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12777977-DS-2 | 29,494,029 | Dear Ms ___,
It was a pleasure caring for ___ at ___. ___ were admitted for
worsening rashes on your abdomen and ear, as well as for
shoulder pain. ___ were examined by our internal medicine,
dermatology, and rheumatology, and neurology teams while ___
were here.
Your skin rash is consistent with a condition called inverse
psoriasis, for which dermatology recommended desonide cream
0.05% applied to the skin twice a day for no more than two
weeks. ___ have a follow-up appointment with the dermatologists
scheduled (See below).
Your joint pain work up was consistent with a diagnosis of
calcium pyrophosphate deposition disease (also called
"pseudogout"). Your xrays of the knees and fluid analyzed from
your knee joint helped to make this diagnosis of CPDD. ___ were
placed on a steroid taper (see medication list), and have a
follow-up appointment with the ___ clinic.
___ were found to have anemia. ___ were started on a daily iron
supplement, which ___ should take with orange juice or other
acidic drinks to improve absorption. Iron can make ___
constipated, so please continue your home bowel regimen.
___ were evaluated by the neurology team for your gait
imbalance. They did not feel that this was the result of any
acute process, however, they would like to see ___ in an
outpatient follow-up appointment. They felt ___ had symptoms of
cervical spondylosis (narrowing of the cerivcal spine) and
recommended ___ wear a soft collar to help the symptoms. They
also recommended the following lab tests to further workup your
symtpoms: folate levels, SPEP, UPEP, RPR, ___. Please discuss
with your PCP getting these labs drawn.
___ also have been complaining of nausea, weight loss, and
night sweats. It is very important ___ discuss these symptoms
with your PCP to determine what further workup is needed. | CHIEF COMPLAINT: Rash and joint pains
REASON FOR ADMISSION: ___ with with a recent diagnosis of strep
A and fungal LLQ cellulitis and inflammatory polyarthropathy,
now presenting from home for 3 days of worsening L groin redness
and oozing, as well as new areas of redness, weeping, and pain
under the breasts and behind L ear, in addition to neck and
upper arm soreness. | 304 | 64 |
15883255-DS-9 | 28,462,549 | Please take your medications as prescribed. Please call your
primary care provider if you have any concerns regarding new
chest pain, shortness of breath, or fever >100.4. If you are
truly concerned, please go to the Emergency Room for further
evaluation.
In terms of post partum care, please be aware of the following
warning signs and contact your primary OBGYN immediately if you
have any of the following:
Passing clots larger than a fist
Heavy vaginal bleeding
Fever greater than 101
Foul smelling blood
Pain not adequately relieved with medication | ___ yo s/p rLTCS presenting with vaginal bleeding and chest pain,
found to have bilateral pulmonary embolism. The patient was
admitted to the Post Partum floor for therapeutic
anticoagulation and pain control, as well as monitoring of her
vaginal bleeding.
*) Pulmonary embolus:
The patient remained hemodynamically stable, with normal 02 sats
on RA, and no evidence of heart strain on a chest CT. Thus,
there was no indication for thrombolytic therapy. On HD1, a
heparin gtt was started per protocol. Hematology was consulted
and the patient was transitioned to therapeutic lovenox and
coumadin. The patient was started on coumadin on hospital day 3.
She continued this until discharge, although coumadin was held
on hospital 5. Plan for going forward was to continue on lovenox
95mg twice daily with bridge to warfarin at starting dose 5mg
qd, goal INR ___. Per hematology, patient should be maintained
on anticoagulation for 3 months with outpatient follow up in
___ clinic. Patient will be followed by ___ initially, as
this is location of primary care.
*) vaginal bleeding
Regarding her vaginal bleeding, she had minimal bleeding on
exam. A pelvic ultrasond demonstrated a clot, but no evidence of
retained products of conception. She was monitored closely
throughout her admission and had very minimal vaginal bleeding.
*) Low grade fevers: On hospital day ___, the patient was noted
to have low grade fevers. A U/A was done and not consistent with
infection and a white count was normal. She did endorse
shortness of breath on hospital day 3 and had a chest-xray that
showed bilateral effusions but no consolidation. By hospital day
5, she was feeling overall well and remained afebrile throughout
the day. Her white blood count was normal, and a repeat Chest
X-ray demonstrated no changes from prior.
*) social: pt reports minimal family support, very concerned
about ability to care for children during her hospitalization.
Social work was consulted, but patient reported no concerns to
social worker.
By hospital day 5, patient was doing overall well, ambulating
without oxygen desaturation and on anti-coagulation with
follow-up arranged. In addition, while she had low grade
temperatures, she had remained afebrile for the day with no
signs of infection. It was thought that the low grade
temperatures were due to blood clots. Precautions were reviewed
and patient discharged home. | 84 | 377 |
19139469-DS-4 | 27,513,410 | Dear Mr ___,
You were hospitalized due to symptoms of problems with speech,
left facial droop, and left sided weakness resulting from an
ACUTE ISCHEMIC STROKE, a condition in which 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
high cholesterol
We are changing your medications as follows:
aspirin 81
atorvastatin 40
Please take your other medications as prescribed. Please
purchase a blood pressure cuff at your nearest pharmacy and
start measuring your blood pressure daily. Keep a log of your
blood pressures and bring them to every appointment. We also
recommend a heart healthy diet (low fat, low salt), daily
exercise, and stress reduction techniques. You were evaluated by
___ who recommended ___ rehab to help you improve your
ability to walk, talk, and use your arms. Please follow up with
Neurology, your Cardiologist, and your primary care physician as
listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Mr. ___ is a ___ yo M with PMHx of Charcot ___ (with
neuropathy), HTN, HLD who had acute onset of left facial
weakness and left arm pronation during an ED admission at an OSH
for anaphylactic shock (allergic to peppers). He was sent to
___ after CTH (15 minutes after symptom onset) was negative
for stroke. Admission labs were significant for HA1c=5.4,
LDL=104. LP in the ED showed 800+ RBCs but no WBCs. CT/CTA
showed elevated mean transit time in the right frontal and right
parietal lobes with corresponding loss of normal gray-white
matter differentiation. MRI showed acute/subacute right MCA
territory infarct with associated hemorrhage. Patient
transferred to ICU and started on mannitol on ___ for concern
for worsening cerebral edema. He improved clinically and was
transferred back to the floor without any additional
interventions. Work up for hypercoagulation was unrevealing
___, beta-2-glycoprotein-neg, lupus-neg, protein c/s-neg,
homocysteine-neg, antithrombin III-p). TEE showed no
intracardiac source of embolism identified (no asd, no pfo,
EF>55%) but did reveal an extensive, complex, mobile atheroma in
the descending aorta. Etiology of stroke remains unknown. He
will need outpatient genetic testing (Factor 5, prothrombin,
MTHFR mutations). He was discharged on aspirin 81 and
atorvastatin 40mg. We scheduled follow up with both Dr. ___
___ follow up with genetic testing) and the patient's
existing outpatient pcp. The patient was informed he will not be
able to drive until cleared ___ ___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2? ()
Yes - (X) No, hemorrhagic conversion
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (hemorrhagic conversion) No, hemorrhagic conversion
4. LDL documented (required for all patients)? (X) Yes (LDL
=104) - () No
5. Intensive statin therapy administered? (X) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? (X) Yes - () No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (X) N/A | 382 | 492 |
17559733-DS-15 | 27,099,758 | You were admitted for evaluation of bloody diarrhea. You were
found to have severe colitis due to a "c.diff" infection and
ulcerative colitis flare. You were started on antibiotic
medication....and given a dose of remicade on ___ | ___ y/o male with UC diagnosed in ___, admitted with
increased frequency of bowel movements, bloody diarrhea,
tenesmus, fevers, fatigue. He was found to have diffuse colonic
inflammation on his CT scan and flex sig, c.diff and have anemia
requiring transfusion.
#severe C diff colitis, severe disease given underlying IBD: No
evidence of megacolon or perforation on imaging. Given flex sig
results, increased vanco to 500mg QID (per pharmacy) vancomycin
and add IV flagyl. Symptoms improved. Downtitrated to 125 QID
per GI upon discharge. 2 weeks from discharge date and then to
continue on daily PO vanc after that which can be started by GI
as patient is to have GI f/u in 2 weeks.
##Ulcerative colitis flare - likely due to C.diff and IBD, also
awaiting CMV pathology. Azathioprine on hold per GI. Continue
home dose prednisone 20mg for now. Remicade 10mg/mg x 1 given
___. F/u with Dr ___ in 2 weeks.
-lactose free diet. s/p MRI of the pelvis.
-MRE done and reviewed, no signs of fistula or crohns.
-- CRS consulted this AM to review surgical options
#acute blood bloos Anemia: Due to #hematochezia. Transfused 3
units prbc and will trend closely. Transfuse for hct less than
21. Last transfusion ___ - hb 9 on DC. | 37 | 207 |
10745195-DS-11 | 21,789,903 | Dear Ms. ___,
You were hospitalized due to symptoms of trouble with speech and
swallowing 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
High cholesterol
Please followup with Neurology and your primary care physician
as listed below.
Sincerely,
Your ___ Care Team | ___ is a ___ woman with dementia who presents with 4
days of evolving left MCA symptoms. on exam she is globally
aphasic with right sided weakness of the face and arm more so
than the leg. Her NCHCT shows an evolving left MCA stroke.
Etiology is likely embolic from atherosclerotic disease. She was
started on 300mg aspirin PR for stroke prevention. She is not
diabetic and a non-smoker. Her ability to swallow was assessed
by speech and swallow with recommendation for NPO as diet and
education on aspiration risk if family would like to feed her
for comfort. A family meeting was held with palliative care to
discuss the severity of her imaging and symptoms. The decision
was made to make her CMO. At this time aspirin and IV fluids
were discontinued.
====================== | 137 | 133 |
17262795-DS-13 | 21,607,315 | Dear Ms. ___,
You were admitted to ___ for seizures
and associated altered mental status. Your seizures occured in
the setting of a low phenytoin level, and also while you were on
certain antibiotics for a UTI which lower the seizure threshold.
We gave you some extra dilantin, and sent you out on an
increased dose of phenytoin. You improved back to your baseline,
and we sent you home with the following updates and
appointments:
CHANGED MEDICATIONS
Dilantin 125/100 changed to 175/100
Please make sure to go to the follow up appointments that are
listed below.
It was a pleasure taking care of you. | Ms. ___ was admitted to the neurology ICU for altered
mental status after having multiple generalized seizures. These
seizures were likely secondary both to the recent use of a penum
antibiotic in treating an ESBL UTI, as well as a subtherpeutic
phenytoin level of 2.2.
#NEURO - SEIZURES
On admission, she was loaded with IV fosphenytoin, and her PO
BID dose was increased from 125/100 to 175/100. Her mental
status quickly returned to baseline and she was transferred to
the floor on ___. By the day of discharge, her dilantin level
was therapeutic at 13.5. She was monitored on EEG, and continued
to have generalized slowing with occasional spikes which is
likely her baseline. On the day of discharge, she was at her
baseline mental status. Trileptal and Keppra levels are pending.
#ID
Her WBC count was 19 on admission, for which she was started on
vancomycin and zosyn, however WBC downtrended to 6 the next day
and was likely a result of her seizure, antibiotics were
discontinued the following day. She was afebrile. CXR was
notable for a retrocardiac opacity from a recent pneumonia which
had already been completely treated. Also, as above, she had
recently been completely treated for a UTI. Urine culture was no
growth. On ___, she spiked a fever and her white count
uptrended, CXR showed bibasilar opacities and CT thorax showed
bilateral consolidations suggestive of aspiration pneumonia. She
was started again on vancomycin and zosyn to treat hospital
acquired/aspiration pneumonia. PICC was placed and she is being
discharged with a 14 day total course.
She was discharged to a rehab facility for continued IV
antibiotics, she will require less than 30 days at rehab.
INACTIVE ISSUES
She was continued on all of her home medications as previously
prescribed, these are detailed in the attached medicatin list.
OUTSTANDING ISSUES
- Check dilantin trough level morning of ___ and adjust dosing
if needed
- Continue vancomycin and zosyn until ___ (14 day course for
treatment of hospital acquired/aspiration pneumonia)
- Check vancomycin level after 4th dose and adjust dose as
needed.
- F/U Trileptal, Keppra levels
- F/U final blood cultures | 99 | 343 |
18686694-DS-10 | 21,354,230 | Dear Mr. ___,
You were admitted to the hospital because:
- You were feeling dizzy and lightheaded
- Your speech was slurred
While you were here:
- You had imaging of your brain which showed no evidence of a
stroke
- Our brain specialists evaluated you who agrees that there was
no stroke or problem in the brain
- You were given IV fluids
- You worked with physical therapy and ultimately your walking,
dizziness and weakness improved and you were discharged home
When you leave:
- Please take all of your medications as prescribed
- Please make a follow up appointment with you primary care
doctor
It was a pleasure to care for you during your hospitalization!
- Your ___ care team | Mr. ___ is a ___ y/o male with a hx of HTN, HLD, DM, and COPD
who presents with lightheadedness and multiple neurologic
complaints of unclear etiology.
#Slurred speech:
The patient presented with slurred speech and possible word
finding difficulty on day of admission following sitting up
during an outpatient MRI brain (being obtained for research
purposes). There was initial concern for an acute stroke given
this focal finding and a code stroke was called. NCHCT was
negative, as was CTA of the head and neck. He received 3 liters
of IV fluid and his speech pattern returned to baseline (with
baseline stutter). Neurology felt that given his negative
imaging and lack of continued focal deficits, primary neurologic
cause was unlikely, and they did not recommend more advanced
head imaging. Per neurology recommendations, he was started on
ASA 81mg daily for stroke prevention, although suspicion for TIA
was low. No clear infectious process uncovered, negative tox
screen, no events on tele. Ultimately his symptoms were
attributed to orthostasis as below.
#Lightheadedness
#Vertigo
Describes acute onset of lightheadedness with standing
associated with sitting up and standing. As above, no focal
deficits, and prodrome with sitting up prior to onset of
symptoms indicative of vasovagal vs. orthostatic hypotension
(although no documented orthostasis in house). The patient was
given IV fluids with improvement in symptoms, and was evaluated
by physical therapy who cleared him for discharge home. He was
normotensive while inpatient, and his home losartan/HCTZ was
held on discharge pending PCP ___. Given that his labs and
presentation were consistent with some degree of intravascular
volume depletion, would continue to hold his HCTZ. If he is
hypertensive at his follow up apt, would start by adding back
his Losartan.
# Atypical chest pain
Presenting with one day of left-sided chest pain. EKG without
ischemia and troponin negative x 2, making ACS unlikely. CXR
negative for pulmonary source, such as pneumonia. PE unlikely
given lack of tachycardia, SOB, or hypoxemia. Chest pain
resolved without intervention and did not recur.
___
Cr 1.3 on admission, improved to 1.0 on discharge with 3L IV
fluid suggesting prerenal etiology. Discharge creatinine 1.0.
=============== | 111 | 348 |
16654740-DS-25 | 24,036,082 | Dear Mr. ___,
You were admitted to ___ for fever and cough, and you were
found to have an infection of your leg (cellulitis) and
pneumonia. You were treated with intravenous antibiotics, which
improved both the infection in your lung and leg.
Changes to your medications:
START linezolid ___ twice daily for 8 days (to treat your
infection)
It was a pleasure to take care of you at ___! | ___ year old male with PMH of achondroplasia, morbid obesity,
obesity hypoventilation syndrome c/b pulmonary hypertension and
right sided congestive heart failure presenting with sepsis,
including fevers, hypoxia/elevated respiratory rate, and
elevated WBC count requiring ICU level care. This was
accountable to primarily leg cellulitis, as well as likely
pneumonia.
ACTIVE ISSUES BY PROBLEM:
# Leg cellulitis: noted to have increase erythema, warmth, and
swelling of left lower extremity suspicious for
cellulitis/erysipelas. Given the clinical severity, surgery was
called for concern of necrotizing fascitis and clindamycin was
added. Surgery felt his exam was not consistent with
necrotizing fasciitis. LENIs were negative for DVT or any
drainable collection. ID was consulted and felt his symptoms to
be most consistent with cellulitis. Slowly, the infection
regressed on vancomycin and clindamycin. He was discharged on a
regimen of linezolid ___ BID to be continued for another 8
days for a 14 day course.
# Respiratory distress/Pneumonia: Has history of recurrent
pneumonia with CXR at ___ reportedly consistent with R-sided
infiltrate prior to transfer here. Given tenous clinical status
on presentation, he was initially admitted to the MICU and
treated empirically for HCAP. On transfer to the unit, he was
tachycardic, sat 94% on 3 L, but he was very somnolent. ABGs
showed CO2 retention and the patient was placed on BiPAP. While
in the ICU, he was started on Vancomycin, levofloxacin and
Tobramycin (unusual HCAP regimen due to multiple drug
allergies). He was given standing nebs with albuterol and
ipratroprium. Home fluticasone was continued. He was also
placed on droplet precautions, respiratory viral panel was
ordered and Tamiflu was started empirically, however these were
discontinued when his viral screens came back negative. Urine
legionella antigen was also negative x2. His respiratory status
improved and he was weaned off levofloxacin and transferred to
the medical floor. On the medical service, he reported his
breathing was back to baseline and he required BiPAP only at
night and occasional ___ L NC, which is his baseline due to
COPD.
INACTIVE CHRONIC ISSUES BY PROBLEM:
# Hypertension: Initially held home metoprolol and losartan
given borderline pressures, however these were restarted prior
to discharge. His BP was actually borderline high on discharge,
may consider increasing losartan dose as an outpatient.
.
# BPH: Initially held terazosin and tamsulosin while blood
pressures were borderline low, however these were restarted
prior to discharge.
.
# Diabetes mellitus: Held home metformin at home and started on
lantus with ISS while inpatient. Metformin restarted on
discharge. | 71 | 430 |
17686683-DS-3 | 26,064,146 | Dear Ms. ___,
You were admitted to the hospital with acute appendicitis
(inflammation of the appendix). You were taken to the operating
room and had your appendix removed laparoscopically. You are
now tolerating a regular diet and your pain has improved. You
are now ready to be discharged home. Please follow the
discharge instructions below to ensure a safe recovery:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ is an ___ y/o F who was admitted to the General
Surgical Service on ___ for evaluation and treatment of
abdominal pain. Admission abdominal/pelvic CT revealed acute
appendicitis, WBC was elevated at 13.6. The patient underwent
laparoscopic appendectomy, which went well without complication
(reader referred to the Operative Note for details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating a clear liquid diet, on IV fluids, and IV
acetaminophen and IV hydromorphone for pain control. The
patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 751 | 218 |
15586468-DS-19 | 26,576,211 | You presented to the hospital with worsening of your back pain.
You were seen by the palliative care team who adjusted your pain
medications. Your pain improved, and so you were discharged on
the new higher dose of fentanyl patch and oxycodone. Please
continue to follow the precautions we discussed while on high
doses of narcotics. In particular, if you do not have a bowel
movement soon with the regimen we have prescribed you will need
to contact your doctors for further instructions. We have
prescribed you for about one week worth of pain medication,
after which your outpatient providers ___ need to continue the
prescriptions, and so as we discussed, it will be important to
sort out which provider ___ be handling this and ensure close
follow-up. | ___ y/o M with metastatic rectal CA, HTN, HLD, DM, CAD who
presents with 3 months of worsening back pain despite
uptitration of narcotic pain medications as an outpatient.
# METASTATIC COLON CANCER
# MALIGNANCY-RELATED PAIN
# CONSTIPATION
The patient presented with 3 months of worsening back pain
despite uptitration of his narcotic pain medications at home.
The pain has been attributed to his retroperitoneal metastatic
disease. Recent MRI was reassuring against any evidence of cord
compression. Neuro exam is also reassuring with no weakness or
focal findings noted. Palliative care was consulted and
patient's regimen titrated to fentanyl patch 75 mcg and q3h PRN
10 mg PO oxycodone. His pain was adequately controlled on t his
regimen and he showed no signs of adverse CNS effects of
narcotics. However he did not have a bowel movement during the
admission and so received an aggressive home bowel regimen. He
was given careful narcotic safety instructions and a narcan
prescription. He did not have follow-up scheduled at the time of
discharge, but he plans to call and set this up tomorrow. He
will discuss amongst his outpatient providers who will be
prescribing his narcotics moving forward. His PCP was contacted
prior to discharge about this issue. (Of note, the patient
preferred not to stay in house for addressing his constipation
and follow-up plans, which was reasonable and medically
acceptable).
======================== | 128 | 227 |
10006431-DS-23 | 28,771,670 | Dear Ms. ___,
You were admitted to ___ for nausea/vomiting/diarrhea and
inability to tolerate food after your recent chemotherapy. You
were given medicine which resolved your diarrhea and helped with
nausea. Since you continued to have difficulty eating, you were
started on a course of steroids.
Please follow up with your oncologist to determine your ongoing
chemotherapy plans.
It was a pleasure caring for you,
Your ___ Healthcare Team | ___ female with with HTN, congenital deafness, and
borderline resectable pancreatic head adenocarcinoma on
neoadjuvant C2D12 Folfirinox who presents with nausea/vomiting,
diarrhea, and inability to tolerate POs.
# Diarrhea/Nausea/Vomiting: Most likely due to side effects of
FOLFIRINOX. Abdominal CT without acute process and exam benign.
Similar symptoms in past after chemotherapy. Less likely
infection especially given negative stool studies. C. diff
negative so after consultation with outpatient oncologist,
treated with typical antidiarrheal regimen of loperamide and
lomotil with resolution of diarrhea. Beginning to improve,
mildly increased PO intake but solid foods still limited.
Diarrhea largely resolved. After discussion with patient and
outpatient oncologist was started on Decadron 2 mg PO daily to
help improve appetite/reduce nausea in order to allow adequate
PO intake for safe discharge.
- Continue 2mg dexamethasone daily, likely will stop after 7 day
course if continued improvement
- Continue anti-emetic regimen
- Continue PPI
#Cough: Having cough intermittently productive of yellow sputum.
Lung exam reassuring, CXR shows no evidence of pneumonia,
afebrile without leukocytosis.
-Monitor off antibiotics, if symptoms worsening consider repeat
chest imaging
-Cont IS
-Encourage ambulation
# Pancreatic Cancer/neutropenia: s/p FOLFIRINOX cycle 2 on ___.
GI sx likely ___ further plans
for
administration of this drug. Neutropenic with ANC ___,
likely ___ recent chemotx, no fevers to date, WBC now improved
with ANC >2800. Will follow with Dr. ___.
- Continue tramadol for pain
# HTN:
- Lisinopril was held initially, restarted on discharge
# Anxiety: She reports having anxiety about leaving the hospital
as after multiple recent discharges she quickly went to a local
ED. She was counseled extensively that she had made gradual
improvement and there was no further treatment recommended in
the hospital at this time.
-Consider outpatient social work or palliative care referral to
help with anxiety and symptom management. | 69 | 288 |
10539937-DS-7 | 27,370,170 | Dear Ms. ___,
It was a pleasure to participate in your care at ___
___. As you know, you were admitted for a
rash over your entire body. The Dermatologists were consulted
and believed that you had a reaction to a medicine that you were
taking. Most likely this was a medication that you started
recently, in particular Celecoxib. They also considered the
possibility that you had an infection, however we have not
identified an infectious source that would explain your
symptoms. When the eye doctors saw ___, they did not believe
you have involvement of your eyes with your rash.
After you leave the hospital, please do not take any unnecessary
medications. Do NOT restart taking Celecoxib or any NSAIDs
including tylenol or ibuprofen. You will need to follow-up with
Dermatology within the next 7 days, and with Allergy after your
rash has resolved. Please call the allergist office at
___ to schedule an appointment.
We also noted that your platelets were low; we think that this
could be due to your omeprazole. We stopped your omeprazole, and
started you on another acid medication. | Pt is a ___ w/ ___ UC, fibromyalgia, connective tissue disorder
p/w sore throat and rash.
# ___: The patient presented with a
progressively worsening erythematous rash that involved her lips
and oral mucosa. Dermatology was consulted and believed her
presenation was most consistent with ___ Syndrome
caused by medication, most likely celecoxib which the patient
recently started. They also considered infectious causes or
erythema multiforme but believed this was less likely.
Celecoxib, NSAIDs, and nortriptyline were discontinued. Her rash
stabilized with symptomatic and supportive treatment. GYN was
consulted to ensure to vaginal lesions, and the patient did not
have ophthalmologic symptoms confirmed on exam by Ophtho. She
was able to tolerate a shower on ___ and was discharged later
that day.
She will need to follow-up with dermatology within 7 days. She
will also have to follow-up with allergy after her rash resolves
to determine if she had a reaction to medications. Unncessary
medications should be avoided in this patient.
#Pharyngitis: likely due to SJS as above. Viral etiologies were
entertained but monospot and viral serologies were negative. She
was managed symptomatically with viscous lidocaine and
chloraspetic spray.
#Thrombocytopenia: Patient had low platelets on admission
(110's) that continued to downtrend with a nadir of 77. Etiology
is unclear - her 4T score for HIT was low (1). Other possible
etiologies include medication effect and her omeprazole was
discontinued. Her platelets remained stable in the 80's for the
last three days of her admission.
#Acute Kidney Injury: The patient had elevated Cr on 1.9 on
admission (baseline 1.1). This was likely prerenal azotemia from
poor po intake due to oral lesions. She was given IV fluids
until she was able to tolerate more intake. Her Cr was back to
baseline at the time of discharge.
Chronic Issues
#CTD/Fibromyalgia - patient was continued on hydroxychloroquin,
bentyl, gabapentin
#UC - she showed no signs of flares during this admission
#HTN - was continued on her nifedipine, triamterene/HCTZ
Transitional Issues
- Avoid unnecessary medications
- f/u with derm over the next week
- when improved, Allergy/Immunology evaluation to determine if
TCA's or Acetaminophen can be re-introduced or used in the
future | 190 | 350 |
18274431-DS-14 | 25,123,553 | Dear Mr. ___.
You were hospitalized due to symptoms of left-sided weakness
that was concerning for 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:
- hypertension
- history of tobacco use
- large left heart chamber increasing risk of hear arrhythmia
We gave you a medication called tPA, which helped break up the
blood clot that caused the stroke. Your weakness improved after
we gave you this medication.
You got better from your stroke, but then you experienced some
vomiting, and we found that you had a small bowel obstruction.
We got CT scans of your abdomen, and put in an NG tube. The
surgery team reduced a hernia which may have contributed to your
small bowel obstruction. The GI doctors did ___ to
look for Crohn's as a cause of your small bowel obstruction.
They weren't able to get past a stricture, so they didn't get a
full look at your intestines, but they did get to take a biopsy
to look for Crohn's or other kinds of cancers. We didn't have
the results back before you were discharged, but they said that
you will be called with the results, and based on the results
you can schedule follow up in the next two weeks. You also had
some blood in your stool after your colonoscopy. However, they
took biopsies so a small amount of blood is expected. Your
hemoglobin was stable, and they will continue to check it at
rehab. Your GI doctor can continue to follow your stool.
The hematology doctors also saw ___ in the hospital because we
were concerned about an abnormal number of white blood cells.
They believe you have something called chronic lymphocytic
leukemia (CLL). This is a blood disorder that doesn't have any
treatment, but fortunately is not a malignant process. You will
need to follow up with the hematologists for follow up as an
outpatient, which we have scheduled for you.
We are changing your medications as follows:
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
35 minutes were spent on discharge.
Sincerely,
Your ___ Neurology Team | ___ gentleman with history of prior MI, hypertension,
hyperlipidemia, and Crohn's disease who presented with acute
onset left-sided weakness.
#Stroke
NIHSS in ED 7 for left facial and left hemiparesis. CT head
without acute process. CTA head and neck showed some
atherosclerotic disease with adequate flow-trough. He was given
tPA at 10:58 am with initial improvement of his NIHSS to 1 (left
nasolabial fold flattening). Post-tPA events notable for
transient episode of hypotension that resolved with IVF. NIHSS
at that time worsened to 4 with improvement s/p hydration.
Within 24 hrs, his post-tPA NIHSS improved to 2 (left facial,
left arm drift). MRI brain with subtle foci of right frontal
foci of diffusion restriction corresponding to precentral gyrus
with ADC correlate suggestive of acute infarct/embolus with
lysis from tPA. Transthoracic echo demonstrated large atrial
volume, increasing risk of arrhythmia and an EF of 55% with no
clots visualized. He was monitored on telemetry, but no atrial
fibrillation was seen while inpatient. He will need a cardiac
event monitor while in rehab or on discharge from rehab to look
for occult atrial fibrillation. ___ was continued on aspirin
81mg daily for stroke prevention. His stroke risk factors were
LDL 41, TSH 1.7, and hemoglobin a1c 5.7. There was no clear
cause of his stroke, so occult atrial fibrillation causing a
cardioembolic stroke was thought to be the most likely culprit.
If atrial fibrillation is found, either a DOAC such as apixiban
or Coumadin should be initiated.
#HTN/HLD
Blood pressure medications were held on admission to allow for
permissive hypertension to SBP 180. Blood pressure medications
were slowly reintroduced, with adequate blood pressure control
(goal SBP <160) achieved on no antihypertensives. On discharge,
we restarted metoprolol XL 12.5mg (half his home dose) and
continued to hold losartan. These medications can be titrated up
as needed at rehab to achieve SBP <160. His home atorvastatin
was continued, as his cholesterol is under good control on
current regimen.
