note_id
stringlengths 13
15
| hadm_id
int64 20M
30M
| discharge_instructions
stringlengths 42
33.4k
| brief_hospital_course
stringlengths 45
22.6k
| discharge_instructions_word_count
int64 10
4.86k
| brief_hospital_course_word_count
int64 10
3.44k
|
|---|---|---|---|---|---|
13947644-DS-6 | 20,142,862 | Dear Ms. ___,
You were admitted to the Acute Care Trauma surgery service on
___ after sustaining multiple injuries including a fracture
in your neck, a fracture in your right arm, an injury to the
ligament in your knee, and a fracture in your midback. You were
evaluated by the spine doctors and your ___ spine was
surgically repaired in the operating room. You were taken to the
operating room with the hand surgery team and had your right
hand repaired. You were evaluated by the orthopedic surgery team
for your right knee injury and you should follow up in the
___ clinic for further evaluation and treatment.
You are now doing better, pain is better controlled, and you are
ready to be discharged to ..... to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Ms. ___ is a ___ yo F admitted to the Acute Care Trauma Surgery
Service on ___ after sustaining a fall while riding the bus
sustaining a C6 and C7 fracture with right wrist fracture. She
was transferred for orthopedic and spine surgery evaluation. The
patient was hemodynamically stable and neurologically intact on
presentation. She underwent further imaging of the shoulder,
knee, and MRI of the neck which showed no new injuries.
On HD1 orthopedic spine was consulted and the patient was taken
to the operating room for open treatment of C6-7 fracture,
anterior cervical decompression, and anterior cervical
arthrodesis using structural allograft. Please see operative
report for details. She was extuabated and taken to the PACU in
stable condition then transferred to the floor once recovered
from anesthesia. CTA of the neck was obtained to assess for
vascular injury of which there was none. She was seen and
evaluated by hand surgery who splinted the wrist and made plans
for inpatient operative repair.
On HD3 foley catheter was discontinued and she voided without
issues. Repeat cervical spine xrays were obtained and showed no
evidence of hardware related complications.
On HD5 she underwent CT scan of the right lower extremity due to
increased knee pain. Orthopedic surgery evaluated the patient,
reviewed the images, and determined the patient to have a medial
collateral ligament injury.
On HD6 the patient lost IV access and a midline was placed
without issues. The patient's hemoglobin/hematocrit remained
stable and therefore subcutaneous heparin for DVT prophylaxis
was started.
On HD7 the patent was taken to the operating room with hand
surgery for Open reduction and internal fixation of her right
distal radius fracture. She tolerated the operation well and
without complications.
The patient was seen and evaluated by physical and occupational
therapy who recommended discharge to rehab to continue her
recovery.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 427 | 349 |
17889959-DS-6 | 23,312,313 | Dear Ms. ___,
You came in because you had food stuck in your esophagus. You
had an endoscopy to remove the food. During the endoscopy the GI
doctors ___ of you esophagus. They dilated this
narrowing to open it.
During the next week you should eat only clear liquids. You can
also have a small amount of pudding. During this time you can
drink ensure to avoid losing weight. It will be important to
keep track of your calories. You can drink as much ensure as you
need to maintain your calories.
If you are tolerating a liquid diet without any issues, you can
advance your diet to soft solids (should be very soft) after one
week of liquid diet (___).
It will also be very important to follow up with the GI doctors
in ___.
It was a pleasure taking care of you and we're happy that you're
feeling better! | Ms. ___ is a ___ year-old female with hx of squamous cell
esophageal cancer and jackhammer esophagus s/p ___
___ who presented with pain secondary to food
impaction. On ___ she underwent emergent EGD with removal of
food impaction. Benign appearing stricture was visualized and
dilation was performed. She then had persistent symptoms of
dysphagia and repeat EGD was performed on ___ which did not
reveal any overt residual obstruction (benign stricture, now
11mm, was still present along with some fluid). She was started
on a clear liquid diet which she will continue for one week. She
will then advance to soft solids after one week if tolerating
liquids. She will follow up with GI clinic in two weeks for
repeat esophageal dilation. She was continued on home PPI BID
# Leukocytosis: mild leukocytosis to 10.7 on admission, likely
stress response. UA was notable for pyuria but culture returned
consistent with contamination
# Chronic pain after surgery: continued home Oxycodone ___
Q4h in liquid form
# Hypothyroidism: continued home synthroid | 146 | 167 |
10098672-DS-8 | 21,229,395 | You were admitted to the hospital with fever and kidney injury
and were found to have a urinary leak from your prostate
surgery. We placed a foley catheter and you will follow-up on
___ in ___ clinic. You were also treated for a urinary
tract infection. | ___ with long standing Crohns on TPN, recent prostatectomy,
presents with malasie and weakness and found to have klebsiella
and proteus UTI in the setting of a post-surgical urinary leak. | 46 | 31 |
14413342-DS-20 | 27,452,396 | You were hospitalized for fevers and cough due to influenza.
You were treated with IV fluids and an anti-viral medication
(Tamiflu). Continue this medication for an additional 4 days to
reduce the duration of your illness. Drink plenty of fluids. | ___ with hx of IDDM, htn, GERD, asthma, breast ca s/p
lumpectomy, chemo and XRT presenting with weakness, fever, and
cough, presumed to have influenza B based on contacts and
influenza-like illness.
# Influenza B: Negative influenza by RT-PCR in ED, but given
husband positive for influenza B and granddaughter also positive
for influenza this week, reasonable to treat presumptively, as
per CDC guidelines.
- Tamiflu x5 days - received 100 mg in ED, per pharmacy renally
adjusted dose is 30 mg BID
# Acute on CKD stage III: Followed by nephrology at ___.
Acute component likely prerenal in setting of influenza.
Improved with IV fluids.
- Encouraged PO hydration
- Per renal notes, ACEI d/ced for cough, ___ is being considered
as outpatient
# Elevated troponin: TnT modestly elevated to 0.06, 0.05 on
repeat. Likely related to renal failure in combination with
demand in setting of infection. No known cardiac disease, but
multiple risk factors for underlying coronary atherosclerotic
disease. EKG without ischemic changes. Patient is without
chest pain. Continued beta blocker, baby aspirin.
# Diabetes mellitus, type II, insulin-dependent, with neuropathy
and nephropathy: Last A1c 10.2, poorly controlled, with
associated CKD. Continue home Lantus and prandial Humalog
coverage.
# Hypertension: Continue home amlodipine, spironolactone,
atenolol. Torsemide held in the setting of dehydration / ___,
but restarted upon discharge.
# Asthma: Continue home montelukast, albuterol
# HLD: Continue home statin
# Hx of breast ca: Continue home anastrozole
# GERD: Continue home PPI
30 minutes on discharge activities, home, no services | 43 | 250 |
16143669-DS-7 | 29,408,419 | Dear Mr. ___,
It was a pleasure taking part in your care while you were
hospitalized at ___. As you
know, you were admitted to rule out dangerous cardiac causes of
the chest pain you were having prior to admission. Fortunately,
subsequent testing showed that you did not have a heart attack,
though stress test showed some evidence of stable blockage in
the blood vessels supplying your heart. It seems that your chest
pain occured as a result of a condition called pericarditis.
Pericarditis involves inflammation of the tissue surrounding the
heart, though it can be challenging to identify the exact cause.
You were treated with ibuprofen, which helped to calm the
inflammation and relieve your chest pain. You should continue to
take the Ibuprofen as prescribed. You also had an echocardiogram
of your heart, which was normal.
Your blood pressure regimen was changed during this admission
due to slightly low blood pressures: Please STOP olmesartan
until directed to restart by your primary care provider ___
cardiologist. Please LOWER metoprolol succinate to 150mg daily.
Please note that you are now on multiple blood thinning
medications, including aspirin, clopidogrel (Plavix), and
ibuprofen. Please contact your doctor if notice blood in your
urine or stool, tarry stools, or excessive bleeding of any kind.
You also should seek medical attention if you strike your head. | BRIEF HOSPITAL COURSE:
=========================
DH is a ___ yr. old M w/ HTN, HLD, and known CAD (s/p STEMI ___,
w multiple PCIs including LAD (Cipher ___, mid RCA (stented x2
___, LAD (DES ___, D1 (___ ___, who presented to ED with
chest pain and was found to have new EKG changes (diffuse ST
elevations unchanged from prior, but new PR depressions), and
was found to have acute pericarditis. | 219 | 69 |
15855215-DS-14 | 20,499,271 | Mrs. ___,
___ were hospitalized for kidney injury and high calcium levels.
This was treated with IV fluids and a few injections of
medication to lower your calcium levels. With these
interventions, your kidney function and calcium levels improved.
Your findings may be concerning for cancer. We have been in
contact with your PCP ___ see her soon after
discharge.
PLEASE MAKE SURE TO EAT AND DRINK PLENTY UPON RETURNING HOME.
THIS WILL BE VITAL IN THE RECOVERY OF YOUR KIDNEY FUNCTION.
It was a pleasure taking care of ___!
Your ___ team | ___ year old female with history of alcohol dependence and spinal
stenosis who presents with acute
kidney injury and hypercalcemia with concern for underlying
malignancy. | 92 | 25 |
15602488-DS-21 | 27,218,054 | Dear Ms. ___,
It was a pleasure being a part of your care team at ___
___. You were admitted because you were
having bleeding from your bowel, which is the same as when you
have had bleeding in the past. We recommended performing a
procedure to stop the bleeding, but you preferred to wait and
see if the bleeding stopped on its own. Fortunately, you did not
have any more bleeding during your hospital stay.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team | This is an ___ woman with a history of CAD w/ BMS, HTN, GERD,
and diverticulosis complicated by lower GI bleeding who
presented to the ED with four bloody stools over a few hours,
found to have bleed in mid-descending colon.
# Diverticular bleed, complicated by anemia and lactic acidosis:
The patient was admitted with a GI bleed, similar to those she
has experienced in the past secondary to diverticulosis. In the
ED, initial vitals were: 96.5 79 173/77 18 98% RA. Rectal exam
was notable for gross blood. Labs were significant for Hgb 13.0
(baseline Hgb ___ and Lactate 2.1. GI was consulted and
recommended admission for further monitoring. The patient was
given Pantoprazole 40 mg IV and was admitted. On the floor
around midnight, she had another large bloody bowel movement,
around 200 cc, with clots. At 2 am she triggered for an episode
of syncope ___ sinus pause) that occurred while having a bowel
movement preceded by nausea and nonbloody emesis. She was given
a 1L LR bolus, and her hemoglobin was found to be 11.7 from 13,
with a lactate increase from 2.1 to 3.0. A CTA was done, which
showed extravasation in mid-descending colon, brisk enough for
embolization. ___ discussed embolization with patient who
declined the procedure. The patient had no further episodes of
GI bleeding throughout the day. A repeat lactate improved to
2.4, and her hemoglobin remained stable at 10.5. She was
discharged the following morning with plan for followup with her
primary care doctor and gastroenterologist. Discharge hemoglobin
9.9.
# Leukocytosis:
On admission, the patient was noted to have leukocytosis to
12.4, which increased to 14.9. Infectious review of systems was
entirely negative. This was therefore thought to most likely
represent stress demargination in the setting of GI bleeding.
Her white count trended down and was normal on discharge.
# CAD: s/p BMS, most recently in ___. On Ticagrelor
previously, switched to clopidogrel due to GIB, but clopidogrel
was also ultimately discontinued due to recurrent GI bleeding.
On admission, the patient was on aspirin 81 mg only. The aspirin
was held in the setting of bleeding, to be restarted at the
discretion of her outpatient providers.
# HTN: Patient was initially hypertensive with SBP of > 170 on
admission. However, it had improved to the 110s/50s on
discharge.
# GERD: As above, the patient was initially started on IV
pantoprazole given concern for upper GI bleed. However, given
the high probability that this was diverticular, as seen on CTA,
this was transitioned to PO pantoprazole, and then stopped prior
to discharge.
============================
TRANSITIONAL ISSUES
============================
- Discharge h/h: 9.9/30.5
- The patient's h/h should be checked at her next appointment.
- The patient's aspirin was stopped on admission due to her GI
bleeding. It can be restarted at discretion of her outpatient GI
and cardiology providers.
- If the patient has additional diverticular bleeding, she has
agreed to undergo ___ embolization of the causative artery.
- Patient reports that she would like to have regular ear
cleanings at PCP office for ear wax buildup. She was discharged
on debrox ear drops. She also is requesting an outpatient
cholesterol check for routine screening.
-Of note, she was set up with Elder Services per her request to
assist with bathing.
# CODE STATUS: Full code
# CONTACT: ___ (daughter) ___
___
Billing: >30 minutes spent coordinating discharge. | 92 | 551 |
10714685-DS-25 | 21,006,213 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You came to the hospital because there was concern that you
aspirated while eating. You had fever, cough, and low blood
oxygen levels.
What happened while I was in the hospital?
- In the hospital, you were given IV antibiotics to treat a
presumed pneumonia. You were fed a modified diet as recommended
by the speech language pathology team during your last
admission.
What should I do once I leave the hospital?
- Be sure to finish your course of antibiotics, the last day
will be ___
We wish you the best!
Your ___ Care Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | SUMMARY STATEMENT:
==================
Pt is a ___ yo M with dementia (lives in ___
home), atrial fibrillation on warfarin, history of recurrent
admissions for pneumonia ___ aspiration who was admitted for
fever, hypoxia, shortness of breath, hypotension, and
leukocytosis following an aspiration event at his nursing home.
