IVF and IV (then changed to PO) opioids with gradual
improvement. GI was consulted for ___ opinion. They agreed
with assessment above. Once cirrhosis was found on RUQ
ultrasound, congestive colopathy was also considered. GI
recommended supportive care and follow up after discharge.
- PATHOLOGY from ___ colectomy deposited to ___ PATHOLOGY for
___ opinion and future GI follow up
- Pain control with home morphine with stool softeners. She was
given a temporary increase in her morphine dose. She was given
15mg tablets to take with her home 30mg tablets for total 45mg
dose q4 PRN. She will follow up with her pain provider
regarding this.
# Cirrhosis, NOS:
She has a history of fatty liver and alcohol use. She was found
to have cirrhosis based on imaging when suspected based on lower
leg edema and ascites seen post-op with slight elevation in INR.
This could be contributing to finding of "colitis" on imaging.
She underwent para with SAAG >1.1 c/w portal HTN. She was
started on IV Lasix 20mg daily, but had SBP down to ___ that
resolved with IV fluids on ___, so decreased to 20mg oral Lasix
daily on discharge.
- Hepatology follow up arranged
# Hypotension:
SBP 80-90s, asymptomatic, which was suspected to be related to
opioids and possibly tizanidine. She triggered on ___ for
SBP down to ___, again likely medication related and in the
setting of getting IV Lasix 20mg earlier in the day. She was
symptomatic with lightheadedness. Her tizanidine was HELD and
she was given 1L IVF with improvement in SBP to 130s. Her MS
___ was decreased back to daily. Lasix was changed to PO
20mg daily on discharge and I personally discussed with her that
if she feels lightheaded again, to drink fluids and talk with
her doctor about whether or not she should remain on Lasix.
# Qtc prolongation: QTC was prolonged to 466ms and down to 399ms
on ___.
# Hypokalemia: K was 3.1 on admission and resolved and was
self-limited. K was 4.9 on discharge, but should recheck as
outpatient since on Lasix now.
# Reflexive sympathetic dystrophy (RSD) - medications confirmed
in ___. Continued home MS ___ 30mg daily plus the PRN
Morphine ___ increase to 45mg Q4H for pain. Held home tizanidine
as above. Continued home dicyclomine, pregabalin, desipramine.
# Type I diabetes - He is on 14 units Tresiba with novolog
sliding scale at home. She has been hypoglycemic related to
poor PO intake and was relatively hypoglycemic here. Long
acting insulin decreased to 7 units QHS plus home sliding scale
on discharge.
# Chronic pancreatitis: Creon with food
# Tobacco use: She was given and prescribed daily nicotine
patch.
# Left eyelid stye: She has a small stye on lower left eyelid
that she says has been present for several days and she has been
using warm compresses. She said she has an allergy to
erythromycin and has gotten steroid treatment in the past.
Recommended that she continue with supportive care with
compresses and if persistent by mid-week when she sees her PCP,
can consider whether to use steroids.
============================= | 261 | 684 |
15691324-DS-13 | 27,161,260 | Dear Mr. ___,
You were evaluated for your lightheadedness and cough. During
your emergency department evaluation you had a chest x-ray
consistent with a pneumonia. You were started on the antibiotic
levoquin and admitted to the intensive care unit and then
transferred to the regular unit as you improved. We recommend
you have repeat chest x-ray in about 1 month to confirm
resolution of the lung changes.
The following changes were made to your medications:
# START levofloxacin 750mg daily for 3 more days
# stop your coumadin until instructed to restart by your primary
care provider. | ___ with Afib on Coumadin, HTN, DM, admitted with multifocal
pnemonia and dehydration.
Brief course: He was treated with levofloxacin and improved. His
transient hypotension responded to fluids and was felt secondary
to dehydration.
Active issues:
#Pneumonia, multifocal: Patient was started on levofloxacin and
since patient was hypotensive during ED evaluation he was
admitted to the ICU. His blood pressure responded to IV fluids,
no pressors/intubation required. ICU course unremarkable and
patient was transferred to the floor. Levofloxacin was continued
and patient is to complete a 5 day course. Patient was sating
well on room air while at rest and ambulating and was
discharged. Recommended repeat chest x-ray in ___ weeks to
confirm resolution and ensure no underlying lung disorders in
this heavy smoker.
# Diabetes: Metformin was continued. As fasting blood sugars
were elevated to >200 patient was placed on standing 2 units of
insulin with meals and placed on an ISS.
#. Hypertension: The patient has a history of hypertension, but
in the setting of dehydration and hypovolemia his
anti-hypertensives were held overnight. Once stable, medications
Lisinopril, Labetalol, and Diltiazem were restarted.
# Acute kidney injury: pre-renal in setting of hypotension,
resolved with fluids.
#. Atrial Fibrillation: On coumadin with therapeutic INR. Held
coumadin on discharge due to supratherapeutic INR of 3.1 likely
due to interaction with levofloxacin. INR should be monitored
closely. Labetalol was continued and diltaizem restarted on
discharge.
#. Hyperlipidemia: Pravastatin was continued per outpatient
regimen.
# Thrombocytopenia: stable mildly low platelet count which
patient says is chronic.
# Elevated BNP: up to 1125, possibly due to atrial fibrillation;
no known heart failure and reported good exercise tolerance. | 96 | 276 |
10582697-DS-12 | 29,745,452 | Discharge Instructions
Surgery
You underwent surgery to remove a tumor from your brain.
Frozen preliminary was: glioblastoma
Please keep your incision dry until your staples are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You have been discharged on a Decadron (dexamethsone) taper.
Please take this medication as follows:
-4mg every 6 hours x 8 doses (2 days); then,
-4mg every 12 hours x 4 doses (2 days); then,
-2mg every 6 hours x 8 doses (2 days); then,
-2mg every 12 hours x 4 doses (2 days); then,
-2mg once daily until follow-up appointment
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener. | Mr. ___ was admitted to ___ on ___ after CT Head
demonstrated a large right-sided brain mass with surrounding
cerebral edema and 4mm midline shift. He was monitored overnight
in the ICU without significant events. He was started on Keppra
and Decadron. His neurologic exam remained stable. MRI was
obtained to further assess the lesion. He was transferred to the
inpatient floor with surgery planned for ___.
On ___, the patient was neurologically stable. A CT torso was
ordered which showed small pulmonary nodules, but no evidence of
malignancy.
On ___, the patient remained neurologically stable and
underwent routine pre-operative planning for surgery.
On ___, Mr. ___ was taken to the operating room for a right
temporal craniotomy for tumor resection. The surgery was
uncomplicated. He was taken to the PACU post operatively where
he was monitored. His post operative NCHCT showed expected post
operative changes. He was agitated post-operatively and his
blood pressure was difficult to control. A narcardipine drip was
started.