#PNA
On admission, he was also found to have a right middle lobe
pneumonia, for which he was treated with ceftriaxone (7 days)
and azithromycin (5 days), and we covered for potential MRSA
with vancomycin. MRSA swab was negative on ___, and vancomycin
was discontinued. His white blood count was notable for
leukocytosis of 37 and he was significantly dehydrated. We
rehydrated him and consulted nutrition for re-nourishment
recommendations, as he was frail on admission. He also had stage
II pressure ulcer on his coccyx, for which a wound consult was
placed. Social work was also consulted to help evaluate and
supplement home care. Physical therapy recommended rehab on
discharge, so patient was sent to rehab on ___.
#CLL
Patient was noted to have abnormal blood counts, which we
discussed with hematology. There was concern for CLL, for which
they recommended workup as an outpatient. We ordered a d-dimer,
which was elevated to 8520. Serum viscosity was normal. They
also recommended sending flow cytometry and cytogenetics, as
well as hepatitis B, hepatitis C, and HIV, which we sent prior
to discharge. One of the CT scans of his abdomen was read as
lymph nodes concerning for lymphoma. We discussed with
hematology, who felt the lymph nodes were more likely reactive
in the setting of a small bowel obstruction. They recommended
outpatient follow up, which we scheduled for after discharge.
#SBO
On ___ AM, patient vomited bilious fluids. KUB showed acute
small bowel obstruction. Patient was made NPO. ACS was
consulted, and colorectal surgery saw patient on ___,
recommended NG tube to suction, and CT abdomen with PO contrast
to look for etiology of obstruction. CT showed a small bowel
obstruction. Surgery reduced a hernia. Patient remained NPO for
the weekend, and vomiting resolved. Surgery did not feel that
the SBO was due to the patient's hernia, and GI did not feel
that the SBO was due to Crohn's flare. The CT scan had lymph
nodes concerning for lymphoma, so we consulted ___ for biopsy. ___
recommended repeating the CT abdomen, which showed a resolved
small bowel obstruction and thickening of the small bowel. There
were lymph nodes that were not amenable to biopsy. Hematology
and ___ both felt lymph nodes were more likely reactive, so we
did not further pursue biopsy. CT scan may need to be repeated
as an outpatient with hematology at follow up to look for change
in lymph nodes. We spoke with GI, who said that he should resume
his home GI medications on discharge. They are not sure if this
is a Crohn's flare or not, but the biopsy will give us the
answer. They deferred starting steroids, as they possibility of
lymphoma was present and this would change his treatment course.
The morning after his colonoscopy, patient had a small amount of
diarrhea on the bed. Per report, it was dark, and concerning for
blood. His next BM witnessed by medical team was diarrhea that
was bilious in color, no bright red blood or melena. We repeated
a CBC, which was stable. We discussed with GI, who said there
could be a small amount of blood that would be expected after
biopsy of the terminal ileum. Since his CBC was stable, there
was no further workup needed, and patient was scheduled to
follow up with GI.
Transitional Issues
===================
[ ] Follow up with hematology after discharge for workup of CLL,
to follow flow cytometry and cytogenetics, consideration of
repeat abdominal imaging to see if lymph nodes are reactive or
suspicious for lymphoma
[ ] Follow up with GI in clinic as scheduled by GI. Patient will
be notified of biopsy results.
[ ] Follow up with neurology in ___ months
[ ] ___ of Hearts (cardiac event monitoring) while in rehab
[ ] Repeat CBC at least weekly to evaluate for ongoing blood
loss from the GI tract
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. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =41 )
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
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. 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:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - no a fib documented | 569 | 1,228 |
13017716-DS-14 | 27,174,300 | Please follow up as directed.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit. | Pt was admitted to the Neurosurgery service and was placed on
bedrest. His wife was able to obtain his MRI from ___
___ (was not transported with patient). Upon review of this
MRI it was found that there were multiple concerning lesions
throughout the spine as well as a new L2 compression fx (approx
25% loss of height). On ___ oncology was consulted and the
patient underwent multiple lab tests as well as a CT Torso and
skeletal survey. The patient recieved a TLSO brace. He was noted
to have hypercalcemia and was treated with IVF and lasix. This
remained stable on repeat check and was cleared for discharge
home per the patient's request and this was cleared by
neurosurgery and oncology. The patient will follow up in the
___ clinic on ___. | 73 | 133 |
18678622-DS-15 | 29,009,022 | Dear Mr. ___,
WHY DID YOU COME TO THE HOSPITAL?
--You came to the hospital because you had a fever at home
WHAT HAPPENED WHILE YOU WERE AT THE HOSPITAL?
--We checked you for an infection, and we can't find any
evidence of infection
--We treated you with antibiotics
WHAT SHOULD YOU DO WHEN YOU GO HOME?
--You should start taking levofloxacin (an antibiotic) that is
once daily and complete five days of treatment total ___ to
___.
--You will be discharged with extra doses of levofloxacin. If
you EVER have a fever at home, you should take this medication
and call your doctor ___. This is because you don't have a
spleen and are at increased risk of infection.
--The doctors in the hospital ___ call you if any of your
culture data shows that you have an infection. If you develop
symptoms concerning for infection, please call your doctor.
Symptoms include abdominal pain, nausea/vomiting, diarrhea,
congestion, fevers, cough.
Best,
Your ___ Team | ___ yo M with hx of main duct IPMN s/p distal pancreatectomy with
stage IIB pancreatic adenocarcinoma s/p neoadjuvant FOLIFIRNOX
followed by pancreaticoduodenectomy ___, radiation therapy
gemcitabine/capecitabine and now single agent gemcitabine (last
dose ___ who presented with fever.
#FEVER
Pt reported fever at home w/o other focal infectious symptoms.
He called his hematology/oncology MD who recommended he come to
the ED. No leukocytosis. CXR was w/o PNA. Flu swab was negative.
U/a was normal. Pt was initially treated with vancomycin and
zosyn in the ED, which was then transitioned to cefepime upon
admission. Pt was HDS and w/o fever in the hospital.
Of note, he had a recent MRCP that showed evidence of
cholangitis and was seen by GI who did not start abx as he had
no clinical evidence of cholangitis. Bilirubin was slightly
elevated in hospital at 2.4, but patient had no clinical
evidence of cholangitis.
He was discharged with levofloxacin 750 mg daily to be taken for
four days unless culture data came back positive. He will be
notified if that is the case and instructed to come to the
hospital. He was also given extra levofloxacin given his
splenectomy and instructed to take one pill and call his doctor
if he develops a fever in the future.
# Pancreatic adenocarcinoma stage IIB,
On Chemotherapy with a curative intent, status post four cycles
of neoadjuvant FOLFIRINOX with CyberKnife radiation and surgery
on ___
C3D9 of Gemcitabine. Last chemo on ___
#Patient was continued on home medications for chronic medical
problems
**TRANSITIONAL ISSUES**
-Discharged w/five day course of levofloxacin
-Discharged with extra levofloxacin given splenectomy and
instructed to take one pill and call his MD if he develops a
fever
-Please ensure that he has had proper immunizations given lack
of spleen
-F/u with hematology scheduled
-Blood and urine cx pending upon discharge
-Of note, sugars were slightly elevated in hospital (200s) and
should be followed up upon discharge | 154 | 311 |
19721002-DS-20 | 25,894,834 | Dear Mr. ___,
* You were admitted to the hospital for a recurrent episode of
collapsed lung. You underwent decompression with chest tube
placement and had a chemical pleurodesis (purposeful
inflammation of your lung lining to prevent recurrent lung
collapse) and you've recovered well. You are now ready for
discharge.
* It is crucial for your health that you stop smoking.
* Continue to use your incentive spirometer 10 times an hour
while awake.
*Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse,
pat dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ office at ___ if you experience
-Temp > 101, chills, increased shortness of breath, chest pain
or any other symptoms that concern you.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. | Mr. ___ was evaluated in the Thoracic Clinic and a chest xray
demonstrated a recurrent left pneumothorax. He was sent to the
Emergency Room for urgent placement of a chest tube. He
tolerated the procedure well and initially had a large air leak.
A subsequent chest xray confirmed placement of the tube at the
left apex and a tiny residual apical pneumothorax. he was
transferred to the Surgical floor for further management.
Later that day he underwent talc pleurodesis with 4 Grams of
sterile talc. Towards the end of the procedure he had some
burning pain which was relieved with IV Dilaudid. The tube was
placed above the level of his heart for 2 hours post pleurodesis
and he repositioned himself frequently to coat the lung then the
tube was placed on -20 cm suction for 48 hours. About 6 hours
later he developed sinus tachycardia to 130 and desaturated to
the low 80's eventually requiring a non rebreather.
He was transferred to the SICU for further management of what
seemed to be talc related SIRS. He was never intubated but
required high flow O2 to maintain sats > 88%. His chest xray
showed no pneumothorax and his pain was controlled with oral
Dilaudid. He spent time in ICU for weaning off of high flow
oxygen and his chest tube was eventually removed on ___.
His post pull film showed no evidence of PTX and he remained
hemodynamically stable without need for repeat CT placement.
He was evaluated by the Pulmonary service and recommendations
were made for reducing his Prednisone to 10 mg daily from 20 mg
daily during this acute phase to allow for appropriate
inflammation and ensure adequate pleurodesis. Given that his
surgical problems had resolved (no recurrence of PTX following
pleurodesis), the deicision was made to transfer patient to
Medicine Service for continued O2 wean and medical management of
his known ILD.
On medicine service, O2 requirement rapidly decreased without
intervention. On DC, satting in low ___ on 2L O2, which is home
O2 requirement. Course also complicated by urinary retention
requiring foley catheter, which had resolved on discharge. | 362 | 356 |
10261129-DS-15 | 22,642,683 | Dear Ms. ___,
You were admitted with symptoms of abnormal vision,
disorientation, and dizziness. You were evaluated for stroke and
your MRI brain did not show stroke. Your symptoms may have been
due to migraine without headache or due to an intraocular cause.
You should follow up with your ophthalmologist Dr. ___ 1
month. You should call ___ for a follow up with
neurology.
It was a pleasure taking care of you.
Your ___ Team | Ms. ___ is a ___ yo woman with multiple vascular risk
factors including afib on Xarelto, HTN, HLD, pre-DM, aortic
stenosis, OSA, and RCC s/p nephrectomy who presented with
transient visual symptoms (described as images breaking up),
disorientation and lightheadedness. These symptoms had resolved
by the time of admission to the hospital and did not recur. Her
neurological exam after admission was normal. Her visual
symptoms were not consistent with stroke or TIA and MRI was
negative for stroke. Her symptoms were possibly due to migraine
or intraocular cause (fragmented, kaleidoscope images).
***Transitional issues:
- follow up with outpatient ophthalmologist
- follow up with neurology | 71 | 102 |
11465246-DS-12 | 28,133,689 | Pt was discharged and admitted to inpatient hospice, please see
discharge summary from ___ | Pt was discharged and admitted to inpatient hospice, please see
discharge summary from ___ | 14 | 14 |
14280440-DS-11 | 29,057,576 | Dear ___,
___ was a pleasure to take care of you at ___
___!
Why were you hospitalized?
==========================
-You were having shortness of breath
What happened while you were in the hospital?
=============================================
-You had an ultrasound that showed that part of your heart is
not pumping as well. A cardiac catheterization showed that you
have a block in your heart vessel and a block in the connection
between your graft and your original heart vessel. A stent was
placed to clear the block in your original heart vessel.
-You also had a fast heart rate, which is probably part of why
you had difficulty breathing, and is probably a result of
scarring from your heart surgery. Your heart rate slowed down
when we increased your medicine, metoprolol.
-You saw a Podiatrist who looked at your ankle wound and wound
vac and there was no infection.
What should you do after leaving the hospital?
==============================================
-Keep taking your medications as prescribed, especially ___,
Asprin, Atorvastatin, as before
-Start taking Lisinpril 2.5mg daily, and start taking Metoprolol
200mg XL daily
-See your primary doctor, and vascular surgery
-See podiatry for a wound vac change every three days
We wish you the best!
Sincerely,
Your ___ Cardiology Team | ___ with T2DM, CAD s/p CABG, and HTN who presents with
progressive DOE, found to have elevated troponin c/f ACS.
# Dyspnea on exertion
hx CABG two mos ago w/o complications, active at baseline, then
acute onset sob x1-2wks progressively worsening, associated with
palpitations, found to have Trop .04-->.09, started on heparin
gtt, got full dose ___. Given no obvious ischemic EKG changes,
third trop stable (0.09) thought to be due to atrial
tachycardia, heparin gtt stopped. However on repeat ECHO, EF
newly depressed to 35% and "moderate regional systolic
dysfunction c/w CAD in the LAD territory," and heparin restarted
prior to cath. R groin access was obtained and cardiac
catheterization revealed 90% stenosis of native LAD and 90%
stenosis of LIMA-LAD graft. A drug eluting stent was placed in
the native LAD. Pt was continued on ___, atorvastatin
80mg, metoprolol (increased to 200mg XL), and was started on
Lisinopril 2.5mg. Also considered PE but r/o by CTA (which also
showed moderate PA dilatation). Lung processes considered--no
hx asthma, smoking, CT negative for ILD process.
# Systolic heart failure
Presented w/ DOE w/o ___ edema, ProBNP 697, Echo this admission
w/ EF 35%. Did not get diuresis at this time as no e/o
hypervolemia on exam.
# Atrial tachycardia
Heart rate to 100s at rest, to 130s when up to bathroom; EKG
change in pwave from baseline c/w atrial tachycardia. Likely
due to scarring from cardiac surgery vs CAD. Likely
contributing to DOE. Improvement in rate and symptoms with
metoprolol (increased to 200mg XL)
# Microcytic Anemia
MCV 75, on Iron supplementation, Hgb relatively stable
(9.6-->9.8-->9.1). Repeat labs during admission: Iron: 29,
calTIBC: 369, Ferritn: 27, TRF: 284. Was continued on home dose
Iron
# DM
On Lantus 40u qAM at home w/ SS Humalog for meals (usually
___, maintained to Lantus 30u qAM + SS Humalog. No
hypoglycemic events
# Right ankle wound: 3x2cm wound at medial/anterior right ankle
which is healing by second intention with assistance of wound
VAC. Being followed by Dr. ___. Original insult was
saphenous vein harvesting with wound repair c/b her peripheral
vascular disease. Podiatry consulted, who took down wound vac,
found granulation tissue, no signs of infection, and replaced
vac | 192 | 378 |
11563027-DS-19 | 21,598,679 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily
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:
- Activity as tolerated
- Left lower extremity: touchdown weight bearing
Physical Therapy:
- Activity as tolerated
- Left lower extremity: touchdown weight bearing
Treatments Frequency:
Site: L hip, L groin
Wound: Surgical incisions
Description: Dry gauze and elastoplast tape dressing
Care: Change dressing every other day or as needed to keep clean
and dry. If incision remains non-draining, OK to leave open to
air.
Follow-up: Pt is to follow-up in 7 days for removal of staples. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. She was found to have
left acetabular fracture and was admitted to the orthopedic
surgery service. She was taken to the operating room on ___
for ORIF left acetabuler fracture, and again on ___ for exam
under anesthesia and anterior column percutaneous screw, which
she tolerated well (for full details please see the separately
dictated operative reports). She was initially given IV fluids
and IV pain medications, and although her diet was advanced to
regular, she was made NPO again after failing to have a bowel
movement for 5 days and developing significant distention and
ileus. ACS was consulted, and they ultimately recommended bowel
decompression with neostigmine in the TSICU, which the patient
tolerated well. After successful bowel decompression, the
patient was transferred back to the floor, NG tube was
discontinued, and her diet was once again advanced to regular.
She passed flatus and had watery bowel movements. Her distention
improved with Reglan. She was also encouraged to ambulate, which
improved her abdominal distention as well. She was given
perioperative antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. She worked with ___ who determined that
discharge to rehab was appropriate. Her 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 she was voiding/moving bowels
spontaneously. She is touchdown weight bearing in the left lower
extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in 7 days. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. | 208 | 304 |
19599211-DS-14 | 22,388,743 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for pain in your chest caused
by an inflammation around the outside of your heart
(pericarditis). You were treated with fluids, ibuprofen and
colchicine.
You should continue to take these medications for ___ months. We
also would strongly recommend that you follow-up with your
regular doctor once you return home from your travels, ideally
within 1 month of this hospitalization.
Best wishes,
Your ___ Team | Mr. ___ is a ___ year old man on vacation in ___ from
___ with a past medical history significant for pneumothorax
X 2 and presenting with acute-onset substernal chest pain with
negative cardiac enzymes, clear CXR and negative CTA; now
clinically stable and being treated for pericarditis.
#ACUTE PERICARDITIS
Mr. ___ presented with signs and symptoms concerning for
pericarditis, namely central pleuritic chest pain worse with
deep inspiration, a fever to ___ on admission, fatigue and
classic diffuse ST elevations/PR depressions on EKG. The
differential initially included ACS, though this was ruled out
based on the EKG findings and negative cardiac enzymes X 3.
Pulmonary Embolism was also ruled out with a negative D-dimer
and negative CTA of the Chest. Of note, UA was also negative.
These findings, in combination with a history of recent viral
symptoms were most consistent with pericarditis. Mr. ___
underwent multiple laboratory studies and the results of these
studies at the time of discharge are contained elsewhere in this
report. He was also given ample fluid resuscitation and started
on a regimen of Ibuprofen 800mg q8hrs and Colchicine 0.6mg twice
daily for presumed pericarditis. He remained afebrile and
clinically stable during his admission and was discharged home
on this medication regimen. | 80 | 206 |
12325058-DS-22 | 22,740,769 | Dear Ms ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
-You came into the hospital because of shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You were found to be short of breath because you had too much
fluid on board. You received medications to help you pee off the
extra fluid and your breathing improved.
-You were found to have new heart failure and decreased function
of your heart muscle.
-You underwent a procedure called a left heart cath to look for
blockages in the coronary arteries. While this procedure did
show that you have coronary artery disease, you did not have
blockages significant enough to require stent placement.
-You will need an MRI of the heart to further determine the
cause of your heart failure, which you will have done after
leaving the hospital.
-You were started on several new medications for your heart
failure. You will follow-up with a cardiologist after leaving
the hospital who will help treat your heart failure going
forward.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed and keep
your appointments.
- Please weigh yourself every day and call your PCP if your
weight goes up by more than 3lbs. Discharge weight: 151.9lb.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
=================
Mr ___ is a ___ y/o F with PMH significant for hx of breast
cancer (s/p chemoradiation/mastectomy in ___, history of
thyroid cancer (s/p thyroidectomy in ___, who presents with
dyspnea with concern for possible new HF. The patient had an
ECHO that revealed a newly decreased EF to 30% with concern for
possible underlying ischemia. She underwent cath on ___
notable for 60% stenosis in LAD, 70% stenosis in diagonal for
which percutaneous intervention was not felt to be needed.
Etiology of her decreased EF was not entirely clear but
ultimately felt most likely to be hypertensive heart disease.
She will undergo outpatient CMR for further workup. She was
discharged with plan for maximal medical therapy for new HFrEF
and close cardiology follow-up.
TRANSITIONAL ISSUES:
===================
Discharge maintenance diuretic dose: Lasix 40mg
Discharge weight: 151.9lb
Discharge Cr: 1.0
[] Please check labs including Cr and K on ___ given new
maintenance diuretic regimen of Lasix 40mg. Please also f/u
volume status on this regimen.
[] She will undergo cardiac MR as an outpatient for further
workup for the etiology of her newly diagnosed HFrEF (with cath
during this admission negative for obstructive CAD).
[] Discharge HFrEF regimen included Lasix 40mg, metoprolol XL
25mg and valsartan 20mg BID (with plan to transition to Entresto
once ACEi washout and pre-auth complete).
[] Please follow-up on transition from valsartan to Entresto.
[] Consider addition of spironolactone as able for further
optimization of HFrEF regimen. | 236 | 239 |
16760982-DS-11 | 27,114,437 | Dear Ms. ___,
It was a pleasure to care for you during your hospitalization.
You were admitted after developing severe left hip pain. After a
thorough work-up including x-ray and MRI, you were found to have
a broken left hip that occurred due to the presence of cancer
that has spread there. You underwent stabilization of this
fracture in surgery on ___ and tolerated the procedure well.
Two days after the surgery, you began to develop lower red blood
cell counts and oxygen in your blood. You therefore received a
blood transfusion which helped to stabilize your red blood
cells. You also underwent imaging studies to rule out any
serious causes of low oxygen. The most likely cause of this low
oxygen was too much fluid in your lungs - this was treated with
a drug that takes fluid out of your body, and since this
treatment your oxygen levels have normalized.
You also underwent additional imaging studies including a bone
scan and brain MRI which showed the presence of the cancer in
multiple different bones of your body including your skull.
Importantly, there was no evidence of any spread to your brain.
It is important that you follow-up at the appointments listed
below for further management and treatment. | Ms. ___ is an ___ y/o female with a hx of stage IIA (pT1c, N1a,
M0) ER positive, PR negative, HER-2 negative, grade II invasive
ductal carcinoma of the left breast, s/p RT and aortic stenosis
s/p AVR who presented to her outpatient oncologist with severe
left hip pain and was subsequently found to have a pathologic
left subcapital fracture due to metastatic breast cancer. | 205 | 65 |
10595567-DS-6 | 23,044,954 | You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving for 24 hours.
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room! | Mr. ___ was admitted to the Neuro-ICU for work up to rule out
to aneurysm or vascular abnormality. He underwent a diagnostic
cerebral angiogram that was negative for aneurysm but
demonstrated diffuse cerebral vasculitis. Post-Procedure he
remained flat x2 hours for hemostasis. Pulses remained bounding
and intact and the groin was without hematoma. There was a mild
ooze from groin that did not extend the boundaries of the
dressing. Stroke neurology was consulted and felt that it was
cocaine induced vasculitis. The patient remained neurologically
intact throughout his hospital stay and his headache improved.
Neurology felt that since his headache improved there was no
need to start a new agent for headache control. They recommend
follow up in 3 months in outpatient clinic or sooner if his
headaches increase in frequency. The patient was counselled on
stopping all cocaine use.
At the time of discharge the patient was tolerating a regular
diet, ambulating without difficulty, afebrile with stable vital
signs. | 249 | 168 |
12647061-DS-7 | 21,527,409 | Dear Ms. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were having fevers. We found that you had a
urinary tract infection. We treated you with antibiotics and
your symptoms improved. You will need to continue taking
antibiotics to finish treatment for your urinary tract
infection. You will also need to take antibiotics to prevent
infection. You should also continue to take your neupogen per
your previously established schedule. | ___ year old female with a history of stage IV bladder cancer
presenting with fevers at home, consistent with UTI as she has
had several over the past few months since her ileoconduit in
___, confirmed EColi, Klebsiella and Enterococcus on urine
culture, now with possible evidence of narrowing of left side of
urinary drainage system.
# UTI- UA reveals > 180 WBCs and patient reported foul smelling
urine from ostomy consistent with prior episodes of UTIs. In the
past, has had E Coli, sensitive to cefepime and macrobid. She
also reports having had enterococcal UTIs in the
past. WBC improved to 7.1, however downtrending was attributed
to chemo-effect in addition to resolving infection. Urine
culture confirmed on ___ dual infection with EColi and
Klebsiella, both sensitive to cefepime. Patient remained febrile
until ___ and remained on IV antibx until transitioned to PO on
day of discharge. Loopogram ___ showed free reflux of contrast
to the right kidney, and some reflux through the ureter of left
kidney, but abruptly stopped before reaching the left renal
collecting system. Urology then asked for a CT abd/pelvis to
further evaluate this issue. Abd/pelvis CT showed no
pyelonephritis, no abscess but possible narrowing at left
ureteroileal anastamosis possibly contributing to frequent UTIs.
Urine culture from ___ growing 10,000-100,000CFU of
enterococcus, most likely colonization, but pansensitive per
micro lab so she was started on a course of macrobid based on
her risk for repeat UTI. Blood cultures continued to be negative
to date. Her po intake, nausea and diarrhea improved by
discharge.
# Bladder cancer - recently started cycle 1 of adjuvant chemo
s/p cystectomy (on paclitaxel, gemcitabine, and cisplatin);
recently also started neupogen. Was scheduled to begin second
cycle ___, however remained an inpatient and starting chemo was
undesirable in this setting. The ostomy nurse was consulted and
she received different supplies for her stoma that appeared to
work better for her than the previous ones.
#Neutropenia: Despite neupogen use after last cycle of chemo,
patient was neutropenic on AM labs on the day prior to discharge
with ANC of 940. She was placed on neutropenic precautions. She
remained afebrile. She was discharged with instructions to
continue taking neupogen as per home dosing schedule.
#Diarrhea: Patient had episodic diarrhea with incontinence which
was likely secondary to antibiotics and recent chemotherapy. C
diff, CMV were both negative. She was supported with IVF and was
started on low-dose loperamide and diarrhea resolved.
# Acute renal failure - Creatinine increased to 1.4, likely in
the setting of insensible losses with fever and poor PO intake.
Resolved with IVF and improved PO intake.
# Hypotension - She was admitted with low BP (90s) in the
setting of possible urosepsis. Patient was not taking lisinopril
of HCTZ prior to admission and these medications were held and
discontinued on discharge.
# Diabetes mellitus type 2 - Currently not on medications but
was well-controlled throughout entire admission.
# Hyperlipidemia - continued crestor
# Anxiety - continued lorazepam PRN | 77 | 493 |
18897917-DS-22 | 27,296,410 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· ***Please do NOT take any blood thinning medication
(Aspirin, Ibuprofen, Plavix, Coumadin) for one week from your
head injury (___).
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating,
and remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptom after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches
but avoid taking pain medications on a daily basis unless
prescribed by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | Mrs. ___ was admitted on ___ after striking her head. She
was found to have a fluid collection at the previous surgical
site that did not appear to be a hemorrhage. She was kept for
observations. Medicine service was consulted for work up of
possible syncopal episode. The EKG and Troponins were negative,
and medicine felt that the syncopal episode was related to
orthostatic hypotension due to possible dehydration. The patient
was hydrated and orthostatic blood pressures were obtained and
were within normal parameters.
On ___ the patient remained neurologically and hemodynamically
intact and expressed readiness to be discharged home. The
patient was discharged home in stable conditions. All discharge
paperwork and follow up were given prior to discharge. | 519 | 120 |
18026603-DS-13 | 24,141,916 | Dear Ms. ___,
You were admitted to the hospital for anemia (low blood count).
You were given a blood transfusion and your blood counts
improved and had remained stable since. The exact source of your
bleeding in not clear at this time. Some bleeding may be coming
from the polyp in your intestine, but at this point it would be
too dangerous to remove it because your platelets are very low
and it may worsen bleeding.
It is important that you follow up with your liver doctor to
continue to monitor your blood counts and make a safe plan for
your care.
It is also important you follow your blood counts every so often
after you leave the hospital.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Also call your doctor if you have difficult
breathing or chest pain. Call your doctor if you pass black or
bloody stool.
Thank you for letting us participate in your care,
Your ___ team | ___ woman with PMHx ___ cirrhosis, DM2, severe AS, and
post-menopausal bleeding recently discharged to rehab on ___
presented from rehab on ___ for anemia and hypokalemia.
While at rehab, found to have acute on chronic anemia with
hemoglobin of 6.7. She was transfused 2 units of PRBCs with an
appropriate increase in Hb. Hemoglobin remained stable in the
following days.
A definite source of bleeding was not identified. She has known
post-menopausal bleeding, though only minimal vaginal bleeding
while inpatient. Her stool was guaiac positive in the ED, but
repeat stool guaiac after admission was negative. She has a
known cecal polyp, which was also implicated but given her
severe thrombocytopenia colonoscopic resection of the polyp is
deferred.
She should follow up with her regular providers, especially
___ and hepatology, for continued outpatient workup of her
anemia.
============== | 161 | 139 |
17833222-DS-28 | 28,929,495 | Mr. ___,
You were admitted with influenza-like symptoms. You received
antibiotics, you will continue this at home. You have been given
a prescription for 5 days of Tamiflu, we are working on a prior
authorization to complete your 28 day course of this antibiotic.
Our case manager will follow up with you early next week in
regards to this. You will be discharge today and your follow up
with Dr. ___ is listed below. | ___ year old male who is s/p MUD ALLO
transplant for AML admitted due to concern for ILI symptoms.
Major complications of transplant have been: chronic extensive
severe GVHD with lung, eye, joint, liver changes. He has had
multiple readmissions for the above complaints.
#Fever with ILI Symptoms: likely ___ viral process more than a
bacterial process. Chest x-ray and UA were unremarkable. Urine
and blood cultures are NTD. Patient refused Flu swab, has
refused
in the past. His history of bronchiolitis obliterans following
stem cell transplant/decreased FVC and FEV1 from most recent
PFTs
in ___ (although he has been stable from a pulmonary
standpoint) increases his risk for bacterial super-infection.
His
exposure as a correction ___ also poses a risk.