On admission had SBP to ___, responsive to fluids. Chest x-ray
showed no opacity. Was initiated on broad coverage with vanc,
cefepime, and flagyl initially. This was switched to ceftriaxone
and azithro due to concern for community acquired pneumonia.
Patient had MRSA swab return positive so received additional
dose of vanc and then switched to oral doxycycline prior to
discharge for 5 day course to end ___. Patient also found to
have UA concerning for UTI. He was treated empirically for
simple cystitis with a three day course of IV ceftriaxone.
#Aspiration pneumonitis vs community acquired pneumonia
Patient admitted for respiratory/systemic symptoms as above. SLP
was not consulted this admission, instead started pureed
solids/nectar prethickened liquids per recommendation from last
admission given that this is a recurring event for him and based
on goals of care discussion w/ patient and family he would not
want to cease eating regardless of SLP recommendation despite
knowing risks of aspiration.
#Supratherapeutic INR:
INR 3.5 on admission, warfarin was held for one day and INR then
became therapeutic and patient restarted on home 2.5 daily
warfarin. Can consider transition to DOAC as outpatient.
#Urinary retention
___ on CKD
#Bacteriuria
Patient has CKD w/ baseline Cr of 1.2. Presented with Cr 1.8
which downtrended to normal with fluids. Patient was retaining
urine and required intermittent straight cath.
==============
Chronic Issues
==============
#Atrial fibrillation
Warfarin as noted above. Continued home metoprolol.
#Prostate cancer
Continued home tamsulosin
#GERD
Continued home pantoprazole
#Neuropathy
Continued home gabapentin
TRANSITIONAL ISSUES
===================
[ ] 5 day course of doxycycline to continue through ___.
Please give after meals.
[ ] Continue pureed solids/nectar prethickened liquids as diet
as outpatient given history of multiple aspiration events. Can
liberalize diet pending decision regarding goals of care with
family.
[ ] Patient continues to take warfarin. Consider DOAC for this
patient to eliminate need for monitoring. Given Cr<1.5 and
weight>60 kg could receive 5 mg bid. | 131 | 346 |
15005294-DS-11 | 28,682,727 | Please call Dr. ___ office at ___ for fever
greater than 101, chills, nausea, vomiting, diarrhea,
constipation, increased abdominal pain, pain not controlled by
your pain medication, swelling of the abdomen or ankles,
yellowing of the skin or eyes, inability to tolerate food,
fluids or medications, the drain insertion site has redness,
drainage or bleeding, or drain output stops or increases
significantly or any other concerning symptoms.
Complete 5 day course of ???( Linezolid and Ciprofloxacin.) Do
not take the Fluoxetine until Linezolid prescription completed.
Abdominal CT scan to reassess collection scheduled for ___.
Abdominal fluid collection drain-Catheter Flushing: Flush to
patient only with 10cc of sterile saline Once daily.
If there is pain with flushing this may mean that the abscess
cavity has collapsed. Notify Dr. ___ ___ ___
___ ___ | ___ h/o L hepatic triseg c/b abscess and wound infx ___
recent admit on ___ with ___ biloma s/p ___
re-presenting with recurrent abd pain N/V/D. CT scan reveals a
recurrent collection. On ___, under CT guidance, an ___ pigtail
drain was placed with fluid sent to micro that was negative. She
was kept on Linezolid and Cipro that she was on at home. On
___, an ERCP was performed with sphincterotomy without seeing
a bile leak. Given concern for leak and recurrent fluid
collection, a ___ Fr biliary stent was placed. She tolerated this
procedure well and was afebrile. LFTs decreased to normal and
she was continued on Cipro and Linezolid. The pigtail drain
output averaged 30cc of thin, clear slightly pink fluid. ID
recommended 5 days of antibiotic from drainage of collection.
She was discharged to home in stable condition, tolerating diet
and ambulating independently. She will have a f/u abdominal CT
on ___ then f/u with Dr. ___. | 129 | 162 |
16103368-DS-9 | 23,080,588 | Dear Mr. ___,
You were hospitalized due to symptoms of right sided sensory
changes and weakness, resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are: high blood pressure, high
cholesterol, PFO
We are changing your medications as follows:
-started baby aspirin for stroke prevention
-started atorvastatin for high cholesterol
-started amlodipine and lisinopril for high blood pressure
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ man, past medical history of borderline
hypertension, who presented to OSH with acute onset R face, arm,
and leg numbness and tingling. Exam notable for diffuse right
hemisensory (face, arms, abdomen, legs) and pinprick loss
without specific dermatomal lesion, and some deficits in
coordination and proprioception. Labs notable elevated LDL
(156), GGT (71), positive lupus anticoagulant. MRI showed
infarct of posterior limb of internal capsule.
Etiology was thought to be hypertensive given location and
clinical history. However, TEE demonstrated PFO, possible
pulmonary vascular malformation, but follow up CT Chest revealed
no evidence of vascular malformation. Given that the size of the
infarct was borderline large for a lacunar infarction, and
detection of PFO, paradoxical embolism could not be excluded.
Ultrasound Doppler of the legs and MRV pelvis were negative. A
hypercoagulable workup was started. This revealed elevated lupus
anticoagulant which has unclear significance and needs to be
repeated in 12 weeks. Blood pressures were somewhat refractory
but better controlled ultimately on Amlodipine 10mg daily and
Lisinopril 20mg daily.
Stroke risk factors included hemoglobin A1c 5.5, TSH 2.5, LDL
156. As a result, patient was started on Atorvastatin 40mg daily
for elevated LDL.
Patient was placed on aspirin 81mg for secondary prevention.
He received gabapentin for symptomatic treatment of
paresthesias.
His LFTs revealed elevated GGT,and ALT, likely caused by
hypoperfusion. Elevated GGT w/ normal Alk phos suggests possible
liver disease in the setting of alcohol use.
************ | 256 | 237 |
19774071-DS-11 | 25,564,992 | Discharge Instructions
Brain Tumor
Surgery
You underwent surgery to remove a brain lesion from your
brain.
You had a VP shunt placed for hydrocephalus. Your incision
should be kept dry until sutures or staples are removed.
Your shunt is a ___ Delta Valve which is NOT
programmable. It is MRI safe and needs no adjustment after a
MRI.
Please keep your incision dry until your staples are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
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 | Patient was admitted to Neurosurgery for further workup of her
brain lesions. She was given Dexamethasone and admitted to the
Step Down Unit. A MRI brain was ordered. A consult for neuro and
rad onc was obtained. She remained stable overnight and on ___
she remained stable. Pt c/o back pain and left hip/pelvic pain.
A CT torso was ordered and showed a new lower right paratracheal
mediastinal lymphadenopathy concerning for metastatic disease.
Dr. ___ hem/onc has been following closely.
On ___, the patient remained neurologically stable. She was
consented for tumor resection and possible VPS placement on
___. Neuro oncology recommended an MRI of the spine with
contrast due to + hyperreflexia on exam. Rad onc recommended
WBRT and resection of tumor vs VPS. The patient stated she has a
daughter that is ___ ___ old and a son that is ___ ___ old and she
feels her son is having a difficult time the mom's condition and
poor prognosis. A social work consult was obtained for family
support. Also, due to her poor prognosis a palliative care
consult was obtained to aid in additional family support in end
of life discussion.
Over the weekend of ___ the patient remained
neurologically and hemodynamically stable waiting for surgery on
___.
On ___, the patient remained stable. The MRI wand of the head
was done this morning. The patient was brought to the OR for
resection of her cerebellar lesions and for placement of a VPS.
Her intraoperative course was uneventful, please refer to the
operative note for further informant ion. She was extubated in
the OR and brought to the ICU for close monitoring. A ___
demonstrated expected post operative changes. ___ showed
expected post operative changes and stable edema.
___, Ms. ___ continued to be neurologically stable. Her
steroids were continued. The post operative MRI was completed
which demonstrated persistent mass effect with no evidence of
hydrocephalus.
___, in the early morning, the patient acutely decompensated
becoming hypoxic and bradycardic. She was re-intubated with
first attempt in the right brainstem and was subsequently
extubated and re-intubated. She was started on pressors and
taken for a stat ___ which showed an acute bleed in resection
bed with increased posterior fossa swelling and enlargement of
temp horns. A 23% bolus of saline was given and her steroids
were increased. Family was contacted to come in and they
consented for an EVD placement as well as a suboccipital
craniotomy for clot evacuation and decompression. A CTA of the
chest was obtained which demonstrated bilateral pulmonary
embolisms. An echocardiogram was performed which was within
___ limits. The patient was taken to the operating room for
her decompressive posterior fossa. Surgery then placed an IVC
filter. Strict blood pressure parameters were maintained.
On ___, the patient's serum Na was 144. She was extubated later
in the day. A repeat serum Na was obtained and was 139.
On ___, the patient remained neurologically stable on
examination. The EVD was raised to 20. Her SBP was liberalized
to <160. A CSF sample was obtained and was sent for cytology.
___, Ms. ___ had a ___ which demonstrated stable
ventricles. Her EVD was clamped and two hours later unclamped
for elevated intracranial pressures. The EVD was lowered to 10.
Her head was wrapped over top of incision.
___, the patient remained neurologically stable and her drain
remained at 10. She was restarted on SC heparin.
On ___, patient was neurologically intact. Her EVD was clamped
at 1pm without any ICP issues. She was pre-oped for the OR for
possible VP shunt.
On ___, patient remained clamped overnight without any changes
in ICP or neurologic exam. Head CT performed showed stable
ventricular size, but new IVH. On exam, her posterior incision
was more larger and boggy. She was taken to the OR for a
placement of a R VP shunt. Post operatively, she remained
intact. Head CT showed that the catheter was in a good location
and no acute hemorrhage. She was transferred to the floor in
stable condition.
On ___, the patient remained neurologically intact on the
floor. She had complaints of gas pain, so she was started on
simethicone. ___ re-evaluated the patient and recommended that
she be discharged to a rehab facility. She was screened for an
available bed. Her discharge was pending insurance
authorization.
On ___ Ms. ___ developed midsternal chest discomfort that
worsened with deep breathing and was found to have an elevated
WBC 28.4. Blood cultures were sent and are negative at
discharge. UA showed moderate Leuks but negative nitrites. CXR
performed was stable. With a history of PE, bilateral ___
dopplers were performed and were negative. CTA chest showed
improving clot burden compared to ___.
On ___ WBC was 10.9. At the time of discharge on ___ she was
tolerating a regular diet, ambulating without difficulty,
afebrile with stable vital signs. | 462 | 812 |
18410637-DS-21 | 25,340,693 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for a fall that you had,
which was probably a seizure.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were found to have likely cancerous tumors in your brain
and lungs. The tumors in your brain bled, which caused the
likely seizure.
- You were evaluated by neurosurgery, radiation oncology,
medical oncology, and neuro-oncology. All teams agreed that the
best plan would be to start radiation therapy for the brain
lesions. You received this without issue.
- You were found to have worsening of your kidney function. It
is unclear why this happened. You needed to have a few sessions
of dialysis, and your kidneys recovered over time.
- You had a procedure to place a filter in the largest vein in
your body (IVC filter). This prevents blood clots from traveling
to your lungs.
- You were found to have diabetes this admission and were
started on insulin to treat this.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed and attend
your doctor's appointments.
- Please work on obtaining your medical records from the ___
and sending it to your cancer doctor's office. This will help
determine what future cancer treatments you should get.
- You were started on multiple new medications during this
hospitalization. Please continue to take these as prescribed.
- You were found to have a new diagnosis of diabetes. It is
important you monitor how much carbohydrates you are eating in
the day, track your blood sugars, and follow-up closely with
your new primary care physician regarding further treatment.
We wish you the best!
Your ___ Team | =======================
PATIENT SUMMARY
=======================
___ ___ male with history of presumed
renal cell carcinoma s/p left nephrectomy (___) complicated by
presumed metastatic disease (on targeted therapy since ___ and
right femoral DVT on Xarelto (___) who presented with
likely seizure and fall secondary to new hemorrhagic presumed
metastatic brain lesions. He was treated with stereotactic
radiosurgery and put on Keppra. His course was complicated by
acute renal failure of unclear etiology requiring urgent
hemodialysis, which improved spontaneously. He also was found to
have a right renal subcapsular hematoma with evidence of small
RP bleeding. He was transitioned to ___ for anticoagulation
which was well-tolerated. He was found to have a new diagnosis
of type 2 diabetes mellitus and put on insulin, especially in
the setting of dexamethasone use for his CNS disease. He will be
transitioning ongoing cancer care to ___ his application for
___ was pending at time of discharge.
=======================
TRANSITIONAL ISSUES
=======================
[] Patient was scheduled to see a new PCP, ___,
neuro-oncology, and radiation-oncology in the ___.
Please see below for appointment times.
[] Medical insurance: The patient began the process of applying
for medical insurance this admission. Please continue to work
with patient on obtaining this. Financial Counseling is familiar
with his case. Him and his daughter understand that it may take
several weeks to hear a decision and that until that time,
appointments will be self-pay
[] Medications were obtained through BI-pharmacy with discount
card that is applicable as his insurance application is pending.
Most medications have a 15$ copay which his daughter agreed to
pay. He has been given a one month supply of these medications.
[] Nephrology: He will need to be seen by Nephrology in ___
weeks after discharge given hospitalization cb by renal failure
and hyperkalemia of unclear etiology (now resolved)
[] Dexamethasone taper: The patient will need to take
dexamethasone 4mg daily for 4 additional days (___), then
2mg daily for 7 days (___), and finally 1mg daily for 7
days (___).