On ___, the patient remained neurologically stable. He was
started on lisinopril 5mg daily, and his blood pressure control
improved. The patient was transferred to the floor.
Post-operative MRI was completed and showed some enhancement in
the anteromedial surgical bed, likely residual tumor versus
intraoperative contusion, along with persistent vasogenic edema
in the right cerebral hemisphere.
On ___, the patient remained neurologically stable. He was
evaluated by physical therapy and occupational therapy, who
cleared him for discharge home without services. His dressing
was removed and his incision was noted to be clean/dry/intact
without erythema or discharge. At the time of discharge, the
patient was tolerating regular diet, voiding and moving his
bowels independently, and ambulating without difficulty. A
thorough discussion was had with the patient and his family
regarding post-discharge instructions and appropriate follow-up.
The patient expressed readiness for discharge. | 411 | 314 |
18001271-DS-2 | 26,435,420 | Dear Mr ___,
It was a pleasure caring for you during your hospitalization at
___.
You presented at our emergency department for chest pain and
shortness of breath after shoveling snow.
In the emergency department, the heart marker in your blood,
called troponin, was normal and your ECG showed some changes,
which were already seen on a prior ECG. We got an image of your
lungs, which was normal. You received aspirin and nitroglycerin,
which improved your pain.
As your chest pain and dyspnea are symptoms raising concern for
disease in the vessels that supply your heart with blood, called
coronary vessels, you were admitted to our cardiology floor. You
were treated with your home blood pressure medication and
atorvastatin 80 mg.
You underwent a catheterization to check your coronary vessels,
which did not show any blockage.
As you noticed that you are wheezing from time to time, we
recommend have lung function testing.
If you get chest pain, chest tightness, shortness of breath,
palpitations, dizziness, lightheadedness, leg swelling or
syncopes, please contact your doctor urgently.
** Do not take viagra or cialis while taking Imdur (isosorbide
moninitrate) because this can cause an unsafe drop in blood
pressure**
Sincerely,
Your ___ Team | Mr ___ is a ___ y/o patient with a medical history significant
for hypertension who presented at the ED for chest pain and
dyspnea in the setting of shoveling snow and was found to have
neg troponin x2 with anterolateral TWI on EKG (unchanged from
prior EKG). He was admitted for concern of unstable angina.
.
#CHEST PAIN / POSSIBLE UNSTABLE ANGINA: Patient presented for
gradual onset substernal chest pain associated with dyspnea in
the setting of shoveling snow. His troponin was neg x 2 and his
EKG showed anterolateral TWI, similar to prior EKG from ___.
His CXR in the ED was unremarkable. He received 3 sublingual
nitroglycerin and 325 mg aspirin, which improved his pain. As
EKG showed signs of LVH and TWI were present in prior EKG, TWI
are more likely due to LVH than acute ischemic changes. On the
floor, his chest pain and dyspnea resolved without futher
nitroglycerin. He was monitored on telemetry. Patient underwent
catheterization on ___, which showed no flow-limiting CAD,
but diffuse artherosclerosis with tortuous vessels suggestive of
hyertensive heart disease. It also showed diffuse very slow flow
consistent with microvascular dysfunction and normal LV
diastolic function. Plan to continue aspirin 81 mg, atorvastatin
80 mg, lisinopril 20 mg, amlodipine 10 mg and isosorbide
mononitrate (Extended Release) 30 mg po dialy. Tox screen for hx
of cocaine abuse was negative. A differential diagnosis is
cold/stress- induced asthma, as patient noticed some wheezing.
We recommend outpatient PFTs.
.
#HYPERTENSION:Patient has a history of hypertension.
He was continued on his home medication: amlodipine 10 mg daily
and lisinopril 20 mg daily.
. | 195 | 261 |
11739512-DS-7 | 24,214,818 | You were admitted with abdominal pain caused by inflammation in
your pancreas. We could not identify a clear cause. With time
you improved. Please drink lots of fluid and eat a low fat
diet. It is very important that you follow up with your PCP as
scheduled, as well as GI. We recommend follow up imaging of
your pancreas once the inflammation subsides to exclude an
underlying process | The patient is an ___ year old ___ speaking male with h/o
dementia p/w acute interstitial pancreatitis.
.
ACUTE PANCREATITIS
- BISAP score = ___ with 1 point for age > ___, 1 point for SIRS
criteria (HR > 90 and WBC > 12K) ? altered mental status,
difficult to ascertain if pt is more confused than baseline
given language barrier. ___ nl, imaging without
choledocholithiasis, and no alcohol use. Namenda considered as
cause but felt unlikely. He improved with NPO, IVF. MRCP
performed showing no stones, PIMN incidentally, and interstitial
pancreatitis. He was ultimately discharged home after 48hrs of
improvement.
- We recommended GI referral and follow up MRCP vs EUS once his
inflammation subsides to evaluate for underlying process such as
malignancy. This was explained in detail to the patient's
daughter, and she expressed understanding of this. | 73 | 141 |
16818407-DS-9 | 20,405,734 | Dear Ms. ___,
It was a pleasure taking care of you at the ___!
You were admitted because of a gastro-intestinal bleed. We
monitored your blood counts, and they were stable while you were
hospitalized. Multiple teams of doctors ___ in your care
including medicine, gastrointestinal medicine, surgical
oncology, medical oncology, and radiation oncology. Tests
showed that you have a large stomach cancer. We set up
appointments with you for follow-up with the cancer doctors once
___ leave the hospital. You are now ready for discharge back to
your nursing home.
Please see below regarding follow-up appointments. | ___ with h/o with history of CHF, T2DM, morbid obesity, who
presents with GI bleed likely from newly diagnosed gastric
cancer.
# GIB: The patient was found to have hematocrit of 31.1 on
admission. With some fluctuations, her crit remained generally
stable, though downtrending, for the duration of her
hospitalization. She was discharged with a crit of 25.9. She did
not require any transfusions. Of note, she had recently
received transfusion prior to this hospitalization. She had 2
small episodes of coffee-ground emesis during hospitalization
and 2 brown/black bowel movements. An abdominal CT showed a
large mass in the lesser curvature of the stomach with invasion
into the liver (see below). The GIB was thought secondary to
this. She was started on an IV PPI and transitioned to PO
pantoprazole 40mg BID. The patient was initially kept NPO, but
on HD4 she was transitioned to PO diet, which she generally
tolerated well, though did endorse nausea that was controlled
with Zofran and Ativan. Multiple teams were consulted including
GI, Surgery, Surgical Oncology, Oncology, and Radiation
Oncology. The patient remained hemodynamicall stable throughout
this admission, though she did have one episode of afib with RVR
(please see below).