-Initiated on Tamiflu (d1: ___ x28D
-Levaquin x 5D for atypical coverage (___)
-continue supportive care; monitor fever curve
#GVHD: chronic, extensive and severe
-lung: continue 1mg Prednisone QOD
-liver: LFTs stable on admission
-oral: continued dexamethasone oral solution
-eye: continued with restasis gtts
#Depression/Anxiety/Insomnia: continued alprazolam 4 mg PO QHS
as
needed and Benadryl 50mg IV prn only during hospital stay
-has history of directing own care, refusing testing, and
overall
being withdrawn/poor communication with staff.
-continue to monitor on this admission
#Infectious prophylaxis:
-PCP: ___: Acyclovir
-Antifungal: None
#DVT Prophylaxis: Lovenox 40mg daily, history of refusal
#Access: PIV. No central access
#FEN: regular diet
#Pain control: none currently
#Bowel regimen: none
#Disposition: home after afebrile >48hrs, f/u ___ or sooner if
issues arise | 73 | 215 |
13840723-DS-19 | 23,384,802 | please call the Transplant Office ___ if you have any
of the warning signs listed below.
-You will need blood drawn every ___ and ___ for lab
monitoring. Labs to be faxed to Transplant clinic at
___
-You may shower, allow water to run over incisions and pat dry.
Do not rub incision, no powder or lotions. No tub baths or
swimming
-Do not lift anything heavier than 10 pounds
No driving if taking narcotic pain medication
There have been several changes to your medications. Please
assure med sheet is up to date and correct with your visiting
nurse, and you fill all new medications and make dosage
adjustments | ___ y/o male who received a liver transplant on ___. The
patient presents with a weekof abdominal pain, worse over the
last few days. An abdominal CT was obtained showing Small bowel
obstruction secondary to probable internal hernia with
obstruction at the level of the jejunojejunostomy. There was
also moderate volume of ascites seen.
The patient was taken on the evening of admission to the OR with
Dr ___ for ___ laparotomy, reduction of internal
hernia and closure of mesenteric defect. At the time of surgery,
from the ligament of Treitz to the terminal
ileum there was a large mesenteric defect between the
jejunojejunostomy. Small bowel had herniated through the defect
and was obstructed. The small bowel was reduced, the hernia
defect closed with interrupted ___ silk sutures. Of note, a
large amount of ascites was removed at time of surgery. He was
stable during the procedure and was transferred to PACU in
stable condition.
The patient was kept NPO with an NG tube in place through POD 3.
Although output was not high, the abdomen remained quite
distended, and the patient was not passing flatus.
On POD 3 the NGT was removed and he was started on sips to
clears over the next 2 days, which were well tolerated. On POD
he had a bowel movement. Diet was advanced to regular and was
well tolerated.
The admission creatinine was 3.2, with his baseline being around
2. The patient was aggressively hydrated on admission, and over
the course of the hospitalization the creatinine was down to
1.2. Medications were adjusted accordingly.
During the hospitalization, the fluconazole was stopped as he
was close to 3 months out.
Blood cultures drawn during the hospital stay have all returned
as no growth. The patient did have a diagnostic tap in the ED
during the admission process which was found to grow
corynbacterium. He received a 7 day of course of Ampicillin, was
afebrile during the entire stay.
A CMV IgG and IgM were sent, he was neutropenic on admission.
IgG was positive at time of transplant, donor was negative, and
as he was at approximately 3 month, the valcyte was stopped at
discharge.
Prograf levels were followed daily and adjustemts made
accordingly. Additionally the patient will be staying on 5 mg
prednisone for pre transplant Dx of autoimmune hepatitis, PCS,
and UC.
TSH was checked as patient had an increase in levoxyl during
last hospitalization. TSH was 0.78, and his dose was decreased.
New TSH level should be checked at the end of ___.
The patient was ambulating, had return of bowel function, was
tolerating diet, less distended abdomen. Incision was C/D/I. He
is discharge to home in ___ with ___. | 105 | 442 |
17774110-DS-8 | 20,726,415 | WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were found to be confused at your clinic appointment, and
sent to the hospital for management of your confusion, as well
as investigation into the new mass seen in your adrenal gland
(sitting on top of your kidney).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given extra doses of lactulose to help improve the
confusion you were having, which was likely due to your liver
disease.
- You had a CT scan of your chest and a bone scan to look for
any other masses in your body.
- You had a lot of blood tests drawn in the hopes that we could
figure out what kind of mass you have in your adrenal gland.
These tests were all normal.
- You grew a bacteria in your blood, but it was not a true
infection. You were on an antibiotic for one day and it was
stopped. You repeat blood cultures had no bacteria.
- You had a biopsy of the mass in your adrenal gland to find out
what it is. The results were not yet back by the time you left
the hospital.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will follow-up with Dr ___ Dr ___ in the liver
tumor clinic.
- Continue to take all of your medicines as prescribed. | ___ with HCV cirrhosis, esophageal varices with history of
bleeding (s/p TIPS on ___, and ___ who presents from liver
tumor clinic with concern for confusion and new adrenal mass.
#ADRENAL MASS: Patient with concerning mass incidentally noted
on imaging. He endorses significant fatigue and weight loss over
the course of > ___ year (weight loss seems intentional). He was
referred into the hospital for expedited evaluation. TSH,
aldosterone, cortisol, ACTH, renin WNL. Normetanephrines just
above upper limit of normal at 0.95, free metanephrines normal.
CT chest w/o metastatic disease and notable for micro nodules,
bone scan negative for metastatic disease as well. Adrenal
biopsy occurred ___, and patient will follow up with oncology
(Dr. ___ and liver doctor (___) on discharge for
further management.
#COAG NEGATIVE STAPH BACTEREMIA: Coag negative staph in ___
bottles from ___. CXR and UA without evidence of infection.
No other evidence for nidus of infection, no recent
instrumentation. No hardware. Recent dental appt but no
extraction or invasive procedure. In the setting of possible
decompensation of liver failure with HE (HE was not apparent on
admission, but was noted in clinic prior to admission), patient
was covered with IV vanc ___. ID was consulted and found that
his overall picture was a contaminant and recommended
discontinuing antibiotic (stopped on ___. Remained HD stable,
febrile, no leukocytosis, no symptoms. Repeat blood cx negative.
#CONFUSION: Patient endorses ___ year of confusion, although is
oriented on neurologic exam without asterixis. TSH and cortisol
normal. There was a question of coag negative staph bacteremia,
as above, but felt to be due to contaminant and patient's mental
status was felt to be at baseline, so do not that there was any
infection nor any acute altered mental status. Maintained ___
BM's per day, no evidence of asterixis throughout admission.
Continued on lactulose (dose changed to 30mg QID), with goal ___
BMs/day.
#HCV CIRRHOSIS:
#ESOPHAGEAL VARICES, s/p TIPS: MELD-NA 10, Child class A. Has
failed HCV treatment with Harvoni and Epclusa plus Ribavirin.
Cirrhosis has been complicated by esophageal varices, which have
bled in the past. s/p TIPS at ___ in ___ TIPS appears patent
on admission RUQ US. No evidence of PVT. History of hepatic
encephalopathy and ascites, currently without enough ascites to
tap. Mild transaminitis is improving, likely ___ untreated HCV.
Continued on home lactulose (dose changed to 30mg QID),
rifaximin, and spironolactone.
#HCC: not yet treated; being seen in liver tumor clinic.
According to liver tumor clinic note from ___, ___ would be
amenable to directed therapy. Concerned that adrenal mass may be
metastatic disease. Will follow up with liver tumor clinic as
scheduled.
#Bipolar disorder: Continued on home aripriprazole, Seroquel,
trazodone, keppra.
#Tobacco abuse: given Nicotine patch, but consistently went
outside to smoke, so the patch was discontinued.
TRANSITIONAL ISSUES
===================
[ ] Adrenal biopsy will be followed-up by liver tumor team.
[ ] Lactulose dose changed to 30mg QID. Can be titrated to
achieve ___ BMs/day. | 221 | 482 |
10131647-DS-21 | 23,709,958 | You were admitted for several serious issues - a pneumonia that
has been treated with antibiotics. Also affecting your lungs and
breathing was a blood clot that had traveled there from your
leg. You were treated with blood thinners and oxygen through
your nose, which improved gradually.
You will need to continue the rivaroxaban. Initially this will
be at 15mg TWICE a day until ___. On ___ you should
switch to the 20mg pill ONCE per day.
Please also take Bactrim as prescribed for a total of three
days, ending ___, for your urinary tract infection.
When you see your primary care doctor, please ask to get a sleep
study to evaluate for obstructive sleep apnea. This is a
condition when your oxygen levels decrease during sleep, and we
saw some evidence for it in the hospital. However, the
evaluation for this condition is tested as an outpatient.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | Ms. ___ is a ___ with past medical history of alcohol use
disorder, COPD, hypothyroidism, seizure disorder,
depression/anxiety who presents as a transfer from ___
s/p multiple falls, found to be acutely intoxicated with
tachycardia, hypoxia, likely pneumonia and concern for
sepsis/septic shock.
ACUTE ISSUES
===========
#Community Acquired Pneumonia
#Sepsis
Patient with possible LLL pneumonia on CXR from OSH. Has been
feeling ill for "few days" prior to admission. Endorsing cough
w/ mucus in chest,
fevers/chills, nausea, diarrhea. lactate elevated to 5 at OSH,
persistently
elevated to 5 in ED here suggesting end organ damage. Admitted
s/p 3L IVF, received additional 2L with downtrending lactate,
BPs stable, never requiring pressors. Received CTX/Levofloxacin
at OSH which was continued. Strep pneumo, legionella, RVP, blood
cultures, urine culture, was found to have GPC growing at OSH.
ID was consulted on the floor and was not concerned by final
cutlure of ___ bottles Strep mitis, which was not found in BID
cultures. On floor transitioned to Ceftriaxone, dropping vanco
(MRSA swab neg) and levaquin. She completed the ceftriaxone
course while inpatient. O2 needs weaned on the floor and she was
breathing comfortably on room air on discharge.
#Sinus tach
PE vs volume depletion vs withdrawal. Persisted despite
withdrawal management and fluids, so thought more likely ___ to
PE. Stables in ___ on discharge.
#Hypoxia
#Multiple Subsegmental PEs
Patient persistently tachycardic to 110-120s despite 5L IVF. EKG
w/ sinus tachycardia. Patient not febrile, not complaining of
pain so CTA Chest obtained which showed filling defects in 2
segmental right middle lobe pulmonary arteries, several
subsegmental arteries of the right lower lobe, segmental artery
in the left upper lobe. PE without clear provoking source, no hx
clots in past, no recent long travel, no known active
malignancy. Started on heparin gtt while in ICU then ultimately
transitioned to po anticoagulation with rivaroxaban, completing
introduction BID dosing at the time of DC. Weaned off O2 and
worked well with ___, recommending home with home ___.
#Intoxication
#Alcohol Use Disorder
Patient w/ history alcohol use disorder, reported heavy alcohol
use recently though patient stating less over last week prior to
admission. EtOH at OSH 380. Was given high dose thiamine,
folate, MVI. Loaded with phenobarb then redosed ___. On floor,
CIWA continued but received no further dosing. No complications
noted.
#Elevated LFTs
Possibly mild alcoholic hepatitis given AST:ALT ratio vs mild
shock liver iso septic shock. Downtrended without issue. No
further workup
#Diarrhea
Unclear chronicitiy, per pt occurs on and off at home. C.diff
negative. Resolved.
#bacteriuria: some burning with urination but there was no
inflammatory reaction in UA. UCx did grow Ecoli with numerous
resistances. ID not concerned and initially elected not to
broaden coverage. However, given persistent symptoms, discharged
with three day course of Bactrim.
CHRONIC ISSUES
=============
#Depression
#Anxiety
-Continued home citalopram, mirtazapine
#Hypothyroidism
-continued home synthroid 75mcg daily, thyroid levels c/w mild
hypothyroid while in house
#Seizure Disorder
Never on AED. Continued to monitor for seizure activity
TRANSITIONAL ISSUES:
======================
RECOMMENDATION(S):
1.A follow up chest CT is recommended in ___ weeks after
treatment of acute pulmonary process taken for resolution.
2. Radiological evidence of fatty liver does not exclude
cirrhosis or
significant liver fibrosis which could be further evaluated by
___. This can be requested via the ___
(FibroScan) or the Radiology Department with either MR
___ or US ___, in conjunction with a
GI/Hepatology consultation" *
Ensure resolution of urinary symptoms s/p antibiotic treatment.
Patient needs sleep study as an outpatient to evaluate for OSA.
PCP follow up scheduled on ___. | 155 | 561 |
11697323-DS-11 | 28,846,818 | Dear ___ and the ___ family,
It was a pleasure caring for you at ___
___. Mrs. ___ was admitted with an infection in
her bloodstream. This most likely originated in her urine. The
infection was very severe and dropped her blood pressures to
levels that were unsafe so we had her on a powerful medicine to
help improve them.
Unfortunately, her mental status, or thinking, remained confused
and she was unable to be taken off the breathing machine. Also,
her kid
After discussions with the family, the decision was made to
transfer Mrs. ___ closer to home to be with family. It was
also decided that she be do not resuscitate.
Thank you for allowing us to participate in the care of your
loved one,
Your ___ Team | ___ yo F with a history of cirrhosis c/b hepatic hydrothorax
presents with acute onset SOB and hypoxemic respiratory failure,
likely secondary to large right sided pleural effusion
complicated by septic shock from urinary source and pulmonary
edema.
# Goals of care: After extended hospital stay with failure to
liberate patient from ventilator, persistant altered mental
status, and worsening renal function unresponsive to albumin
challenge, the decision was made with her brother to transfer
her care to ___ which was closer to her home. This was done
so that family members could visit the patient due to her poor
and grave prognosis. She was also made Do Not Resuscitate. She
remained intubated. After family visits, there will have to be
continued decisions regarding management of her medical
co-morbidities and whether or not to pursue comfort measures
only.
# Hypoxemic Respiratory Failure: Multifactorial in setting of
hepatic hydrothorax with possible secondary infection, heart
failure, or portopulmonary/hepatopulmonary syndrome. Patient
was intubated prior to arrival, was started on broad-spectrum
antibiotic coverage (vancomycin/meropenem/levofloxacin), was
diuresed, and underwent thoracentesis (diagnostic but with
additional large amount of fluid remova). Patient remained
intubated through discharge due to poor mental status precluding
liberation from ventilator.
# Septic Shock from Urinary Source: Patient presented with T103
and very high band count with positive OSH urinalysis.
Eventually found to be growing Klebsiella, Enterococcus, and
___ from her urine and klebsiella bacteremia. She
was initially on broad-spectrum antibiotics and narrowed to
ceftriaxone alone based on sensitivities under Infectious
Disease consult guidance. Ascites fluid and pleural fluid did
not grow any organisms and ___ blood/urine cultures remained
negative. She was discharged on 0.4mcg/mcg/min of phenylepherine
for continued blood pressure support.
# Altered Mental Status: Remained minimally responsive
throughout hospitalization despite minimal sedation. Lactulose
was trialed without improvement in her mental status. She was
discharged without sedation. NCHCT was negative for acute
intracranial process. EEG was not read at time of discharge -
this was because of the desire to transfer Mrs. ___ closer to
home.
# Acute kidney injury: At first thought to be from over-diuresis
due to aggressive diuresis. However, her renal function failed
to improve after albumin challenge. Thus, she likely has HRS.
# Cirrhosis: Patient with newly diagnosed cirrhosis of unclear
etiology on ___ complicated by thrombocytopenia, hepatic
encephalopathy with paranoid/agitated delirium, and hepatic
hydrothorax presents with MELD 20. Patient had unchanged RUQ
ultrasound, was given albumin for volume resuscitation as
needed, was given lactulose/rifaximin with some improvement in
mental status, diagnostic paracentesis not suggestive of SBP
when WBC was corrected for RBC, and was seen by Hepatology would
did not recommend TIPS for hepatic hydrothorax treatment.
# Guaiac-Positive Stool: Noted at OSH to have guaiac-positive
stool (brown with some red around the other stool) but with
hemoglobin improved from prior discharge (Hgb 10 from 9). She
was started on pantoprazole BID. She was transfused on ___
for dropping H&H in an attempt to help her remain stable for
transfer to ___.
TRANSITIONAL ISSUES:
--------------------
# Communication: ___ (brother/HCP) at ___ or
___
# Code: DO NOT RESUSCITATE/okay to intubate (as she is
intubated)
# Will need further discussion regarding goals of care - made do
not resuscitate and family decision will be made regarding
further care once everyone is together at ___ where she was
transferred to | 128 | 556 |
11258973-DS-14 | 20,079,955 | Dear Mr. ___,
You were admitted to the cardiology service at ___ for
management of your heart attack. For this, you received a
cardiac stress test which showed some abnormalities consistent
with a heart attack, and a pacemaker to keep your heart rate
stable. | Hospital course by problem:
# NSTEMI. No previous EKG for comparison on admission. EKG with
T wave inversion and STD changes in the inferolateral leads and
heart block. Trop positive x3 (first one was in ___, here
0.77, 0.56. Patient received ___ (unclear dose) and heparin gtt
prior to arriving ___. Bradycardic but HDS on admission.
Patient denied ever experiencing chest pain and denied chest
paint throughout his hospital stay. Patient underwent exercise
stress test with mibi perfusion showing decreased in SBP 30mmHg
on exercise with uniform tracer uptake (see results section for
full report). Given patient's age and the fact that he is and
always has been asymptomatic, we did not proceed with cardiac
cath in favor of medical management of CAD with Beta blocker,
Aspirin, and statin. The patient received IV vancomycin fo 48
hours post pacemaker placement and was switched to ___
clindamycin on discharge per EP recommendations. He continued on
his home dose lasix ___, atorvastatin while in hospital. His
lisinopril was reduced to 2.5mg and his imdur was discontinued
due to some low blood pressure (SBP to ___ the day prior to
discharge. With these medication changes, his BP improved to
110s systolic. We also added low dose metop XL to his regimen.
# Fall. Patient presented to ___ s/p fall with deltoid
laceration. His troponins and EKG findings (see above) were
found incidentally, which prompted his transfer to ___. Based
on history, the fall was likely mechanical in nature. No LOC.
Patient did not hit his head and CT head was negative for bleed.
He had no complaints of chest pain or SOB during or after fall.
___ evaluation was done and determined that patient should be
discharged to an extended care facility.
Bradycardia - because of multiple conduction abnormalities seen
on ECG and monitoring, the decision was made to place a dual
chamber pacemaker. This was done without significant
complication. He will follow up with device clinic for wound
check and continued pacemaker evaluation.
# Skin tear, ___ fall - patient received appropriate wound care
with improvement in deltoid laceration
TRANSITION OF CARE
- follow up with primary cardiologist and device clinic | 43 | 360 |
16177747-DS-53 | 24,781,811 | Dear Mr. ___,
You were admitted to the hospital for sickle cell vaso-occlusive
crisis. You did not have evidence of acute chest syndrome or
pneumonia on imaging or on labs. Your blood counts were low, so
you were given a blood transfusion and your blood counts were
stable after that. Your pain was treated with a PCA initially
and you were eventually transitioned back to oral pain
medications.
Your primary care doctor (___) was contacted and
informed of this hospital stay. You should follow up in his
office next week as detailed below.
Best of luck with your continued healing.
Take care,
Your ___ Care Team | Mr. ___ is a ___ male with history of Sickle Cell
Disease with frequent admissions for sickle cell
pain crises status post surgical splenectomy, recurrent episodes
of acute chest syndrome, AVN of L femoral head with chronic hip
pain, and history of R parietal intraparenchymal hemorrhagic
stroke complicated by seizure disorder, who presents with chest
pain back pain and abdominal pain consistent with acute
vaso-occlusive crisis. | 104 | 65 |
11441366-DS-17 | 20,659,200 | Dear ___,
We are so sorry for your loss. You were admitted to the
gynecology service after your procedure, and for treatment of an
infection in your uterus called chorioamnionitis. You have
recovered well and the team believes you are ready to be
discharged home. Please call Dr. ___ office with any questions
or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* No intercourse and nothing in the vagina until your follow up
appointment (at least 6 weeks).
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the gynecology
service after undergoing a D&E complicated by chorioamnionitis
for preterm labor. She was given 20 units of pitocin and 200ug
methergine in the OR.
Please see the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with tylenol and ibuprofen. She
was continued on her antibiotics for her diagnosis of
chorioamnionitis.
By post-operative day 1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. However, she continued to have
fundal tenderness with intermittent tachycardia. At that time
the decision was made to prolong her antibiotics to a total of
48 hours after presentation.
Early morning on POD2, she endorsed some midline positional
chest pain, only present when lying flat on her back in the
setting of a large meal prior to sleeping. Her evaluation was
benign and was given some heart burn medication with resolution
of her symptoms.
On POD2 the patient continued to do well and without any chest
pain or other concerning symptoms. She no longer had fundal
tenderness, was no longer tachycardic and after completing her
48 hours of antibiotics, she was then discharged home in stable
condition with outpatient follow-up scheduled. | 119 | 208 |
14020151-DS-41 | 28,315,577 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were feeling
confused because of your liver disease.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were started on lactulose and your confusion resolved
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 3 pounds
- Please maintain a low salt diet and monitor your fluid intake
- Please make sure to take lactulose as prescribed to avoid
mental status change. As discussed, you can mix lactulose with
foods you like.
- Seek medical attention if you have new or concerning symptoms
or you develop
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY
Ms. ___ is a ___ year old female with history of Child B
NASH cirrhosis decompensated by portal hypertension and ileal
variceal bleed post TIPS presenting with 48 hours of increasing
somnolence and confusion concerning for hepatic encephalopathy
in the setting of holding home lactulose. | 188 | 46 |
16958025-DS-11 | 24,701,244 | Dear Mr. ___,
You came to the hospital because you were confused and you were
unable to walk. We were initially concerned that you had an
infection of your brain, but it was ultimately determined by a
brain biopsy that you had brain cancer. After discussion with
your family, it was felt that you would prefer to focus on
comfort rather than undergo treatments such as chemotherapy,
which would not be able to cure the disease. You went home on
hospice, where you can be with your family and your care can be
focused on comfort and quality of life.
Sincerely,
Your ___ Care Team | ___ w/ PMHx of NPH s/p Right VPS, HTN, undefined neurocognitive
disorder, recurrent PE (now off DOAC), recent admission for
collapsed right ventricle and VPS adjusted, now p/w
encephalopathy and imaging findings c/f meningitis c/b brain
abscesses and subacute strokes, however no signs of recovery on
broad spectrum antibiotics and ultimately underwent brain
biopsy, which diagnosed high grade glioma, after which patient
was transitioned to comfort care and discharged to home hospice.
# Encephalopathy
# Glioblastoma
Initially his encephalopathy was assumed to be ___ oxycodone,
however the patient had ___ positive blood cultures with CoNS
which raised suspicion for VP shunt infection. He was started on
vanc/cefepime/Bactrim/acyclovir for empiric coverage. A bedside
LP was attempted and was unsuccessful. ___ performed a guided LP
which was grossly bloody, w/ lymphocytic predominance and high
protein c/f viral/fungal meningitis. However, no specific micro
data resulted. Due to an unwitnessed fall, he had a CT head that
showed a subacute infarct which prompted more imaging. His MRI
brain w/ & w/o contrast showed findings of meningitis,
cerebritis, multiple brain abscesses and concern for septic
emboli. At that point, TTE didn't show vegetations and a CTA
Head/Neck w/o carotid stenosis. His mental status didn't improve
after a week of antibiotics. There was concern that one of the
lesions in the MRI could represent malignancy, so a brain biopsy
was performed, which ultimately revealed glioblastoma. After
extensive discussion with the neurooncology service, the family
decided that the patient would prefer comfort care. He was
discharged home on hospice. At the time of discharge the
patient was intermittently oriented x3 but with waxing and
waning of mental status and drowsiness. Mostly comfortable
except intermittent nausea and headache.
#Nausea
- mostly mild and intermittent; zofran and reglan available
#Headache
- mild, intermittent, and responsive to tylenol
#Urinary Retention
- Foley kept in place for comfort
# HTN
- Stopped antihypertensives
# Depression
- Continued home citalopram, seroquel
# GERD
- Stopped home omeprazole
# Hypothyroidism
- Continued home levothyroxine
>30 minutes in patient care and coordination of discharge | 103 | 328 |
11763197-DS-14 | 28,316,654 | YOU WERE HOSPITALIZED FOR TREATMENT OF ULCERATIVE COLITIS. YOU
RECEIVED A FIRST ___ OF INFLIXIMAB ON ___. YOUR SECOND ___
SHOULD BE AROUND ___. YOU WILL TAPER YOUR STEROIDS BY 10MG
FOR THE FIRST WEEK, YOU ARE ON 60MG PREDNISONE AS OF ___
(DECREASE TO 50 MG ON ___. AFTER THAT DECREASE YOUR ___ BY
5 MG EVERY WEEK. IF YOU DEVELOP ABDOMINAL PAIN, WORSE DIARRHEA,
FEVER YOU NEED TO SPEAK WITH A DOCTOR IMMEDIATELY.
YOU ARE BEING TREATED FOR LATENT (NOT ACTIVE) TUBERCULOSIS. YOU
ARE TAKING INH AND B6 VITAMIN DAILY FOR THIS FOR 9 MONTHS OF
TREATMENT. YOU WILL NEED REGULAR BLOOD WORK INCLUDING CBC AND
LFTS TO MONITOR YOUR LIVER FUNCTION AND BLOOD COUNTS WHILE ON
THIS (LABS APPROX ONE A MONTH)
YOU HAVE HAD PRIOR HEPATITIS B, BUT YOU ARE CONSIDERED IMMUNE.
HOWEVER, WITH INFLIXIMAB THIS IMMUNITY CAN BE WEAKNED. THUS YOU
WILL NEED TO HAVE BLOOD WORK TO MEASURE THE LEVEL OF THIS
ANTIBODY (TITERS) TO MAKE SURE YOU REMAIN IMMUNE AND THAT
HEPATITIS B DOES NOT REACTIVATE. THIS SHOULD BE DONE EVERY ___
MONTHS.
YOU WERE TREATED FOR A STAPH BLOOD STREAM INFECTION. THERE IS
NO INDICATION OF A CARDIAC INFECTION. YOU FINISHED IV
ANTIBIOTICS ON ___.
.
MEDICATION CHANGES: SEE NEXT PAGE | .
___ yo w/ulcerative colitis presents from ___
___ in ___ for evaluation and treatment of a
UC flare refractory to steroids.
.
# moderate to severe UC
He underwent evaluation by GI and ___ surgery with a
plan to manage him medically. Steroids were continued with IV
Solu-Medrol and hydrocortisone enemas. Infectious stool studies
(cdiff, culture, O+P, crypto) were all negative. He underwent
flex sig on ___ with the following findings: Diffuse erythema,
congestion, ulceration, with old blood in lumen. The disease
appeared worse more proximal than in the distal rectum with
otherwise normal sigmoidoscopy to descending colon. His biopsy
showed chronic moderately active colitis, without granulomata or
dysplasia identified and no evidence of CMV colitis, despite a
serum CMV VL of 1,200 copies. Given this biopsy, she was not
treated with ganciclovir. His symptoms continued to improve and
his stools returned to ___ at a quantity of about 5 a day
(2 of which followed his enemas). The patient had been started
on vitamin C/iron for microcytic anemia and he had a increased
stool output. This resolved the next day following
discontinuation of the vitamin C and supportive care. The
patient was transitioned to po steroids several days prior to
his discharge and he tolerated this well. Our plan is to taper
his ___ by 10mg weekly until he gets to 20mg, and then taper by
5mg weekly. If the patient has a longer course of prednisone,
proton pump inhibitors should likely be started for ulcer
prophylaxis. The patient received his first loading ___ of
Remicade on ___ (5mg/kg), and his repeat ___ would be on
___, and then 4 weeks after that. His hydrocortisone
enemas where discontinued prior to discharge.
.
# Latent TB
He had two INDETERMINATE guantiferonGOLD assays for latent TB
and his CXR did not show any infiltrates or lesions. With the
input of ID consultation, he was started on INH therapy for
treatment of possible latent TB given prior epidemiological
exposures. Started INH 300mg qd with B6 (pyridoxine) 50mg qd on
___. He should have monthly LFTs monitored. Plan for 9
months of therapy.
.
# line related s. lugdunensis bacteremia
He was diagnosed and treated for a catheter related bacterial
infection with growth of staph LUGDUNENSIS growing on cultures
on ___. His L IJ placed at the OSH was the suspected source
and it was immediately removed. He received empiric vancomycin
and then nafcillin when sensitivities were known. He underwent
TTE and TEE both negative for endocarditis or vegetations. A
PICC line was placed but then removed given the concern that he
may have still bacteremic since there was a gap in the time till
his blood cultures were repeated on ___ (negative). This PICC
was removed and he had no central lines for 48hrs and then a new
PICC placed on ___ for access to complete his IV antibiotics
which ended on ___ (2 week course from ___. All
subsequent blood cultures were negative.
.
#normocytic anemia
The patient presented with a Hgb between ___. The patient had
symptoms of fatigue which gradually improved over the course of
his treatment. The patient also experienced some mild dizziness
after ambulating in the setting of a Hgb of 7.1. The source of
this was thought to be slow GI related blood loss with a
component of anemia of chronic disease. As a result it was
decided to transfuse the patient 2 units of PRBC's. He
tolerated this well. He will be discharged on iron 3 times a
day.