[] Insulin: The patient newly diagnosed with diabetes this
admission. A1c is 9. His insulin regimen is morning NPH with
standing humalog. Please continue to titrate the patient's
insulin, as he tapers down his steroid regimen. His daughter has
supplies to measure FSBGs at home.
[] Hepatitis B: Hep B non-immune, first dose received on ___.
He will need 2 additional doses.
[] Sunitinib: Please continue to hold pending further discussion
with Medical Oncology.
[] IVC filter: Please discuss optimal timing to remove the IVC
filter with his oncologic team.
[] PJP prophylaxis: Patient was given inhaled pentamidine on
___. If patient requires further prophylaxis, please consider
initiation of dapsone pending G6PD status or atovaquone if
insurance approval is obtained. Unable to provide atovaquone due
to high copay.
#CODE STATUS: Full Code
#HCP: ___ (Daughter ___
=======================
___ PROBLEMS
=======================
# Presumed hemorrhagic brain metastases
In setting of subacute neurological findings including numbness
and weakness to left face. Underwent imaging which showed
presumed metastatic lesions with associated edema and midline
shift. His presenting event was attributed to seizures. The left
facial numbness/weakness was attributed to metastatic lesion in
Meckel's cave, near the trigeminal nerve. The patient was
evaluated by Neurosurgery, who did not recommend surgical
treatment of the lesions due to lack of severe neurological
deficits and the location being near language areas.
Neuro-oncology recommended initiation of dexamethasone and
Keppra. For PJP prophylaxis, was on atovaquone in-house. Not a
candidate for Bactrim given borderline hyperkalemia and CKD.
G6PD pending on discharge, so unable to give dapsone. Atovaquone
was too expensive for the patient given lack of medical
insurance. Hence, gave pentamidine inhalation on ___, as he
will need around 11 days of additional high-dose steroids (2mg
or more of dexamethasone daily). Radiation Oncology recommended
stereotactic radiosurgery, which was given in-house and
well-tolerated. His face pain was managed with gabapentin and
prn Tylenol. Dexamethasone taper initiated as above.
# Presumed stage IV renal cell carcinoma
# Presumed metastases to lungs, brain, ?pancreas
Had previously received all care in the ___. Underwent left
nephrectomy in ___. He was started on targeted therapy in ___,
and most recently has been on Sunitinib for the past year. We
attempted to get records from ___ however his daughter was
skeptical that this would not be possible. His sunitinib has
been held given acute illness. Plan is for patient to see renal
cell carcinoma specialist outpatient at the ___ to determine
further treatment options of immunotherapy vs. tyrosine kinase
inhibitors. He will not be returning to the ___ for his
oncologic care according to his daughter.
# Acute on chronic kidney disease
# Acute tubular necrosis
# Hemodialysis
# Hyperkalemia
Presented with creatinine 1.9 with hematuria. Presumably has
CKD. Baseline creatinine unknown. He developed rapid renal
failure of unclear etiology. Nephrology was consulted and he was
initiated on dialysis ___ for hyperkalemia, anuria via
temporary HD line. All workup for possible intrinsic etiology
and renal ultrasound were unrevealing. After three sessions of
HD, his creatinine started to improve and his urine output
substantially increased which suggested ATN. He was put on Lasix
PO 40mg to manage hyperkalemia and fluid status. Cr at discharge
was 2.0
# DVT: right common femoral vein
# Intracranial bleeding
# R renal subcapsular hematoma with evidence of small RP
bleeding
Diagnosed in ___, and had been on Xarelto since then. Due to
evidence of presumed hemorrhagic metastatic lesions, the xarelto
was stopped. He underwent reversal with andexanet on admission
and IVC filter placement on ___. R renal subcapsular hematoma
with evidence of small RP bleeding was discovered incidentally
on imaging (was not felt to be contributing to patient's renal
failure). Upon initiation of treatment of brain lesions with
radiation, felt that patient could safely resume
anticoagulation. He tolerated anticoagulation well with heparin
gtt and transitioned to Lovenox on discharge. Lovenox has a high
copay of ~$600 without insurance which the daughter was willing
to pay in the first month as his application for ___ is
pending. DOACs were not felt to be a good option given CrCl and
potential need for reversal (given CNS bleed, RP bleed).
Coumadin remains an option but he would require several INR
checks as an outpatient and as his ___ application is
pending, the costs of those visits (self-pay) were felt to
outweigh the costs of Lovenox.
# Type 2 diabetes mellitus
New diagnosis. No known family history. Patient's A1C was 9.1%
on admission. With the addition of dexamethasone, patient
developed significant hyperglycemia. He was discharged on AM NPH
with standing humalog at meals. He will need to have his insulin
dosing adjusted as an outpatient, especially as dexamethasone
taper is pursued.
# Hypertension
Maintained on labetalol TID with goal SBP < 160 for active
hemorrhagic brain metastases.
# Blood loss anemia
# Right renal subcapsular hematoma
Admission hemoglobin of 13.4, decreased to 9.3 over the course
of his hospitalization and stable prior to discharge. Imaging
revealed small bleeding within the right kidney, with evidence
of small RP bleeding on the right. Per nephrology, this was
unlikely to have caused his subsequent acute renal failure.
Underwent reversal of Xarelto initially with andexanet in the
setting of hemorrhagic brain mets. Anemia currently stable and
likely ___ acute insults as above and anemia of CKD.
# Perirectal sebaceous cyst
Patient noted just before discharge that he has had this for
many years and it was untreated in ___. Exam notable for
small, possibly sebaceous cyst a few cm to the right of the
rectum which was draining a small amount of blood-tingled,
mucoid material. Area was nontender or erythematous, not c/w
infection. Discussed with patient and daughter that he will need
this to be followed up as an outpatient. | 297 | 1,246 |
14762428-DS-19 | 22,078,485 | -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
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-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) for
2 weeks.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 2 weeks | The patient was admitted to Dr. ___ service from
the ___ ED after undergoing cystoscopy w/ left ureteroscopy,
laser lithotripsy and stent placement. No concerning
intraoperative events occurred; please see dictated operative
note for details. The patient received ___ antibiotic
prophylaxis. Patient's postoperative course was uncomplicated.
On POD0 the pt was tolerating a regular diet, nausea had
resolved, and pain was well-controlled on PO analagesics.
Flomax was given to help facilitate passage of stone fragments.
Creatinine improved from 2.0 -> 1.6. At discharge, patient's
pain was well controlled with oral pain medications, tolerating
regular diet, ambulating without assistance, and voiding without
difficulty. He was given explicit instructions to call Dr.
___ follow-up for stent removal and his PCP to ensure
resolution of ___. | 219 | 130 |
11120163-DS-10 | 20,775,563 | Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use 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
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 until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
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
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Patient was found to have extensive extensive thrombus extending
from the left superficial femoral vein into the IVC and also
from the right internal iliac into the common iliac. The
etiology of these thromboses was unclear. He got ___ Duplex that
showed acute deep venous thrombosis in the left common femoral
vein extending distally into the calf veins. Superficial
thrombosis involving the left greater saphenous vein as well.
No evidence of deep vein thrombosis in the right lower
extremity. Patient received 4400 units of heparin in the ED and
was admitted to the Vascular surgery service. He was started on
a heparin drip at 1000U/hr.
On ___, he was taken to the operating room with Dr. ___
ultrasound-guided access to right jugular vein for placement of
___ sheath, Ultrasound-guided access to right common
femoral vein, ___ sheath, Ultrasound-guided access to left
soleal vein for placement of a ___ sheath, Cavogram, Pelvic
venogram, Venogram of left lower extremity, Placement of
inferior vena cava filter, Placement of catheter in the third
order vessel soleal vein on the left, AngioJet thrombectomy and
Placement of venous lysis catheter for overnight thrombolysis
with tPA. Patient had an uneventful postoperative course other
than mild pain in his left arm with a benign exam.
The next day ___. Patient was taken back to the operating room
for placement of first-order venous catheter in the left common
iliac vein, pelvic venogram, including inferior vena cava,
venous AngioJet thrombectomy and placement of Wallstent times 2
(size 20 x ___s 18 x 60 mm), to the left common
iliac vein as well as the inferior vena cava. Te venogram showed
external compression of left iliac system, with residual clot in
the proximal left common iliac vein as well as in the distal
IVC. Contrast load was 40mL for a total fluoroscopy time of 10.8
mins.
A Left venous sheath was left in place with heparin infusion and
the right venous sheath was locked in the OR. 2 hours post
transfer to the PACU, the right sheath was removed without
complications. However, patient started complaining of pain in
his left arm with marked increase in swelling and warmth from
the mid upper arm down to the forearm with palpable radial
pulse. Upper extremity ultrasound was obtained in the PACU and
revealed a heterogeneous rounded collection in the axilla
measuring at least 4 x 2 x 5.9 cm. An impending compartment
syndrome was of concern so the patient was taken back to the
operating room with Dr. ___ surgery) for
exploration and found extensive hematoma throughout biceps and
triceps muscle bellies area, and much of it had infiltrated into
the muscle bellies.
We identified the artery and during our dissection came upon a
branch of the artery that was actively bleeding. It was
possible that this was the source of his hematoma. This branch
was ligated using silk ties, and hemostasis was
achieved. We inspected the remainder of the brachial arteryfor
approximately 5 cm and there was no other evidence of injury or
bleeding. We made several attempts to evacuate hematoma from
the arm, but much of it was in the muscle and
not easily evacuable. The rest of the brachial artery
tributarier were ligated and Left superficial and deep forearm
fasciotomy and Left carpal tunnel release was performed. A JP
drain was placed in the anterior compartment of the arm and his
arm was in an elevated postion on a sling. Patient was extubated
immediately posteoperatively and was transferred to the PACU in
a stable condition where he remained overnight. He received 2U
PRBC for a drop in HCT to 15 which he responded well. On POD1,
patient's LLE sheath was removed, his hep drip was continued and
he was started on coumadin at a dose of 5mg. On POD2, his foley
was discontinued without event, he was transitioned to PO pain
medications and a regular diet. On POD3 he received 1U PRBC for
HCT of 21 and responded to HCT 27. His coumadin was redosed at
the same dose for POD3 and POD4 with an uptrending INR. On POD3,
patient's left arm splint was removed and he started working
with physical/occupational therapy with great progress.
By POD4, patient was out to chair, his heparin drip was
discontinued with a transition to Lovenox at an INR of 1.7. Hi
JP drain was removed with an output of less than 30cc/day.
Patient's vitals remained stable with palpable pulses throught
his postoperative stay. By the time of discharge, patient was
tolerating a regular diet with good pain control and voiding
without difficulty. He is to be discharged to a rehab facility
where he will regain more strength. He has a follow up
appointments with vascular and hand surgery as shown below. He
is also to get daily INR levels to dose his coumadin while being
bridged with Lovenox he is being discharged with. | 326 | 815 |
10597762-DS-28 | 29,522,703 | Ms ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with back pain and concern for your
breathing. You were worked up for a cause you and you were felt
to have pain in your sacroiliac (SI) joint. You were seen by the
physical therapists in the hospital who agreed that the pain was
likely coming from there. They felt that you should continue
with home physical therapy. We also feel that she will do well
with an anti-inflammatory medication, ibuprofen, which should
help with the pain. We are also setting you up with an
appointment for the pain clinic as well to see if it would be
beneficial for an injection if you do not continue to improve.
Your breathing was also evaluated and you had a number of tests
to rule out several causes. Your oxygenation level was stable
when you walked and you did quite well. This may be a component
of deconditioning associated with this and should improve as you
are more active.
You were given several medications for your pain and you should
take them as directed. Please keep the appointments below.
Thank you for allowing us to participate in your care. | PRIMARY REASON FOR HOSPITALIZATION:
===============================================
___ y/o female with PMHx significant for CKD, DM, HTN who
presents with several weeks of dyspnea and right lower back
pain, with acute worsening in her dyspnea over the last several
days. | 205 | 36 |
16638679-DS-2 | 24,650,453 | Dear Mr. ___,
You were admitted to the hospital for alcohol withdrawal and for
medical clearance so you can enter a rehab program. You were
found to have c. difficile (C.Diff) colitis causing diarrhea
while you were here. You were treated for the C.Diff colitis
with vancomycin and also treated for alcohol withdrawal as well
as for the blood clot you have had previously.
You should continue the vancomycin tablets for 14 days:
vancomycin 125 mg by mouth every 6 hours, day 1- ___, and the
last day will be: ___.
You should continue to follow up with your doctor at ___ and
you should have labs drawn ___ at ___ (lab in ___
first floor lobby, Quest). Appt time and details below. | ___ y/o M with PMHx significant for alcohol abuse and alcohol
withdrawl seizures (documented) as well as reports of DTs (not
documented), depression with suicide attempts (documented
w/pills and alcohol), as well as HTN, GERD, and recently
diagnosed right subclavian vein thrombosis on coumadin sent in
from his PCP for medical clearance so that he can enter an
alcohol detox program. | 121 | 61 |
10641888-DS-9 | 28,086,936 | You were admitted to the hospital after falling during which you
sustained multiple left-sided rib fractures and a laceration of
your spleen. You recovered in the hospital and are now
preparing for discharge to home with the following instructions:
* Your injury caused multiple 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
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Also, due to your splenic injury:
AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having inernal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA. | Mr. ___ was admitted to the trauma surgical service a ___
after suffering an witnessed fall. Imaging obtained upon
presentation included a chest x-ray, Head CT, Spine CT, Chest
CT, Abd/Pelvic CT which were revealing for left-sided rib
fractures (___) and a splenic laceration without
hemoperitoneum. He was initially admitted to the TSICU, but he
was doing well, tolerating a diet and his hcts were stable so he
was transferred to the floor on HD1.