Given her GI bleeding, subcutaneous heparin was held during this
admission, and the patient was maintained on Pneumaboots. The
patient should continue to wear Pneumaboots while at ___.
# gastric cancer: As mentioned above, the patient was found to
have large stomach mass. Outside lab pathology from ___
___ showed poorly differentiated gastric adenocarcinoma
with signet ring features. An endoscopic ultrasound was done
which confirmed surgery's initial opinion that the cancer was
stage 3B non-operable, as per surgical oncology. After
conferring with the various teams, the patient, and the
patient's family, it was decided that she would follow up with
outpatient oncology upon discharge.
She has an appointment with Dr. ___, MD on
___ at 4:00pm, at the ___. Coordination of outpatient
oncological follow-up, plan for treatment, and further steps
will commence from there under the direction of Dr. ___.
Radiation oncology also saw the patient while in house and
thought it best to defer radiation therapy at the time given the
patient's co-morbidities. A possibility for palliative
radiation was discussed. If palliative radiation is deemed to be
helpful in the future, it may be logistically more feasible at
___ Oncology (___) in ___,
which Ms. ___ says is much closer to her living facility in
___.
# New Afib: Newly diagnosed during admission to ___
5 days prior to this admission. Metoprolol was started at that
time, which was held initially given her GI bleed. On HD 4 the
patient resumed a normal diet and in the midst of this became
tachycardic to the 180s and was given metoprolol. Her
metoprolol was then resumed at a higher dose, 37.5mg BID, for
rate control. Anticoagulation was held in the acute setting of
her GIB. On discharge, she was adivsed to use pneumatic
compression boots as DVT ppx since bleeding will be an ongoing
issue for her given her large tumor burden.
# CHF: Recent echo from ___ at ___ showed EF 50%, with mild LVH
and low normal systolic function. She did not have any CHF
symptoms during this hospitalization. Patient did not appear
fluid overloaded and was stable. Furosemide was initially held
but later restarted at her home dose 60mg PO QD.
# Proteus UTI: The patient complained of some dysuria which
resolved with treatment with pyridium. A Urine culture showed
pan-sensitive proteus. She was given a 3 day coure of Bactrim
which she finished with the resolution of symptoms.
# OSA: The patient uses 2L NC at home while sleeping at her
baseline. She was continued on this while in patient. She had
been on Bipap in the past, but did not tolerate it well. By
hospital day ___ or ___, she was noted to require an additional
liter of oxygen, with good saturations on 3 L. He bicarbonate
was also noted to be trending up at this time. She never
complained of any repsiratory distress. This was attributed to
obesity hypoventilation syndrome. A suggestion was made that
she should reconsider trying BiPAP, which per patient, had been
tried before but was poorly tolerated by her.
# DM II: The patient was initially placed on an insulin sliding
scale. Her sugars remained in good control. Nutrition was
consutled who recommended small frequent meals with a protien
source at each meal, and glucerna supplements TID. Her home
doses of 75/25 were held, as her diet was initially minimal.
However, upon discharge, her home dose of insulin can be
restarted and titrated as needed.
# Hypothyroidism: The patient was continued on her home
levothyroxine. | 96 | 802 |
17213193-DS-13 | 25,637,335 | Dear Ms. ___,
You were admitted to the Neurology ICU after an episode of
generalized stiffening during which you required ventilator
support. After extubation, your brain wave activity was
monitored on EEG during multiple episodes and we found no
evidence of seizure activity. Your neurologic exam remained
completely normal. We did not change any of your medications and
discharged you home in stable condition.
It has been a pleasure caring for you,
Your ___ Neurology team | ___ yo female with history of PNES initially presenting with
generalized shaking, unresponsiveness, given multiple AEDs and
eventually intubated and transferred to the ICU. Multiple events
in the ICU without EEG correlate, consistent with PNES.
Neurologic examination unremarkable. Work-up also included
normal imaging (head CT, head and neck CTA, MRI brain) and bland
LP. Collateral confirmed that patient has history of PNES. AEDs
and empiric antibiotics were discontinued prior to transfer to
floor. Psychiatry consulted and recommended follow-up as planned
with Dr. ___ at ___ for PNES. Discharged on her home meds
which include: clonazepam and fluvoxamine.
Transitional Issues:
#Anemia: Patient noted to have microcytic anemia (hgb 6.3);
transfused with 1U pRBCs on ___. Discharge hgb 7.4. Labs not
consistent with hemolysis (normal LDH, bilirubin, haptoglobin).
Reticulocyte count 1%. TIBC 325, iron 15, ferritin 21. Could be
consistent with iron deficiency anemia, follow-up as
out-patient.
#Thyroid nodule: Noted incidentally on CT chest, recommend
follow-up thyroid ultrasound as an outpatient. | 76 | 158 |
17757894-DS-25 | 23,093,264 | ___, It was a pleasure to care for you. On the MRI we saw
swelling exactly where you are having pain. This pain will get
better with time, but it may take some time. For some patients
it takes several months to go away. We usually recommend
ibuprofen but you cannot take this so instead we would recommend
Tylenol. As we discussed, you can walk and do things as you can
tolerate. | ___ with recurrent "colitis". In reviewing prior episodes has
had nml EGD/colonoscopy. In terms of etiology thought initially
maybe ischemic colitis or infectious. On most recent
hospitalizations had no diarrhea, bloody stools and thought
secondary to severe constipation. Has been treated aggressively
with anti-constipation meds in interim.
In terms of what brings her in today. I'm struck by the location
of her pain which is on the pubic symphsis and left inguinal
crease. Though she is not great in terms of history she says
this has never happened. I wonder if she had an occult pelvic
ring fx that is causing her pain. Her CT did not show anything,
but MRI shows "Focal edema in the left pubic symphysis, with
faint T1 linear defect. No displaced fractures. ___ represent
bone contusion or focal, tiny nondisplaced fracture. There is
edema in the adjacent left pectineus and external obturator
muscle with intermuscular edema." In speaking with orthopedics
they looked at films and this also could be osteitis pubis or
small fracture. In either case, conservative management will be
necessary. Follow-up is not critical, but follow-up with ortho
sports as they typically manage this issue. Unfortunately could
take some time to improve.
Had a long chat with her and her son that this could take
several weeks to months to improve. She is pain free when lying
or sitting, but certain movements cause severe pain.
Regarding her colitis, she does have constipation on KUB, but
her RLQ pain and constipation symptoms resolved without any
intervention. The CT scan findings are unchanged. she feels that
she has a good regimen in terms of addressing constipation and I
encouraged her to be a bit more aggressive based on KUB finding.