.
# HBV exposure
His Hep B serologies show prior cleared infection with positive
HBVcAb, positive HBVsAb, negative HBVsAg. His HBV and HCV viral
loads are negative. His HBsAb titer is between 100-500 IU/mL.
Plan was to watch this every 3 months and start lamivudine if
titer dropped to ___ IU/mL.
.
# TRANSITIONAL ISSUES
[]MONTHLY LFTS WHILE ON INH
[]INH WITH B6 FOR LATENT TB 9 MONTH COURSE TO END ON ___
[] HbsAb titers every 3 months
[]continue Remicade dosing and prednisone taper-consider adding
a proton pump inhibitor for ulcer prophylaxis
[] Follow up with ___ physician and PCP in ___ and re-check a
CBC in ___ weeks and have it faxed to these physicians-his GI in
___ is Dr. ___ is ___
. | 221 | 731 |
10349029-DS-12 | 27,420,021 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for abdominal pain, vomiting,
and diarrhea. You were found to have Clostridium difficile
colitis. You were started on Vancomycin oral antibiotics, and
should also take probiotics when you leave the hospital.
It is important that you keep all follow up appointments, and
take all medications as prescribed. | The patient is a ___ woman with distant history of gastric
volvulus s/p repair, s/p appy and s/p cholcystectomy, recent
admission for ischemic colitis ___ and also with history of
prior C.Diff colitis who presents now with abdominal pain,
vomiting, and diarrhea, found to be C diff positive.
# C diff infection: likely causing abdominal pain, nausea,
diarrhea. The patient has a prior h/o C diff infection, and per
daughter she was told she had to take oral Vancomycin for that
infection. Since this represents a recurrent infection and the
patient required Vancomyin during last infection, we decided to
pursue PO vanc as treatment. GI also saw the patient and
recommends probiotics as well upon discharge. The patient was
able to tolerate a BRAT diet upon discharge, and pain was
greatly improved since admission. First day of oral Vancomycin
therapy was ___.
- Oral Vancomicin 125 mg Q6 for 2 weeks, followed by a taper (1
weeks of BID the 1 week QD). Thus, the patient will get a total
of 4 weeks of therapy including the taper. First day of therapy
was ___.
- Supplement with probiotics: Florastor (Take two sachets daily
during treatment with Vancomycin and once daily thereafter)
# Colitis: Recent CTA scan did not show evidence of ischemia,
lactate not elevated. IV fluids were continued in the hospital
to prevent ischemia from developing in the setting of
dehydration. HCTZ was held. The patient was also found to have
guiac positive stool. Patient was diagnosed with iron
deficiency. Because of the prior noted CT findings of extensive
colitis in ___ in ABSENCE of C.diff or mesenteric stenosis,
GI was consulted. They recommended outpatient follow up once
acute C diff infection resolved, and further discussion of the
need for colonoscopy vs flex sigmoidoscopy. The patient was also
started on iron supplimentation.
# Dirty UA: UCx shows contamination. No Sx of UTI
- no treatment indicated at this time
# PUD: Chronic, stable
- Hold off on Omeprazole 40mg BID given C.Diff
# CAD, stable angina: No acute changes in SOB or chest pain.
- hold HTN meds (See below)
- maintain hydration
# HTN: Chronic, stable. Held HCTZ and metoprolol on admission
given concern for prior ischemic colitis, and current
dehydration. Her BP remained well controlled without either of
these medications. Metoprolol was restarted at home dose and
HCTZ was continued to be held.
- recommend holding HCTZ indefinently given history of
questionable ischemic colitis and well controlled BP on
metoprolol
- Coninue Aspirin 81 mg PO DAILY
# HYPOTHYROIDISM: Chronic, stable
- Continue Levothyroxine Sodium 75 mcg PO DAILY
# DEPRESSION: Chronic, stable
- Continue Citalopram 20 mg PO DAILY
# HLD: Chronic, stable
- Continue Simvastatin 20 mg PO DAILY
# PPX: heparin SQ, hold off on bowel regimen given diarrhea
# CODE: DNR/DNI(confirmed with patient and HCP)
# CONTACT: Daughter and HCP ___ ___,
___ Son ___ ___
TRANSITIONAL ISSUES
- F/U with GI once infection resolved
- follow up with PCP | 61 | 504 |
18215220-DS-4 | 24,923,728 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted after you lost consciousness
while getting your nails done. Upon admission, you were seen by
the Neurology team and imaging of your head was performed which
did not show any evidence of stroke. Your heart rhythm was
normal and there was no evidence of cardiac damage. It is likely
that your symptoms were a result of a "vagal" response that was
triggered by putting your feet into the warm water.
Specifically, this a benign condition that is characterized by
lightheadedness, sweating, feeling nauseas, and can lead to
fainting. Your symptoms improved without any further episodes.
Please follow-up with your primary care provider for further
management.
Best Wishes,
Your ___ Team | Brief Hospital Course:
Ms. ___ is a ___ year old female with PMH HTN, breast
cancer s/p XRT and lumpectomy, and known thyroid nodule who
presented to the ED following a syncopal episode likely
vasovagal in nature. Specifically, the patient suffered sudden
loss of consciousness when placing her feet in warm water when
getting a pedicure. Had associated diaphoresis, but no preceding
palpitations, nausea, vomiting, changes in vision. No post-ictal
confusion or bowel or bladder incontinence. Neurology consulted
and neuro exam unremarkable (has known left sided ptosis and
pupillary dilation following cataract surgery). ___ negative
for intracranial process. Cardiac w/u negative. No
signs/symptoms of infection and no leukocytosis. Monitored on
telemetry without events. Likely vasovagal in the setting of
placing feet in warm water. Plan to follow-up with primary care
physician ___ further management.
Of note, the patient an episode where she thought the people in
the television were speaking to her. Neuro consulted and deemed
to be a fixed delusion secondary to reduplicative paramesia.
Specifically, this condition arises from hypoperfusion of the
frontal lobes as a result of longstanding hypertension and
microvascular disease. Per their recommendation, no need for
further neurologic work up or neuro imaging. | 128 | 196 |
18585502-DS-8 | 27,156,395 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or,
if applicable to you, the indwelling ureteral stent. You may
also experience some pain associated with spasm of your ureter.
-The kidney stone remains in place; you will follow up with Dr.
___ definitive ___
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urinethis, as noted above, is expected and will gradually
improvecontinue to drink plenty of fluids to flush out your
urinary system
-Resume your pre-admission/home medications EXCEPT as noted.
-You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care doctor.
-IBUPROFEN (the active ingredient of Advil, Motrin, etc.) may be
taken even though you may also be taking ACETAMINOPHEN
(Tylenol). You may alternate these medications for pain control.
-For pain control, try TYLENOL FIRST, then the ibuprofen (unless
otherwise advised), and then take the narcotic pain medication
(if prescribed) as prescribed if additional pain relief is
needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that may
be health care spending account reimbursable.
-Docusate sodium (Colace) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated | Mr. ___ was admitted to ___ for urgent
decompression after fluid resuscitation and pharmaceuticals
failed. He was admitted with left obstructing stone and acute
kidney injury and underwent cystoscopy with urethral dilation
and left retrograde ureteral pyelogram and left double-J stent
placement. He tolerated the procedure well and recovered in the
PACU before transfer to the general surgical floor. See the
dictated operative note for full details. Overnight, the patient
was hydrated with intravenous fluids and received appropriate
perioperative prophylactic antibiotics. On POD1, catheter was
removed and he voided without difficulty. Mr. ___ was then
discharged to home with oral pain medications, tolerating
regular diet, ambulating without assistance, and voiding without
difficulty. He was given explicit instructions to follow up
with Dr. ___ as the indwelling ureteral stent must be
removed and or exchanged and definitive stone management
addressed. | 351 | 141 |
18082168-DS-7 | 27,917,683 | Dear Ms. ___,
It was our pleasure to care for you at ___.
You came to the hospital because of low blood pressure, diarrhea
and vomiting.
WHAT HAPPENED IN THE HOSPITAL?
- you received IV fluids and nutrition via the IV (TPN) with
improvement of your blood pressures and electrolytes
- you were treated symptomatically for your diarrhea (including
supplementing nutrition via the IV) which improved
- you were diagnosed with a blood clot in the R leg and were
started on a different blood thinner
- you had fluid removed from your belly (paracentesis) and
received medications to help reduce swelling in your legs
- you were diagnosed with an enzyme deficiency (UGT1A1) and as
such, received a round of chemotherapy (FOLFOX) without
irinotecan
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with your oncologist Dr. ___
- continue to take your medications as directed
- watch closely for signs of bleeding including
lightheadedness/dizziness, blood in stool, black stools; please
call the oncology office (___)
We wish you all the best!
Sincerely,
Your care team at ___ | ___ with history of metastatic pancreatic adenocarcinoma on
FOLFIRINOX and recent admission for N/V/D who presents with
hypovolemic shock in the setting of recurrent nausea, vomiting,
diarrhea after therapeutic paracentesis. In the ED, she was
found to be hypotensive so was given 2L IVF, started on
Vancomycin + Cefepime + Flagyl, bedside U/S without evidence of
ascites, and a CT A/P which showed complete occlusion of her
portal vein with cavernous transformation and possible focal
superior mesenteric vein branch thrombosis with diffuse
small/large bowel edema and 2 linear areas of hypoenhancement in
right kidney c/f pyelo versus tiny infarcts. Patient was
initially admitted to the MICU for undifferentiated shock. She
briefly received vasopressors in addition to aggressive volume
resuscitation and broad-spectrum antibiotics in the setting of
neutropenia. Her blood pressure improved she was transferred to
the oncology hospitalist service on ___.
Her hospital course was complicated by persistent diarrhea for
which GI was consult. She was started on antidiarrheal
medications and TPN with gradual improvement of her symptoms.
___ was consulted for possible intervention on her portal vein
thrombus/SMV thrombus given suspicion for clot burden
contributing to bowel edema and subsequent diarrhea. ___
deferred intervention given repeat imaging showing decreased
size of thrombus in the main portal vein and recommended
continued anticoagulation. Patient was transitioned from a
heparin drip to Lovenox and an antifactor Xa was noted to be
slightly low. In setting of thrombocytopenia and anemia likely
___ recent chemotherapy, patient was discharged on 50mg/kg BID
of lovenox with instructions to follow closely in outpatient
___ clinic.
# Diarrhea:
Improved. Likely multifactorial including tube feeds, portal
vein thrombus leading to bowel wall edema and resulting
malabsorption, and chemotherapy (irinotecan). Infectious studies
negative. GI consulted and suspect large component of diarrhea
related to worsening PVT causing venous outflow obstruction
leading to extensive bowel wall edema causing inability to
absorb fluid contained in intestines. Repeat imaging showed
persistent but decreased size of thrombus in the main portal
vein.
-UGT testing revealed that she likely has decreased UGT1A1
enzyme levels conferring increased sensitivity to irinotecan,
which may explain why her diarrhea worsened significantly s/p
chemotherapy administration
-c/w lomotil, loperamide PRN
-Feeds attempted = ___ most recently x4 days, Vivonex
Elemental prior to that, and vital 1.5. No difference in
diarrhea between each formulation
-Tube feed holiday started ___ with improvement of diarrhea
-c/w TPN, will require on discharge
-c/w lovenox for PVT
# Malignant Ascites:
Has required paracentesis with cytology positive for malignant
cells. Also worsening portal vein thrombus likely contributing.
- Monitor and drain PRN, s/p ___ para ___
# Non-Anion Gap Metabolic Acidosis:
Resolved. Likely due to diarrhea. Responded well to intermittent
bicarb administration
- weekly ___ as outpatient while on TPN
# Hypokalemia:
# Hypophosphatemia:
# Hypomagnesemia
Resolved. Secondary to diarrhea and malnutrition
- weekly ___ as outpatient while on TPN
# Nausea/Vomiting:
___ have be related to ascites vs. chemotherapy vs. tube feed
intolerance, has since resolved
- zofran, compazine and ativan PRN
# Cancer-Related Abdominal Pain:
Due to tumor burden and also portal vein thrombus.
- Continue PO dilaudid PRN
# Febrile Neutropenia
Resolved.
- Monitor for fevers
- s/p neulasta support following this round of FOLFOX
# Portal Vein Thrombus:
# Superior Mesenteric Vein Branch Thrombosis:
# Right Peroneal Vein DVT:
Abdominal CT on admission noted worsening of PVT. Bilateral
LENIs showed right peroneal DVT. Given diarrhea in outpatient
setting patient may have had ineffective absorption of apixaban
leading to clot progression
- s/p heparin gtt, started on lovenox BID, anti-factor Xa level
subtherapeutic, will recheck as outpatient with oncologist given
concern for supratherapeutic dosing in setting of low weight and
thrombocytopenia
# Anemia in Malignancy:
# Thrombocytopenia:
Secondary to malignancy and chemotherapy. DIC and hemolysis labs
negative. Counts stable though noted to be decreasing after most
recent round of chemotherapy
[] will require CBC w/ diff on ___ with results to be faxed to
outpatient oncologists office (Dr. ___
- ___ for Hb<7, plt<10
# b/l ___ edema
In setting of severe malnutrition and hypoalbuminemia as well as
R DVT c/f PTS. Received intermittent diuresis with albumin
support with improved edema
# Severe Protein Calorie Malnutrition:
In setting of weight loss, muscle depletion, and decreased PO
intake. Feeds attempted = ___ most recently x4 days,
Vivonex Elemental prior to that, and vital 1.5. No difference in
diarrhea between each formulation
- continue TPN as outpatient
- Multivitamin daily
# Metastatic Pancreatic Adenocarcinoma:
# Secondary Neoplasm of Liver:
# Secondary Neoplasm of Lung:
Previously on palliative FOLFIRINOX. CA ___ Downtrending.
- s/p FOLFOX (Day ___ as per outpatient oncologist, s/p
neulasta after this cycle
- will follow up with Dr. ___ 1 week after discharge on
___
# Coagulopathy:
Elevated INR likely secondary to malnutrition. She is s/p
Vitamin K 5mg IV x 3 days with improvement.
# Mucositis
- Viscous lidocaine and magic mouthwash PRN
# Fatigue
- c/w Dexamethasone 1mg daily
# GERD
- Continue home PPI
- Continue simethicone
# Pancreatic Insufficiency
- Continue home Creon with meals and snacks
# Hypothyroidism
- Continue home levothyroxine
# Peeling of hands
In setting of chemotherapy
- hydrocortisone ointment PRN
# Hemorrhoids
- HC ointment PRN | 170 | 808 |
10864697-DS-16 | 20,366,935 | Ms. ___,
You were recently hospitalized at ___ for an infection of
your kidney, called pyelonephritis. Your pain was treated with
medications, and you were given antibiotics through an IV. We
additionally gave you medicine to help with your neck pain. We
continued your coumadin and gave you heparin to help with your
anticoagulation, as your INR was low. Please take all your
medications as described below and attend all follow-up
appointments as scheduled. You will see the urologist as an
outpatient for further workup.
You should have your INR checked on ___ and have it
faxed to your primary doctor. Do not stop Lovenox until you are
told to do so. Again, it was a pleasure taking part in your
care.
-Your ___ Care Team | ___ is an ___ F with a PMHx of paroxysmal a fib,
recent L MCA stroke, HTN and HLD who presented with 1 wk of L
sided abd pain and severe HA x2d found to have severe
hydroureteronephrosis.
#Pyelonephritis: Pt with L sided abd pain, nausea and vomiting
with severe L sided hydroureteronephrosis on CT scan w/o obvious
obstructing etiology but c/f enhancing lesion at UVJ with
evidence of UTI consistent with a complicated pyelonephritis. At
this time ddx for possible obtruction at UVJ include impacted
stone vs malignant mass vs less likely polyp. Pt with remote hx
of smoking and no personal hx of kidney stones, also with
pulmonary nodules on CT c-spine concerning for mets. Pt also
requiring lido patches to L lumbar area possibly MSK in origin
though this is a dx of exclusion at this time given more
worrisome GU pathology. Urology was consulted who noted that
both kidneys were draining contrast appropriately on CT. They
were initially concerned for neurogenic bladder as the cause,
however the patient had very low post-void residuals. She was
treated with ceftriaxone in the interim given her clinical signs
of pyelonephritis. Her creatinine remained at 0.5 during her
admission, without evidence of kidney disfunction. The patient's
pain was controlled with tylenol. Cx results from patient's
initial diagnosis of urinary tract infection revealed e.coli
sensitive to bactrim, fluoroquinolones, and cephalosporins.
Given that the patient was also on propafenone, it was decided
to complete her course with bactrim as an outpatient, and to
have the patient follow-up with urology as an outpatient for
possible future cystoscopy vs ultrasound.
#HA/neck pain: pt with x2 days of severe HA and neck pain, noted
visual changes but no photosensitivity. DDx included meningitis
vs SAH vs GCA vs malignancy vs mastoid sinusitis. Pt initially
tender over temporal arteries with limited flexion of her neck,
however this quickly improved on HD2 with transdermal lidocaine
patches and was believed to be secondary to MSK stiffness and
strain rather than an underlying rheumatologic or infectious
process.
#Afib/flutter- pt s/p ablation procedure EKG in NSR with PAC's
and recent ischemic stroke, with strong suspicion for cardiac
origin. Pt was recently d/c'd off ASA but kept on coumadin.
Coumadin was stopped in the setting of cipro tx per her PCP. INR
1.3 on admission. The patient continued to be in NSR on
telemetry during her admission, and a heparin drip was started
while she bridged to an appropriate INR. The patient was
transitioned to lovenox subcutaneous shots to continue bridging
therapy as an outpatient. Her propafenone was continued while in
house for rhythm control.
#Elevated alk phos, transaminitis- Pt with elevated liver
function tests, most prominently alkaline phosphatase and GGT
which are markedly elevated, concerning for possible primary
biliary cirrhosis. However, AMA was negative. Imaging including
RUQ US and CT scan showed no evidence of disease. She should
have her LFT's re-checked to evaluate for resolution and further
work-up at PCP discretion including ___.
#Anemia: baseline hemoglobin ___, hgb 9.7 on admission,
without evidence of active bleeding from GI source or otherwise.
Recent iron studies with elevated ferritin, concerning for AoCD.
Likely decreased production, reticulocyte studies showed
hypoproliferation in the setting of anemia. Concerning for
possible myeloproliferative process given occasional tear drop
cells on red cells. Her hemoglobin remained stable throughout
her admission.
#Pulmonary nodules: noted on CT c-spine, pt with h/o BOOP, CXR
on ___ poor film quality and nodules not noted at that
time. Concerning for scar from previous BOOP vs malignant
process. Pt should have dedicated chest imaging in AM CXR vs CT
#Pancreatic mass- As seen on CT abd/pelvis, appears c/w ___,
___ need f/u imaging as outpatient. Low suspicion for cause of
elevated Alk phos.
#HTN: pt mildly HTN during admission without need for
pharmacologic intervention.
#HLD/ history of stroke: pt was re-started on coumadin and
bridged with heparin as above. The patient's aspirin was
discontinued and her home gabapentin was continued for
post-stroke nerve pain.
TRANSITIONAL:
-Last day of bactrim ___, dose adjusted because of coumadin per
pharmacy
-Will need dedicated Chest CT to further evaluate her pulmonary
nodules noted on C-Spine CT
-Pt with elevated liver function tests, alkaline phosphatase and
GGT, concerning for possible primary biliary cirrhosis. She
should have her LFT's re-checked to evaluate for resolution.
Her imaging here was negative. Consider ___ as outpt.
-Pt will be discharged on lovenox to contiue bridging to
coumadin until she is at therapeutic goal of ___, will continue
taking 2mg coumadin QPM during this bridge. Will need INR
checked ___ and faxed to ___ Attn: Dr
___, patient with hypoproliferative anemia with normal MCV
concerning for anemia of chronic disease, with recent elevated
ferritin so unlikely d/t iron deficiency.
-Pancreatic mass- As seen on CT, appears c/w ___
# Code Status: DNR/DNI
# Emergency Contact/HCP: ___ ___ | 132 | 792 |
12789108-DS-21 | 24,302,134 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You were unable to take your insulin and your blood sugar
was too high, something called Diabetic Ketoacidosis or DKA.
What happened while I was in the hospital?
- You received insulin until your blood sugars was normal.
- You spoke to financial assistance and social work to ensure
that you will have better access to medications and insulin in
the future.
- You left prior to securing you insulin scripts and
consequently you left against medical advice
What should I do once I leave the hospital?
- Take your medications as prescribed, and call your primary
doctor if you have trouble accessing insulin.
- Follow up with your doctor appointments below.
- Check your blood glucose regularly, before meals.
We wish you the best!
Your ___ Care Team | SUMMARY:
========
___ y/o male with a history of DM1 and multiple prior episodes of
DKA presenting with weakness, abdominal pain, nausea, and
vomiting in the setting of not taking insulin for 24 hours,
found to have DKA. He was admitted to MICU and treated with
insulin drip, IV hydration, and electrolyte repletion as needed.
___ Diabetes team was consulted and assisted with insulin
titration. ICU course complicated by persistent abdominal pain
and nausea preventing ___ from taking adequate po. Insulin
drip able to be discontinued and ___ maintained on
subcutaneous insulin regimen starting ___.
ACTIVE ISSUES:
==============
# Discharge:
Attempts were made to obtain scripts for insulin with the help
of social work, case management and the financial aide office.
These were unsuccessful as of ___. Despite not having secure
scripts ___ chose to leave and because he did not have
insulin scripts this was against medical advice. ___ stated
he would go to ___ on ___ to obtain insulin.
# DKA
# Type 1 Diabetes
___ initially presented with nausea, vomiting, abdominal
pain, muscle pain, and fatigue after not taking insulin for 24
hours. Found to have laboratory evidence of hyperglycemia,
elevated anion gap, low Bicarb, low pH all consistent with DKA.
___ admitted to ICU for continuous IV insulin infusion
according to DKA protocol. Provided with IV hydration and
electrolyte repletion per protocol. ___ Diabetes team
consulted and assisted with insulin titration. Able to
transition to subcutaneous insulin from IV insulin ___.
Social work was consulted for assistance with affording insulin
and diabetes supplies as access to medicine/supplies identified
as barrier for this ___. He will be going home on Tressiba
15 units at night and Humalog ___ with meals.
# Rash:
___ found to have lesion on R forearm and back of neck w/
violaceous borders and associated scaling. R forearm lesion has
been present for 6 months. Neck lesion present for over a year.
Non-pruritic, non-tender, unclear what this etiology is. ___
had recent negative HIV testing and testing for syphilis was
pending at the time of discharge. Will need follow up with
dermatology.
# ___:
Presented with creatinine elevated above baseline. Felt to be
most likely pre-renal injury iso hyperglycemia causing polyuria
and volume depletion. Cr improved after volume resuscitation.
# ALT elevation:
Unclear etiology. Has had transaminitis during past admissions
for DKA. ___ be related to viral illness or mild fatty liver
disease. Improved without further intervention.
# Pancytopenia:
___ w/ Hgb down-trending to ~9.6 and stable for last several
days prior to discharge, with a MCV > 100. Folate/B12 in normal
range. Retic and iron studies were pending at the time of
discharge, low concern for ongoing bleed. Also mildly
thrombocytopenic at ~150 and leukopenic ~ 3.5 w/ similar values
during prior admissions. Continue to follow in outpatient
setting. | 160 | 457 |
11502553-DS-20 | 23,557,971 | Dear Mr. ___,
You were admitted to the Epilepsy Monitoring Unit because you
were having increased seizures at home, and because you were
having problems with unsteadiness on your feet while walking. We
felt that these problems were related to the anti-epileptic
medications that you take, so we changed them as listed below.
We also monitored you on EEG to try and capture your seizures
and found that you were not having them.
We have made the following changes to your medications:
STOP
Tegratol
START
Vimpat 200mg twice per day
INCREASE
Lamotrigine evening dose to 400mg
DECREASE
Zonisamide to 500mg at bed time
Please attend the outpatient appointment listed below with Dr.
___.
It was a pleasure taking care of you, we wish you all the best! | ___ yoM with intractable epilepsy followed by Dr. ___
presented with worsening gait/ataxia and worsened seizure
frequency.
# NEURO: Patient was admitted to the Epilepsy Monitoring Unit
where he was placed on continuous EEG long-term monitoring. Exam
on admission was notable for marked gait imbalance (Romberg
positive). He denied vertigo, nausea. Overall, his seizure
frequency over the past several months has been quite variable
and at times has acheived good control. On other occasions it
appears that his medication regimen was
leading to an intolerable side effect profile resulting in
ataxia and increased falls (for example when increasing lamictal
several months prior).
Several changes were made to anti epileptics: discontinued
tegratol, started vimpmat 200mg bid, increased pm lamotrigine
dose to 400mg, decreased zonisamide to 500mg qhs. Mr. ___ will
follow up with Dr. ___ in clinic.
# PSYCH: continued home haldol and celexa for bipolar disorder.
# ORTHO: continued outpatient alendronate for osteoporosis. | 119 | 153 |
14716081-DS-13 | 28,818,150 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing exploration of your abdominal wound. You have
recovered from surgery and are now ready to be discharged to
home. Please follow the recommendations below to ensure a speedy
and uneventful recovery.
ACTIVITY:
- You may climb stairs.
- Don't lift more than 10 lbs until otherwise instructed. (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 while
the wound vac is in place, however showering is OK with the
wound vac in place. Ask your doctor when you can resume tub
baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision where the wound vac sponge is placed may be
slightly red around the edges. This is a normal reaction to the
sponge material.
- You may gently wash away dried material around your incision.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | Mr. ___ was admitted on ___ under the acute care
surgery service for management of her acute cholecystitis. He
was taken to the operating room and underwent an exploration of
his abdominal wound, and placement of a wound vac. Please see
operative report for details of this procedure. He tolerated the
procedure well and was extubated upon completion. He was
subsequently taken to the PACU for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. Preoperatively, he had been
on antibiotics for the collection, but once it was opened and
washed out in the OR it was determined that antibiotics were no
longer indicated, and they were discontinued. He was initially
given IV fluids postoperatively, which were discontinued when he
was tolerating PO's. His diet was advanced on the morning of to
regular, which he tolerated without abdominal pain, nausea, or
vomiting. He was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and by the time of
discharge he was not requiring any medications for pain.
On ___, he was discharged home with ___ and instructions to
follow-up with Dr. ___ in ___ days. | 534 | 220 |
19007901-DS-5 | 22,243,396 | Dear Mr. ___,
You were admitted to ___ for
evaluation of abdominal pain and were found to have a small
bowel obstruction. You were treated non-operatively and had a
nasogastric tube inserted to help decompress your stomach. You
are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Patient is a ___ year old male with pmh significant for ILD, RA.
Patient presented to the emergency department with complaints of
abdominal pain. Imaging was completed which demonstrated
1.Small-bowel obstruction with gradual transition point in the
right lower
quadrant where there is a segment of hyperemic and thickened
small bowel which
may represent inflammatory bowel disease such as Crohn's
disease.
2. Hyperemic sigmoid colon may represent a skip lesion in the
setting of
inflammatory bowel disease.
3. No evidence of free intraperitoneal air.
4. Colonic diverticulosis without evidence of acute
diverticulitis.
5. Small to moderate sized fat containing umbilical hernia
without significant
secondary inflammatory changes.
6. Small hiatal hernia.
Therefore nasogastric tube was inserted for decompression with
good effect.
Once pain was well controlled, and the patient experienced a
return of bowel function, their diet was advanced as tolerated.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient
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. He was
afebrile and his vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and their pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement. | 272 | 233 |
13652044-DS-6 | 25,484,981 | Dear Mr. ___, you have been admitted to ___, on the
Neurosurgical team for your recent complaint of back pain and
right leg weakness. You have known spondylisthesis and
spinal stenosis, and have experienced a recent injury. As your
surgeon discussed with you, your recent images showed multilevel
canal stenosis, L4 on L5 anterolisthesis
with spondylosis without evidence of cord impingement. The need
of surgical intervention has been ___ with you by your
surgeon, it is our understanding that you will like some time to
think about the surgery before consenting for surgery. Our
office will contact you to book your appointment within the next
two weeks, if you happen not to hear from us, you may contact
our office by calling ___.
Do not smoke.
No pulling up, lifting more than 10 lbs. or excessive bending
or twisting.
Limit your use of stairs.
Take your pain medication as instructed; you may find it
best if taken in the morning when you wake-up for morning
stiffness, and before bed for sleeping discomfort.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 10.5° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control). | Mr. ___ presented to the ED on ___ with back pain and
right lower extremity weakness. He was admitted to the
neurosurgical team for pain control. He was transfered to the
floor and started on Oxycodone and valium with fair effect.
Dexmathasone was added and he had great improvement to his back
pain. An MRI of the L spine was obtained and showed multiple
levels of spondylosis with neural foraminal stenosis and spinal
canal narrowing most severe at L2-L3, L3-L4, and L4-L5 as
described. On the MRI of the Lspine it was noted that there was
a lesion, questionable for synovial cyst at the level of right
L2 to L3. Images of the lumbar spine were also obtained and
showed abnormal motion of L4 and L5, related to
anteriorlisthesis. On ___ Dr. ___ with patient the
need for surgery and was placed on the OR schedule for ___.