On the floor, the patient's pain regimen was transitioned from a
dilaudid PCA to oral prn oxycodone with effective pain control.
He remained stable from both a cardiovascular and pulmonary
standpoint; incentive spirometry and frequent ambulation were
strongly encouraged. The patient continued to tolerate a
regular diet and voided adequate amounts. His hematocrit
remained stable and was noted to be 37.1 on day of discharge on
HD3. He will follow-up in the ___ clinic within 2 weeks. | 343 | 157 |
10427443-DS-6 | 26,245,059 | Mr. ___,
You were transferred to ___ for treatment of your chest
pain and arrythmia. You EKG was concerning and upon arrival you
were taken to the cardiac cathterization lab where a blockage
was found in the left anterior descending artery. A ___ was
placed to open the blockage successfully. Following the cardiac
cathterization an ultrasound of the heart called an
echocardiogram was done which revealed a clot in the left
ventricle which puts you at risk for stroke. You were started on
anticoagulation called coumadin which we are monitoring its
effectiveness by drawing a lab called an INR. Dr. ___ will call
you to dose your coumadin appropriately based on these labs. You
will receive lab slips for the outpatient lab work.
Because you had a lethal arrythmia called ventricular
tachycardia you needed an ICD, defibrillator which was placed in
the chest and will activate if you go into another lethal
arrythmia while at home. You have a follow up in the device
clinic to assess the site and the settings.
You now have a history of heart failure and need to weigh
yourself every day. If your weight goes up more than 3 pounds in
1 day or more than 5 pounds in 2 days please call Dr. ___. Your
weight on day of discharge is 295 pounds.
You have been started on insulin for your blood sugars which was
not well controlled on pills alone and have been given injection
teaching and wil have a follow up with ___ for care in the
next week.
You have been given an updated list of the medications you are
taking on discharge.
Activity restrictions per nursing.
It was a pleasure taking care of you this hospitalization. If
you have any queations related to your stay please feel free to
contact the heartline. | ___ with PMH of HTN, poorly controlled diabetes who was admitted
to CCU for management of LAD STEMI s/p DES. Now s/p ICD for VT
and newly-dx LV thrombi being managed with Coumadin.
#) ACUTE CORONARY SYNDROME: Patient most likely had the LAD
STEMI about three weeks ago as evidenced by his q waves. He had
complete occlusion of his LAD s/p ___ on ___. Was
subsequently treated with tirofiban for 8 hours, and was started
on Aspirin 81mg daily, Clopidogrel 75mg daily (after being
loaded with 600 mg initially), and Atorvastatin 80mg Daily. Also
treated with heparin gtt for multiple LV thrombi seen on ECHO
(as below). Dose of lisinopril increased from 10 mg to 40 mg
daily. Was started on metoprolol succinate 100mg po qam and 50mg
po qpm.
#) APICAL THROMBUS: multiple LV thrombi seen on ___ ECHO - a
large (2.7 x 2.3 cm) apical thrombus, as well as two smaller
thrombi along the distal inferior wall. Heparin gtt started
___. Started on coumadin, which was titrated to 4 mg qd on
discharge. INR on ___ was 3.5. Patient will f/u with Dr. ___
___ for INR management. Will need repeat ECHO in 3 months to
reassess LV thrombi.
#) SYSTOLIC HEART FAILURE, TTE ___ with EF 30%: Patient has
clinical symptoms of heart failure with shortness of breath,
orthopnea and PND for the past three weeks. Patient initially
diuresed with 20 mg IV lasix, and then transitioned to 40 mg PO
lasix daily. Managed with metoprolol and ACEI as above.
#) V TACH: initially presented to ___ on ___ with
ventricular tachycardia @ 205 bpm. VT likely in setting of
infarct. Was cardioverted to sinus rhythm, and transferred to
___ for further management. On ___, a ___
Energen dual-chamber ICD was successfully implanted for
secondary prevention of sudden cardiac death. Patient was
treated with 1 dose of vancomycin, followed by 3 days of
cephalexin. Will f/u with EP and device clinic.
#) DIABETES: Uncontrolled; HbA1c now 12.6. ___ consulted.
Patient treated with lantus + HISS while in-house. Patient will
be discharged with ___ f/u, on Lantus + Humalog ISS, while
continuing metformin.
#)HYPERTENSION: increased dose of lisinopril and started on
metoprolol as above. | 302 | 373 |
16293344-DS-36 | 25,076,230 | Dear Ms. ___,
You were admitted to ___ with weakness in the setting of
multiple falls. We determined that your weakness was likely
related to the recent increase in doses of your diuretic
medications, and resulting decrease in your weight. We were able
to modulate your diuretic dose so that you would be able to stay
at your optimal weight, and not feel weak.
Upon discharge:
#You have an appointment to be seen by your PCP, ___
___ on ___ at 10:30AM (___).
#Please schedule an appointment to be seen by your cardiologist,
Dr. ___ (___), within two weeks of your
discharge.
It was a pleasure taking care of you!
We wish you all the best!
Your team at the ___ | Ms. ___ is an ___ lady with CAD s/p PCI w/ DES to
pLAD and dLAD ___, NSTEMI ___ with POBA of mLAD (no stent
given ITP and platelets of 80k), HFpEF (EF 60%), Type A aortic
dissection s/p emergent repair ___, HTN, chronic
thrombocytopenia, who presents with weakness found to have
evidence of hypovolemia with concentrated labs, ___, new TWI in
anterior and lateral leads with mildly elevated troponin
concerning for type II NSTEMI.
#Hypovolemia: Patient has had reduced appetite/poor PO intake
over last several days and has had diuresis with high doses of
torsemide 300 mg PO QD and metolozone 5 mg PO QD as outpatient.
Lactate 4.0 on admission which improved to 1.6 with IVF
(1750cc). On admission, patient w/o elevated JVD and 1+ pitting
edema to ___ way up to knees from ankles bilaterally on exam.
Her torsemide was reduced to 100 mg daily and remained even with
I/Os on this dose. Her discharge weight was 138.1 lbs, which was
her outpatient dry weight. She was continued on her
spironolactone, however her metolazone was discontinued.
#Chest Pain, ECG Changes: Patient with chest pain with exertion
with deep TWI in inferior leads on ECG, trop on admission 0.02
in setting ___ with repeat <0.01 most likely c/w type II
NSTEMI. Of note patient has been holding ASA since ___
thrombocytopenia at request of hematologist. Of note, patient is
no longer on Plavix (s/p ___ year of therapy), and ranolozine
d/c'ed ___ falls. Repeat ECG on ___ notable for QTc 475,
persistent TWI in V1-V6 and persistent LVH. No events on
telemetry since admission. Likely that persistent TWI in V1-V6
are repolarization changes associated w/LVH, although there may
have been component of Type II NSTEMI as discussed above. She
was continued on her home statin, beta blocker, and Imdur. After
discussion with her outpatient hematologist and improvement in
her platelets, her ASA was resumed.
#Acute Kidney Injury: Cr 2.1 on admission from baseline 1.8, but
after receiving 750cc in ED, Cr improved to baseline, therefore
thought to be pre-renal in setting of overdiuresis as above.
Encouraged PO intake with assistance from nutrition and SLP.
#Thrombocytopenia: Plts in the ___ on ___ (admission), 82 on
___, 81 on ___, which is her baseline ___, per OMR. She
has known chronic thrombocytopenia, followed by Dr. ___.
Thought is low platelet count immune mediated. Plan is to
monitor platelets, if downtrending treat with steroids. Patient
also has known chronically elevated WBC PCR negative for BCR
ABL, s/p BM biopsy with normal triliniage. ASA re-initated as
above.
#Rectal Burning: Patient w/known diverticulosis and internal and
external hemorrhoids on colonoscopy ___. Rectal burning
likely ___ constipation and hemorrhoids. Rectal exam notable for
___ nonbleeding, external hemorrhoids. Patient denies melena or
BRBPR. She was continued on hydrocortisone cream with
symptomatic improvement.
#Chronic Diastolic Heart Failure: LVEF 60% without acute
exacerbation. Discharged on torsemide 100 with discharge weight
138 lbs. Metoprolol and spironolactone resumed, however held
home metolazone.
#Leukocytosis: Acute on Chronic (baseline WBC ___, w/WBC 23.8
on admission (___). Likely ___ to hemoconcentration iso
dehydration, as H&H 16.1/48/8. Patient did not have any clear
evidence of infection by history, exam, or imaging. Pt received
vanc/cefepime x1 in the ED. Had 1 of 4 BCx resulting w/GPC in
clusters that are coagulase neg, likely Staph epidermidis
contaminant, as patient is still afebrile and w/no e/o infection
on exam. Urine cx w/o growth (final).
#Hypertension: Continued home metoprolol, isosorbide
#GERD: Continued home Omeprazole 40 mg PO DAILY
#Depression: Continued home Duloxetine 60 mg PO DAILY
#Gout: Continued home allopurinol ___ mg daily due to renal
function.
TRANSITIONAL ISSUES:
=====================
#1.9 x 1.8 cm cystic lesion in the pancreatic head, stable from
___. This may reflect a side branch IPMN, and follow up
with ultrasound or MRI can be performed in ___ years.
#Discharge weight: 138 lbs
#Discharge diuretic: torsemide 100 mg daily
#Would continue monitoring platelets; if falls below 40, would
consider holding aspirin
#CODE: Full code except does not want long term intubation, okay
to intubate for resuscitation
#CONTACT: HCP/Son ___ ___ | 118 | 676 |
12704339-DS-18 | 21,449,337 | Dear Ms. ___,
You were admitted to the hospital from ___.
WHY WAS I ADMITTED?
- You were admitted because your heart rate was fast.
WHAT HAPPENED WHILE I WAS ADMITTED?
- We restarted your home medications that control heart rate.
- We evaluated you for an infection and did not find one.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Follow up with your doctors as listed in this packet.
- Take all of your medications as prescribed.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES
=====================
New Medications: Lisinopril 5mg daily, coreg 12.5 BID, lorazepam
1mg PO TID
Held Medications: Furosemide, HCTZ
Changed Medications: None
[] Warfarin - per recent discharge summaries, goal INR 1.5-2.5
while on ECT though this should be confirmed as an INR of
1.5-2.0 would not offer adequate protection against stroke.
[] Hypertension - Hypertensive during admission with several
adjustments to regimen listed below. BP should be monitored as
an outpatient and electrolytes (K, Mg, Cr) should be monitored
by PCP ___ 2 weeks.
[] Patient should continue with appropriate psychiatric follow
up for ongoing depression and catatonia as well as standing
Ativan regimen
[] Family concerned about dementia, can consider outpatient
cognitive neurology follow up if necessary
___ w/ atrial fibrillation, MDD w/ multiple hospitalizations for
psychiatric needs, HTN, DM, HLD presented with RVR. Briefly,
patient presented for her scheduled ECT appointment and found to
be in atrial fribrillation with RVR and was subsequently
admitted to cardiology after being started on a diltiazem gtt in
the ED. Hospital course otherwise notable for intermittent RVR
as well as management of catatonic state and UTI described
below:
#Atrial fibrillation with RVR
Suspect medication noncompliance as the main inciting factor
with possible contribution from hypertension (SBP 160s on
presentation). Per patient's son, she has been deferring her
medications recently, and he suspects she may have been told not
to take diltiazem prior to ECT. Possible contribution from UTI,
treated with ___uring hospitilization.
Experienced relapse in setting of hypokalemia while inpatient
but has been in NSR since ___. Patient maintained on home
diltiazam ER regimen and started on coreg 12.5 BID during
hospitalization. Patient warfarin adjusted and discharged home
on adjusted regimen of 2mg daily.
#HTN
#Hypokalemia
Patient was noted to be hypertensive to SBP 160s throughout
hospitalization. Patient was transitioned from
hydrochlorothiazide to lisinopril 5mg and coreg 12.5 BID regimen
which improved blood pressure control, mitigated incidence of
hypokalemia, and provided additional rate control for atrial
fibrillation.
#UTI
Patient with leukocytosis of uncertain etiology as well as low
grade temperature, pyuria on UA was deemed to have likely UTI
and treated empirically with Ceftriaxone (grew pan sensitive E
coli during prior hospitlization).
#MDD complicated by catatonia
Patient appeared increasingly catatonic over course of
hospitilization and ultimately was unable to verbalize, follow
commands, or take PO. Primary team consulted psychiatry service
who initiated standing Ativan 1 mg TID regimen as well as
inpatient ECT on ___. Patient clinical status improved, and
per psychiatry team, patient was back to previous baseline at
time of discharge.
CHRONIC ISSUES
==============
HTN, major depressive disorder as addressed above | 81 | 412 |
14729395-DS-15 | 23,729,222 | Dear Ms. ___,
You were admitted with diverticulitis, which is a minor
infection of your colon. This will improve with a week of
antibiotics and a bland diet. Try to eat bland foods such as
bananas, rice, applesauce, and toast for the next few days. You
will see your new primary care physician, ___
___.
The following medication changes were made:
START levofloxacin 500mg daily for the next 5 days for your
infection
START metronidazole 500mg three times daily ( every 8 hours) for
your infection
START nicotine patch for help quitting smoking (It is very
important that you quit smoking for your health!)