I think follow-up with GI as scheduled seems reasonable. | 72 | 292 |
16137455-DS-5 | 27,725,008 | -Please also refer to the handout provided on ""Taking Care of
Your Nephrostomy Tube"
NEPHROSTOMY TUBE INSTRUCTIONS FOR CARE---FOR ___ & FAMILY:
Please leave LEFT PCN tube to external gravity drainage and
flush forward with 10 mL normal saline solution twice daily to
maintain tube patency. Please monitor and record urine output
from the PCN tube.
Catheter flushing: If there are excessive blood clots or debris
or thick urine within the connecting tubing, this can also be
flushed as needed to clear from the stopcock into the drainage
bag.
Change dressing daily. Gently cleanse around the skin entry site
of the catheter with povidone iodine or dilute hydrogen
peroxide. Dry and apply sterile gauze dressing.
Catheter security: a) Every shift, check to be sure the
catheter, the connecting tubing and thedrainage bag are securely
attached to the patient and are not kinked. b) If the catheter
appears ___ pulling, please notify Interventional Radiology. c)
If the catheter pulls out, please notify Interventional
Radiology with in 8 hours. SAVE THE CATHETER for us to inspect.
Do not throw it away.
Call Angio for ANY catheter related questions or problems.
___ or Fellow/Resident (___)
Catheter is attached to drainage bag for external drainage;
please measure and record the net output every shift (or more
often if the urine output is high).
DISCHARGE INSTRUCTIONS
--No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequency over the next month.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Tylenol should be your first line pain medication, a narcotic
pain medication has beenprescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments (if
applicable).
-You may shower but do not bathe or immerse in water.
-Do not drive or drink alcohol while taking narcotics or operate
dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
-Resume all of your PRE-admission/home medications, unless
otherwise noted.
-Call your urologists office for follow-up AND if you have any
questions.
-You will be discharged home with visiting nurse services to
facilitate care of your left PCN and administration of your IV
antibiotics--please complete the course as instructed.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor. | Patient was admitted to the Urology service from the ED with
fevers to 102oF. On HD 2 the patient had a L percutaneous
nephrostomy tube placed for mild hydro nephrosis on CT scan and
concern for infected collection within his renal pelvis. We
consulted ID who recommended ceftriaxone, after his blood
culture and urine culture grew out E. coli. He continued to
spike fevers to 102 and on HD6 we obtained a CT scan that showed
no discernible collection that could be drained from his kidney,
but continued evidence of pyelonephritis. On HD6 the patient
did not spike any fevers and was feeling well. We had a PICC
line placed and ID recommend the patient continue 1gm of
ceftriaxone until ___. The patient was discharged home on
HD7 with a L PCN and a PICC line with follow-up with Dr.
___ infectious disease. On his day of discharge he was
tolerateing a regular diet, ambulating without assistance, and
his pain was well-controlled. | 445 | 171 |
14716808-DS-23 | 27,700,673 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___. You came to the hospital because you developed
weakness at home. We found that you have an infection in your
blood. You spent one day in the Intensive Care Unit because of
this infection. We treated you with antibiotics and you got
better with this treatment. We do not know the source of your
infection. You will continue to receive antibiotics for several
days at home after you leave the hospital.
You also retained urine while in the hospital so we placed a
foley catheter to help you urinate. You had some blood in your
urine and your stools. When you go home, you will have a foley
catheter in place. You have an outpatient appointment scheduled
with a urologist, they will determine when your foley catheter
can be removed.
Please continue to follow-up with your doctors as ___ and
to take your medications as prescribed.
We wish you all the best,
Your ___ care team | ==================
SUMMARY STATEMENT
==================
Mr. ___ is an ___ year old man with a past medical history of
multiple myeloma s/p 40 cycles of daratumumab, pomalidomide,
dexamethasone, pAF on apixaban, HTN, HLD, severe MR, AAA s/p
repair, and CVA who presented with weakness and one presyncopal
episode, with no clear etiology discovered. He was briefly
admitted to the ICU for sepsis, found to have Strep viridans
bacteremia, treated with ceftriaxone. His course was complicated
by urinary retention and new hematuria as well as intermittent
bright red blood per rectum. | 166 | 86 |
16604247-DS-5 | 29,332,298 | Hi Mr. ___,
It was a pleasure taking care of you during your recent
admission. You were admitted with pancreatitis from your cancer.
You underwent stenting of the pancreas which ultimately seemed
to improve your ability to eat without vomiting. You also had
severely low potassium which was most likely due to taking
cesium in the past. We started a medication called amiloride to
prevent you from urinating out all of your potassium and it
seemed to work well. We also started a fentanyl patch and a few
other things for pain control. | Mr. ___ is a ___ w/ hx of metastatic small cell
neuroendocrine laryngeal cancer on carboplatin/taxol and recent
radiation therapy who presents with pancreatitis secondary to
pancreatic tail metastasis and intraabdominal progression of
known cancer.
# Pancreatitis: Mild (BISAP 0). Seen on CT abdomen on admission
and MRCP ___. This was thought to be secondary to pancreatic
duct obstruction from new pancreatic metastasis. He had clinical
improvement of his abdominal pain and nausea after the first few
days of IVF and bowel rest, however, due to ongoing pain and
nausea ERCP was consulted and they placed a stent in the
pancreatic duct at a 15 mm stricture seen at the neck of the
pancreas. There was mild post obstructive dilation and a 7cm by
___ pancreatic stent was placed successfully traversing the
obstruction to see if he will have symptomatic improvement. He
recovered from the procedure with brief bump in his LFTs that
then resolved. He was able to tolerate PO intake without emesis
by discharge. ERCP recommended repeat ERCP in 6 weeks.
# Hypokalemia/qtc prolongation: Patient presented with history
of taking significant potassium supplementation PTA. He had been
taking cesium chloride
as an over the counter anticancer treatment, which was suspected
to have caused a tubulopathy associated with impaired potassium
channel function. His QTc was not prolonged on admission, but he
was initially monitored for QTc prolongation given hypokalemia
and significant repletion needs. He was initially requiring
80-120 mEq of potassium to maintain K in a range of 3.0-3.7 and
in spite of adequate magnesium repletion. Serum ___ were
normal. He had sequential 24 hour urine collections to assess
kaliuresis, which seemed to improve when he was hypovolemic and
sodium avid. Send out tests for cesium showed significantly
elevated levels consistent with the original hypothesis. With
nephrology consultation he was started on amiloride 20mg BID and
his kaliuresis improved, eventually requiring no potassium
repletion in the 24 hrs prior to discharge, deriving everything
from his diet. He had outpatient follow up for this with lab
checks.