On ___, A CT of the lumbar spine was obtained and was consitant
with the findings on the MRI, for the exception the synovial
cyst, which was not visualized on the CT. The patient decided to
hold of from having surgery and wanted some time to think about
doing the surgery.
On ___, the patient was discharged in stable conditions and
neurologically intact, and pain under control. He was was
discharged with a prednisone taper and will follow up with Dr.
___ to schedule his surgery within the next week or two. | 269 | 241 |
19802576-DS-7 | 28,362,473 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having
nausea/vomiting and couldn't eat anything. We gave you fluids,
made sure your electrolytes stay normal, and discharged you once
you were eating some food. Best of luck to you in your future
health.
Please stop consuming marijuana, as we think this is
contributing to your nausea. Please take all medications as
prescribed, attend all physician appointments as directed, and
call a physician with any questions or concerns. | ___, a ___ yo F PMHx chronic daily marijuana use and
hemorrhoids s/p hemorrhoidectomy ___ presents with persistent
nausea/vomiting with abdominal pain and inability to tolerate PO
and refractory to numerous anti-emetics. On ___ AM, she was
able to tolerate clears diet and crackers and was willing to go
home.
# Cannabinoid Hyperemesis Syndrome / PONV: Persistent
post-operative nausea with inability to take PO. Has elevated
lactate with leukocytosis and ketonuria but has normal
BMP/LFTs/Lipase/hCG/AXR. Most likely post-op nausea and vomiting
given time course, although marijuana-induced hyperemesis also
in ddx given daily marijuana use and relief with hot showers.
Patient previously had recurrent episodes of nausea and vomiting
attributed to cyclic vomiting vs marijuana hyperemesis. Also
with significant psychiatric history, which may be contributing
to symptoms. eosinophilic esophagitis also a possibility given
hx of ectopy but less likely. EKG in AM showed bradycardia to
48, sinus, QTc 457. She was initially treated with ondansetron,
prochlorperazine, and lorazepam IV along with scopolamine patch
and famotidine for symptomatic relief. She went home with PO/PR
anti-emetics and instructions to avoid marijuana as it was
causing her nausea/vomiting.
# Hypokalemia: K 2.8 on AM labs from 3.3 in ED, likely related
to repeated emesis. She was given several IV K+ repletions as
part of maintenance IV fluids and as an initial bolus. Final K+
was 3.5 on discharge.
# Bradycardia: HR ___ without clear lightheadedness,
dizziness, pre-syncope, or chest pain. Possibly constitutional
(otherwise healthy patient) and parasympathetic tone from
repeated Valsalva maneuvers. She remained hemodynamically
stable in sinus throughout her hospital stay.
# Abdominal Pain: Epigastric likely related to vomiting,
improved with PR acetaminophen and famotidine. Patient
requested avoidance of opioids as this may increase her nausea.
Substantially improved on discharge.
# Status-Post Hemorrhoidectomy ___: Post-operative
nausea/vomiting was at least a component but hard to define
feature of her presentation. She was continued on a
Senna/Docusate bowel regimen to avoid constipation.
# Mood Disorder: Variable but stable history of depression,
anxiety and agorophobia continued on home olanzapine 10mg qHS.
# Atopy: Chronic stable issues, but eosinophilic esophagitis is
a potential cause of nausea/vomiting in this patient (less
likely with prompt improvement). Continued on home albuterol
inhaler, fluticasone nasal spray
# Iron-Deficiency Anemia: Patient has had chronic issues with
anemia, attributed to bleeding from her hemorrhoids. Home
ferrous sulfate held during hospital stay given risk of
constipation but restarted on discharge.
# Code Status: Full Code, no health care proxy documented. | 91 | 411 |
14847272-DS-18 | 24,495,762 | Dear Mr. ___,
You were admitted to ___ due to low blood pressure and
shortness of breath. You were given intravenous fluids and your
blood pressure improved. You were given inhaled medications and
your breathing improved. Please ensure that you are using your
inhalers and drinking plenty of fluids.
Your blood pressure was elevated on discharge. After discussion
of the risks of high blood pressure, you and your family decided
to go home. Please come to the ED if you have any headaches,
vission changes, chest pain, nausea, vomiting. Please check
your blood pressure tomorrow at Dr. ___ or at home.
If the top number is greater than 170, please call Dr. ___.
Please also follow-up with Dr. ___ on ___ at
11:15AM.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___ | ___ ___ gentleman with history of Stage IV CKD (urate
nephropathy), hx pulmonary TB s/p RIPE ___, and mild dementia
admitted due to hypotension and dyspnea.
# Dyspnea. Pt. admitted with 2 week history of mild acute on
chronic dyspnea. Pt. was afebrile, saturating well on room air,
without leukocytosis. Pt. did have wheezes on exam, but no
other features concerning for pneumonia or CHF exacerbation. CXR
with evidence of COPD but no acute findings. Suspect bronchitis
or URI with mild COPD exacerbation. Pt. improved significantly
with nebulizers alone. He was saturating well on room air at
rest and with exertion at the time of discharge.
# Hypotension. Pt. hypotensive with systolic in the ___ at
outpatient office visit prior to admission. Hypotension
resolved rapidly with IVF administration, though pt. remained
orthostatic. IVF resusicitation limited by hypertension.
# Hypertension. Pt. hypertensive at time of discharge, though
asymptomatic. This was likely due to IVF administration in
setting of poor renal function. Pt. declined to stay for further
monitoring, but he and his family were given strict instructions
for home blood pressure monitoring and return to care
guidelines.
# Acute on Chronic Kidney Disease. Due to urate nephropathy.
Creatinine elevated to 3.4 on admission, increased from baseline
of 3.0. Pt. reports poor PO intake recently. Creatinine
returned to baseline on discharge after administration of IVF.
# Transitional issues:
- blood pressure check
- confirm pt. using mometasone-formoterol and albuterol; pt
reported some trouble obtaining these medications at the
pharmacy, but does not seem to be an entirely reliable historian
- encourage hydration
- consider pulm eval with PFTs
- flu vaccine and pneumococcal vaccine | 146 | 272 |
10653013-DS-20 | 25,408,801 | Dear Mr. ___,
It was pleasure to take care of you during this hospitalization.
You were admitted to ___ for chest pain that was concerning
for pericarditis (inflammation of the sac around your heart).
You were treated with oral medications for this (colchicine and
indomethacin). Monitoring of your heart did not show any
inflammation or damage. The Rheumatology team saw you for this,
and they recommended that you continue the oral medications
above and that you follow-up with them as an outpatient.
You remained stable throughout this hospitalization, and are now
safe to go home. You are being discharged on oral medications
to treat possible pericarditis. You have follow-up for this
hospitalization scheduled with general medicine, Cardiology, and
Rheumatology.
Please take your medications as prescribed and follow-up with
your doctors. | CHEST PAIN: The patient had had multiple admission for chest
pain consistent with pericarditis over the last year. At the
time of admission, the only therapy he was on was indomethacin.
He presented to ___ ED on ___ with chest pain and
shortness of breath. There, he was administered morphine with
improvement in his chest pain. An EKG was negative for
conduction delay and ST/T changes. He was seen by Cardiology
(Dr. ___, who recommended that the patient be admitted and
restarted on colchicine (and continued on his home indomethacin)
for a concern of pericarditis. During this hospitalization, the
patient's EKG remained without conduction abnormalities or
ischemic changes. Telemetry showed occasional sinus tachycardia
but was negative for arrhythmia. The patient had a repeat
transthoracic echocardiogram on ___ that was normal (EF 65%,
normal cavity sizes/pressures, normal systolic and diastolic
function) other than some borderline/mild bileaflet mitral valve
prolapse. The Rheumatology team was consulted for a possible
autoimmune etiology for his recurrent pericarditis. They
recommended that the patient be seen by Rheumatology as an
outpatient for further work-up of causes of recurrent
pericarditis such as lupus, rheumatoid arthritis, mixed
connective tissue disease, adult onset stills, scleroderma, and
Sjorgens as well as Familial mediterranean fever and Tumor
necrosis factor receptor-1 associated periodic syndrome (TRAPS).
The patient remained stable in the hospital, and was discharged
on daily colchicine and indomethacin. At the time of discharge,
he was scheduled to see Cardiology and Rheumatology as an
outpatient. | 132 | 253 |
14839126-DS-17 | 25,673,402 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touchdown weight bearing left lower extremity in unlocked
___ Brace
- nonweightbearing of right upper extremity in case
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Touchdown weightbearing to left lower extremity
Range of motion as tolerated in unlocked ___ brace
Treatments Frequency:
Please return to clinic in ___ days for incision check
Please keep extremity elevated | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation of
left tibial plateau fracture and again on ___ for revision
ORIF of same fracture, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the left lower extremity, and will be
discharged on <<>> 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. | 342 | 269 |
18595899-DS-21 | 26,078,531 | Dear Ms. ___,
You were admitted to the hospital after a fall at home. You had
a fractured right clavicle, fractured left ribs, and partial
collapse of your left lung. To treat the collapsed lung, surgery
placed a chest tube to help the lung re-expand. You were
evaluated by Physical Therapy who recommended discharge to a
rehab facility to help you get more mobile and get back to
normal functioning. Your aspirin and Plavix were stopped while
you were in the hospital because you had some bleeding. You
should get a lab check at rehab on ___ and if your blood count
is stable, then you should restart your home dose of aspirin and
Plavix.
You were also found to have some kidney injury, which is likely
due to dehydration. You received IV fluids and a blood
transfusion, which helped your kidney function.
Please continue to follow up with Orthopedic Surgery and with
your outpatient Vascular Surgeon Dr. ___.
It was a pleasure to take care of you while you were in the
hospital. We wish you the best!
Your ___ Team | ___ with history of HTN, HLD, C2-C6 laminectomy, b/l carotid
stenting ___ on Plavix, presents after fall at home. The
patient was admitted to the hospital after she sustained a
mechanical fall at home landing on her right shoulder. She did
not have loss of consciousness. She followed up the following
day at an OSH where imaging was done. She was reported to have
left ___ rib fractures, left pleural effusion, small left
pneumothorax and a right distal clavicle fracture and a S5 body
fracture. She was transferred to ___ for further management.
See below for details of hospital course. She is now being
discharged to rehab. | 178 | 109 |
18249179-DS-9 | 21,953,437 | Dear Ms. ___,
It was a privilege to care for you during your stay at ___.
You were admitted to the hospital because of prolonged seizures.
You need to be intubated and had a long stay ___ the ICU. Your
seizures were well controlled with a new regimen of medications.
You needed to have a tracheostomy tube and G-tube (gastrostomy
tube) to help you breath and take nutrition. You had an
infection of your lungs that was treated with antibiotics. You
were doing much better and were transferred out of the ICU to
the medical floor. You continued to improve and were doing much
better on discharge.
You will be going to ___ Rehab ___ to help you regain
your strength. You will follow up with the pulmonology doctors
there to have your tracheostomy downsized ___ the future. You
will also be evaluated while at ___ for a speaking valve
for your tracheostomy.
You will follow up at ___ ___ the Epilepsy Clinic and with the
Infectious Disease clinic. Your appointments are listed below. A
list of your medications is included with your discharge
paperwork. It is important to bring this list to all of your
appointments.
We Wish You the Best
- Your ___ Care Team | ___ is a ___ year old woman with a history of a right
AVM status post embolization, complicated by pediatric stroke ___
___ status post VP shunt, with resultant seizure disorder and
recent frequent breakthrough seizures, who presented to ___
___ with a prolonged convulsive seizure. She was intubated
for airway protection and transferred to ___. She was admitted
to the ICU. She had a complicated medical course with failure to
wean from the ventilator, stenotrophomonas VAP, stress
cardiomyopathy, and ___ due to ATN, s/p tracheostomy and PEG
placement. | 202 | 90 |
18151496-DS-18 | 29,811,189 | Dear Mr. ___,
You were admitted to the ___ medical service after it was
found during dialysis that your heart rate and blood pressure
were low. We think that you had not completely recovered from
your congestive heart failure exacerbation over the weekend,
making you feel weak. We noticed that you had an abnormal rhythm
on your telemetry strip called bigeminy, with one normal strong
beat and one weaker beat that was not being picked up on the
pulse oximeter, causing it to think that you had a low pulse
(which can also make you feel weak). Your pacemaker is
functioning normally and the rate of your pacemaker was
increased to decrease the frequency of these abnormal beats. We
also started metoprolol with should help decrease the number of
those abnormal beats.
If you experience worsening fatigue, chest pain, shortness of
breath, please seek immediate medical care. Please continue all
of your home medications as prescribed and continue taking the
metoprolol. Please continue your regular dialysis sessions and
follow up with your primary care doctor.
It was a pleasure taking care of you! | Mr. ___ is a ___ w/ h/o CAD s/p CABG ___, pacemaker for
bradycardia due to heart block, ESRD on HD recently admitted
with CHF exacerbation presenting with bradycardia, hypotension
and shakiness at dialysis, condition much improved s/p 2
sessions of HD. | 181 | 44 |
17009662-DS-9 | 28,876,526 | Ms. ___,
It was a pleasure taking care of you during your admission to
the hospital. You were admitted to the hospital with sleepiness
and low oxygen levels. You were found to have pneumonia. Your
condition improved with antibiotics, although you continued to
have some low oxygen levels when you walked around for several
days.
You were also found to have difficulty emptying your bladder
which improved.
You also reported poorly controlled chronic pain despite the
Dilaudid that you take at home. This is an important issue to
discuss further with your primary care doctor. In the meantime,
it is very important that you take your pain medications only as
prescribed. Do not take extra doses of pain medications as this
can cause confusion, difficulty breathing, and even death.
Please follow up with your PCP at the appointment below.
We wish you the best,
Your ___ Care team | ___ is a ___ woman with a history of
breast cancer s/p
resection, hypertension, and hyperlipidemia, who presentED with
hypoxia and somnolence, found to have a multifocal pneumonia and
with hypoxic hypercarbic respiratory failure that required
initial BiPap and ICU admission but improved to nasal cannula
with ceftriaxone and azithromycin.
#Multifocal PNA
#Leukocytosis -
#Acute hypoxic respiratory failure
Flu neg. CXR c/w multifocal PNA. Legionella Ag neg. Blood cx
drawn ___ NGTD. Strep Ag pending. Her hypoxemia improved
quickly, although she but continued to require O2 with
ambulation, likely the result of her pneumonia. Leukocytosis
persisted, although given clinical improvement, this was not
suspected to be caused by treatment failure. She was treated
with ceftriaxone/azithro for a total 7 day course. She was
discharged on Cefpodoxime to complete final 2 days of
antibiotics. Ambulatory saturation improved prior to discharge
and the patient did not require oxygen on discharge.
#Cachexia
#Poor PO intake
#Poor mobility
#Chronic pain
#Somnolence on presentation likely due to polypharmacy
Patient takes 4 mg TID of dilaudid at home, although may take
more intermittently. Also on amitriptyline HS. Per report no
longer on gabapentin or tizanidine. Some concern was raised that
she presented with excessive somnolence due to medications. She
reported that her pain is poorly controlled on the current
dilaudid regimen and indicated at times that she might take more
than she is prescribed. Contacted PCP to discuss and consulted
social work. Also consulted ___, OT, and nutrition. Ultimately
she declined rehab and returned home with instructions to take
her medications only as prescribed and with close PCP ___.
Would consider weaning Dilaudid as outpatient as it does not
seem to be managing pain adequately and may be causing adverse
effects.
#Urinary retention
Patient intermittently retained during the admission, up to
700s-800s, although at
other time she did not retain significantly. Per patient and
family this was a new issue. Her amitriptyline was stopped and
ambulation was maximized. The patient's urinary retention
improved prior to discharge.
#Troponin elevation
ECG shows evidence of LVH but no acute ischemic changes.
Troponin leak likely due to demand in setting of acute illness..
Patient did have elevated proBNP. TTE was performed which was
normal.
#Constipation
Increased regimen during admission
___, resolved
#HTN
Restarted lisinopril 10 mg daily after initially holding
#Parkinsonism
Continued carbidopa/levopa, unclear why patient is on this
medication.
#Lower extremity edema
Held Lasix 20mg daily during the admission as indication was
unclear, please resume on follow up if indicated.
#T2DM
Continued slightly reduced insulin regimen. Victoza held. Per
her daughter she is off other DM meds at this point due to
hypoglycemia.
#History of breast cancer
Continued exemastane
#HLD
Continued simvastatin
#GERD
Continued omeprazole
#?Mild cognitive impairment:
Continued memantine 10mg BID
#Allergies
Held loratadine 10mg daily during admission. Continued
fluticasone intranasal
====================
==================== | 148 | 437 |
12406461-DS-15 | 27,547,600 | You were admitted to the hospital with nausea and vomitting
after getting a dose of methotrexate. You got a EGD and Ct scan
which were within normal limits. You were treated with
anti-emetics, IV fluids and supportive care. You gradually
improved. You also developed unsteadiness which improved with
fluids and medications. You will be sent home on steriods. You
need to follow up with your Allergist, GI and new PCP.
.
Medication Changes
1) stop prednisone
2) start methyprednisolone 32 mg PO QD
3) stop budesonide
4) stop nystatin
5) start zofran ___ mg PO Q8H prn for nausea
6) start zofran ___ mg ODT Q8H if unable to tolerate pills for
nausea-do not exceed 32 mg po QD
7) meclizine 12.5 PO Q8H prn dizziness | ___ yo F with PMHx significant for eosinophilic gastroenteritis
managed with acid suppression and steroids, recently started on
MTX after EGD showed worsening of gastric ulcers now admitted
with severe nausea/vomiting after methotrexate dose.
.
#Nausea/vomiting:
The likely etiology of this nausea and vomiting is a side effect
from the methotrexate administration. The ___ was treated
aggressively with IV fluids and anti-emetics. The ___
symptoms took several days to resolve. The ___ had an EGD
to further investigate the etiology of these symptoms. The EGD
showed moderate gastritis, mild duodenitis and a 1.5 cm pyloric
ulcer. The ___ also got a CT of her abdomen and pelvis to
assess for gastric outlet obstruction or another etiology of
nausea and vomiting and none was found. The ___ symptoms
eventually improved. She will be sent home on folate 5 mg QD.
It is also advised that the ___ be pre-medicated with zofran
prior to administration of MTX. It should also be considered
that the MTX be dose reduced. The ___ was send home on
zofran odt (if unable to tolerate pills).
.
# Eosinophillic gastritis
A flare of the above was considered as an etiology of her
symptoms. She has already failed ___ and often has worsening
of her symptoms when her steroids are tapered. Her EGD showed
only rare eosinophils. Malabsorption of her steroids was also
considered and a cosyntropin stimulation test was performed.
Her 60 minutes cortisol was 22.3. It would be expected that
this ___ who is chronically on prednisone would be adrenally
insufficient. Malabsorption vs. inability to convert to active
metabolites was considered. As a result, the ___ was
converted to IV dexamethasone. Her symptoms gradually improved
and she was sent home on methyprednisolone 32 mg QD. Her
budesonide was discontinued due to the presence of evidence of
chemical irritation on her biopsies. She is to follow up with
Allergy for administration of the next dose of MTX.
.
# Dysequilibrium
The ___ experience significant dysequilibrium while
ambulating while in house. This had no clear exacerbating
factor and she had no ENT related symptoms. The ___ was not
orthostatic but a midline was placed due to difficulty obtaining
peripheral access and she was hydrated. She was also treated
with mecilzine and she improved. She was sent home on prn
meclizine.
.
# h/o ___ from prior biopsies
Her most recent biopsies were negative and her nystatin was
discontinued.
.
# H/o gastric and duodenal ulcers
These appeared to be healing on repeat endoscopy. The patients
budesonide was discontinued and she was sent home on carafate,
ranitidine and omeprazole.
.
# Normocytic anemia
Baseline Hgb is ___. On the day of discharge, her Hgb was
10.4. She showed no obvious clinical signs of bleeding. This
should be followed up as an outpatient.
.
# Transitional Issues:
-Follow up with GI and PCP to establish care in the ___ area
-Follow up with Allergy for administration of next MTX dose | 125 | 503 |
18130295-DS-6 | 20,341,117 | 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 one month or while taking narcotics. Driving
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 cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Ms. ___ was admitted from the emergency department when a
chest radiograph revealed a large pleural effusion. A subsequent
cardiac echo revealed a large pericardial effusion and she was
taken to the cardiac catheterization lab for drainage. This
procedure drained 480ml. A left pleural pigtail was placed to
drain her pleural effusion. This was discontinued per protocol.
Aspergillis grew from her pericardial fluid and the infectious
disease service was consulted. She was started on an antibiotic
and anti-fungal regimen. This was discontinued as growth was
deemed contamination.
Vascular surgery saw the patient given her residual type B
dissection and lower back pain, but they recommended follow-up
as an out-patient as her repeat CT showed no change in her
dissection. Dysrhythmia was noted on tele and the EP service
was consulted. Per EP attending:
"Episodes of transient
bradycardia/heart block are consistent with vagal episodes;
there
is P-P slowing, PR prolongation, and gradual onset/offset. The
patient has not had any symptoms related to these episodes, most
of which have occurred while sleeping. She has no prior
lightheadedness or syncope. Her resting ECG has no conduction
abnormalities. No further workup is required at this point in
time. She had some AFib in the setting of having a pericardial
drain in place, but she is anticoagulated because of her valve
anyway."
She was also seen in consultation by the ophthalmology service
for a complaint of floaters, but they were felt to be benign.
Coumadin was continued for mechanical AVR. Dr. ___
continue to follow this as an outpatient.
The patient is stable for discharge on hospital day ___. She
will be discharged to her brother's home with family support.
She is instructed on appropriate follow-up. | 106 | 282 |
10956035-DS-12 | 24,012,395 | Please sponge bath daily. Do not allow chest dressing to get
wet. Do not change chest dressing. Empty and keep a record of JP
drainage and bring to your follow up appointment with Dr.
___.
Look at your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving until you are told to do so by your surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Labs: ___ for Coumadin indication afib
Goal INR ___
First draw ___ then every ___ until INR
stable and on a stable dose of Coumadin.
Results to be managed by rehab medical staff then rehab staff to
arrange follow up with PCP upon discharge from rehab.
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ s/p CABG ___, discharged home on
___. Had subsequent atrial fibrillation that was treated at
___ where he was started on Coumadin. Reported
sought follow-up w/PCP and found to have INR 16. At that time
also noted to have fluctuant fluid collection at superior pole
of sternal wound and transferred to ___ for further
management.
Once here he received Vitamin K and started on Vancomycin. He
was brought to the operating room for evacuation of sternal
debridement and fluid evacuation on ___. Please see the
operative report for details. Following surgery he was brought
to the cardiac surgery ICU in stable condition with an open
chest. He was kept paralyzed and sedated until he returned to
the operating room on ___ for chest closure with plating and
ties by the plastic surgery service, please see operative report
for details. His paralytics and sedation were stopped and he
weaned from the ventilator and extubated on POD1.
Anticoagulation for atrial fibrillation was resumed. He
transferred out of the ICU to the step-down floor on POD4. Once
on the floor he worked with nursing and physical therapy to
increase his strength and endurance.
His wound culture came back with STAPHYLOCOCCUS, COAGULASE
NEGATIVE. SPARSE GROWTH, so Infectious disease was consulted.
It was felt this was likely a contaminant but given new hardware
antibiotics were to be continued for at least two weeks. At
follow-up appointment with infectious diseases the duration of
antibiotic treatment will be determined. On POD7 from chest
closure he was discharged to rehabilitation at
___ at ___. He is to follow-up with plastic surgery in
1 week and with infectious diseases in 2 weeks, and with Dr.
___ in 1 month. All appointments were made before discharge. | 167 | 285 |
16736890-DS-18 | 22,948,460 | Dear ___,
___ were admitted to the neurology service because of a
transient episode of speech difficulty. ___ also informed us
that ___ have a history of clumsiness, and your initial
examination did show some signs of imprecision and some
difficulty with your tandem gait. Your examination improved on
its own and ___ are now back to your baseline.
We performed head CT, brain MRI, and arterial imaging of your
head. We did not find any strokes or vascular abnormalities to
explain your symptoms. Your cerebellum, which is the part of the
brain that controls the balance, seems to be smaller than usual.
Your findings can potentially fit with a rare syndrome, called
episodic ataxia syndrome, which is usually familial and is
characterized by these intermittent problems with speech or
walking, as well as some clumsiness.
We would like to start ___ on a medication called diamox, which
can help with the symptoms of dizziness and imbalance. This
medication can cause carbonated beverages (beers/sodas) to taste
flat.
We will have ___ follow up with Dr. ___, as well as Dr.
___ runs the ___ clinic in order to
consider genetic testing for your condition. | Mrs. ___ improved markedly overnight after her admission
without any intervention.
Our working diagnosis during the admission was an episodic
ataxia syndrome, but we needed to rule out other pathologies
such as stroke or vertebrobasilar insufficiency.
Her brain MRI showed an atrophic cerebellum, but no lesions. Of
note, thin cuts through the brain stem were obtained.
We obtained a neck and head CTA, and the vasculature looked
normal without any evidence of stenosis. We also obtained a
flexion extension neck X-ray to rule out any vertebral disease
or spondylolisthesis, and it was normal.
We started Mrs. ___ on diamox 250mg BID. Episodic ataxia
syndromes, namely type II, is responsive to diamox.
She will follow up in clinic with Drs. ___ further
neurogenetic testing as indicated, and with Dr. ___ who is
her primary neurologist. | 189 | 129 |
17871276-DS-14 | 29,986,037 | Dear Mr. ___ and ___,
You were admitted to ___ after worsening abdominal pain and
inability to move your bowels. You were found to have a
significant amount of constipation. Because of the amount of
colon distension noted on imaging, you underwent a sigmoidoscopy
to evaluate for potential obstruction. In addition, you had a
rectal tube in place to help with constipation.
Sigmoidoscopy and CAT scan did not reveal any signs of
obstruction.
Medication changes:
You were started on increasing doses of Miralax to be take with
milk.
It is also very important for you to be doing the behavioral
modifications to help with bowel movements as discussed by Dr.
___.
Developing a regular schedule where you are to sit on the toilet
to try to have a bowel movement at least three times per day
after every meal.
Please continue to take Dulcolax suppository as prior and
continue to take milk with Miralax as performed in this
hospital.
If you continue to experience inability to move your bowels
please contact your PCP and arrange for a manual disempaction. | ___ y/o man with mental disability with history of chronic
constipation requiring multiple hospitalizations for bowel
obstruction, disimpaction, who now presents from group home with
lack of BMs x 5 days and abdominal distension.
His abdominal distension improved markedly after placement of a
rectal tube and stool output was noted of 600cc over the next ___
hours with use of Miralax QID in milk. He initially underwent
an evaluation by CT abdomen (see above) showing severe
dilatation of the sigmoid colon without evidence of obstruction.
Nonetheless, given the extent of the dilatation he underwent a
non-prepped sigmoidoscopy (see above) which did not show any
evidence of obstruction. It was felt that his findings were due
to chronic constipation. He tolerated a liquid diet of milk and
miralax. Serial exams were benign and KUBs noted above, showed
recurrence of imaging on admission on ___, however patients
clinical condition remained stable.
Per discussion with GI team it was felt that these findings were
consistent with chronic constipation. We discussed with
caregiver team that ___ require to continue his home regimen
and in addition the following should be instituted:
- Miralax in milk TID
- TID toilet positioning to encourage bowel movements
- if no BM by 3 days after returning to his home, would
recommend evaluation for a manual disimpaction.
An additional option of partial colectomy was discussed, however
give that more conservative approache have not be exhausted
(above), this was deferred.
Followup should be arranged with his PCP and his
___, Dr. ___.
Finally ther were incidental findings on CT imaging as below
which will reuqire f/u with his PCP:
"There is an 11 x 8 mm hypodensity within the head of the
pancreas seen on series 2, image 31....There is a
simple-appearing cyst in the left renal interpolar region
measuring approximately 3.2 x 2.9 cm" | 182 | 306 |
14385224-DS-11 | 21,972,433 | You came to the hospital with abdominal pain and were found to
have 2 hernias that were causing your pain and incarcerated a
portion of your small bowel. You were taken to the operating
room and had these hernias repaired. You are recovering well and
are now being discharged home with the following instructions:
Please follow up in ___ clinic at the appointment scheduled for
you below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 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.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Ms. ___ was admitted on ___ under the Acute Care
Surgery service for management of her incarcerated hernias. She
was taken to the operating room and underwent hernia repair X 2.
(see operative note for details). She tolerated the procedure
well and was extubated upon completion. She was subsequently
taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her diet was slowly advanced as tolerated over the next
___ hours. A foley catheter was placed perioperatively for urine
output monitoring and was removed in the AM of POD1, at which
time she voided without difficulty. She was encouraged to
mobilize out of bed and ambulate as tolerated, which she was
able to do independently. | 785 | 119 |
11832757-DS-7 | 29,131,037 | You were admitted with respiratory compromise related to a
healthcare acquired pneumonia. This was treated with Cefpime and
Azitromycin both antibiotics.