START tylenol ___ every 8 hours for pain (take this every 8
hours on a scheduled basis for 2 days, then take only if you
have pain)
START oxycodone 5mg every 6 hours as needed for SEVERE pain | A/P: ___ yo F with depression, chronic neck/back/abdominal pain,
admitted with new onset nausea/vomiting, LLQ abd pain, and
diarrhea for the past day and found to have mild sigmoid
diverticulitis on CT scan.
#Abdominal Pain/Diarrhea/Vomiting: Likely from diverticulitis.
Recent colonoscopy done over ___, a rectal polyp (which was
mass-like) was removed as precaution even though it was an
adenomatous mucosa (no dysplasia). No complaints of bloody
stools, BRBPR and this episodes seems acute, no chronic
diarrhea/constipation prior to this episode. UA was negative.
Appendix normal. No fevers recorded and no elevation in white
count. CT scan showed diverticulitis. Started on Levofloxacin
(Cipro allergy) and Flagyl. IVF as needed. Pain meds as needed.
Pt was no longer experiencing nausea or pain when interview by
primary team in the morning. Diet was advanced and there was no
recurrence of sxs. Pt was discharged home with instructions to
complete a 7day course of antibiotics (Flagyl and Levofloxacin).
___ an appt with her new PCP in ___ tomorrow.
# Depression/chronic diffuse body pains: Chronic pain possibly
due to depression/fibromyalgia, but also with fibroids in CT
which could be contributing to abd pain at baseline. She was
restarted on antidepressant medications just last week, and so
is not likely deriving a benenfit from them just yet. Patient
also lost her brother ___ today and is teary eyed and
understandably upset. Pt offered SW, respectively declined. ___
need w/u for fibromyalgia as outpt.
- cont fluoxetine 20mg daily
- cont ambien 5mg Qhs prn insomnia
- close outpatient follow up and titration of medications
- would not recommend narcotic treatment of pain as this is a
poor long term solution given addictiveness of these medications
# Asthma:
- Cont prn home albuterol and flovent, currently asymptomatic
# Liver lesions: Thought to be hemangiomas
- Non-emergent US can be obtained for confirmation as outpt
# Pulmonary Nodule: Consider f/u CT Chest in one year if patient
is high risk (current smoker) to assess nodule. | 141 | 332 |
13961294-DS-23 | 29,417,226 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
You came to us because of worsening lower extremity swelling
concerning for worsening heart failure. While you were here, we
did an ultrasound of your heart which revealed that its pumping
function was decreased, likely in the setting of you having
difficulty taking your medications.
We gave you water pills, first through your IV, then via an oral
route, to get rid of the excessive fluid and help you feel
better. You will be discharged on a water-pill called Torsemide,
you will alternate 20mg and 10mg every other day. Please weigh
yourself daily, and call your doctor if your weight goes up by
more than 3 lbs; you will likely have to double the dose of your
water pill if this happens. You will need to be seen in the
Heart failure clinic within one week. You should receive a phone
call with an appointment. If you do not hear from the heart
failure office, please be sure to call ___ to schedule
an appointment.
We also made some adjustments to your heart failure medications.
As you know, certain medications have been shown to have a
mortality benefit in people with heart failure, some by
preventing the heart muscles from changing size and shape in
response to cardiac disease or cardiac damage ("prevent
remodeling"), some by reducing the pressure against which the
heart needs to work. These medications include: metoprolol,
hydralazine, imdur. It is very important that you continue to
take these as prescribed! Other changes that we made to your
heart medicines include discontinuing your digoxin, as you were
having episodes of slow heart rates.
You will need your kidney function rechecked in one week.
Finally, we asked the rheumatologists to look at your hands.
They recommend continuing 15 mg prednisone daily for one week
followed by 10 mg daily until having ___ in outpatient
rheumatology. They also recommend continuing methotrexate 10 mg
weekly with folic acid supplementation.
Please take care, we wish you the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ woman with a PMH notable for
nonischemic cardiomyopathy (HFrEF now 25%), atrial fibrillation,
seronegative rheumatoid arthritis, and diabetes, who presented
with worsening lower extremity edema concerning for acute on
chronic heart failure exacerbation. Her course was complicated
by acute kidney injury and flare of rheumatoid arthritis.
# Acute on Chronic Diastolic and Systolic Heart Failure: Her
exam is consistent with subacute heart failure from volume
overload. BNP was 2983 and CXR showed mild/moderate pulmonary
edema. Likely cause was thought to be poor medication compliance
(TSH elevated and Digoxin sub-therapeutic on admission
supporting non-compliance; patient admitted to difficulty taking
medications due to home situation- lives with daughter who is a
___) and dietary salt intake. History is not suggestive of
an MI precipitating this decompensation; TTE was without focal
wall motion abnormalities. Troponin was slightly elevated with
normal CK-MB, likely secondary to demand and/or renal
dysfunction. Repeat ECHO on ___ showed worsening global
biventricular systolic function with EF now reduced to 25% (from
50% in ___. Diuresis was initially achieved with a Lasix gtt
that resulted in significant improvement in her volume status.
She was transitioned to daily Torsemide alternating 20mg/10mg
for her diuretic regimen. Her weights were unreliable this
admission, as they were bed weights and fluctuated widely from
day to day; therefore this was not used as a metric of her
volume status. Digoxin was discontinued secondary to
bradycardia. Home metoprolol was switched to 100 mg daily.
Hydralazine and Imdur were started for afterload reduction.
# Acute kidney injury. Cr was 1.5 on admission, stable from
prior in ___, but higher than a baseline of 1.2 established
on ___ and ___. Likely cardiorenal in the setting of
slowly progressive volume overload, given that her Creatinine
initially improved with diuresis. However, Creatinine rose to
2.0 likely secondary to over-diuresis; urine microscopy did not
show evidence of casts. Creatinine on discharge was 1.9; she
will require re-check BMP at her next cardiology outpatient
appointment.
# Atrial Fibrillation. Rate controlled with metoprolol. Home
apixaban was initially continued but given development of acute
kidney injury with Cr > 2.___pixaban was held and
heparin gtt was started temporarily. She was transitioned to
apixaban prior to discharge.
# Hypothyroidism: TSH elevated to 34 on admission, likely in the
setting of medication non-adherence. Patient was continued on
home levothyroxine. She will require re-check of TSH within 4
weeks of discharge for titration of levothyroxine dose.
# Diabetes mellitus. Treated with insulin sliding scale. Home
glimepiride was held.
# Rheumatoid Arthritis. Home hydroxychloroquine and methotrexate
were continued. She was also supposed to be on prednisone 5 mg
daily at baseline. Pain control was achieved with Tylenol and
Oxycodone PRN. She was seen by rheumatology, who recommended
Prednisone 15mg for ten days, followed by prednisone 10 mg until
her next rheumatology appointment. If she will be on chronic
steroids, please consider monitoring of bone health; she also
requires monitoring for MTX and hydroxychloroquine toxicity as
an outpatient.
# Hyperlipidemia. Continued home atorvastatin
# GERD. Continued home omeprazole
# CAD Prevention. Continued home aspirin
# Urinary tract infection: Per NF admission note, patient
reports intermittent dysuria. UA on admission was positive for
infection. Previous cultures with Klebsiella (resistant to
amp/sulbactam and nitrofurantoin) and pansensitive E.coli. She
remained afebrile without CVA tenderness or suprapubic
tenderness on exam. Urine culture on this admission ___
speciated to Klebsiella and was treated with five day course of
ceftriaxone. Repeat UCx was sent on ___ and grew >10^5
Enterococcus. At that time, patient had Foley in place and was
asymptomatic (NO fever, rigors, altered mental status, malaise,
or lethargy with no other identified cause; flank pain;
costovertebral angle tenderness; acute hematuria; pelvic
discomfort); hence per ___ ___ guidelines treated as
asymptomatic bacteruria and did not cover with antibiotics.
Transitional issues
====================
- Discharge weight: Her weights were unreliable this admission,
as they were bed weights and fluctuated widely from day to day;
therefore this was not used as a metric of her volume status.
She was euvolemic on exam.
- Discharge diuretic regimen: daily Torsemide, alternating 20mg
and 10mg every day.
- Discharge heart failure medication regimen: Metoprolol XL 100
mg daily, Imdur ER 30mg PO daily, Hydralazine 10mg PO TID.
- Please note that patient is not on ACE-I ___ due to
angioedema.
- Consider adding spironolactone as outpatient; held off due to
unstable renal function and question of medication compliance as
outpatient
- If after 3 months of optimal medical management, LVEF < 35%,
consider ICD
- Discharge Cr 1.9.
- She will require repeat BMP to be drawn in one week, ___.
- Management of seronegative rheumatoid arthritis: Prednisone
15mg x10 days (day 1= ___, then start prednisone 10mg
daily until her next outpatient Rhuematology appointment.
- Consider outpatient DEXA scan as well as MTX and
hydroxychloroquine toxicity toxicity monitoring
- PCP ___ of repeat TSH in 4 weeks post discharge for
further titration of levothyroxine dosing.
# CODE: FULL
# CONTACT: ___, daughter, Phone: ___ | 338 | 823 |
15810619-DS-9 | 28,964,819 | Dear Ms. ___,
It was a pleasure to care for you at the ___ ___
___. You came to the hospital because you developed
chest pain. In the hospital, we performed blood tests and an EKG
to evaluate your heart. The results of the tests we performed
were all normal. We believe it is safe for you to return to your
nursing home facility.
Please be sure to follow up with your doctors as listed below,
to continue your scheduled dialysis sessions, and to continue to
take all of your home medications.
We wish you all the best!
-Your ___ care team | Ms. ___ is a ___ year old woman with a past medical history
of CAD status post CABG ×2V, grade I diastolic HF (EF 60-65%),
CKD on dialysis, severe AS s/p TAVR, dementia presenting from
dialysis with chest pain. Problems addressed during her hospital
admission are listed below:
ACTIVE ISSUES:
=================================
# CAD s/p CABG
# Chest pain:
Patient reported one episode of stabbing ___ anterior chest
pain in hemodialysis that lasted < 1 hour, self resolved without
intervention in the morning of ___ during hemodialysis session.
No additional chest pain. EKG changes with TWI in V1-V2, aVL
unchanged from prior. Troponin 0.05->0.06->0.06 in setting of
renal failure. Continued home metoprolol, ASA, atorvastatin.
# S/P TAVR:
# Elevated BNP:
BNP elevated >42000, however in the setting of end stage renal
disease on dialysis is difficult to interpret. Received 80 mg IV
Lasix in ED, without significant urine output. No other signs of
volume overload.
CHRONIC/STABLE ISSUES:
====================================
# Renal failure:
ESRD on dialysis.
# Microcytic anemia:
Likely secondary to renal failure. Remained at baseline
(8.3-8.5). | 98 | 173 |
14274161-DS-13 | 26,197,190 | Embolization
Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
You are instructed by your doctor to take one ___ a day
and Brillinta two times per day. Do not take any other products
that have aspirin in them. If you are unsure of what products
contain Aspirin, as your pharmacist or call our office.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg | ___ yo female with left eye visual changes presents after
outpatient MRA showed a 9mm Left ICA aneurysm.
# Patient presents after MRA shows left ICA aneurysm near the
optic nerve. She remained Neurologically intact. She was
loaded with Brilinta and ASA. She underwent cerebral angiogram
and pipeline embolization of the left ICA aneurysm on ___
and was transferred to PACU. She remained neurologically and
hemodynamically intact. She ambulated well with nursing on POD
1 and was discharged home. | 369 | 83 |
18514633-DS-13 | 29,710,111 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of your chest pain
and abnormal stress test.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- Your lab tests, EKGs did not show a heart attack. While you
were in the hospital, we performed another stress test and an
ultrasound of the heart that showed it does not function as well
as previously.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- If you are experiencing new or concerning chest pain that is
coming and going you should call the heartline at ___.
If you are experiencing persistent chest pain that isnt getting
better with rest or nitroglycerine you should call ___.
- You should also call the heartline if you develop swelling in
your legs, abdominal distention, or shortness of breath at
night.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor at
___
if your weight goes up more than 3 lbs.
- Your discharge weight: 214 lbs. You should use this as your
baseline after you leave the hospital.
- You will need further imaging of your heart, a test called a
CT Angiogram, to rule out potential of a blockage in your heart.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES
===================
- Recommend CT angiogram to assess for presence of proximal
blockage leading to global hypoperfusion and decreased ejection
fraction discovered on nuclear stress and echo.
- Consider adding spironolactone to management of HFrEF
- Encourage alcohol cessation and medication compliance
- Ongoing evaluation of reduced EF (40%).
HOSPITAL COURSE
===================
___ yo M w/ PMH HTN, HLD, DMII, who presented with chest pain of
3 day duration. Chest pain had some features concerning for
angina (left sided with radiation to left back and shoulder)
though was not worse with exertion. Patient underwent pMIBI that
showed good functional capacity without anginal symptoms, but
did show septal hypoperfusion with EF 40%. TTE was obtained that
confirmed EF 40% but was not of good enough image quality to
exclude regional wall motion abnormalities.
ACUTE ISSUES
=================
#HFrEF
#Dilated cardiomyopathy
LV dilation and reduced EF 40% discovered on pMIBI despite
normal stress portion and no perfusion deficits on nuclear
imaging. Dilated cardiomyopathy was confirmed on TTE but images
were image quality was not adequate to exclude focal wall motion
abnormalities. Our highest suspicion is for nonischemic dilated
cardiomyopathy, though outpatient cardiologist could consider
coronary CT angiogram to assess for proximal lesion leading to
global hypoperfusion (low suspicion given excellent exercise
tolerance). Per ___ records, he was previously diagnosed with
hypertension induced cardiomyopathy and had a recovered normal
EF on prior echo. In light of persistently elevated BP, we
increased carvedilol dose to 25mg BID to optimize hypertension
and heart failure. Chagas antibodies were pending at time of
discharge. Patient should also be encouraged to quit alcohol
completely. Cont carvedilol, lisinopril.