# Metastatic laryngeal neuroendocrine cancer: Metastatic small
cell neuroendocrine
laryngeal cancer. Dx ___. Has involvement of hilar,
mediastinal, cervical LNs, adrenals, likely liver, spleen,
abdominal wall, and now pancreas, all with interval enlargement
on imaging relative to ___. C2 of carboplatin/taxol at ___
and tx ___ of radiation therapy at ___ (on hold for
laryngeal edema). He was seen by palliative care. He will
followup with his outpatient oncologist for the consideration of
alternative chemotherapy regimens, including clinical trials,
versus hospice. | 92 | 415 |
13802481-DS-19 | 28,921,784 | You were admitted to the surgery service at ___ for evaluation
and treatment of your abdominal pain. You have done well in the
hospital and are now safe to return home to complete your
recovery with the following instructions:
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Please call your doctor or nurse practitioner if you experience
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 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. | The patient was admitted to the General Surgical Service for
evaluation and treatment of his epigastric pain and vomiting on
___.
Upon arrival, a full set of laboratory studies was obtained, as
well a Right Upper Quadrant Ultrasound (reader referred to
'Pertinent Results' section for details). Of note, the h. pylori
serologies that were drawn on his previous admission were
positive. Thereafter, he was admitted to the general surgical
floor, where he was NPO, on IV fluids, and IV unasyn. His liver
enzymes were mildly elevated, but his abdominal pain resolved
throughout the day, and he had no pain in the RUQ even with deep
palpation. His vital signs were routinely monitored and he
remained afebrile and hemodynamically stable throughout his
stay. The patient was seen by the attending surgeon Dr.
___ discussed with the patient and his family the
options for further management. Because the patient's
pain/nausea/vomiting resolved and he had no evidence of acute
inflammation or infection, the patient was given the decision to
stay overnight for observation versus going home this evening
(hospital day 1). The patient opted to go home this evening on
___. He was given a Prevpac for 10 days to treat his h.pylori,
an appointment to follow up with Dr. ___ in 2 weeks (where
an elective lap chole will likely be scheduled), and
instructions for contacting the GI clinic to schedule an
outpatient endoscopy. He verbalized understanding and agreement
with the discharge plan. | 271 | 242 |
18222476-DS-2 | 29,441,794 | Dear Mr. ___,
It was a pleasure taking part in your care. You were admitted to
___ on ___ for frequent bloody diarrhea, abdominal
pain, and fevers. A number of studies were conducted, which did
not show evidence of any obvious infection. The gastroenterology
doctors performed ___ flexible sigmoidoscopy on ___ which found
extensive inflammation in your lower colon, likely due to a
severe ulcerative colitis flare. You received intravenous
steroids for 2 days to which you had a positive response, and
your laboratory tests improved, showing less inflammation. At
the time of discharge from the hospital, you were feeling much
better with fewer bowel movements.
The IV steroids were switched to an oral form, and you should
continue this until you meet up with Dr. ___ in ___ weeks to
discuss the steroid taper plan as well as possibly starting
TNF-inhibitor therapy. You may resume your home mesalamine and
hydrocortisone medications but please limit enemas to once
nightly and do not take budesonide until instructed to by your
outpatient gastroenterology doctor.
We wish you the best,
Your ___ care team | ___ h/o IBD on immunosuppressants p/w 2mo BRBPR/diarrhea + 1wk
fevers (CT A/P pancolitis, flex sig severe UC) c/f IBD flare.
#Diarrhea / BRBPR / fevers:
Given initial fevers/diarrhea, infectious workup (C diff, stool
studies) was performed and negative. Received 2 days of IV
steroids with rapid and positive response (stool frequency
decreased from 20 to 10 per day after the first day, less blood,
CRP down from 116 to 40). On day of discharge, patient continued
to have improved symptoms (although still notes somewhat
increased BM compared to baseline) and was transitioned to PO
steroids until outpatient GI follow-up. | 178 | 99 |
16609021-DS-6 | 22,940,762 | Dear Mr. ___,
You were admitted to the Neurology Service at ___ after you
had a prolonged seizure, which we believe was due to having a
low level of Depakote, your anti-seizure medication. You
received extra medication and did not have any more seizures. We
increased your Depakote dose by 125mg to 875mg qam / 1000mg qpm.
It is unclear why your Depakote level was so low, but on the new
dose, your level was at a good level (90).
We monitored you for fever or other signs of infection that also
might have predisposed you to having a seizure, but did not find
evidence of this.
It is important that after discharge you continue to take all
your medications, particularly your anti-seizure medications, on
time as prescribed, as this should minimize your chances of
having future seizures.
Medication changes:
- Increase your Depakote to 875mg qam + 1000mg qpm.
After discharge, you should follow up with both your primary
care provider and neurologist. You should call your primary care
provider to arrange an appointment within the next ___ weeks,
and we will set up your follow-up appointment in neurology
clinic.
You should also have bloodwork done in one week to check your
Depakote level to make sure your medication dose is adequate.
It was our pleasure taking care of you during your stay.
All the best,
___ Neurology Team | The patient is a ___ year old man with history of remote TBI w/
VP shunt, epilepsy, cognitive impairment, long time nursing ___
resident, who was admitted for prolonged breakthrough convulsive
seizure followed by prolonged somnolence, and found to have
leukocytosis, lactate elevation, and subtherapeutic Depakote
level (45) on admission.
# Breakthrough seizure
He was maintained on his home Keppra 500mg BID and received a
15mg/kg bolus of Valproic acid due to subtherapeutic level of 45
on admission. Post-load level was 112. He was treated with
short-acting Valproic acid ___ q6h during his stay, with
maintenance of a therapeutic level at 92 and 90 on discharge. He
was transitioned back to long-acting Divalproex ___ in the AM
and 1000mg in the evening. The reason for lability of level was
very unclear; it not appear that he had missed any doses, had
recent infection, or had any change or addition of other
medications that induce or inhibit hepatic metabolism. LFTs were
normal on admission. His mental status and neurologic
examination improved back to baseline.
# Leukocytosis, lactate elevation
The patient's WBC was elevated to 14.2 on admission, with a peak
of 15.7, and lactate elevated to ___. He was noted to be
tachycardic, and was treated with multiple boluses of IV fluids
for suspected hypovolemia, which helped to resolve his
tachycardia. Bicarbonate was also low to 21. He was afebrile
throughout his entire admission, vital signs otherwise normal,
and underwent thorough infectious workup including: UA/Urine
culture no growth, Blood cultures pending but no growth x3 days,
chest X ray showing streaky atelectasis. His mental status
remained at baseline and he developed no signs concerning for a
shunt infection. His leukocytosis and bicarbonate both
normalized spontaneously throughout admission and his discharge
WBC was 10.8. Due to these factors, leukocytosis and lactate
elevation were not felt to be due to acute infection and more
likely due to prolonged recovery after convulsive seizure.