You also experienced atrial fibrillation with a rapid
ventricular response. We initiated you on anticoagulation called
Coumadin, which you will take on a daily basis to prevent clot
from forming in your heart. We also increased your beta blocker,
metorpolol XL to 150 mg dialy.
When you came into the hospital it was also thought that you had
some evidence of diastolic heart failure which has resolved, we
hav eresume dyour home lasix resumed your lisinopril as well as
your beta blocker, only at a higher dose given your atrial
fibrillation | Ms. ___ is a ___ yof with dCHF, AFib previously not on
anticoagulation, aortic stenosis, HTN, CKD, HLD, hx aortic
dissection ___, and ulcerative colitis who presented to
OSH with dyspnea and cough the transferred to ___ ED where
found to have AFib with RVR which converted with amiodarone
shortly after admission.
# AFib with recent RVR: CHADS 3. Unknown if acute or chronic,
but was documented on ___ problem list. Not on
anticoagulation. We initated heparin gtt, she loaded with
Amiodarone and was converted spontaneously on ___ but
remained hypotensive on neo gtt prompting her admission to the
CCU. Neo gtt was weaned shortly after converting to sinus, Amio
gtt was stopped and she was and restarted Metoprolol. Warfarin
was initiated this admission due to CHADS score.
-Metoprolol succinate 150mg daily
-Aspirin 81mg po daily
-started Warfarin 2mg daily titrate to INR ___.
# Hypoxic Respiratory Distress: Unclear etiology. Likely some
acute on chronic CHF in addition to HCAP pneumonia. Patient was
given few moderate doses of IV Lasix which was unclear if helped
her respiratory status. Patient also started on 10 day course of
Cefepime, and completed 5 day course of Azithromycin. Patient
needed up to 6L nasal cannula and improved to low 90's on room
air at time of discharge. Patient was influenza negative this
admission.
# CHF, diastolic: EF over 55%. Please see full ECHO report
attached. Patient may have had acute on chronic CHF on
admission. She was given few moderate doses of IV Lasix which
was unclear if helped her respiratory status. Oxygen
requirement with mild pulmonary edema on CXR on admission.
Improved at time of discharge with sats mid 90's on room air.
-continue home Lisinopril 40mg po daily
-continue home Metoprolol tartrate 50mg po TID
-continue home Pravastatin 20mg po daily
-Resumed home lasix dose of 40mg daily at time of discharge
# HCAP: Initially presented with c/o dyspnea and minimally
productive cough without fever. ON ___ she became more hypoxic
with increased oxygen requirements, and on exam was rhoncherous
and wheezing. She Tmax at 100.7 and WBC count elevated. UA was
positive for WBC's only, no luekocytes. Flu swab negative. CXR
without obvious signs of PNA but given luekocytosis and
persistent O2 requirement intiated antibiotics for HCAP: Vanc/
Cefepime/ Azithromycin. Vanc DC'd on ___. Inhaled fluticasone
started for wheezing given hx of smoking and likely some element
of chronic lung disease. Hypoxia greatly improved and now weaned
to room air. Patient also started on 10 day course of Cefepime,
and completed 5 day course of Azithromycin. Since intiation of
antibiotics pt afebrile and WBC count trending down to normal.
Exp and Insp wheezes remain on exam and inhalers should be
continued.
# Urinary Retention: Developed urinary retention with
incontinence on ___. PVR's every 8 hours revealed > 400mL
of urine requiring startight cathing. UA sent and was negative
and culture pending. Ipratropium inhaler changed to prn.
Patient will require q6h bladder scan with straight cath for
volumes over 400cc.
# Delirium: Pt with episodes of agitation and delirium
throughouot hospitalization. Intiated seroquel 12.5mg with
initial relief and then somnulence after two days of
administration. Gerentology consulted and weaned dose to 6.25mg
only at night. Pt mental status has since greatly improved and
she is now alert and oriented.
# Brief Hypotension: Likely due to AFib w/ RVR. Transient and
resolved once in normal sinus rhythm. Neo weaned and
antihypertensive meds restarted.
# Hx of Hypertension: added Amlodipine as new medication not on
PAML for intermittent SBP's as high as 190's.
-continue home Lisinopril 40mg
-continue home Metoprolol XL 150mg daily
-Initiated and continue Amlodipine 2.5mg daily
-Continue home lasix 40mg daily
# Hyperlipidemia
-continue home Pravastatin
# CKD: Creatinine 1.1 on admission which is her baseline.
-renally dose meds
# Ulcerative colitis
-not currently on any UC medications
# Hx Migraines
-acetaminophen prn
## TRANSITIONAL ISSUES ##
-continue ___efepime with last day ___
-q6h bladder scan with straight cath for volumes over 400cc
-consider home lasix adjustment pending respiratory status and
creatinine as outpatient | 111 | 663 |
19250934-DS-33 | 27,944,971 | Ms. ___,
You were admitted with fever found to have kidney damage, which
was likely from your vancomycin. Infectious disease was
involved and adjusted your antibiotics. Your orthopedic
surgeons were also involved and you had a joint aspiration of
your left knee done on ___. You were discharged on IV
Daptomycin and Ertapenem
It was a pleasure taking care of you. Please be sure that your
antibiotics are given on regular intervals. | ___ h/o osteoarthritis s/p bilateral TKAs ___ and ___
(complicated by DVT/PE) w/ left knee revision ___
(complicated by hematoma and polymicrobial joint infection on
vanc/ertapenem for 6 weeks s/p revision/debridement ___ who
is admitted for ___ and fevers.
1. ___
-Urine electrolytes consistent with pre-renal etiology likely
due to poor PO intake w/ fever; however, she received 3L IV
fluids without improvement in creatinine. In setting of
supra-therapuetic vanco trough of 46 there was initial concern
this is actually ATN. Vancomycin was stopped and Switched to IV
Dapto. Renal US without hydronephrosis. Seen by nephrology. Also
agreed w/ switch. Did not feel ___ was related to AIN either.
Lisinopril held and to be stopped at discharge as well.
Neohrology also recommended DC of PPI which was done. Cre
steadily improved, down to 1.8 at discharge
2. Fever and leukopenia h/o left knee polymicrobial joint
infection
-Patient spiking fever while on vancomycin/ertapenem concerning
for resistant organisms or inadequate coverage. ID was
consulted who replaced vancomycin with daptomycin given ___,
replaced ertapenem with meropenem, and added levofloxacin
pending arthrocentsis culture, which did not show any growth.
Ultimately discharged on IV Ertapenem and Daptomycin which pt
will finish until ___
3. Acute on chronic normocytic anemia
-Unclear etiology with no reports of bleeding. ___ be related
to knee surgery (?hematoma) vs anemia of chronic disease. She
notes multiple blood transfusions over the past few months and
is worried this contributed to her current infections; because
of this she declined further transfusions. Anemia work up
showed normal iron level but started on PO iron here.
4. h/o DVT/PE w/ supratherapeutic INR
-h/o clots during previous surgeries and when coming off
Coumadin. She was counted on prophylactic SC heparin until
cleared by surgery and then transitioned back to home coumadin.
Will be discharged on 4 mg as INR supratherapeutic at 3.5 today.
She should hold warfarin tonight and then have INR checked daily
until therapeautic
5. Acute encephalopathy
-Likely multifactorial in setting of infection, fever,
hospitalization, medications. Zolpidem, cyclobenzaprine,
oxycodone, and lorazepam are all potentially contributing to
sedation/confusion and tried to minimize polypharmacy.
- Resolved, at baseline mentation at discharge
6. Hypomagnesemia
-Repete and monitor. Chlorthalidone stopped.
7. HTN
-Chlorthalidone stopped in setting of ___.
>30 minutes spent on discharge planning. | 74 | 375 |
18534971-DS-21 | 25,749,660 | Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions | Mr. ___ was admitted on ___ after Today, he presents 1
week after noticing that the cloud in his right eye vision had
increased in size. Saw retinal specialist
and, in consultation with PCP, was referred for carotid series
US
and echo at ___ on ___ which found 80-90%artery stenosis on
the Right. He was started on a heparin drip and maintained on
such and home meds until the day of surgery on ___. His
procedure was uncomplicated requiring Neo for slight hypotension
in PACU. This was weaned off POD0. On POD1 A line, Dextran drip
were D/C'd. His diet was advanced to regular which he tolerated
well and was ambulating independently. He is ready for
discharge. | 376 | 116 |
18424796-DS-22 | 27,234,368 | Dear Mr. ___,
You were admitted to the hospital because you were fatigued and
had lab abnormalities (low sodium and high bilirubin).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We held your diuretic medications and restricted the amount of
fluid you can drink because this was causing your low sodium
levels.
- We updated ___ hospital daily because you are followed by
their transplant team.
- You had a paracentesis procedure to remove fluid from your
stomach for comfort.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or you will die
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- 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 | TRANSITIONAL ISSUES:
=======================
[] Discontinued diuretics (spironolactone, furosemide) given
hyponatremia to 123 on admission to OSH.
[] Given persistent hyponatremia ordered serum cortisol and
cosyntropin stimulation test which were low however this was not
with free cortisol --> if he continues to have refractory
hyponatremia consider testing free cortisol levels.
[] Will need intermittent therapeutic paracenteses as
outpatient, he will arrange for these with his outpatient GI Dr
___ at ___.
[] Discussed with patient his multiple hospitalizations recently
at ___ and enrollment with ___ transplant teams, he voiced that
he wishes to better establish his care within the ___ system and
will follow up with Drs ___ his community and ___
GI, respectively.
Discharge MELD: 28
Discharge Cr: 0.6
Discharge Na: 131 | 217 | 115 |
10496294-DS-9 | 29,020,861 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital for weight loss and back
pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have a 7cm mass in back. A biopsy was
performed revealing prostate cancer. Oncology started you on
bicalutamide treatment for this prostate cancer.
- Your pain was treated with Oxycodone, Tylenol, and Lidocaine
patches
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ man with history of prostate
cancer s/p prostatectomy (___), COPD, and blindness who
presented with months of chest pain and abdominal
pain, weight loss, and findings of R Psoas mass, now s/p biopsy
with demonstration of metastatic prostate cancer. | 121 | 44 |
14577114-DS-15 | 21,257,784 | Dear Ms ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You were admitted because you had nausea, vomiting and abdominal
pain at home and you were not able to keep anything down.
WHAT HAPPENED IN THE HOSPITAL?
You had an image taken of you abdomen which did not show any
problems in your intestinal tract. The image showed you have a
cyst in your right ovary which you will need to follow at your
upcoming gynecology appointment.
We managed your nausea with IV medication, and then we
transitioned you to oral medication. We gave you a patch to help
with your nausea.
You were able to eat small bites and drink before discharge.
You were also seen by our social worker and our psychiatry
colleagues because you reported some hallucinations. They think
it is very important for you to ___ with your psychiatrist
on ___ at 2pm.
WHAT SHOULD YOU DO AT HOME?
You need to stop smoking marijuana as it can cause some of the
symptoms of nausea/vomiting/abdominal pain.
It is very important you ___ with your psychiatrist to
manage your depression and mental health.
You need to ___ with gynecology about your ovary cyst.
You need to ___ with the gastrointestinal doctor about
your nausea, vomiting and abdominal pain symptoms. If you want
to continue your care here at ___ our team will be happy to
see you.
You need to ___ with your PCP - we made an appointment for
you with a new PCP at ___.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | TRANSITIONAL ISSUES:
====================
[] Patient presenting with nausea and vomiting likely due to
cannabinoid hyperemesis syndrome - patient should strictly avoid
cannabis
[] Could consider empiric rifaximin for SIBO as an outpatient if
abdominal pain/ nausea/ vomiting not improving
[] Consider adding TCA as an outpatient to control GI symptoms
[] If ongoing abdominal pain, would trial low dose Levsin PRN
[] Limit QTc prolonging meds since she was found to have QTc as
high as 470
[] Patient requires GI ___ for her H Pylori gastritis 8
weeks after finishing her treatment (___)
[] Patient requires close ___ with her psychiatrist (Dr ___
___ from ___ and titration of her
depression/bipolar medications. She was not taking any of her
medications prior to this admission.
[] Patient would benefit from a ___ to cope with
her anxiety and depression
[] Please provide patient with nutritional education or put her
in touch with a nutrition expert to help her avoid foods which
could trigger nausea/vomiting/abdominal pain.
[] Patient found to have a 2.6 x 2.9 cm hemorrhagic cyst in the
right adnexa. This will need to f/u as an outpatient by GYN.
[] Discharged on omeprazole 40mg daily. Titrate on outpatient
basis and consider discontinuation given that she will need
repeat testing for h pylori.
[] Had vaginal bleeding after pelvic ultrasound which decreased
in amount subsequently, likely traumatic injury. Follow up on
outpatient basis with GYN and ensure she is uptodate on her pap
smear. HCG negative.
[] Urine toxicology was positive for oxycodone although patient
does not confirm use. Please follow up on outpatient basis.
Code status: full code
Health care proxy/emergency contact: ___ (sister) ___ | 264 | 267 |
16656904-DS-20 | 26,268,227 | Dear Ms. ___,
It was a pleasure to care for you at ___.
You came to the hospital because you developed chest pain at
home. We found that you were likely having a heart attack and we
considered performing a procedure ("cardiac catheterization") to
help treat your heart attack. You and your family decided that
you did not want to pursue any procedures in the hospital and
will instead be transitioning to comfort care and hospice at
home.
Please continue to take your prescribed medications and
follow-up with your doctors as ___.
We wish you all the best,
Your ___ care team | Ms. ___ is an ___ with PMH of ESRD on HD (MWF), CAD,
dementia, severe AS, HTN, history of GIB secondary to AVM, who
presented initially to BID-N with chest pain, found to have GIB
and transferred to ___.
#GOC: GOC discussion held in ED by cardiology and ED attending
with decision made to transition to ___ care/home
hospice. Per daughter, prior to admission, they had been working
on transitioning patient to hospice but had not yet been able to
set up services. In setting of acute illness, they opted to
decline further intervention or procedures, declined further HD,
and declined further blood transfusions.
#GIB: History of GIB in setting of AVM, requiring transfusion as
an outpatient. Presented with Hgb 4, s/p 1U PRBC in ED prior to
GOC. Was hypotensive to ___ on arrival and briefly on peripheral
levophed, discontinued in ED after GOC. Patient and family
decline further blood transfusions.
#Chest pain: EKG c/f ACS with diffuse STD, and STE in AVR/V1.
Declines catheterization or medical management at this time.
Dilaudid PRN for chest pain in-house. Discharged with morphine
and ativan.
#ESRD on HD: Declines further HD. Discontinued home midodrine,
calcitriol, sevelamer, nutritional supplements
#HTN: continue home labetalol
#HLD: discontinue atorvastatin
Transitional issues:
- will be discharged to home with Hospice with scripts for
morphine and Ativan | 97 | 216 |
11532659-DS-9 | 23,385,885 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this again now.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Pt admitted to neurosurgery service ___ with headaches and CT
w ?stroke vs. mass, later determined to be c/w cortical laminar
necrosis. Pt NVI, no focal deficits, motor/sensation intact
throughout. Coumadin held.
___ pt remained intact, exam unchanged. Spoke to neurology who
asked for pt to f/u in 2 wks w repeat head CT and felt that she
was safe to restart coumadin. INR checked - 2.3, coumadin
restarted and pt d/c'ed home in stable condition, pain
contriolled. | 152 | 78 |
18828819-DS-16 | 26,947,287 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. You were admitted to
the hospital with fevers, shortness of breath, and weight loss.
We thought your symptoms were most consistent with a pneumonia,
specifically a PCP ___ (similar to the episode you have
had previously in ___. For concern of a heart or lung
etiology of your symptoms, an echocardiogram was performed which
revealed moderately elevated pressure in the lung which may be
related to your ongoing infection although we can not be 100%
certain at this time. You were discharged on ongoing treatment
for your PCP pneumonia with atovaquone. Please continue to take
atovaquone through ___. Please be sure to call ___ to
schedule an appointment with ___.
We wish you a speedy recovery and all the best,
Your ___ Care Team | ___ year old gentleman with HIV/AIDS (last CD4 23 ___
intermittently adherent with ART, h/o PCP PNA on prophylactic
dapsone admitted with fevers, weight loss, and exertional
dyspnea.
# Fever/Weight loss/Dyspnea: Broad differential in setting of
CD4 23. Only localizing sxs are respiratory with dyspnea on
exertion and previously documented hypoxia to 83% with
ambulation, here noted to be 94% with ambulation. High on the
differential is recurrent PCP infection and pt. was empirically
started on at___ for treatment. Beta-glucan elevated,
though LDH normal. CT chest essentially clear without obvious
evidence of PCP. Other infectious causes are on the
differential including mycobacterial infection (no documented
PPD and low risk), viruses including disseminated CMV, and
fungal disease. Malignancy is also on the differential, though
no e/o found on CT chest. Lymphoma less likely given no night
sweats, no lymphadenopathy on exam, and normal LDH.
HIV-associated pulmonary hypertension on the differential and
TTE on day of discharge with evidence of new moderate pulmonary
hypertension. Induced sputum negative x3 for AFB. Pt. was
discharged home on 21 day course of atovaquone for pneumocystic
jirovecci pneumonia. He will have close follow-up with his
primary care physician for further discussion of his pulmonary
hypertension and symptoms.
# HIV/AIDS: Last CD4 23 ___. Long history of nonadherance
to ART with persistently low CD4 count. Pt. was continued on
ritonavir/darunavir, truvada. He was started on azithromycin
1200mg weekly for prophylaxis.
# ? Esophageal thrush: Pt. denies any symptoms of dysphagia or
odynophagia, No thrush noted on exam of the posterior
oropharynx. Fluconazole discontinued on admission with no
reoccurence of symptoms.
# Transitional issues:
- Atovaquone course: To be continued for 21 days (Day #1
___
- Elevated pulmonary pressures: Seen on echocardiogram, requires
outpatient work-up and follow-up with cardiology
- Please f/up iron studies, B12, and vitamin D.
- ___ AFB smear pending at discharge.
- Code: DNR/DNI (confirmed twice)
- Emergency Contact: ___ (brother) ___ | 145 | 322 |
16912184-DS-17 | 21,190,083 | Please call Dr ___ and then proceed to the emergency
room at ___ if you develop the same pain that brought you into
the hospital.
Avoid fried foods, and heavy cream sauces, gravies, higher fat
meats.
Continue all home medications as you were previously taking
Follow up appointment with Dr ___ to discuss risks and
benefits of removing the gallbladder.
Complete antibiotic course. Do NOT drink alcohol while taking
these medications. Best to avoid alcohol altogether | Mr ___ was admitted to the ___ Surgical service ___
for evaluation of right upper quadrant abdominal pain. He had
mild transaminitis at the time of admission. He was kept on
clear liquids and IV unasyn was started. By ___, the patient
was free of abdominal pain. His exam was without tenderness. He
tolerated a regular diet without any further abdominal pain. His
transaminase levels were downtrending. He was afebrile
throughout his hospitalization with a normal WBC count. He was
transitioned to oral antibiotics on discharge. He was
specifically counseled that if he has any further episodes of
abdominal pain or high fevers to return to ___ ED. The patient
was voiding independently, ambulatory and was in agreement with
the plan for followup at the time of discharge. | 72 | 128 |
17960804-DS-8 | 26,198,489 | Dear Ms. ___,
You were admitted to ___ and
underwent chest tube placement and exploratory laparoscopy. You
are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Warm regards,
Your ___ Surgery Team | ___ presents as transfer from ___ after a stab
wound to L chest. At OSH, she had a chest tube placed for
hemo/pneumothorax, with ~300cc blood initial ~5 hrs. Although
she was hemodynamically stable, there was concern for
diaphragmatic injury given trajectory and extensive discussion
with radiology. She underwent exploratory laparoscopy which
revealed no other injuries. The chest tube was put on suction
and then to waterseal with continued output >100cc output though
improving CXR. The chest tube was removed and CXR showed a small
left pneumothorax, which resolved, and left basilar atelectasis
and effusion. She also noted SOB/wheezing though improved with
albuterol. Her vitals remained stable and she was discharged
with ___ clinic follow-up. | 331 | 116 |
15213234-DS-13 | 25,692,859 | General Instructions
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber. We generally
recommend taking an over the counter stool softener, such as
Docusate (Colace).
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen
etc.
You may safely resume taking Aspirin on ___.
You are being discharged on Keppra (Levetiracetam) for seizure
prophylaxis, you will not require blood work monitoring. You
will continue this medication for 7 days.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
ENT DC instructions
- do not use hearing aid until canal is clear (this can be
verified by her PCP ___ ___ weeks, prior to follow up with ENT)
- dry ear precautions until f/u with ENT: use cotton ball coated
in Vaseline when showering, no swimming | Ms. ___ was admitted to the Neurosurgery service in the
setting of bifrontal contusions Left > Right after a mechanical
fall for frequent neuro checks and systolic blood pressure
control. She was started on Keppra 500mg BID for seizure
prophylaxis. ENT consult was called for right ear laceration
and right parietal-temporal bone fracture. They recommended
ciprodex drops to the right ear BID and follow up in ___ clinic
in 2 months for a formal audiogram. No hearing aide to right
ear due to right external canal laceration. She must keep the
right ear dry x 2 weeks.
Repeat head CT on ___ showed slight blossoming of right frontal
contusion with stable left frontal contusion and the patient
remained neurologically intact. Social work was consulted,
requested by family for unsafe home environment. She was
hypotensive to the high ___ and low ___ and c/o dizziness with
elevation of the HOB. Her Blood pressure improved. Her
dizziness however persisted and was aggravated with movement.
While working with physical therapy she experienced dizziness
that precipitated emesis and she was started on PRN meclezine
which helped with these symptoms.
On ___, she remained stable on exam, her magnesium and
potassium was repleted. She has been ambulatory so SQH was held.
On ___ she was being seen by ___ and OT and she was discharged
to rehab on ___. | 188 | 230 |
12660552-DS-15 | 25,805,130 | You were admitted to ___ for a
dehiscent wound in your right inguinal region from your
angioplasty incision. You were treated with operative
debridement and placement of a wound vaccuum. You are now stable
for discharge.
Medications:
Please resume your pre-admission medications. You are being
discharged on medications to help control the pain associated
with having a wound vaccuum. Please take these as prescribed. Do
not take greater than 4,000mg tylenol per day and do not drive a
car or drink alcohol while taking narcotic pain medications.
Your Vaccum:
This will provide helpful information in caring for your wound.
If you have any questions or concerns please talk with your
doctor or nurse. You have an open wound, as opposed to a closed
(sutured or stapled) wound. The skin over the wound is left open
so the deep tissues may heal before the skin is allowed to heal.
Premature closure or healing of the skin can result in
infection. Your wound was left open to allow new tissue growth
within the wound itself. The wound is covered with a VAC
dressing. This will be changed around every three days.
The VAC:
- helps keep the wound tissue clean
- absorbs drainage
- prevents premature healing of skin
- promotes healing
When to Call the Doctor:
Watch for the following signs and symptoms and notify your
doctor if these occur:
-Temperature over 101.5 F or chills
-Foul-smelling drainage or fluid from the wound
-Increased redness or swelling of the wound or skin around it
-Increasing tenderness or pain in or around the wound
Your ___ may assist you in showering while your wound vaccuum is
in place. Please do not shower with wound vac on as it may harm
the seal and prevent your therapy from proceeding appropriately.
You have no activity restrictions. | Ms. ___ is a ___ who presented to the ___ ED for an infected
and dehiscent inguinal wound. While in the emergency department
she displayed seizure like activity and was intubated to protect
her airway. She was admitted to the medical ICU for further
management of her airway and was extubated on the morning of
hospital day 2, approximately 12 hours after intubation. On
hospital day 2, she was taken to the operating room for washout
of her dehiscent wound with debridement and placement of a VAC.
She tolerated this procedure well and was extubated in the PACU.
After a brief PACU stay she was transferred to the vascular
floor for the remainder of her hospital stay.
Neuro: Neurology was consulted for the patient's seizure like
activity in the ED and recommended close monitoring without any
medical intervention unless further seizure activity was
observed.
CV: The patient had no cardiac issues during her
hospitalization.
Resp: The patient was intubated in the ED and was extubated
after admission to the medical ICU. Pulmonary toilet was
encouraged and the patient had no further respiratory issues
during her hospitalization.
GI: The patient was tolerating a diet at discharge.
GU: The patient had a florid UTI upon admission to the ED. She
was started on broad spectum antibiotics for her infected wound.
Urine cultures drawn from her Foley on POD1 did not grow any
bacteria and her initial UTI may have been contaminated from her
dehiscent and draining wound. She was voiding independently at
discharge.
ID: The patient was started on broad-spectrum empiric coverage
once admitted to ___. Wound cultures were obtained which grew
out 1+ GPC/GNR/GPR with mixed bacterial growth and no
speciation. She will be discharged on a 2 week course of
bactrim.
Heme: The patient's hematocrit remained stable during her
hospitalization.
On ___, the patient was discharged to home with a VAC in
place. She will have visiting nurses to assist her with her
vaccum changes and to monitor her wound. At discharge she was
voiding independently, tolerating a diet, afebrile with stable
vital signs, and her home wound VAC was in place. Discharge
plans were communicated to the patient and she was in agreement.
She will follow up in the clinic in 2 weeks. | 288 | 372 |
14311395-DS-17 | 29,852,236 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for foot pain, which
we believe is a combination of pain from swelling as well as
skin infection. We got an xray that showed no broken bones in
your foot. The podiatrists also evaluated your foot and believed
that there was no gout, but just swelling and skin infection. We
treated you with several doses of intravenous antibiotics with
improvement of the infection. We also wrapped your foot/leg to
improve the swelling.
Please use your compression devices at home to control the
swelling, as this was largely contributing to your pain.
Remember to take only Tylenol for pain and not ibuprofen/advil
or aleve, as these are not allowed after your gastric surgery.
Please take all of your antibiotics as prescribed.
On behalf of your ___ team,
We wish you all the best | ___ with chronic lower extremity venous insufficiency presenting
with worsening lower extremity pain and swelling after OSH
admission for sleeve gastrectomy.
#RLE pain: Patient has a history of chronic venous insufficiency
with ___ R > L edema for which he does mechanical compression at
home. However, he had worsening pain in the R foot and was
ultimately unable to ambulate. He had RLE U/S that was negative
for DVT. XR foot was negative for fracture. Given tenderness
along R lateral midfoot and erythema, exam was most concerning
for cellulitis. Podiatry was consulted and recommended several
doses of IV then po antibiotics for cellulitis as well as
compression given worsening edema. Patient had improvement in R
foot pain with Tylenol and compression. He received 1 dose of
vancomycin in the ED and two doses of cefazolin. He will
complete a total of 7 day course of Bactrim/Keflex ending
___. With decrease in his swelling and pain, he was able to
ambulate after working with ___ and so was able to be discharged.
# Left knee pain: most likely secondary to osteoarthritis. Exam
not concerning for septic arthritis, gout, or traumatic injury.
He was continued on tylenol. NSAIDs should be avoided in setting
of gastrectomy.
# Diabetes: Insulin and oral hypoglycemic have been held by the
patient's outpatient providers following his bariatric surgery.
Patient reports well-controlled sugars at home, around 150
recently, off of his medication. His FSG were wnl around 120s
this admission; resumption of DM medications can be considered
in the outpatient setting. | 148 | 252 |
17953959-DS-24 | 27,994,575 | You were admitted with recurrent DKA. You were found to have
pneumonia and completed treatment for this. ___ diabetes
team co-managed your diabetes and uptitrated your insulin
regimen. Please follow their instructions. You were seen by
social work, and are encouraged to follow up with your
outpatient social worker and therapist. | ___ with hx of HTN, DM1 on insulin c/b recurrent DKA, asthma,
depression, prior ETOH, chronic paincreatitis, HTN, HLD, GERD,
chronic back pain from stabbing incident in past, presented with
5 dasy abdominal pain, found to have DKA, ___ in setting of
pneumonia vs viral gastroenteritis. Initial concern for ST
elevations on ECG, but repeat ECG was unchanged and enzymes were
flat. He was fluid resuscitated, started on an insulin gtt and
transitioned to subcutaneous insulin once his anion gap
metabolic acidosis normalized. He was able to tolerate PO and
was transitioned to a diet. He was transferred out to medical
ward where insulin was uptitrated. He had multiple days of poor
control and ___ team up-titrated his regimen. It was
discovered that he hadn't been written for diabetic /
carbohydrate consistent diet until ___ and this was changed
with improvement in his BG levels. On discharge, the patient
stated that he has no insulin at home. We wrote Rx for insulin,
which was initially Glargine 60 units BID. However, ___,
did not have this in stock without prior authorization, so I
discussed with ___ who changed it to Tresiba (degludec)
120mg SC in AM only. This has the advantage of only needing once
a day injections given his overall poor compliance. He was
treated for CAP, and tested negative for norovirus. It was
presumed that the diarrhea was either a viral gastroenteritis,
or simply from his chronic pancreatitis. He complained of
chronic abdominal and back pain for which toradol,gabapentin,
duloxetine, and Tylenol were continued, with intential refrain
from using opiates. He was started on ACE-inhibitor therapy with
Lisinopril for BP control; beta blocker was stopped. His
antidepressants were continued, and sleep aids were continued.