#Chest pain, atypical
Patient remained HDS throughout, without any SOB. Found mild,
non-sustained relief with sublingual nitroglycerin. Thought
chest pain likely to be due to non-cardiac causes given
excellent exercise tolerance with improved sx with exercise,
normal perfusion images, and relief with Maalox. Had low concern
for PE or dissection.
CHRONIC ISSUES
=================
#HTN
- Increased home carvedilol from 12.5 to 25 mg BID
- Cont chlorthalidone 25 mg
- Cont amlodipine 10 mg
- Cont lisinopril
#NIDDM; most recent A1c 7.7
- Continue SSI
- Hold home metformin
- ASA 81 mg
#HLD
- Cont Atorvastatin 80 mg
#GERD
- Cont omeprazole 20 mg | 268 | 347 |
12275484-DS-12 | 22,343,175 | Dear Ms. ___,
You were admitted to the ___
for vertigo. Although you did not have a heart attack, you were
found to have EKG changes concerning for possible ischemia, or
heart disease, and you had a stress echocardiogram, which showed
possible ischemia. In order to better evaluate your heart, you
had a MIBI scan, which did not show evidence of heart disease.
With this result, we feel comfortable that you do not have a
significant blockage of one of your coronary arteries. We
started you on an aspirin and arranged outpatient ___ with
Dr. ___ at ___.
During your admission, you had a different sound over your left
carotid artery. As an outpatient, Dr. ___ will consider an
ultrasound of your carotid arteries to better evaluate their
blood flow.
You continued to show signs of anemia, although you had no
active bleeding. We recommend you have your anemia rechecked on
___. Please walk in to ___ or your regular
outpatient lab for the blood test.
During your admission, you also had symptoms of depression and
anxiety. You were seen by the Psychiatry consult service, who
determined it is safe for you to go home. It is very important
that you arrange ___ with Dr. ___ the next week
for further psychiatric care.
We made the following changes to your medications:
- START Aspirin 81 mg daily | Ms. ___ is a ___ woman with a history of
depression and anemia (currently being worked-up by PCP) who
presented with the sudden onset of nausea, vomiting, and
vertigo. She was admitted due to anterior T-wave inversions seen
on EKG changes. Admission EKG also showed a new prolongation in
QTc.
ACTIVE ISSUES
1. EKG changes: Upon review of prior tracings, patient's
anterior T-wave inversions were present as early as ___, but
the one tracing showing a newly prolonged QTc was concerning for
possible ischemia. She was without chest pain (with exception of
symptoms during an episode of severe agitation; please see
below) but did endorse fatigue in the setting of anemia
(currently undergoing outpatient work-up). Patient had multiple
sets of cardiac enzymes, all of which were negative. She
underwent a stress ECHO, which suggested possible inducible
ischemia of the mid-to-distal anterior septum. She then
underwent a stress MIBI, which was negative for inducible
ischemia. Patient was reassured that, with these results, she is
unlikely to have a significant arterial blockage. She was
started on an aspirin and scheduled for outpatient Cardiology
___ with Dr. ___.
___. Agitation: On the evening before MIBI scan, patient became
acutely agitated. She was seen by her roommate to be flailing
her arms and legs in bed. Her nurse came to see patient, who was
not responsive, and a Code Blue was called and then canceled, as
patient had pulses and was following commands, spitting
purposefully, and tracking with her eyes. Patient then became
behaviorally dysregulated, using abusive language towards her
providers. She complained of chest pain and asked for her heart
to be cut out of her chest. EKG and enzymes were negative.
Patient was seen by the psychiatry consult service on the
following day, who felt her behavior may have been a
dissociative episode in the setting of stress vs. volitional vs.
pseudoseizure. She was cleared by psychiatry for discharge and
encouraged to ___ with her outpatient psychiatrist at ___.
3. L Carotid Bruit: Consider carotid ultrasound as outpatient.
4. Vertigo: Given association with tinnitus, Meniere's disease
was considered most likely, She did not have recurrent symptoms
during her hospitalization. She was referred back to her PCP.
Please consider outpatient audiology/ENT referral.
5. Anemia: Patient's anemia is microcytic and has been chronic,
currently undergoing outpatient work-up. She did not have
melena, hematochezia, or hematemesis during hospitalization. HCT
trended down during admission, which may have been due to
phlebotomy. Patient was instructed to walk in to her PCP's
office for repeat CBC.
CHRONIC ISSUES
1. Depression: Patient reported stopping her previous outpatient
psychiatric medications on her own, which included fluoxeting,
quetiapine, bupropion. She was referred back to her outpatient
psychiatrist as above.
2. Barretts Esophagus: Continued home Prilosec.
TRANSITIONAL ISSUES
- Repeat HCT
- Consider referral to outpatient audiologist/ENT for further
evaluation of vertigo
- Schedule with ___ psychiatrist within next week
- Continue anemia work-up
- Patient was noted to have a left carotid bruit. Consider
outpatient carotid dopplers. | 227 | 491 |
10441206-DS-17 | 21,838,440 | Dear Mr. ___,
You were admitted for monitoring, and you have been stable
during this admission and are OK to go back home. Please
continue with the instructions you were given at your prior
discharge (see below).
You may take over the counter oral Benadryl for itching. Do NOT
apply any creams, lotions, or ointments to your wounds.
You were admitted to the hospital after arRobotic
abdominoperineal resection for surgical management of your
recurrent rectal cancer. You have recovered from this procedure
well and you are now ready to return home. Samples of tissue
were taken and has been sent to the pathology department. 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 a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have ___
bowel movements daily. If you notice that you have not had any
stool from your stoma in ___ days, please call the office. You
may take an over the counter stool softener such as Colace if
you find that you are becoming constipated. Please watch the
appearance of the stoma (intestine that protrudes outside of
your abdomen), it should be beefy red/pink, if you notice that
the stoma is turning darker blue or purple, or dark red please
call the office for advice. The stoma may ooze small amounts of
blood at times when touched but this will improve over time. The
skin around the ostomy site should be kept clean and intact.
Monitor the skin around the stoma for any bulging or signs of
infection listed above. Please care for the ostomy as you have
been instructed by the ostomy nurses. ___ the skin around
the stoma for any bulging or signs of infection listed above.
You will be able to make an appointment with the ostomy nurse in
the clinic ___ weeks after surgery. Please call the ostomy
nurses clinic number which is listed in the ileostomy/colostomy
handout packet given to you by the nursing staff. You will also
have a visiting nurse at home for the next few weeks to help
monitor your ostomy until you are comfortable caring for it on
your own.
Currently your colostomy is allowing the surgery in your large
intestine or rectum to heal which does take some time. At your
follow-up appointment in the clinic, the surgeons will determine
the best time for the next step: reversal surgery. Until then,
the healthy intestine is still functioning as it normally would
and continue to produce mucus. Some of this mucus may leak or
you may feel as though you need to have a bowel movement. You
may sit on the toilet and empty this mucus as though you were
having a bowel movement or wear clothing that prevents leakage
of this material such as a disposable pad.
If you have any of the following symptoms please call the office
at ___:
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
Incisions:
* Please monitor your incision lines closely for signs of
infection: opening of the incision, increased redness, increased
pain, if you have a fever greater than 101, swelling of the
tissues around the incision line, drainage of
green/yellow/grey/white/thick drainage, increased pain at the
incision line, or increased warmth.
* You may shower with incisions and drain. Be sure the drain is
secured to you and not left dangling on the shower floor. Let
the warm water run over the incisions and ___ all areas
dry with a clean towel, and keep open to air but as clean and
dry as possible. If the incisions become irritated, you may
apply a dry sterile gauze dressing to the incision line. Please
follow-up with Dr. ___ questions related to your most
current surgery.
* Continue to monitor the flaps that were placed in your
___ area. These should remain warm and a similar color
to the rest of your skin. If you notice that these areas are
changing in color to: red, purplish, blue, black, or pale please
call Dr. ___ immediately.
* Please change position while in bed or in a chair frequently.
Please walk frequently. Please avoid sitting in a chair for the
time being. Please avoid frequent bending at the waist or
lifting anything greater than 5 pounds until cleared by Dr.
___. Please continue good hygiene.
* Please avoid smoking as this will result in poor blood supply
and healing to your surgical areas.
Pain
It is expected that you will have pain after surgery, this will
gradually improve over the first week or so you are home. You
should continue to take 2 Extra Strength Tylenol (___) for
pain every 8 hours around the clock. Please do not take more
than 3000mg of Tylenol in 24 hours or any other medications that
contain Tylenol such as cold medication. Do not drink alcohol
while taking Tylenol. You may also take Advil (Ibuprofen) 600mg
every 8 hours for 7 days, please take Advil with food. If these
medications are not controlling your pain to a point where you
can ambulate and perform minor tasks, you should take a dose of
the narcotic pain medication oxycodone. Please do not take
sedating medications or drink alcohol while taking the narcotic
pain medication. Do not drive while taking narcotic medications.
Activity
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs, and
go outside and walk. Please avoid traveling long distances until
you speak with your surgical team at your post-op visit. Again,
please do not drive while taking narcotic pain medications.
You will be discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this for 30 days after
your surgery date, please finish the entire prescription. This
will be given once daily. Please follow all nursing teaching
instruction given by the nursing staff. Please monitor for any
signs of bleeding: fast heart rate, bloody bowel movements,
abdominal pain, bruising, feeling faint or weak. If you have any
of these symptoms please call our office or seek medical
attention. Avoid any contact activity while taking Lovenox.
Please take extra caution to avoid falling.
* Drain care:
1. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
2. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day. Re-establish drain suction.
3. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
Thank you for allowing us to participate in your care, we wish
you all the best! | Patient presented to ED with reported fevers at home. Since
admission he had remained afebrile and hemodynamically stable.
His WBC was 8.1, no bands on CBC diff, electrolytes were normal,
urinalysis was normal. He had a CT abdomen and pelvis with
contrast which did not show any abscess or intra-pelvic or
abdominal infection. Patient was evaluated by the colorectal
surgery team who did not believe there was any indication for
admission or surgical intervention, no significant intrabdominal
process. The patient was also evaluated by the plastic surgery
team, who noted well healing ___ flaps without signs of infection
or abscess. They did recommend a short course of bactrim for
prophylaxis and acyclovir due to some small lesions at the flap
and the patient's history of HIV. On imaging workup, CXR showed
left basilar opacity but CT abdomen pelvis showed L lower lung
which showed no consolidation, and patient did not have symptoms
consistent with pneumonia. Patient was admitted for observation,
where he remained afebrile and HDS. His exam was unchanged and
he was in stable condition for discharge home with services. He
was advised to take PO Benadryl PRN for itching at the flap
site. | 1,181 | 197 |
10015701-DS-13 | 25,619,291 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for lethargy and an abdominal mass. It was found that you had
significant splenomegaly and concerning lab abnormalities. You
were seen by Hematology specialists who performed a bone marrow
biopsy. Although the final results are not back, the
preliminary findings suggests a Splenic Marginal Cell Lymphoma.
This does not need to be treated during this hospitalization,
and instead, you will have the hematology doctors ___ the
___ as an outpatient. You have a scheduled hematology
appointmet at the time/office found below.
Please make sure to follow up with physicians as noted below. | ___ yo female with several month history of malaise now with
Anemia, Thrombocytopenia, massive splenomegaly, elevated DDimer,
low hapto and elevated LDH.
.
# Splenic Marginal Zone Lymphoma - Patient presented with FTT
with Massive Splenomegaly, Low Hapto, elev LDH,
Thrombocytopenia, Anemia, Positive Direct Coombs, atypical
Lymphocytes - Patient's presentation was in the setting of URI
she experienced ___, however, given further evidence noted
in her labs, we pursued a malignancy work up. Moreover, a
Spleen of 24cm is atypical for viral infections. Hematology was
consulted after atypical cells were seen in periphery. Patient
was never in any acute distress and her vitals remained stable.
Her symptoms of malaise and cough improved during her stay. Her
symptom of early satiety, likely related to the massive spleen,
did not resolve fully. She remained in the hospital to have a
Bone marrow biopsy. The preliminary results, as described
verbally by the HemeOnc fellow showed "Splenic Marginal Zone
Lymphoma". On the last day of the patient's stay, we discussed
these results with first the patient's daughters. At the time
of our discussion we presumed a diagnosis of MZL. Family and
patient were made aware that the final results will not be back
until ___, the day of her appointment with Dr. ___. The
family insisted not to use the term "Cancer" with the patient,
and we respected this wish. The hematology fellow did describe
the findings and how she can be treated with Rituximab. The
prognosis of ___ years as a median number was given to the
family, if indeed this is the final diagnosis. The family was
very thankful and understanding. They were anxiously awaiting
the appointment on ___. At discharge, final results were
pending, as were Hepatitis serologies.
.
. | 108 | 302 |
10795503-DS-7 | 26,171,310 | Dear Ms. ___,
You were hospitalized at ___.
Why did you come to the hospital?
=========================
- You were admitted to the hospital for worsening of your
orthostatic hypotension
What did we do for you?
=================
- We gave you IV fluids to increase your blood pressure.
- We tested your cortisol level, which was normal.
What do you need to do?