#Tachycardia, PVCs
He had a period of persistent tachycardia in the 130s on the day
of admission, which improved with fluid boluses and was likely
secondary to hypovolemia. He was noted to have infrequent PVCs
on admission (also noted in OSH records), which increased in
frequency during his stay but improved with electrolyte
repletion (Mg 1.8 -> 2.0, Phos 2.6 -> 3.7). EKG revealed no
concerning ischemic changes, and his cardiac enzymes were
negative. This can be followed up as an outpatient.
Transitional issues:
[ ] Please obtain Valproate level in 1 week given recent
fluctuations of unclear etiology. Please communicate with his
neurology team here at ___ (Fax: ___ regarding his
level and whether his dose needs to be adjusted.
[ ] Continue Keppra at his previous dose, 500mg BID.
[ ] Follow up in Neurology clinic as above.
[ ] Please obtain CBC, complete metabolic panel in 2 days, to
ensure WBC continues to improve, as well as evaluate for
electrolyte abnormalities that may require standing repletion.
[ ] Follow up final results of blood cultures from ___ and ___
(thus far no growth). | 225 | 495 |
14566882-DS-18 | 29,831,546 | Dear Ms. ___,
You were hospitalized at ___
because you were having difficulty breathing. This was due to
fluid in your lungs. This happened because your heart is not
able to pump blood forward as effectively as it should. The
major reason your heart has difficulty pumping blood is due to
problems with two valves in your heart: one of them is leaky and
one of them does not open all of the way.
You decided that you did not want to have a procedure called a
heart catheterization which would tell us more information about
how well the valves were functioning. You also did not want any
surgeries or procedures to fix or replace the valves.
We increased your dose of torsemide to 60 mg, which should help
prevent the build up of fluid in your lungs. You can take an
additional 10 mg if your weight has increased by more than 2 lbs
in a day.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team | ___ is an ___ year old woman with a history of
diastolic heart failure (EF > 55%, TTE ___, moderate to
severe MR, and moderate to severe AS who presented with dyspnea
on exertion and edema consistent with heart failure exacerbation
likely due to worsening valvular disease.
# Acute on chronic decompensated diastolic CHF: Patient appeared
volume overloaded on exam and had elevated BNP at 2475. She
improved with IV Lasix. A repeat TTE showed 4+ MR and decreased
___, although this may have been misrepresented due to a low
flow state secondary to the MR. ___ it was thought that
her valvular disease (mitral regurgitation and/or aortic
stenosis) was the likely contributor contributor to her
worsening heart failure. She declined cardiac catheterization to
better characterize the extent of aortic stenosis and was not
interested in valve repair/replacement at this time. She
liekwise declined hospice services. She was discharged on an
increased dose of torsemide (60 mg PO instead of 40) with
instructions to take an extra 10 mg PRN for increase in weight.
# Atrial fibrillation: Patient has afib, rate controlled with
metoprolol and diltiazem and also on warfarin. These medications
were continued.
# Chest pain: Patient described chronic episodes of chest
pain/pressure likely due to aortic stenosis versus CAD. She
declined cardiac catheterization. She had a negative stress in
___. Troponins were negative x2 and she had an ECG without
ischemic changes.
# Acute on chronic renal failure: Patient with baseline
creatinine ___. She had a mild increase to peak 1.4 in the
setting of diuresis, thought to be due to pre-renal azotemia.
Diuresis was held and creatinine normalized. | 175 | 271 |
16767173-DS-15 | 28,134,407 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted because it was discovered that
you had developed blood clots in your lower extremities. These
blood clots were not causing you any significant discomfort and
so it was decided that we would not treat them given the
significant risks associated with treatment, namely a high risk
of bleeding.
You were also noted to have some evidence of fluid overload and
so we have restarted your lasix (water pills). | ___ hx of dementia, atrial fibrillation on aspirin (previously
on Coumadin and Lovenox but discontinued ___ frequent falls),
chronic renal disease and recent GI bleed while on aspirin only,
who presented from ___ for bilateral DVTs found
incidentally following a TIA workup.
# Bilateral DVTs: DVTs were found incidentally during a TIA work
up at ___ and notably have been asymptomatic. It is unclear
how long they have been present for. Given her continuing
decline, history of frequent falls and recent gastrointestinal
bleed, it was decided that the risks of starting systemic
anticoagulation outweighed the benefits. Specifically, given
her risk factors of advanced age, fall risk, chronic kidney
disease and prior gastroinsteinal bleeding, her bleeding risk
can be estimated to be 12.3 bleeds per 100-patient years (based
on HEMORR2HAGES score of 7) or > 8.7 bleeds per 100-patient
years (based on HAS-BLED score of 5). Additionally, given the
temporary nature of an IVF filter, the need for a procedure
(though minimally invasive), and the question of the acuity of
the clots, IVF filter placement was additionally declined.
Throughout the admission, Ms. ___ remained stable with 96-100%
O2 sat on room air, atrial fibrillation with rates in the
70-80s, normotension, and was without subjective pain or
shortness of breath.
.
# Acute exacerbation of diastolic heart failure: Patient was
satting well on room air, however there was evidence of volume
overload on CXR at OSH and here at ___. She imtermittently
noted some mild chest discomfort and tachypnea despite normal
sats and ECG with afib but no signs of ischemia. BNP was noted
to be 7770 and patient's home diuretics of lasix 40mg PO MWF had
been discontinued the week prior. She was given a dose of lasix
20mg IV x1 and restarted on her previous home regimen of lasix
40mg PO MWF.
.
# H/o GIB: Patient experienced a gastrintestinal bleed as
recently as ___ while on aspirin daily. Unknown source as
this was not worked up during admission. While inpatient, she
was continued on her home regimen of omeprazole 20 mg BID.
Anticoagulation for DVTs was not started as risk was felt to
outweigh the benefit.
.
# OSTEOARTHRITIS: Continued lidocaine 5 %(700 mg/patch) to back
daily x 12 hrs as needed and started tylenol ___ TID.
.
# Chronic kidney disease: Patient remained at baseline kidney
function, Cr 2.0.
.
# Hyperlipidemia: Continued on simvastatin 20 mg Qhs.
.
# Atrial fibrillation: Continued on home aspirin 325mg daily and
metoprolol succinate 50 mg daily.