Of note, there was a time where he was refusing insulin, as he
has done on multiple different hospital stays, which seems in
part, to be leverage to try and receive opiates. I explained
very clearly that he would not be having any changes to his pain
medications during his stay. He once said he was not going to
take his insulin at home (without providing a good reason), but
after discussion, agreed to do so. Given his multiple
bounce-backs and non-compliance, if he were to get admitted
again, a multidisciplinary care team meeting would be beneficial
to discuss expectations and follow-up. I would have conducted
this, given his behavior the morning of discharge, but because
he was able to go home and eventually agreed to cooperate, the
timing was not prudent this admission.
# DKA w/ poorly controlled DM1 (A1C 11.1%)
# AGMA - resolved
# PNA - treated w/ Azithro/Cephalosporin
# Diarrhea - resolved; negative noro
# ___ resolved
# Chronic Pancreatitis - on creon
# HTN - started lisinopril
# HLD - continued home treatement
# GERD - PPI
# Stabbing in ___- R upper thorax, axilla, mid lower back
# Chronic back pain with self reported R sided motor weakness in
# Depression w/ prior suicide attempts
# Insomnia
TRANSITIONAL ISSUES
===================
- Should received follow up chest imaging to ensure resolution
of pulmonary opacity | 53 | 510 |
17461892-DS-16 | 26,968,266 | You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With 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 getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 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.
oLimit 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 have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while 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. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-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
___ 2. 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.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: as tolerated
LSO for ambulation; may be out of bed to chair without.
Treatments Frequency:
Please continue to change the dressing daily | Ms. ___ was admitted to the ___ Spine Surgery Service on
___ and taken to the Operating Room for L5-S1 interbody
fusion through an anterior approach. Please 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 condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled L5-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. A bupivicaine
epidural pain catheter placed at the time of the posterior
surgery remained in place until postop day. She was kept NPO
until bowel function returned then diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Foley was removed on POD#2 from the
second procedure. She was fitted with a lumbar warm-n-form brace
for comfort. Physical therapy was consulted for mobilization OOB
to ambulate. 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. | 369 | 232 |
13561991-DS-9 | 29,241,450 | Dear Ms. ___,
You were brought to the hospital due to bizarre behavior. We
found that your blood alcohol level was very high and that your
thyoid level was very low because you had not taken your home
levothyroxine in awhile. We cannot stress to you how important
it is to take your levothyroxine every single day. You were
evaluated by the psychiatry team and they determined that it was
unsafe for you to leave the hospital. You were transferred to
the inpatient psychiatry floor at ___
___. You will continue your medications as prescribed.
It was a pleasure taking care of you, be well!
Your ___ Team | ___ yr old woman w/ hx thyrotoxicosis ___ Graves disease s/p
ablation and subsequent hypothyroidism, substance abuse,
dyslipidemia and prior psychosis presumed secondary to
hypothyroidism requiring hospitalization p/w hypothyroidism in
the context of not taking levothyroxine. She was evaluated by
the psychiatry team and they determined that she was exhibiting
signs of psychiatric decompensation with psychosis and paranoia
requiring transfer to inpatient psychiatry floor at ___
___.
ACUTE ISSUES
# Hypothyroidism- Pt has been noncompliant with her
levothyroxine in the past and admitted after a similar
presentation of psychosis in the context of not taking
levothyroxine. She again hasn't taken any in a couple of weeks.
She presents with a TSH of 47. Continued home dose 175 mcg
levothyroxine daily. Education about the importance of taking
her medication daily was provided.
# psychosis- Pt initially presented w/ psychosis endorsing
hallucinations and paranoia. However, at the time of that
evaluation she was drunk with a blood alcohol level of 197.
During her admission she did not express any hallucinations,
SI/HI and remained calm and cooperative. Psychiatry evaluated
and thought she was unsafe to return home or leave the hospital.
She was issued a ___ and was transferred to an inpatient
psychiatry facility. She was started on risperidone 1 mg BID.
# alcohol withdrawal: Patient did not score on CIWA. Thiamine
100 mg IV/IM initial dose, then 100 mg po daily x 5 days. MVI 1
tab po qd. Folate 1 mg po qd.
# macrocytosis. This appears to be a chronic problem since at
least ___. Folate was 9 and vitamin B12 >700 in ___ when it
was last checked. ___ be secondary to B12 deficiency vs alcohol
abuse. Continued vitamin supplementation.
# Acute Renal FAilure. Pt also had ___ the last time she was
admitted with psychosis thought to be ___ to levothyroxine. It
appeared that she may be dehydrated based on her history but her
BUN/Cr <20 so was unlikely to be pre-renal. Patient's creatinine
improved to 1.3 and stayed steady. Renal US was normal. She
should have f/u chem 7 in one week.
# vitamin D deficiency-
- 50,000 units vitamin D/week for 8 weeks, then outpatient
recheck of vitamin D level to decide how to change dose
TRANISITIONAL ISSUES
LABS TO CHECK:
Please check chem 7 in one week to ensure stability in renal
function. | 106 | 386 |
14149991-DS-8 | 21,794,541 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had fever, sore throat, muscle
cramps, a cough and urinary urgency.
What happened while I was in the hospital?
- You had a chest x-ray which was concerning for pneumonia. You
were started on antibiotics, "Levaquin", for 5 days. You will
need to continue to take this antibiotic until ___ at home.
- You were also found to have a urinary tract infection. The
antibiotic you are on right now should also treat your urine
infection. Continue this antibiotic until ___ as above.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | ___ PMH HTN, fibromyalgia, LDRT renal (brother) in ___ at
___ on Cellcept and Tacrolimus, w/ no known history of
rejection, presenting w/ 1 day of fever, sore throat, muscle
cramps, cough, w/ evidence of PNA on CXR as well as urinary
urgency c/f UTI.
# CAP vs. Viral URI:
Patient presented with respiratory symptoms, productive cough,
fevers, and leukocytosis. Also, immunosuppressed in the setting
of kidney transplant. Febrile and tachycardic on presentation.
CXR with evidence of right lung base opacity concerning for
pneumonia. Otherwise, no hypotension or hypoxia, saturating well
on RA. Less likely strep throat, but does have tender LAD and
reports exposure. Strep throat swab negative. Initially treated
with CTX/azithromycin (___) for community acquired
pneumonia, now narrowed to Levaquin to complete 5 day course
(last dose: ___. Sputum and blood cultures with no growth to
date. CMV viral load pending at discharge.
# Urinary tract infection
Patient reporting suprapubic discomfort and urinary urgency. UA
with moderate leuks, few bacteria. First urine culture
contaminated, second urine culture pending. Treating with
Levaquin for CAP as above, which should also cover for urinary
tract infection. Urine cultures no growth to date at discharge.
# ESRD s/p LDRT renal (brother) in ___
___ function at baseline on presentation. Continued home
tacrolimus and cellcept. Tacrolimus level was monitored during
admission (trough was felt to be poorly timed, thus home dose
was continued).
# GERD: Continue ranitidine 150 mg QHS.
# HTN: Continue home losartan 25 mg, amlodipine 2.5 mg, and HCTZ
12.5 mg QD
# HLD: Continue atorvastatin 20 mg QPM.
TRANSITIONAL ISSUES:
====================
[] Complete 5 day total course Levaquin to complete 5 day course
(last dose: ___.
[] Follow up with PCP ___ 1 week of discharge.
[] Please follow up urine culture which is pending at discharge.
[] Please follow up CMV viral load which is pending at
discharge.
#CONTACT: ___ (son) ___
#CODE: Full | 163 | 303 |
11265975-DS-4 | 22,652,889 | 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.
REHAB INSTRUCTIONS:
Patient was found to be retaining urine on multiple occasions
necessitating intermittent catheterization. Please monitor for
urinary retention with regular bladder scans with plan for
additional intermittent catheterization vs. foley placement if
patient continues to retain.
ACTIVITY AND WEIGHT BEARING:
- NWB LUE ADLs as tolerated - start pendulums in 2 weeks; WBAT
RUE - avoid extremes of abduction/external rotation.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
NWB LUE ADLs as tolerated - start pendulums in 2 weeks; WBAT RUE
- avoid extremes of abduction/external rotation.
Treatments Frequency:
No surgical dressing in place | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have a left proximal humerus fracture/dislocation and was
admitted to the orthopaedic surgery service. The patient was
taken to the operating room on ___ for close reduction of left
proximal humerus/dislocation, 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 anticoagulation per routine. The patient's
home medications were continued throughout this hospitalization.
The patient worked with ___ who determined that discharge to
rehab next field was appropriate.
Postoperative x-ray and CT demonstrated adequate reduction of
the fracture/dislocation.
On multiple occasions throughout hospitalization, patient was
found to be retaining urine requiring intermittent
catheterization. Patient will be discharged to rehab with
instructions to monitor for urinary retention with regular
bladder scans and catheterized/Place Foley as needed.
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
NWB LUE ADLs as tolerated - start pendulums in 2 weeks; WBAT RUE
- avoid extremes of abduction/external rotation and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 657 | 308 |
10994390-DS-15 | 20,300,939 | Dear Ms. ___,
You were admitted to ___
appendicitis. You had your appendix removed and now you are
ready to be discharged home from the hospital. Please read the
following instructions to assist with a successful recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute appendicitis. WBC
was elevated at 11.3. The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor.
The patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
Psychiatry was consulted due to patient's request. The patient
reported she was not coping well with her eating disorder and
wanted to speak to psychiatry about it. Psychiatry made
recommendations for a partial outpatient program, no inpatient
admission warranted. The Social Worker was at the bedside,
helping to arrange this for the patient.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 342 | 255 |
18571213-DS-20 | 23,146,090 | Dear Ms. ___,
You were hospitalized due to symptoms of apahasia resulting from
an ACUTE HEMORRHAGIC STROKE, a condition where you have bleeding
in your brain. The brain is the part of your body that controls
and directs all the other parts of your body, so damage to the
brain from 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 adding the following medications for blood pressure
control:
amlodipine 10mg daily
chlorthalidone 25mg daily
Lisinopril 40mg daily
You will stop taking:
Aspirin 81mg daily
Losartan Potassium 50mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure taking care of you!
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ ___ year old woman with a history of
hypertension who presented with acute-onset complete inability
to
produce speech. On initial exam she was found to have a global
aphasia, agraphia, and impaired comprehension as demonstrated
when asked to follow commands. CT shows a 3.7 x 3.1 cm IPH,
exerting mild mass effect from cytotoxic edema and no midline
shift. MRI redemonstrated this lesion and also shows chronic
microvascular changes. Etiology unclear at this time. She was
hypertensive during hospitalization, though the IPH is in a very
atypical location of hypertensive bleed. There could possibly be
underlying lesion given location at ___ or
possibly first presentation of amyloid angiopathy (there are no
microbleeds on MRI to support this diagnosis at this time). We
will therefore control hypertension and reimage after blood has
been reabsorbed. This IPH occurred on ASA 81mg daily, and given
that she has no absolute indication for aspirin, it is being
held indefinitely. She had persistent dysphagia and failed
multiple SLP evaluations, eventually receiving a PEG on ___
without complications. She is tolerating TF at goal rate.
Goal SBP <150, however patient consistently had high BP values
requiring IV hydralazine, switched ___ to prn PO labetalol. Her
antihypertensive regimen was uptitrated to: lisinopril 40mg
daily, chlorthalidone 25mg and amlodipine 10mg with PRN PO
labetolol 200mg. Holding all anti-platelets and NSAIDs.
Course was also complicated by R knee pain with preserved ROM,
attributed to known osteoarthritis. On ___, the pain was
somewhat higher in the leg, and therefore DVT u/s was done of
RLE, which showed no DVT.
=========================== | 283 | 262 |
19598913-DS-6 | 28,410,026 | 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:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Ms. ___ was admitted on ___ under the Acute Care
Service for management of her acute appendicitis. She was taken
to the operating room that day for a laparoscopic appendectomy.
Please see operative note from Dr. ___ details of the
procedure. She tolerated the procedure well and was extubated
upon completion. She was transferred to the PACU initially
postoperatively, and then to the surgical floor when
hemodynamically stable.
Her pain level was routinely assessed and she was given IV
analgesics initially as needed to control her pain. She was
later transitioned to oral narcotics when tolerating PO's. She
was started on clear liquids postoperatively and given
additional IV fluids for hydration. On POD 1 she was started on
a regular diet, which she tolerated without increased abdominal
pain or nausea. Her vital signs were routinely monitored.
Initially her urine output was borderline and she was noted to
be slightly hypotensive in the low 80's systolic; however, it
was noted that the patient's basline systolic BP's are in the
90's. By the day of discharge on POD 2, she was making adequate
amounts of urine and her SBP's remained in the high 80's-90's.
She remained afebrile without any signs of infection. She was
started on IV ciprofloxacin and flagyl initially postoperatively
for ruptured appendicitis noted in the OR, and was transitioned
to PO antibiotics prior to discharge. She was encouraged to
mobilize out of bed and ambulate, which she was able to do
independently.
On postop day 2 she is tolerating a regular diet and
hemodynamically stable. Her pain is well controlled with PO pain
medications and she is out of bed ambulating independently. She
is being discharged home with scheduled follow up in the ___
clinic on ___. | 796 | 286 |
11052273-DS-29 | 21,358,027 | Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had a fall.
====================================
What happened at the hospital?
====================================
- You were found to have low oxygen levels, from fluid build up
behind your heart. You were treated with diuretics to help
remove the extra fluid and your oxygen levels improved.
- You had bleeding from your colon and got 6 units of blood and
a colonoscopy. They did not find any active bleeding but could
not appropriately screen for colon cancer. They found 1 polyp
but did not remove it due to risk of bleeding. Please discuss
with your primary care doctor whether you would like to repeat a
colonoscopy to screen for colon cancer at your next primary care
visit.
- You also had a gout flare and you were treated for this.
- you had a small mass seen on your lung CT scan, and a special
scan called a PET scan is recommended, as the mass increased in
size since your last exam where they saw the mass in ___, to
make sure the mass is not cancer. Please discuss scheduling
this with your primary care doctor.
- Your metoprolol was increased to 100mg TWICE A DAY
- Your amlodipine was stopeed
- You were started on a medication called advair, an inhaler to
help with your lungs.
==================================================
What needs to happen when you leave the hospital?
==================================================
- Take your medications every day and have your blood laboratory
level checked as directed by your doctors
- Make an appointment to see your primary care doctor within ___
weeks.
- Call ___ to schedule an appointment with your
cardiologist as soon as possible after you leave the hospital.
- Weigh your self daily; if you weight goes up by more than 3
pounds in 1 day or 5 pounds in 3 days, call your doctor.
- Please attend all of your doctor appointments.
- Discuss with your doctor about having another colonoscopy in
the future.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team | Mrs ___ is a ___ year old woman with history of
chronic diastolic CHF, CKD stage 4, NIDDM2, COPD not O2
dependent, AFib s/p ___ ablation not on anticoagulation due to
recurrent severe GIB, HTN, HLD who was admitted for fall at
home, found to have a UTI, acute CHF exacerbation, ___
hospital course was complicated by an acute LGIB.
ACUTE ISSUES
# Acute Lower GI Bleed: After 3 days of diuresis and 5 days in
the hospital, patient developed sudden onset of large-volume
painless BRBPR with clots. GI was consulted and recommended
colonoscopy, but patient initially confused. She remained
hemodynamically stable despite ongoing large volume bleeding so
I was of concern for contrast-induced injury for her CKD she was
initially treated pull-through with 4 units PRBCs and remains
stable. 3 days later, however she had another large episode of
bleeding with a episode of relative hypotension and a CTA was
performed that did not demonstrate any signs of active bleeding.
Leading subsequently self resolved 2 additional units of PRBCs
and did not recur. Hemoglobin remained stable for 3 days
subsequently. She did undergo a colonoscopy which demonstrated
large diverticuli and a few polyps but no signs of active
bleeding. Blood counts and blood pressure remained stable for 4
additional days through the time of discharge.
# Hypoxia
# Acute on Chronic diastolic heart failure
# COPD not previously O2 dependent: Patient presented with
asymptomatic hypoxia after experiencing a fall at home. She did
not have clear left-sided heart symptoms but was noted to have
an elevated BNP JVD. LENIS and VQ scan were negative for VTE.
Chest CT with small b/l effusions, but did not demonstrate
significant emphysematous or bullous changes consistent with
COPD, although she does carry this diagnosis. She was diuresed
starting ___ hospital course with significant improvement in her
hypoxia symptoms. Diuretics were temporarily held during her
bleeding episodes as detailed above. Discharged home on home
diuretics
# Spiculated Mass: Seen on Chest CT, and was noted to have
intervally increased in size since ___. PET-scan recommended
for further eval. Patient was informed of finding, but further
evaluation deferred to the outpatient setting.
# Presyncope / Fall: Patient's initial presenting symptom was a
fall. Bleeding or CHF symptoms prior to. She was found to have
a likely UTI and was treated with 3 days of antibiotics. Her
other issues were managed as above. Patient wa initially
screened by ___ who recommended discharge to rehab, but patient
firmly refused and wanted to go home, and so was discharged home
with services.
# Afib RVR: Developed early in her hospital course and did not
recur. Likely triggered by infection and hypovolemia. Improved
with fluids and antibiotics. Did not recur after initial HD #1
and HD #2. Remains off systemic anticoagulation given her
history of severe GI bleeding (done prior to this admission).
Notably she, she also had metoprolol increased to 75 mg tartrate
3 times daily which was later converted to 100 mg twice daily at
time of discharge.
# Left wrist/left foot pain: Radiographs rule out fracture.
Likely gout flare based on past gout history and exam. Improved
with colchicine/predisone (x 5 d course).
# NIDDM2: Maintained on a Humalog sliding scale and nightly
glargine while hospitalized. Home oral anti-glycemic's were
resumed at time of discharge.
# HTN: Losartan was continued through hospitalization, held only
for contrast exposure. Metoprolol was increased to 100 mg twice
daily. Amlodipine was held through time of discharge.
# CKD stage 4: - stable
# HLD: Continued home statin | 393 | 597 |
15330843-DS-19 | 27,760,682 | Dear Mr. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were hearing voices that were possibly telling you to hurt
people
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We ensured your safety
- Psychiatry evaluated you and helped us with your treatment
- We started a medication to treat your auditory hallucinations
- We recommend that you try to get back to ___. See below for
resources.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take your new medication-- risperidone. We got you a free 2
week supply of this, which you should take twice daily.
- Seek medical attention if you have new or concerning symptoms
of auditory or visual hallucination, feelings of paranoia or
that you feel that you may want to harm yourself or others.
These are the resources in ___ - for psychiatric medication management and
substance use counseling:
p: ___
___ Living (Group recovery home)
Pt can return to live here for $520/month
p: ___
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team | Mr. ___ is a ___ year old male w/ ___ depression and
schizophrenia who is presenting with auditory hallucinations and
homicidal ideation. He was admitted under ___.
ACUTE ISSUES
=============
#Acute depressive episode with SI, HI
#Auditory, visual hallucinations
Episode appears similar to recent hospitalizations per record
review by Psych. Current trigger likely medication non
adherence. He was medically cleared in the ED but was admitted
to medicine pending psychiatry bed. Psychiatry initially had
patient under ___ but this was subsequently discontinued
as the patient's auditory hallucinations resolved with
initiation of anti-psychotics. He was cleared by psychiatry
team for discharge home and was no longer felt to be a risk to
himself or others. He was maintained on Abilify 10 mg for one
day while in house and discharged on risperidone 1mg twice daily
because of cost. He was given a free two-week supply.
#leukocytosis
Initial labs with leukocytosis WBC 15, no labs since ___. Per
documentation no complaints of cough, fever, loose stool, skin
breakdown. Urine culture negative and CXR w/o consolidation.
Improved to 11 on discharge.
#Med rec
Patient with inconsistent medication history, reportedly taking
both aripiprazole and valproic acid. However, recently
discharged from OSH on risperidone. He was discharged on
risperidone as above.
CHRONIC ISSUES
===============
#Asthma: Not on albuterol inhaler. Continue to monitor for
symptoms
#Tobacco use disorder: Smoker of 7 cigarettes daily. Did not
want nicotine patch while in house.
TRANSITIONAL ISSUES
===================
Patient plans to take bus to return to ___. He was agreeable
to pay the fee as quoted by ___. Unfortunately no further
financial assistance regarding this could be given.
MEDICATION: Risperidone 1mg twice daily | 210 | 257 |
11090542-DS-7 | 26,223,617 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital because you had a fall. You
were found to have a fracture of one of the bones in your neck.
You do not need surgery at this time to fix the fracture, as it
will heal on its own, but you will need to wear a neck collar
for the next 6 weeks to makes that it is able to heal. Please
follow up with Ortho in 2 weeks, with Dr. ___. Please call to
make this appointment.
You were also found to have a vertebral artery dissection with a
blood clot. The vascular surgeons evaluated you and determined
that you needed a daily aspirin.
You were also found to have anemia (low red blood cell count).
You were found to be low in iron, so you were started on iron
pills with improvement of your blood counts.
You also had some fast heart rates which improved with
medications.
Your appointments and medications are listed in the discharge
paperwork.
We Wish You The Best!
-Your ___ Care Team | Mr. ___ is an ___ yr old man with a history of Afib not on
anticoagulation, dementia. history of CVA, PE, intracranial
hemorrhage ___ traumatic head injury, colon CA s/p colectomy,
presenting s/p fall, found to have a new anemia.
HOSPITAL COURSE
#s/p fall c/b C2 fracture:
Patient with unwitnessed fall backward at ___
___ in which he fell backwards and hit his head. The
etiology of the fall is not clear. The differential for the
possible fall included possible seizure, arrhythmia given atrial
fibrillation, symptomatic anemia or mechanical etiologies. An
EEG was done; results still pending. The patient has continued
to be in atrial fibrillation, rate controlled with metoprolol,
and was hemodynamically stable throughout. A TTE was also
peformed and these results showed no structural cardiac cause of
syncope identified. Normal global biventricular function. Mildly
dilated right ventricle. Mild aortic and mitral regurgitation.
___ tricuspid regurgitation. EF: >55%.
A CT head post fall was negative for acute intracranial
pathology, but a CT C spine revealed an acute odontoid fracture
which compromised the right vertebral artery. A subsequent CTA
was done which revealed concern for vertebral artery dissection
in the setting of the C2 fracture. Vascular surgery was
consulted for assistance with managment. Given that the patient
remained hemodynamically stable and without neurologic
compromise from baseline, the patient was likely compensating
through collateral circulation from his left vertebral artery. A
subsequent MR ___ spine was without abnormal cord signal or spinal
canal narrowing. He was managed non operatively by the
orthopedic surgery team. He was continued in a ___ J collar at
all times for a 6 week course. He will need to follow up with
Dr. ___ in orthopedics in 2 weeks.
In regards to the vertebral artery dissection with occlusion,
Vascular surgery recommended 81 mg indefinitely. He will not
need Vascular Surgery follow up.
# Normocytic anemia
The patient was found to have a new normocytic anemia with a
drop from Hgb of 14.8 in ___ to 8.6 now. While the MCV was 83
the RDW was elevated suggesting a possible multifactorial
picture. The patient was found to be iron deficient with a
concomitant low ferritin, and was started in ferrous glucanate
TID. The iron deficiency anemia was concerning given his history
of colon cancer s/p resection. The family will discuss whether
they will pursue a colonoscopy as an outpatient with the PCP.
# Leukocytosis
The patient was admitted with a leukocytosis to 12.5 that
resolved when trended. This was likely reactive in nature. The
patient had anegative UA, CXR, and was without any other
localizing symptoms. He remained afebrile.
# Atrial fibrillation
On recent admission digoxin was held given bradycardia.
Metoprolol decreased from 200 mg to 25 mg. Warfarin discontinued
given history of intracranial hemorrhage. The patient had an
episode of Afib with RVR which resolved with PO metoprolol. He
was subsequently continued on a regimen of metoprolol 12.5 mg
BID to good effect.
CHRONIC ISSUES
====================
#CVA
Patient continued aspirin and simvastatin.
#HLD
Patient continued simvastatin.
#GERD
Patient continued omeprazole.
#Dementia
Patient continued quetiapine, sertraline, trazodone.
#Glaucoma
Patient continued timolol eye drops.
TRANSITIONAL ISSUES
=======================
[ ] 1 week PCP ___
[] Follow up in ___ clinic with Dr. ___ in 2 weeks:
___ or ___.
[] Continue ASA 81 mg indefinitely for vertebral artery
dissection, no vascular follow up appointment necessary.
[ ] CBC, Chem 7 at next PCP visit - trend H/H, BUN/Cr.
[ ] Metoprolol started this hospitalization for episode of
atrial fibrillation with RVR
[ ] Please follow up with PCP regarding need for colonoscopy for
evaluation of anemia. H/H improving with iron supplemenation
CODE: DNR/DNI
CONTACT; ___ ___ | 186 | 584 |
10598395-DS-7 | 21,552,039 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because of recurrent
falls and excessive alcohol drinking. You were found to be
unsteady and confused, a condition called "Wernicke", which is
due to vitamin deficiency secondary to excessive alcohol
drinking. We treated you with intravenous vitamins and gave you
some medications to treat your alcohol withdrawal symptoms.
We did imaging for your head and any fractures or bleeding. You
were found to have a rib fracture, which only required some pain
control.
We strongly encourage you to stop drinking alcohol due to the
negative effects on your health. Please make sure to take all
your medications on time and follow up with your doctors as
___.
Best regards,
Your ___ team | ___ yo M with history of EtOH dependence and abuse, presumed
cirrhosis, HTN, and depression, thrombocytopenia, who presented
with dizziness, tremulousness, and anxiety in the setting of
heavy drinking as well multiple mechanical falls the last of
which was on the day of admission.
#WERNICKE'S ENCEPHALOPATHY: He was found to have truncal and
gait ataxia with intact proprioception, and also with nystagmus
and encephalopathy with indifference and inattentiveness in
setting of chronic alcoholism. MRI head without contrast showed
minimal abnormalities in the vicinity of the mammillary bodies
and periaqueductal gray. There was no evidence of stroke on MRI.
His symptoms were thought to be secondary to Wernicke's
encephalopathy and he was treated with IV thiamine.
# ACUTE ALCOHOL DEPENDENCE WITH WITHDRAWAL: Longstanding
significant alcohol dependence, who unfortunately is not able to
stay sober and has failed multiple attempts of detoxification.
He has no prior history of withdrawal seizures. In terms of his
alcohol intoxication, he was initially placed on CIWA score with
diazepam PRN.
#RECURRENT FALLS: CT head was negative for any intracranial
process and rib series showed left rib fracture. Recurrent falls
were attributed to his alcohol intoxication and Wernicke's. As
discussed above, he was found to have truncal and gait ataxia
with intact proprioception. The ataxia was improving at time of
discharge and patient was discharged to rehab. The expected
length of stay at rehab is not more than 30 days.
# THROMBOCYTOPENIA: This is a chronic issue. During his prior
admission, blood smear was reviewed with hematology, and
thrombocytopenia was thought to be likely related to cirrhosis,
splenomegaly, and alcohol abuse.
# LOWER EXTREMITY WEAKNESS:
Patient has chronic lower extremity weakness, most likely
related to deconditioning and excessive alcohol intake. He was
noted to have right foot drop during prior admission, possibly
related to prior injury to alcoholic neuropathy. At that time,
he was seen by physical therapy, who recommended that patient be
discharged with a walker, as well as with ___ physical therapy.
Vitamin B12 was within normal limits. ___ was consulted and
recommended acute rehab. | 128 | 338 |
15155703-DS-11 | 22,510,519 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam) to prevetn
seizures, which you should take for a total of 7 days. You will
not require blood work monitoring. | The patient was admitted to Neurosurgery for monitoring of his
small left temporal SAH and SDH. He was admitted to the floor
for neuro checks. He was placed on a CIWA scale for his history
of alcohol abuse and started on folate, thiamine, and a
multivitamin. He was continued on his home metformin and placed
on an insulin sliding scale with a diabetic carb-controlled
diet. He received Tylenol as needed for headache.
A repeat head CT scan on ___ showed stable appearance of the
small left temporal subarachnoid hemorrhage. He was placed on
Keppra 500 mg BID for seizure prophylaxis and should complete a
total 7-day course. He remained neurologically intact. ___ and OT
were consulted to evaluate him and recommended discharge home
with outpatient ___ services, for which he was given a
prescription.
He will follow-up in 4 weeks with a non-contrast head CT scan. | 94 | 144 |
11804719-DS-8 | 28,217,586 | Mr. ___,
You were hospitalized after falling.
* Your injury caused some left rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | The patient brought to ___ ED on ___ for trauma evaluation
s/p mechanical fall. Pt was evaluated by the ED and the acute
care surgery team. | 249 | 26 |
10439110-DS-29 | 26,144,054 | Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted because you had some
more difficulty breathing and weight gain. You also had noticed
some rectal bleeding. You were feeling better after getting some
Lasix through the IV. We think that the bleeding is from
hemorrhoids, and your blood counts were fine.
You can take all of your normal medications when you go home.