==================
- It is important that you follow-up with your outpatient doctor
for further management of your orthostatic hypotension. You
already have an appointment scheduled for ___
- It is important that you get an ultrasound of your heart
(echocardiogram), pulmonary function tests, and a CT of your
chest as an outpatient.
- You should follow up with ___ Neurology (appointment
information below)
- Please note you have both a PCP appointment and ___ capsule
endoscopy on ___, please call your PCP to verify if you should
get your endoscopy that morning.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team | ___ y/o F with long history of orthostatic hypotension and
iron-deficiency anemia presenting with lightheadedness,
dizziness and DOE found to have orthostatic hypotension.
#Orthostatic Hypotension: The patient has a two year history of
orthostatic hypotension without clear etiology, with worsening
of sx over last month requiring multiple visits to ED/UC for IVF
despite use of florinef. She appeared hypovolemic on exam and
endorsed thirst, making hypovolemia a likely cause of her
orthostatic hypotension. There was low suspicion for cardiac
etiology given lack of cardiac history, negative troponins x 2,
and reassuring ECG. No recent ECHO on file. Her oxygen
saturation remained above 94% with ambulation. Repeat
orthostatics on ___ showed lying BP of 150/90, standing
128/78. he was given a total of 4L of IVF, and her orthostatic
hypotension resolved after IVF. As per new guidelines about
supine hypertension, positive orthostatics include systolic BP
drop >30 and diastolic drop >20. Patient does not meet criteria
for orthostatic hypotension. We arranged follow up with ___
Autonomics (Neurology) for further workup of her orthostasis.
Of note, AM cortisol level ___ was low at 5.3, but it was
normal (7.2) when it was checked the morning of 11.29. She
responded appropriately to the cosyntropin stimulation test
(7.2-->25.3-->32.2). ACTH level was normal at 10 (reference
range ___ pg/mL). She does not have primary or secondary
adrenal insufficiency.
#Dyspnea on Exertion: She has been having increasing dyspnea on
exertion since ___ but states that it has been worse over the
past month, and particularly the past week as she has begun to
notice dyspnea with minimal exertion. As above, there is low
suspicion for cardiac etiology. She may have other respiratory
pathology contributing to progressive dyspnea including a mass
not visualized on CXR or pulmonary HTN given history of OSA. She
presents with anemia, however her Hgb is consistent with her
baseline iron-deficiency anemia. Ambulatory O2 saturation
remains in mid to high ___. It would be beneficial to obtain a
TTE as an outpatient. Further consideration of outpatient PFTs
and a non-contrast CT of the chest may also be helpful. ___
evaluated the patient and recommended outpatient physical
therapy.
TRANSITIONAL ISSUES
===================
#Orthostasis
- The patient should follow up with ___ Neurology
(specifically ___ who specializes in autonomic
neurology) for further management of her orthostatic
hypotension.
- Consider discontinuing fludricortisone (since it does not
appear to be effective), and consider starting midodrine 2.5mg
TID for orthostatic hypotension. Patient would need close blood
pressure monitoring for supine hypertension given that she is
also on Adderall.
#Shortness of Breath
- It may be beneficial to obtain a CT of the chest and PFTs to
further evaluate the patient's shortness of breath.
- The patient should get an echocardiogram to evaluate cardiac
function or pulmonary hypertension given persistent shortness of
breath.
- Patient should begin outpatient physical therapy
# CODE STATUS: Full code (confirmed)
# CONTACT: ___ (daughter, ___,
___ (daughter, ___ | 158 | 486 |
13454573-DS-10 | 25,241,450 | Dear ___,
It was a pleasure caring for you at ___. You were admitted
with abdominal pain, nausea, and vomiting. We spoke with your
out-patient gastroenterologist and reviewed your imaging and
labs. Based on these findings, your presentation is most
consistent with debris near your gallbladder.
Please follow up at your follow up appointments listed below.
You can talk to Dr. ___ your surgeon about the possibility
of surgery in the future.
Thank you for choosing ___.
Sincerely,
Your ___ Team | ___ obese, h/o crohns (on pred taper and ___ with recent
adission for flair presents with epigastric pain x 2 days
ACUTE ISSUES
#Epigastric pain:
Patient's abdominal pain was most likely due to biliary colic
given the location of her pain, the fact that food precipitates
her pain, and biliary sludge seen on RUQ ultrasound. Her pain
was less likely to be due to a Crohn's flare given that her
inflammatory markers were decreased from her last admission 1.5
weeks prior, and the location and quality of her current pain is
not typical of Crohn's disease. She denied any fevers, was
afebrile during admission, and did not have an elevated white
blood cell count making infection or abscess as a complication
of her Crohn's Disease less likely.
The patient tolerated a PO trial of food without nausea or
emesis. Her out-patient gastroenterologist Dr. ___ was
contacted and it was decided that the patient could follow up
with the surgical staff to discuss possible cholecystectomy as
an out-patient.
CHRONIC ISSUES
# Chronic anemia:
The patient's anemia is likely related to IBD. She would likely
benefit from IV iron infusion which she can get as outpatient.
Hct at baseline of 33. | 77 | 201 |
15650137-DS-27 | 20,019,239 | Dear Ms. ___,
You were admitted for a blood clot in your left leg and
cellulitis (infection) in your right leg. A hematologist was
consulted to help us manage your anticoagulation and recommended
enoxaparin (also known as lovenox). Your dose will be 50mg every
12 hours.
You will also be discharged on an antibiotic moxifloxacin, which
you should take once a day. your last day of antibiotics will be
___.
Be sure to follow up with your hematologist Dr. ___
cannot make an appointment for you because it is ___. | Ms. ___ is a ___ year old woman with episode of necrotizing
fasccitis in ___ s/p skin grafts, provoked DVT (___) s/p IVC
filter placement and later treated with Coumadin for about ___
years (which was later stopped after she had an episode of
vaginal bleeding in the context of a supratherapeutic INR), and
also carries a dx of Sneddon syndrome (a form of vasculitis with
livedo reticularis) with prior stroke (residual L sided
symptoms) on mycophenolate mofetil complicated by recurrent
infections and chronic pancytopenia (followed by hematology Dr.
___ as outpatient on IVIG injections); who presented
to her PCP at ___ with R leg swelling and redness, found to
have RLE cellulitis and LLE DVT (admitted for management of the
latter.
___ Hematology was consulted while inpatient who reviewed her
prior hypercoagulability workup and noted that although she has
a history of "antiphospholipid syndrome" in her chart, she has
only had one marginally positive lupus anticoagulant but has
since had negative testing so she does not carry any known
clotting diathesis. Regardless, this is at least her second clot
and this time appears unprovoked. After a discussion with the
patient, we decided to continue her on lovenox and she will
follow up with her hematologist to discuss newer novel
anticoagulants as well as the goal duration of therapy (?
indefinite). Rest of hospital course and plan are outlined
below.
# Deep venous thrombosis: patient with history of clotting in
past, with confirmed antiphospholipid syndrome, found to have
LLE DVT at PCP's office. Patient has significant history of
bleeding while on warfarin. She reports being on an herbal
anticoagulant called Nattokinze.
-hypercoagulability workup to date including normal homocysteine
level, negative factor V Leiden testing (___). Note that she
had a transient marginally positive lupus anticoagulant which
was negative on subsequent testing and does not constitute APLS.
-given complicated bleeding complications, Dr. ___
hematology did not recommend starting DOAC/NOACs
-prothrombin ___ gene mutation which was not available to be
ordered while inpatient and will need to be ordered when she
follows up with her hematologist. Other thrombophilia testing
was not possible at this time given current anticoagulation.
- per hematology, started on lovenox 50mg q12h
-note that I believe the patient may have an IVC filter in place
since ___ (the patient wasn't sure if this had been removed or
not) which needs to come out, the patient is aware of this.
-pt requesting home services for lovenox injections (because of
hand weakness relating to stroke), which was arranged.
-prior auth was completed for one month supply of sc lovenox
50mg q12h at ___, ___. Address: ___, ___
# Cellulitis: patient with erythema of left leg and pain to
palpation. Dx of cellulitis was questionable but given
immunosuppression and apparent improvement with one dose of
linezolid given in the ED, we opted to treat. Given multiple
allergies to oral and IV antibiotics and amox allergy listed as
"AIN" would avoid all beta lactams and cephs. Has tolerated
moxifloxacin in the past which has good strep coverage so opted
for this.
-repeat ___ ultrasound ordered to r/o clot in R leg to explain
the redness there which showed no clot so infection was felt
more likely so we proceeded with antibiotics.
- given one dose of linezolid in the ED but we avoided
continuing this due to potential exacerbating effect on
pancytopenia
- advised to keep legs elevated
- moxi x 5 days (___)
# Pancytopenia: relatively new finding, may be related to immune
suppression from mycophenolate. stable this admission
# Hyponatremia: chronic, stable to improved since admission,
unclear cause.
# Vasculitis: continue home mycophenolate
# Hypertension: continue home lisinopril, carvedilol
# Asthma: continue home albuterol, Advair, montelukast,
tiotropium
# Transitional Issues:
- moxi x 5 days (___)
- patient will need to schedule herself for follow up with
hematology (since this is a ___ Dr. ___ for follow
up and to decide on duration of anticoagulation and continued
prescription of lovenox injections.
-our hematology consultant recommended checking a prothrombin
___ gene mutation which was not available to be ordered while
inpatient and will need to be ordered when she follows up with
her hematologist.
-note that I believe the patient may have an IVC filter in place
since ___ (the patient wasn't sure if this had been removed or
not) which needs to come out at some point, the patient is
aware of this. Will need eventual outpatient ___ referral for
evaluation.
-note the patient is on aspirin, would defer the decision as to
whether to continue this medication to outpatient hematologist
given increased risk of anticoagulation plus antiplatelet,
especially in the setting of chronic mild thrombocytopenia.
# DVT ppx: enoxaparin
# Diet: Regular
# Code status: Full, confirmed
# Dispo: was at home with services. D/c home with continued
services on ___ after teaching and if tolerates injections.
> 30 minutes were spent seeing the patient and organizing
discharge. | 90 | 812 |
10250358-DS-17 | 22,882,570 | It was a pleasure taking care of you at ___. You were admitted
with abdominal pain, nausea, and vomiting that are most likely
related to your cancer. This cancer is called hepatocellular
carcinoma and is widely spread. As a result, we focused on
prioritizing your comfort and coming up with a regimen to treat
your symptoms that will hopefully allow you be at home.
Palliative care service was consulted and we have come up with
the following plan for your pain and nausea.
For pain: oral dilaudid
For nausea: compazine suppositories/tablets, reglan tablets,
decadron
Please see the appointments below. | ___ with HTN and newly diagnosed HCV cirrhosis and metastatic
HCC who presents with poorly controlled abd pain and
nausea/vomiting.
# Metastatic Stage IV HCC, HCV cirrhosis: Pt with ongoing N/V
likely related to her metastatic HCC. Diagnostic paracentesis
negative for SBP. Family meeting was held in conjunction with
Palliative care service with plan to transition to home hospice
and focus on comfort care measures only. Prognosis very poor and
given the rapidity of her decline, life expectancy of weeks to
months was relayed to the family who supported patient's wish to
return home as soon as possible. Pt was made DNR/DNI. There was
no evidence of acute process and it was felt that her symptoms
are secondary to her end stage underlying malignancy. She
responded well to low dose oral dilaudid (standing) for pain.
She received compazine and reglan for antiemetics with good
control. She exhibited poor appetite and the family was
encouraged to focus on comfort eating - small bites, frequently
throughout the day and de-emphasized focus on nutrition. No
indication for percutaneous gastric or jejunal feeding tube
given her ascites. Family deferred nasogastric ___ given her
current goals of care and ongoing nausea. Her current bilirubin
level would exclude any palliative chemotherapy. Further w/u of
her elevated bilirubin with repeat CT scan to assess for biliary
obstruction and possible percutaneous drain placement were
declined by the patient and her family.
# Hypoxia- patient with new O2 requirement in the setting of
mild tachycardia. She is wheezy on exam. most likely related to
high degree of malignant pulmonary infiltrate. She was treated
with albuterol nebulizer treatments with plan for treatment of
any SOB or air hunger with opioids.
# Hyponatremia: Na 129 at admission, largely unchanged from 131
at recent admission. Na improved with IVF last admission. Most
likely hypovolemic hyponatremia ___ poor po intake. Improved
with colloid administration consistent with hypovolemia.
# HCV Cirrhosis with metastatic HCC: LFTs at recent baseline,
bili elevated compared to prior. Not anticoagulated for portal
vein thrombosis as it is not clear if this is tumor or clot.
Given short life expectancy and risk of bleeding, will continue
to hold anticoagulation.
# CODE: DNR/DNI, comfort measures only
# CONTACT: ___ (husband) ___
+
=
=
=
=
=
=
=
=
=
================================================================
Transitional issues
- dc home with hospice
- Pain control with oral dilaudid, decadron. Antiemetics with
compazine, reglan. | 97 | 397 |
12938377-DS-25 | 29,425,304 | You were admitted to ___ with epigastric abdominal pain and
found to have pancreatitis. You were placed on IV fluids, given
pain medications and a MRCP was taken of your abdomen. This
confirmed findings of pancreatitis. Your pain improved and your
diet was advanced slowly. You tolerated this well. You will be
discharged home with close follow up with GI and your PCP.
.
Medications Changes
-stop nortriptyline
-use oxycodone for moderate pain (about 30 pills that patiennt
has from prior prescription at home)
.