.
Transitional Issues
Code Status: DNR/DNI
EMERGENCY CONTACT HCP: ___ ___
- Started tylenol ___ TID for generalized discomfort.
- Patient should remain on some regimen of lasix as she had
evidence of pulmonary congestion on CXR after having been off
her home diuretics for a week. BNP 7770 this admission. | 84 | 453 |
18633159-DS-22 | 25,346,235 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please continue your pradaxa.
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
Physical Therapy:
- weight bearing as tolerated RLE
- range of motion as tolerated RLE
Treatment Frequency:
- dressing to come off on POD5
- if oozing, may place ABDs+tape
- ok to leave incision open to air | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF R hip fracture, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to her assisted living
facility was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on her home medication of pradaxa 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. | 231 | 263 |
13278241-DS-31 | 27,842,743 | Dear Mr. ___,
You were admitted to the hospital because you had an episode of
confusion during your dialysis session. We this this was likely
do to low blood pressure during your session.
At the hospital you were found to have a low red blood cell
level. You were given a transfusion of blood.
When you leave the hospital you should follow up with all of
your outpatient doctor's appointments. You should continue to
take all of your medicine as prescribed.
Weigh yourself every morning, call your doctor if weight goes up
more than 3 lbs.
It was a pleasure taking care of you.
We wish you the best!
Sincerely,
Your ___ Treatment Team | Mr. ___ is a ___ year-old man with ESRD on HD (___), HFpEF,
multiple myeloma, prior embolic strokes on warfarin, and IDDM
with recent hospitalization for weakness when he was treated for
UTI despite negative urine culture, who presents after AMS
during
HD that has now resolved. | 113 | 44 |
17822730-DS-11 | 23,785,506 | Dear ___,
___ were admitted to the hospital on ___ and were diagnosed
with HTLV-1 associated Adult T cell Leukemia/Lymphoma. ___
completed one round of chemotherapy and were then started on
medications (Interferon and Zidovudine) to treat the HTLV-1
infection that is associated with your cancer. ___ were also
started on several other antibiotics to treat and prevent
infections.
While ___ were in the hospital, ___ were also diagnosed with
stomach ulcers and were started on medication to treat these
ulcers.
Please note the changes in medications:
START:
Interferon Alfa-2B 3 Million Units SC 3/WEEK (___)
Zidovudine 250 mg PO/NG twice a day
Atovaquone Suspension 1500 mg PO/NG DAILY
Fluconazole 400 mg PO/NG daily
Ciprofloxacin 500 mg PO twice a day
ValGANCIclovir 900 mg PO twice a day
LaMIVudine 100 mg PO DAILY
Pantoprazole 40 mg PO twice a day
We have set up a visiting nurse to help ___ with your
medications.
Please follow up with Dr. ___ on ___ (appointment has
already been scheduled for ___.
It was a pleasure meeting and taking care of ___ while ___ were
in the hospital.
-Your ___ Team | ___ previously healthy women who was diagnosed with HTLV-1
associated ATLL and completed part A of hyperCVAD therapy (cycle
1, day 1 = ___. Her hospital course was complicated by
pancreatitis, c. diff, and gastritis (gastric ulcers with biopsy
staining for CMV).
.
#T-ALL
Pt presented with leukocytosis and lymphocytic predominance. She
also had elevated lactate, LDH, and uric acid suggestive of TLS,
managed with IVFs and allopurinol.
Immunophenotyping and bone marrow biopsy suggested a T-cell
malignancy but was inconclusive; she was transferred to ___ for
further mgmt. Given +HTLV-1 antibodies, a diagnosis of
HTLV-driven T-ALL was made. HyperCVAD was initiated and she
completed part A. She was then started on IFN three times per
week (___) and AZT BID to treat the HTLV-1 infection.
.
#Chest wall discomfort
In the setting of HyperCVAD, pt developed tenderness to
palpation first in the R upper chest (below the clavicle,
between the midclav/ant axillary lines), exacerbated by
pectoralis contraction or palpation of the bony surface. As this
resolved, she had similar pain at the R costal margin, then
later in the L upper chest (same location/quality as R sided
pain but on the other side). ECG neg, no cardiac history. CTAP
obtained ___ showed no concerning intrathoracic or chest wall
lesions. Attributed to marrow expansion in setting of
malignancy, and pain is being managed with PO pain medications.
.
#Epigastric abdominal pain
1. Medicine service: Abd pain, nausea, early satiety on
admission, with mild transaminitis and alk phos elevation. RUQ
ultrasound demonstrated gallbladder wall edema. CTAP showed
gallbladder wall edema and a left renal lesion (cyst vs
malignant lesion). LFTs suggested biliary obstruction and pt had
RUQ tenderness with ___. HIDA was performed, showing no
cholecystitis but delayed tracer efflux c/f possible biliary
obstruction. MRCP was obtained, showing no evidence of
cholecystitis, biliary obstruction or other biliary pathology.
H. pylori stool Ab testing was positive. Clear etiology never
found.
2. BMT service: RUQ pain with ___ recurred, so
amp-sulbactam was started, surgery was consulted, and RUQ
US/CTAP were obtained ___. Her pain was determined to be most
likely due to pancreatitis (see below) She had ongoing RUQ
discomfort and repeat HIDA was performed, showing no biliary
pathology. She then underwent EGD which showed gastric ulcers;
biopsies showed some lightly staining CMV cells and she was
started on Valgan and PPI BID. Improved over hospital course.
.
#Pancreatitis
On BMT,pt noted some costal margin pain, prompting repeat Abd US
___ -> showed only gallbladder wall edema. CTAP ___ to look for
pleural or abd causes. HSM was again noted, but only
redemonstrated gallbladder wall edema c/w third spacing in
setting of large volume fluid admin. She began having epigastric
pain, so ___ were checked, demonstrating amylase/lipase
>3x ULN. The patient was made NPO, given morphine PCA, and
treated aggressively with IVFs. Over several days, the patient
was able to advance her diet as tolerated and her pancreatic
enzymes started to trend down.
.
#CMV infection
Patient had uptrending CMV viral loads and a positive CMV stain
on biopsy, so she was started on Valgan (900 mg BID x 2 weeks,
then 450 mg BID as prophylaxis)
.
#Shortness of Breath:
Pt intermittently had increased RR and mild SOB with large
volume fluid administration during chemotherapy and aggressive
hydration for episodic hypercalcemia. Brisk diuresis and
resolution of sxs with furosemide 20 PO daily.
.
#Uncomplicated cystitis/pyelonephritis:
Suggested by abnormal urinalysis and migrating lower
abdominal/flank pain. UCx grew E.coli and Klebsiella, both
Bactrim sensitive -> treated x3d with improvement.