Please see below for your discharge appointments.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team | ___ female with PMH of tracheobronchial malacia s/p
trachea-bonchoplasty (___), trach on ___, and a T tube
placed ___, as well as CHF with EF of 49%, COPD, Afib, RUE
DVT on apixaban presents with worsening shortness of breath and
complaints of bright red blood per rectum.
============================
ACUTE ISSEUS ADDRESSED
============================
# Bright red blood per rectum
# Anemia:
Patient initially presenting with complaints of bright red blood
per rectum and hemoglobin 8.9 from 9.4 at last hospitalization.
She was started on an IV PPI and her apixaban was held. However,
stool guaiac was negative, and patient was found to have
hemorrhoids on exam. Hgb stayed stable at 8.4. It was felt that
this was unlikely to be an active GI bleed. Her home medications
were resumed.
# Dyspnea: Patient with normal CXR and BNP elevated to 1000. She
received IV Lasix 40mg in the ED with improvement of symptoms.
She felt back to her baseline the following day, and was able to
be discharged on her home medications.
============================
CHRONIC ISSEUS ADDRESSED
============================
# h/o RUE DVT: Diagnosed on ___ in the right axillary
vein. Has been anticoagulated since then. Her apixaban was held
on admission given concern for GI bleed, but given that her
hemoglobin remained stable with no evidence of active bleed, was
able to be restarted.
# COPD/Tracheobronchial Malacia: Known COPD and tracheobronchial
malacia. Patient felt that her breathing was at baseline.
Continued home Albuterol, Benzonatate, Mucomyst, Fluticasone and
T Tube maintenance. Dr. ___ notified via ___ fellow by
phone of patient's admission.
# Afib:
# Rate-dependent LBBB: Currently with well controlled heart
rates. Was continued on home metoprolol and dilt, and
anticoagulation was restarted as above.
# CAD: Continued aspirin and atovastatin
# Rheumatoid Arthritis Currently follows with a rheumatologist.
Has taken
multiple RA meds at various points in the past, including MTX,
plaquenil, Enbril, and Humira. Not currently on a DMARD or
biologic. Continued home medications.
# Fibromyalgia: Continued pregabalin 75mg PO TID.
# T2DM: Held home glimepiride and start ISS while in house.
Discharged on home medications.
# GERD: Patient with recent NSAID use in the setting of RA. Last
EGD demonstrated antral erythema. Initially given IV PPI given
concern for GI bleed, but was discharged on home pantoprazole.
# DEPRESSION: Continued home Fluoxetine, Buspirone, and PRN
Ativan
# RLS: Continued home Flexeril
============================
TRANSITIONAL ISSUES
============================
[] Patient was discharged on her home medications.
[] should have CBC recheck on ___ at time of next
appointment
[] Found to have QTc of 576. Would avoid any QTc prolonging
medications. Patient aware of prolonged QTc as well. Would
continue to closely monitor.
[] please ensure all health maintenance including colonoscopy
are completed given iron deficiency anemia
[] consider sleep apnea workup as cause of pulmonary issues
[] urine with GNRs following discharge. Inpatient team will f/u
results and contact patient to be sure not having symptoms
HCP: ___ (sister)
Phone number: ___
- Code: Full, Confirmed | 97 | 474 |
13801559-DS-15 | 29,793,685 | 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.
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 ___ y.o. female with PMH of granulomatous
polyangiitis (Wegener's) on rituximab, subglottic stenosis (s/p
multiple dilation procedures by Dr. ___ one in ___ & R
breast lymphoma s/p XRT (___) presenting with 4-day history
of
sore throat, fever, stridor & dyspnea on exertion ___ to flu,
admitted to ___ for airway monitoring given ~6-7mm patent
airway #Stridor iso subglottic stenois
Hx of Granulomatosis with polyangiitis c/b subglottic stenosis
(~6-7mm patent airway) w c/f airway iso likely influenza vs.
alternative viral larynogpharyngitis. Patient was admitted to
SICU for airway monitoring. Sats were maintained >97% through
out on RA, saline nebs, saline sprays and humidified O2. Started
on steroids and abx. Scoped by ENT on ___ w improving airway
edema.
Fiberoptic exam
In the context of the patient's clinical presentation and the
need to visualize the regions in close proximity, the decision
was made to proceed with an endoscopic exam. Accordingly, after
verbal consent, the fiberoptic scope was passed to visualize the
regions of concern. The findings were:
Nasal cavity: Turbinate mucosa dry, red, scattered mucus and
crusting throughout extending to NP. Minimal residual adenoid
tissue, no lesions or masses
Oropharynx: Symmetric soft palatal elevation, no mucosal
lesions,
masses, or erythema, tongue base without lesions
Hypopharynx: No masses or lesions in vallecula, piriform
sinuses,
or post-cricoid area; no erythema; no pooling of secretions
Larynx: Moderate erythema without edema of bilateral arytenoids,
epiglottis non-edematous or erythematous; True vocal cords
symmetric with normal movement bilaterally; Normal movement of
vocal processes; no mass lesions.
Subglottic stenosis w/ mild inflammation, ~7mm patent airway.
___: Ordered aztreonam as allergic to PCNs
___: + flu, contact/droplet precautions. stopped abx. clear
liquid diet. currently asx. will watch overnight. can go
floor/home tomorrow.
___: Discharged on Prednisone taper ___ with
follow up with Dr. ___ | 203 | 282 |
11811453-DS-25 | 26,358,752 | Mr ___,
You were admitted to the hospital with generalized weakness. At
first your symptoms felt similar to your prior strokes. We did
an MRI which showed that you did not have a new stroke causing
your symptoms. We additionally did an ultrasound of your kidneys
to see if you were retaining urine as your symptoms were
worsened during that time at home. Your ultrasound was normal.
You will need to follow up with the renal doctors for ___
___ of your kidney disease. You should also follow up
with your primary care doctor for management of your blood
pressure.
Please start taking amlodipine 5 mg daily for your blood
pressure and stop taking your lisinopril until follow up with
your primary care doctor on ___.
You have follow up with your neurologist, Dr ___ today at 12
___ and follow up with your primary care doctor on ___.
The renal doctors ___ for follow up in their clinic as
well.
We will reactivate your visiting nurse services to help manage
and monitor your blood pressure and your symptoms at home.
It was a pleasure taking care of you
- Your ___ team | SUMMARY/ASSESSMENT: Mr. ___ is a ___ male with a PMHX
of DM, CKD, HTN, HLD, and hx of multiple CVA presenting with ___
days of unsteadiness during urination found to have ___ on CKD
# Dizziness, imbalance
On admission, patient reported several days of imbalance that
felt similar to prior stroke. Reported that symptoms worsen iso
urination. Higher risk given known BPH. On arrival, had negative
orthostatics vitals in the ED. CT scan similar to prior brain
imaging. He received 1.5 L of fluids on admission. He reported
persistent dizziness post fluids, hence MRI/MRA ordered that did
not show evidence of acute infarct. Symptoms thought to be
recrudescence of old CVA symptoms in the setting ___ on CKD.
Continued on DAPT, statin therapy. Throughout hospitalization,
pt was observed to be ambulatory without any concerns. ___ was
consulted and reviewed case, however, given observed
independence, they did evaluate him further. In discussion with
patient, he reported discontinuing his ___ services a couple
weeks ago because he was too fatigued to open the door for
nurse. An OT consult to assess for cognitive functioning was
considered to see if patient may benefit from short term rehab
placement, however, he reported that he would decline SAR if
option were presented to him. After stressing importance of
close BP and symptom monitoring to patient, he was more amenable
to restarting ___ services at home, which were done.
# ___ on CKD
Cr 4.5 on admission, was ___ in early ___. Had worsening ___
during recent hospitalization in ___ that improved with
fluids. He has continued taking his lisinopril at home. On
admission, FENa 2.4% consistent with intrinsic disease, and
urine P/C found to be elevated. On review, patient had
previously seen renal outpatient but has not followed up in
several years. His Cr improved to 3.7 off of lisinopril and with
fluid administration. Renal US was done that did not show any
e/o hydronephrosis. Renal was consulted and recommended
remaining off of lisinopril to assess if persistent improvement
in Cr. They will follow up with patient in clinic in ___.
# Hx of CVA
Continued on home ASA/clopidogrel, atorvastatin 80mg. Needs TTE
with bubble as outpatient
# HTN
Continued on home propranolol. Home lisinopril held and patient
was started on amlodipine ___ for additional BP management.
Plan to follow up with PCP on ___ for BMP and BP check and
likely restart of lisinopril
# T2DM
Last A1c of 5.4. Cont diabetic diet | 189 | 401 |
18477975-DS-18 | 27,548,167 | Dear ___,
You were admitted to ___
because you were having muscle aches and developed a fever to
100.4 degrees.
Because your immune system is low right now, you were given
strong intravenous antibiotics just in case you had an
infection. Fortunately, no source of infection was found and you
did not have any more fevers while you were here. We
discontinued these strong antibiotics and started you back on
your home Ciprofloxacin.
While you were here, you completed the remaining 4 of your 5
days of chemotherapy and tolerated this very well. You were also
transfused 1 unit of red blood cells during your
hospitalization.
As mentioned above, your immune system is very weak right now
while you are undergoing treatment. Therefore, please follow a
strict diet (called a neutropenic diet). If you need a reminder,
please refer to the following website:
h
t
t
p
:
/
/
w
w
w
.
u
p
m
c
.
c
o
m/patients-visitors/education/cancer/Pages/neutropenic-diet.aspx
Your medication list is essentially the same as when you came
in. However, we have decreased the frequency of your Tacrolimus
dosing. Please take your Tacrolimus 0.5mg every other day as
opposed to 5 days a week. You are due for this medication on
___.
Finally, if you develop a fever (100.4F or greater), chills,
mouth sores, sinus pain, pain with swallowing, cough (dry or
with mucous), shortness of breath, chest pain with deep
breathing, abdominal pain, nausea, vomiting, diarrhea, abnormal
rashes or any other symptoms that concern you, please call your
doctor or return to the emergency room.
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely,
The team at ___ | SUMMARY:
___ w/ HTN, DL, NSTEMI, L parietal meningioma, and polycythemia
___ transformed to AML s/p MUD RIC allo HSCT ___ w/
relapse, now on decitabine, who p/w isolated fever to 100.4 and
muscle aches after receiving dacogen and platelets, w/o
localizing symptoms. | 262 | 43 |
10168921-DS-23 | 20,241,674 | Dear ___,
___ were hospitalized due to symptoms of right sided weakness
and confusion, 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.
While ___ were in the hospital, your family decided to pursue
comfort measures only for your care. ___ were given only
medications to keep ___ comfortable.
It was a pleasure taking care of ___.
Sincerely,
Your ___ Neurology Team | Pt is a ___ female with a past medical history of CKD,
HFpEF,
hypertension, and pulmonary hypertension who was found down at
her home and subsequently found to have large L MCA infarct on
CT at OSH. She was transferred to ___ and admitted to Neuro
ICU for monitoring. Prior to admission, pt was noted to be
DNR/DNI by son in ___. | 113 | 61 |
14959010-DS-7 | 21,241,417 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You came to us due to feelings of paranoia, and
you spoke with our medical team, our Pyschiatrists, and our
social workers. We did not find any major underlying medical
problems, but treated you for a mild urinary tract infection.
As a side issue, some lung nodules that were seen on prior chest
x-rays from ___ were again seen. You should see your primary
care doctor to discuss when you should have these evaluated
again in the future.
While you were here, some changes were made to your medications:
Please START docusate for constipation.
Please INCREASE risperidone to 0.5mg every evening. | BRIEF HOSPITAL COURSE
___ with history of GERD, breast CA, osteoporosis, with no
previous psychiatric history, who presented with subacute
paranoia and inability to make decisions for herself. Many of
her central issues with paranoia centered around money and
bills. She was evaluated by Psychiatry, Social work, and
Occupational therapy. She was medically stable during her
admission, and was treated for an uncomplicated UTI. She was
transferred in stable condition to ___ Mental
Health-___ on day 13 of her hospital course.
.
ACTIVE ISSUES
# Paranoia/Inability to make decisions - Likely Mood disoder NOS
and Anxiety Disorder NOS. Appears to be subacute process
occuring over the last 4 months. Other causes of mental status
changes were unremarkable. B12, TSH, RPR were within normal
limits. She was found to have a mildly positive urialysis
without urinary symptoms, but she was treated with a 7 day
course of antibiotics given question of mental status changes.
The time course is not consistent with her several month
decline, and this is likely an incidental finding. No other
apparent toxic-metabolic abnormalities. Psychiatry evaluated the
patient, and determined low concern for delirium or psychosis
due to unremarkable cognitive exam, although she may have mild
cognitive decline/dementia and underlying depression. Patient
will likely benefit from formal inpatient Geriatric/Psychiatric
evaluation and therapy, and patient is agreeable to this option.
Left message for outside psychiatrist Dr. ___ at ___. Alt ___. Increased her risperdone 0.5mg
QHS. She did not require ativan for anxiety during her
admission.
.
# Uncomplicated UTI: From positive UA but unlikely to be major
contribution to subacute change in mental status/anxiety -
Treated with Bactrim x 7 days (last dose on ___ AM). Of note,
patient became concerned about fungal infection of tongue mucosa
(she had recently perused bactrim side effect list) - her tongue
mucosa appears normal, with no sign of infection/abnormalities.
.
CHRONIC ISSUES
# Osteoporosis: Continued calcium/vitamin D at reported home
doses.
.
# Asthma: Continued albuterol inhaler prn.
.
# Persistent Right upper lobe nodular opacity on CXR - Discussed
possible CT-scan of her lung nodule, but patient would like to
defer scanning of that until later given her current psychiatric
condition. She feels that deciding about repeat scans, any
subsequent procedures on the nodule (if necessary), or a
potentially distressing diagnosis would be too much for her to
handle right now, and prefers to follow up on this once she
improves.
.
TRANSITIONAL ISSUES
1) Focal peripheral right upper lobe nodular opacity appears
slightly more prominent than on prior studies, possibly due to
overlap of the right scapula. However, further evaluation with a
chest CT may be helpful to more fully characterize this region
and to exclude the possibility of a slowly growing lung
adenocarcinoma at this site.
2) She needs skilled OT services to address areas of money and
home management.
3) She will need a follow up appointment with her PCP ___ weeks
after discharge from the psychiatric facility.
4) Consider starting daily baby aspirin in this patient. | 110 | 483 |
17185697-DS-11 | 27,312,623 | Dear Ms. ___,
You came to the hospital because you were having confusion. We
gave you medication to help you calm down. We also did lab
testing and imaging, all of which did not show an explanation of
your confusion. We believe you have dementia which is a
progressive, chronic condition.
It is important however, to make sure that you avoid medications
like pseudophedrine and Benadryl as these can cause confusion.
You later developed a urinary tract infection which we treated
with antibiotics.
Your discharge medications and follow up appointments are
detailed below.
We wish you the best!
Your ___ care team | Ms. ___ is a ___ year old woman with afib (not on
anticoagulation) who presented with sudden onset of altered
mental status x1 day, likely baseline vascular dementia given
stepwise decline over time.
ACTIVE DIAGNOSES:
#DEMENTIA, likely vascular: Patient presented to ED with AMS x1
day prior to admission. Had been seen normal the evening prior,
the was found 2 hours later banging on neighbor's door,
demanding to speak to her husband and daughter, both of whom are
deceased. Non-contrast head CT was normal. Urinalysis negative
for infection. No leukocytosis or significant metabolic
abnormalities. No changes in medications. Patient had been in
her usual state of health prior and based on collateral from
family she was very independent and interactive, though has
significant visual and auditory impairment. Of note the patient
had a similar episode a few weeks ago from which she recovered.
Patient's home aides states that the patient had been feeling
well prior to this event. No fevers/chills. No cough, no dysuria
or abdominal pain and had not taken any OTC medications,
specifically, no pseudophedrine or Benadryl. Patient received
Haldol in the ED and then Zyprexa on the floor. This with time
improved her agitation, but she was still confused. At the time
of discharge, patient was calm, AAOx1-2 and not requiring
antipsychotic medication. Given lack of an obvious underlying
cause, in the setting of a step-wise decline per family in a
patient with known atrial fibrillation, understandably not on
anticoagulation, this is suggestive of vascular dementia.
Patient was seen by physical therapy and occupational therapy
who recommended long-term care placement.
#URINARY TRACT INFECTION: UA and UCx were obtained upon
admission and were negative. However, while in house the patient
had urinary retention requiring intermittent catheterization.
Given her increased frequency of retention a repeat UA and UCx
were sent which returned with pan-sensitive E. coli. Patient was
given 1 dose of CTX on ___ and then switched to Bactrim DS on
___ upon return of sensitivities with goal to treat for 7 days
(last day ___.
#METABOLIC ANION GAP ACIDOSIS: On presentation AG 16,
delta/delta 1.3 which is consistent with a pure metabolic anion
gap acidosis, further supported by elevated lactate of 2.7.
Patient had been in ED for over 24 hours, likely had not been
eating much. No IVF given. This in addition to likely agitated
movements is likely sufficient to cause a slightly elevated
lactic acidosis. Otherwise hemodynamically stable without signs
of end organ damage or infection/sepsis. This resolved with IV
fluid.
#ACUTE KIDNEY INJURY: sCr 1.4 at presentation which appears to
be near baseline based on labs over the last ___ years, likely CKD
though no formal diagnosis made in chart. sCr improved to ___
s/p 500cc NS. Elevated lactate described as above. No
hyponatremia or other electrolyte abnormalities.
#ATRIAL FIBRILATION: Not on anticoagulation. Rate controlled
with labetalol and diltiazem prior to the admission. Continued
on diltiazem, but we reduced the dose because of bradycardia.
Stopped labetalol because of hypotension and bradycardia.
#HYPERTENSION: The patient was hypotensive and bradycardic
during her admission. Her home labetalol and HCTZ were both
stopped. Diltiazem was reduced from 240mg daily to 120mg daily.
On discharge her systolic blood pressure was in the 120-150
range.
#HYPERLIPIDEMIA: She was on simvastatin 20mg QHS at home. This
was stopped because it interacts with diltiazem and because her
life expectancy does not warrant further treatment with a
statin.
TRANSITIONAL ISSUES
[]Monitor urinary output and assess need for intermittent
straight catheterization
[]discuss with family about feasibility of patient returning
home
[]Bactrim last day ___
# CODE: DNR/DNI
# CONTACT: ___ (Niece and Primary HCP) Cell: ___ Home:
___
___ (Niece and other HCP) ___ | 96 | 599 |
13123854-DS-7 | 22,791,211 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because you had bleeding from your rectum.
What happened while I was in the hospital?
- Your blood counts were monitored. You had a procedure done
that helped to close the blood vessel that was causing bleeding.
You then had imaging which showed ulcers in your colon, for
which you will ___ in liver clinic in 1 month.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Come back to the emergency room if you have any more bleeding.
- Please have labs drawn on ___
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | SUMMARY:
=========
___ old male with history of cirrhosis secondary to PBC with
known gastric varices and autoimmune hepatitis who presented
with recurrent BRBPR and downtrending hemoglobin. He was found
to have a rectal AVM on CTA and underwent coil embolization of
his superior rectal artery on ___, with expected small volume
bloody stools following the procedure. He underwent flexible
sigmoidoscopy on ___ and was found to have multiple ulcers, 1
enlarged and clotted, for which he will follow up in liver
clinic in 1 month. His course was notable for asymptomatic
hypotension which resolved, and sensation of urinary retention
after starting tramadol.
=============
ACTIVE ISSUES
=============
# BRBPR
# Rectal varices
# Acute blood loss anemia
Patient initially presented to the ED on ___ with BRBPR.
Initial EGD showed no esophageal varices. ___ was consulted in ED
who felt bleed likely secondary to small AVM seen on CTA. He was
given 2u PRBCs and discharged home due to stability. Patient
then presented back with recurrent bleed, downtrending
hemoglobin. He remained hemodynamically stable throughout his
course and did not require transfusion. Interventional radiology
performed mesenteric angiography on ___ which showed "Superior
rectal arteriogram demonstrates an early filling vein (prior to
parachymal filling) suggesting AV malformation." He under went
successful embolization of the superior rectal artery branch
supplying rectal AVM with EtOH and coils. He had expected small
volume bright red blood in his formed stools following the
procedure, and received flexible sigmoidoscopy on ___ which
showed multiple small ulcers and a large, cratered ulcer with
overylying clot, for which he will ___ in liver clinic in
1 month. He was started on ceftriaxone for prophylaxis due to
GIB in the setting of cirrhosis, but this was discontinued
before discharge as he had minimal blood in his stools. He was
observed for stability and discharged home with 1 week PCP
___ and CBC.
[] Repeat CBC on ___
#Hypotension
Patient had soft blood pressures ranging from 90-110 systolic,
below his baseline 130-160 systolic starting ___. He was
switched form oxycodone to tramadol and nadolol was
discontinued. 50g albumin bolus was given twice on ___. Hb
remained stable, he denied hypotensive sxs, and no signs of
sepsis/infection throughout his course. BPs normalized to
baseline values before discharge and he was restarted on half
his normal dose of nadolol.
[] Increase nadolol to original dose of 20 mg as tolerated
#Urinary retention
Patient reported new weak stream and retention on ___ after he
had started tramadol. He had PVR showing residual volume of 0 on
___. He had no dysuria or frequency. UA on ___ showed no
evidence of UTI but did show trace urine protein.
[] Follow up urine culture
[] Repeat UA for proteinuria
CHRONIC ISSUES
==============
#Gastric varices
EDG in ___ showed non-bleeding type II gastric varices
in
the cardia. EGD in ED on ___ showed no esophageal varices.
Continued home omeprazole and nadolol was held then resumed at
half home dose as above.
#Cirrhosis
#Primary biliary cholangitis
Patient has cirrhosis secondary to PBC and autoimmune hepatitis.
His Meld-Na was calculated to be 7, and he was ___ Class
A. RUQUS on ___ showed no evidence of ascites and he was
without evidence of hepatic encephalopathy or decompensated
cirrhosis on exam and labs throughout his course. Continued home
omeprazole and ursodiol. nadolol was held then resumed at half
home dose as above. | 147 | 541 |
18119724-DS-7 | 24,306,795 | Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were found to have atrial fibrillation
which is an abnormal heart rhythm that puts you at increased
risk of stroke. You stayed in this rhythm during your
hospitalization and we started metoprolol to help control your
heart rate. This worked as well when the medication took full
effect and we were able to take fluid off of you with a diuretic
called Lasix. You no longer need losartan and amlodipine.
We checked for a blood clot (pulmonary embolism) in your lung as
well as your structural components of your heart and did not
find a reason for your atrial fibrillation. It could possibly be
caused by your ibrutinib (6% of patients) so your oncology team
has asked that you hold this medication until you follow-up with
them in clinic.
We were unable to control your heart rate with metoprolol and
due to interactions of other medications the decision was made
to do a cardioversion. You had that procedure prior to discharge
and successfully are back in normal sinus rhythm.
We have started you on a blood thinner called Coumadin or
warfarin. This is a medication that will help prevent strokes
which are a 4% risk per year due to your atrial fibrillation.
The goal INR (level) for your Coumadin level is ___. You will
follow-up with your primary care doctor to monitor your levels
this next week. We also need you to hold your Coumadin and call
your doctor if you have any bleeding (nose bleed, rectal bleed,
etc). Your platelets and blood counts will likely drop after
being off ibrutinib and we have asked that you hold your
medications per instructions by your PCP if your counts are too
low.
We have made an appointment with a ___ cardiologist for you to
discuss your atrial fibrillation and possible options. Please
hold your ibrutinib until follow up with oncology.
Please weight yourself daily. If you gain >3 pounds in 3 days
please call Dr. ___.
Please continue Lasix 40 mg until f/u with your PCP. Then you
can change to 20 mg after your PCP has evaluated you. | Mr ___ is a ___ nurse ___/ CLL/SLL,
hypogammaglobulinemia, hypothyroidismcurrently on treatment with
ibrutinib presents with dizziness and oliguria on ___
found
to have hyponatremia and new onset afib with RVR. CTPE and
echocardiogram was pursued without evidence of acute heart
failure or pulmonary embolism as cause of afib. Patient had an
elevated JVD and increased crackles that improved but not
resolved on discharge.
# Atrial fibrillation w/ RVR - new onset. No chest pain. trop
neg
x2, EKG neg. TSH 9 - normal T4 known hypothyroidism. CTA neg for
PE. TTE without right heart strain or heart failure.
Uncontrolled
rate with po dilt and iv push on ___ transitioned to metop 12.5
QID titrated to 25 QID ___ with still HR 110s-150s. sBP now
___. Cardiology consult recommended diuresis and then
uptitration to 37.5 mg po q6hr on ___. However, this did not
control her rapid ventricular rate. She underwent a Successful
DCCV ___ now in NSR.
- Appreciate Cardiology recommendations, they are arranging a
follow-up appointment with a cardiology specialist and will call
the patient for information
- Toprol XL 25 qdaily
-Coumadin x 1 month post ___ for coverage. INR 2.5 on
discharge. DCCV occurred ___. 1 month ___.
-6% possibility of ibrutinib causing afib, oncology requested to
hold until f/u. Will need to monitor CBC closely to ensure that
Coumadin benefit of stroke prevention outweighs risk of
bleeding.
# volume overload. Ms. ___ was consistently net negative
during this admission. She was placed on a fluid restriction and
continued to obtain diuresis. TTE did not show signs of heart
failure so likely due to her medication ibrutinib.
- d/c on Lasix 40 mg x 7 days until re-evaluation with PCP.
- If still elevated JVD on f/u appointment will continue Lasix
40. If not, will change to Lasix 20 mg qdaily.
# Hyponatremia- presented hypervolemic with Na 121 and urine
studies showing Na 20 and Osm 112 making hypervolemic
hyponatremia likely. This improved with diuresis but then
worsened when gave back fluids attempting to help with HR.
Still mildly volume overloaded on exam so Lasix given on
discharge. Na 125 on discharge but stable over several days.
Repeat studies revealed a Na 40 and Osm 265 making a component
of SIADH. Fluid restriction was started at 2L.
- Continue fluid restriction 2L
- Continue Lasix 40 mg po qdaily until f/u with oncology on
___ and PCP ___ 7 days. If JVD has improved could decreased
down to 20 mg qdaily
# Bronchiectasis
Minimal improvement of symptoms, stable cough, afebrile. WBC
likely due to hemoconcentration. Levaquin dc'd ___ (14 day
course).
- cont inhalers, IS
# CLL/SLL
WBC/plt dropping since held ibrutinib on admission.
- hold ibrutinib due to afib, expect labs to drop. Plan to hold
until f/u with oncologist
# Hypogammaglobulinemia
- t/b BMT team re next infusion, will be as outpatient
# Pleural effusion, Left
She was found to have this on POCUS in ED, left sided. Chronic
per patient with no oxygen requirements. CTA no focal
infiltrate.
# Mouth sores
Will start magic mouthwash, encourage oral hygiene
# Hypothyroidism - cont levothyroxine 75 mcg. Pending Free T4
1.6. Will keep levothyroxine at 75 for acute illness and repeat
in 6 weeks.
# Essential HTN- controlled
- hold amlodipine as above
- hold valsartan, Toprol 25 XL started
FEN: Low salt diet, 2L fluid restriction
CODE STATUS: Full code
HCP: Health Care Proxy: ___
PCP: ___, MD
CONSULTS: ___ signed off, Cardiology ___
DISPO: Today
# Active meds: reviewed
>3o minutes was spent on this discharge and planning. | 357 | 561 |
13521465-DS-7 | 24,647,431 | You were admitted to the hospital after a small bowel resection
and ileocecectomy for surgical management of your ___
bowel obstruction. You have recovered from this procedure well
and you are now ready to return home. Samples from your colon
were taken and this tissue has been sent to the pathology
department for analysis. You will receive these pathology
results at your follow-up appointment. If there is an urgent
need for the surgeon to contact you regarding these results they
will contact you before this time. You have tolerated a regular
diet, passing gas and your pain is controlled with pain
medications by mouth. You may return home to finish your
recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___. You may
gradually increase your activity as tolerated but clear heavy
exercise ________.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck! | ___ hx ___ disease, prostate CA s/p prostatectomy, SBO
presenting with LLQ pain and abdominal distention, SBO on
imaging.
# Small bowel ___: Likely due to known
stricturing ___. Less likely volvulus given pt not in
significant pain. No e/o abdominal sepsis. Rapid recurrence and
stricturing nature of disease points to the need for operative
management. Malnourished. He was started on IV steroids, mIVF
with dextrose, thiamine, folate, MVI. ___ held per GI. Attempts
at diet advancement failed after NGT removed and the pt was
transferred to the colorectal surgical service for a Small-bowel
resection and ileocecectomy which he tolerated well. At the time
of discharge he was tolerating PO, was passing flatus and having
bowel movements. He will follow up in Colorectal surgery clinic
and will continue to follow with his PCP and GI physicians.
# Osteoporosis: Cont vit D, Ca held as it interfered with Phos
repletion.
# Nutrition: Pt was started on TPN while in the hospital, which
he tolerated well. Post op he was began on a clear diet, then
transitioned to a regular diet, which he tolerated well. His
PICC was d/ced prior to discharge
# Pneumonia: He was treated for Hospital acquired pneumonia with
vancomycin and Levofloxicin, which he tolerated well. | 591 | 207 |
Subsets and Splits