.
#Acute Renal Failure/Acute Kidney Injury:
Pt ___ during first days of admission on medicine service,
ddx included constrast nephropathy v allopurinol v prerenal
azotemia due to osmotic diuresis of hypercalcemia. Resolved with
IVFs.
================== | 178 | 606 |
19122057-DS-8 | 20,724,667 | Dear Ms. ___,
It was a pleasure caring for you during you admission to ___
___. You were admitted for
evaluation of slow heart rate and had a pacemaker placemennt.
You will need to follow up in the cardiac device clinic on ___ to ensure your device is working properly. In addition,
you were noted to have an abnormal heart rhythm called atrial
fibrillation. You were started on a blood-thinning medication
called warfarin to help reduce the risk of strokes. You will
need to have your warfarin levels checked by your primary care
physician to ensure you on the correct dose. Your will need to
have your warfarin level checked tomorrow at your primary care
physician's office (Dr. ___, you are scheduled to have
this done at 1pm tomorrow.
We hope you continue to feel better.
- Your ___ Team | Ms. ___ is a ___ yo woman PMH ESRD on HD ___, DM2, HTN,
lung cancer s/p lobectomy presenting with pre-syncope found to
have bradycardia and pauses on telemetry.
ACUTE ISSUES
============
# Pauses on telemetry/EKG: Unclear if she is having sinus pauses
secondary to sinus node dysfunction or conversion pauses as she
was intermittently in atrial flutter in ICU. Both possibilities
suggested some underlying sinus node disease. Therefore, she had
a pacemaker placed on ___. Her carvedilol was initially held,
but was restarted after PPM placement. She was given an initial
dose of vancomycin with HD for PPM placement. She will have her
last dose on ___ with HD to complete an adequate 3 day course.
She was scheduled follow-up in device clinic and with EP.
# Atrial flutter: The patient has no previous history of atrial
flutter and alsono known underlying valvular disease. She was
started on warfarin without a heparin bridge, as she went for
PPM placement. At the time of discharge, the patient was
informed that she would need to have her INR checked on ___ and
she was continued on the dose of warfarin 7.5mg at discharge.
CHRONIC ISSUES
==============
# ESRD: She continued on ___ schedule during this
hospitalization.
# HTN: She had diastolic HTN on admission as well as a history
of uncontrolled HTN per patient report. Her lisinopril was
initially held, and she was continued on her home hydralazine
and isosorbide. Her amlodipine was also restarted after her PPM
placement. Because her pressures were relatively well-controlled
on these 3 agents, her lisinopril was restarted at a decreased
dose of 20mg and this dose was continued on discharge.
# DM: Per report, diet controlled. She was maintained on ISS
in-house. Her blood sugars were under good control and no
insulin as continued at discharge.
# Lung cancer s/p lobectomy: Stable. She was continued on her
home oxygen 2L NC.
TRANSITIONAL ISSUES
===================
# Results pending: MRSA screen and CXR (final report)
# New/changed medications: Vancomycin 1000 mg IV x 1 (final
prophylactic dose at next HD session), warfarin 7.5mg daily.
Lisinopril decreased from 40mg to 20mg daily.
# Follow-up: Cardiology, device clinic, PCP
# ___ should get one more dose vancomycin in HD on ___
for post-pacemaker 72hr antibiotic coverage.
# Lisinopril dose was decreased to 20 mg daily as she did not
need as high of dose of blood pressure medications
# She will be discharged with visiting nursing services to
assist with medication management and pacemaker management
# ___ consider alternative statin as major drug interaction
between simvastatin and amlodipine
# CODE: Full
# CONTACT: ___ (son-in-law) ___ | 143 | 422 |
16709771-DS-21 | 28,419,168 | Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___.
As you know, you were admitted to our hospital with shortness of
breath. Your lung exam, blood results and chest x-ray were
consistent with pneumonia, or an inflammation in your lungs.
This most likely occurred because food or water went to your
lungs and caused some inflammation. Your condition improved on
antibiotics while you were in the hospital.
Your INR was also very high when you were admitted, meaning your
blood was very thin. It is very important that you continue to
take warfarin (Coumadin) as prescribed in order to prevent your
INR from becoming too high or too low. Given that your INR
sometimes becomes too high, it is important that you seek
immediate medical attention if you hit your head or notice
excessive bleeding of any kind.
You are discharged home on 2 antibiotics, levofloxacin and
metronidazole, which you are to take until ___.
Please take your medications as prescribed and follow up with
your doctors as detailed below. | Mr. ___ is a ___ year-old male with a history of COPD,
coronary artery disease status-post stent, seizure disorder,
recent HCAP pneumonia who presented with sudden onset dyspnea.
He has had several recent hospitalizations for HCAP/ aspiration
pneumonias. He was recently diagnosed with a left lower
extremity DVT in ___, and is now on home warfarin,
discovered to have supratherapeutic INR on presentation to 5.6. | 175 | 65 |
18321569-DS-16 | 26,923,028 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because of
increased swelling in your legs as well as some altered mental
status. Your mental status improved once you were admitted and
there were no lab or physical exam abnormalities to explain the
change that both you and your father noticed at home. We suspect
that these intermittent changes in mental status are most likely
due to the high dose of pain medicine and anxiety medicines that
you are taking, and possibly some changes in blood gases due to
your obstructive sleep apnea. We recommend that you continue the
evaluation/treatment of your sleep disorder with your PCP ___.
___.
For your leg swelling, we did not believe that there was an
infection, as you had no increase in your white blood cell count
and no fevers. We treated the swelling with IV lasix initially
and then a by mouth. Your pain and swelling improved with this.
We recommend that you continue to wear compression hose, keep
your legs elevated while resting, and continue to do physical
therapy/stay active, as this will prevent reaccumulation of
fluid. You should weigh yourself daily at home. He normally
takes fentaNYL citrate 800 mcg buccal q4-6h:prn headache at home
but this will not be available at ___, so this was held on
discharge and he was rx'd oxycodone ___ mg Q6H prn headache.
You should examine your legs daily. If you notice that they are
swollen or red, please take your lasix 20 mg by mouth until the
swelling resolves. Call your PCP if the swelling does not
improve with your lasix. | Mr. ___ is a ___ yo male with ___ disease, chronic
venous stasis complicated by recurrent cellulitis and
compartment syndrome in RLE, hypogonadism, anxiety, p/w slowed
mental status, worsening b/l leg swelling that improved with
diuresis.
DISCHARGE WEIGHT: 163.2 KG
============= | 274 | 41 |
Subsets and Splits