-New medications
-dilaudid 2 mg Q3H prn for severe pain | This is a ___ yo F with a PMHx of congenital choledochal cysts
s/p resection and multiple procedures, chronic pancreatitis and
pancreas divisum who p/w acute on chronic pancreatitis with a
lipase in the 3K range
.
##Acute on chronic pancreatitis
The patient presented with signs and symptoms typical of prior
flares of pancreatitis from an OSH. At the OSH, her RUQ was
found to be normal and her lipase was found to be elevated.
Upon transfer to ___, the patient was treated for acute
pancreatitis with IV fluids, pain medications and bowel rest.
MRCP showed interstitial pancreatitis without necrosis. He pain
improved with conservative treatment. Her nortripyline was
stopped. The exacerbating factor of her pancreatitis is unclear
but the thought is that it was either medication induced from
TCA's, from a small stone in the pancreatic duct remnant or from
alteration in hormones in the post partum period. Her diet was
advanced slowly without worsening pain. She has oxycodone at
home for moderate pain and she was sent home with 6 dilaudid
pills for moderate to severe pain. She was discharged on a BRAT
diet and with close follow up with GI and her PCP.
.
##Transitional Issues
-Follow up with PCP ___ ___ weeks and with GI in ___ weeks. | 93 | 217 |
12553855-DS-4 | 21,679,964 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed Cholelithiasis with
acute
cholecystitis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor,
on IV fluids, and dilaudid and Tylenol for pain control. The
patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 729 | 191 |
14927306-DS-19 | 26,799,923 | Ms. ___,
You were admitted for concern that you were dehydrated from
nausea, vomiting, and diarrhea, which may have been due to a
virus. Fortunately, your symptoms resolved within 24 hours and
you felt well enough to return to rehab.
We wish you the best! | Brief Hospital Course:
========================================
___ PMH of CAD (s/p CABG), HFpEF, HTN, HLD, T2DM, ESRD on HD
___, with recent hospitalization for seizures and SMA stenting
for chronic mesenteric ischemia, who presented from rehab with
fatigue, vomiting, diarrhea, thought to be ___ viral
gastroenteritis as resolved within 24 hours of presentation and
therefore returned to rehab | 43 | 54 |
17867575-DS-2 | 23,697,967 | Dear Ms. ___:
It was a pleasure caring for you at ___
___. You were admitted because you experienced
palpitations and your EKG was concerning. Imaging of your chest
showed small blood clots in your lungs. You were started on
medication (warfarin/coumadin) that thins your blood to prevent
further blood clots.
A procedure to look at the vessels in your heart did not
demonstrate any significant blockages of your heart. An
ultrasound of your heart was also performed and showed mild
thickening of one wall of your heart, and mild stiffness of one
heart valve. You should have a repeat ultrasound in ___ years
for further evaluation.
Dr. ___ was notified of your need for
anti-coagulation due to the blood clots in your lungs. They will
monitor your INR (a measurement of how thin your blood is) as an
out-patient.
Thank you for choosing ___. We wish you the very best.
Sincerely,
Your ___ Team | ___ with past medical history of RA on adalimumab, CAD s/p
angioplasty in ___ presented with sudden onset palpiations and
found to have troponin leak and subsegmental PE's.
ACUTE ISSUES
# Provoked Subsegmental Pulmonary Emboli: Found on CTA after a
positive D-Dimer in ED. ECG showed ST depressions anteriorly but
no overt evidence of RV strain. No evidence of RV enlargement of
CT scan, though troponin mildly elevated (0.02, less than cutoff
for acute MI) which could indicate an element of strained
myocardium. .The cause of the PE ___ be a combination of recent
plane flight and her treated RA. Adalimumab has been linked to
arterial/venous thrombosis. The mechanism is unclear, but some
postulate that anti-adalimumab antibodies ___ contribute.
(___ et al. Arthritis and Rheumatism Vol 63. No 4, ___ Patient is likely at higher risk for these antibodies
because she was already exposed to adalimumab in the past.
Patient was treated with heparin drip then started on warfarin
with an enoxaparin bridge at discharge. Symptoms resolved by
time of discharge.
-___ to manage INR (confirmed).
# CAD s/p Angioplasty in ___: ECG changes were concerning for
ACS though given CTA findings entire presentation was most
likely from PE. Patient remained chest pain free. In addition,
her anginal equivalent in the past was jaw pain that radiated
down the arm. She has had no such symptoms recently. She had
cardiac catheterization that showed RCA had a 30% proximal
tubular plaque and otherwise mild luminal irregularities, but
otherwise normal coronary arteries. She was treated with
standard medical therapy including aspirin, statin, beta
blocker.
CHRONIC ISSUES
# Aortic Stenosis: Recommend repeat echo in ___ yrs.
# Rheumatoid Arthritis: Patient has had complicated history of
RA with several different medication regimens over the years
(See PMHx). Continued MTX and leucovorin for now
# Osteoporosis: Continued calcium, vitamin D, and PTH analogue
# GERD - Continued home lansoprazole | 150 | 322 |
17821946-DS-3 | 22,248,730 | Dear Mr. ___,
You were recently admitted to the ___
___ pain, likely due to sickle cell crisis. There was no
concern for infection. You chose to leave against medical advice
to tend to a family emergency. Please seek immediately medical
care if you have any symptoms that are concerning. We urge you
to establish medical care with a primary care physician to
continue ongoing management of your sickle cell anemia. This
should help you maintain better control of your pain in the
future. You are always welcome to come back for medical care at
the ___.
We wish you the best,
Your ___ Care Team | Mr. ___ is a ___ man with sickle cell disease s/p
splenectomy and cholecystectomy, that has been complicated by
multiple pain crises, prior acute chest syndrome, most recently
left AMA on ___ for back pain, hip pain, and rib pain c/w acute
pain crisis, now admitted with upper body pain.
#SICKLE CELL VASOOCCLUSIVE CRISIS:
Patient presented on ___ with diffuse upper body pain, most
prominently in upper and lower back, shoulder and lateral ribs,
c/w the sx he has experienced during his prior episodes of pain
crisis. Of note, patient left ___ AMA on ___ because he had
missed two days of work. During that time social work provided
him contact information to ___ programs. Prior to that
hospitalization he had been to 4 hospitals in 2 weeks for
similar episodes. Likely triggers are dehydration, overexertion,
heat exposure at work iso of current hot temperatures (___
season). On presentation he did not show signs/symptoms or lab
e/o acute chest syndrome, hand-foot syndrome, or renal crisis.
Patient was given 2L IVF, and acetaminophen 1000mg,
hydromorphone 1mg IV, and oxycodone 5mg for pain management.
Patient left AMA before receiving folic acid. Patient should be
evaluated to see if vaccinations are updated and whether he
should be started on hydroxyurea. Lifestyle changes should be
discussed to limit sickle cell crisis. Patient was informed to
remain hydrated. Establishment of care with a PCP and
hematologist was strongly encouraged.
#ANEMIA:
Anemia is secondary to sickle cell disease. Current Hgb is 8.7,
unchanged from at time of AMA discharge, but significantly
decreased from prior Hgb in ___ of 13.5. He had no signs of
acute bleeding. LFTs wnl. LDH 220 and Tbili 0.4, not suggestive
of hemolysis. Reticulocyte % is 1.9 with abs retic count of
0.06, and retic index of 0.8, suggesting insufficient response
to anemia. Iron studies were not able to be drawn, however
should be considered as low ferritin on prior admission. | 103 | 319 |
14954759-DS-20 | 29,533,260 | Vascular Surgery Discharge Instructions
- You were admitted with blood clots in your arterial system.
You underwent several operations to help restore blood flow to
your legs. You will need to be on an injectable blood thinner
(lovenox/enoxaparin) for the rest of your life.
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for at least ___
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!
2. It is normal to have some swelling of the leg
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin , plavix and lovenox as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions | Mrs. ___ was admitted from the ER and started on a heparin
gtt immediately. CTA showed an embolus in the left common iliac
artery, as well as concern for a distal embolus. She was taken
to the angio suite on ___ where she underwent a left lower
extremity arteriogram with lysis(please see op note for details)
. Lysis catheters were left in, and the pt has alteplase running
in over night. She was taken back to the angiosuite the next
morning, and was found to have good flow. All catheters were
removed, and she was transfered back to the floor. Later that
day she had diminished signals , her heparin gtt was bolused and
increased. A CTA showed concern for bilateral iliac artery
thrombus. The pt was taken back to the OR and underwent kissing
CIA stents , and a left SFA thrombectomy with patch. She had
good signals post-op and was transfered back to the VICU. She
was continued on heparin/coumadin bridge. She made steady
progress. Hematology/Oncology consulted and recommended stopping
heparin/coumadin and switching to lovenox 1mg/kg bid for life,
and this was done. Pt did well on lovenox and continued to
remain stable. On ___ she was deemed stable for discharge home.
She had a PET scan while in house, and this will be followed up
by her primary oncologist tomorrow. SHe will be on lovenox for
life. SHe is being discharged with physical therapy and a ___.
She will follow up with vascular surgery in 2 weeks. | 365 | 254 |
17465152-DS-3 | 24,080,920 | You were sent in by your Urologist Dr. ___ worsening
kidney function. We think that this is due to a blockage of
your ureters, or the outflow tract of your kidneys due to a
recurrence of your cancer. We placed external drains to drain
your urine to the outside. We also treated you for a severe
urinary tract infection caused by the obstruction.
We are sending you home to resume visiting nurse services for
your new drains and physical therapy.
Please complete your entire course of antibiotics and return if
you have worsening fevers/chills, decreased output from your
drains, worsening abdominal/back pain, or if you have any other
concerns.
It was a pleasure taking care of you at ___
___. | ___ female with history of bladder cancer s/p cystectomy
and ileal conduit ___ and chemotherapy who presents with
bilateral hydronephrosis and ___ now s/p bilateral percutaneous
nephrostomy tube placement admitted to the ICU for concerns of
urosepsis.
# Urosepsis
# Septic Shock
The patient was initially admitted to the ICU in the setting of
leukopenia, tachycardia, and fever to 103 after bilateral
nephrostomy tube placement/decompression concerning for
urosepsis and possible transient bacteremia. She was started on
broad-spectrum antibiotics with vancomycin and cefepime given
recent instrumentation and altered GU anatomy. There were no
prior urine cultures available for sensitivities however, the
patient had no recent history of antibiotic use. Blood and
urine cultures were sent and the patient was given approximately
89 L of IVF. On ___, she was started on vasopressors-
norepinephrine, vasopressin, and phenylephrine due to MAPs in
the ___. An arterial line was placed to closely monitor blood
pressures. Her 3 pressor shock slowly resolved with continued
antibiotics and she was completely weaned off vasopressors on
___. She remained off vasopressors for more than 24 hours and
was thought to be stable enough to transfer to the medical
floors for further care. After transfer to the floor, pt
continued to improve with leukocytosis that improved from 33 to
10 on day of discharge. Her abx were de-escalated to CTX and
subsequently Cipro for completion of 14-day course.
# Acute kidney failure
# Bilateral hydronephrosis
An outside hospital CT read with R ureteral obstruction from
soft tissue mass to right of L5 causing ureteral obstruction.
Her Cr improved with placement of bilateral PCN tubes and with
volume resuscitation, though the slow rate of renal recovery
also suggested that there was likely a component of
post-obstructive ATN as well.
# Hyperkalemia->hypokalemia
Her K was mildly elevated at 5.3 upon presentation likely d/t
ARF. This improved with relief of urinary obstruction and pt
developed post-obstructive diuresis and associated hypokalemia.
K was aggressively repleted and was stable at 4.1 on discharge.
# ___ Edema: Pt noted to have 2+ R>LLE edema upon transfer to the
floor. Etiology felt to be ___ aggressive volume resuscitation
in the ICU, considered diuresis but pt noted to be orthostatic
after ambulation (likely due to venous pooling in the ___ due
to venous insufficiency). RLE dopplers were obtained and were
negative for DVT. She will be given compression stockings to
help with venous pooling.
# Transitional cell carcinoma of bladder
# R abdominal soft tissue mass
# Weight loss
The patient was followed at ___ by Dr. ___. Patient
presented with a possible new R paravertebral mass and 20lb
weight loss, concerning for recurrence of known transitional
cell carcinoma versus a new malignancy. Her outpatient
oncologist was contacted for further management recommendations
and plans to f/u with her post-discharge.
# Macrocytic anemia
Per patient her anemia was chronic but there was some thought of
whether she was having GI blood loss as an outpatient. She had
no e/o active bleeding, most likely inflammatory cause. She
received 2U pRBC transfusions during this hospitalization with
discharge Hb stable at mid 9's-10.
# Hypothyroidism
She was continued on home levothyroxine 125 mcg daily. | 122 | 523 |
11197581-DS-7 | 22,899,225 | Dear Dr. ___ were hospitalized due to symptoms from a subdural hematoma.
During this hospitalization, ___ were found to be hypotensive
when standing. Due to this, we have recommended the following
changes to your home medications:
1) stop taking losartan
2) Please take your quinapril at night
Please also wear ___ stockings and an abdominal binder.
Please followup with Neurology, your cardiologist and your
primary care physician as listed below.
It has been recommended that ___ continue physical therapy at
home to help in your recovery and reduce your risk of further
falls.
It was a pleasure taking care of ___ this hospitalization. | Dr. ___ is an ___ year old right handed (although he feels he
was actually left handed) with history of ITP, who presents 6
days after a mechanical fall at home in which he struck the back
of his head. He had nausea, headache, generalized
weakness for several days afterward. Outpatient CT of the head
showed a subdural hemorrhage and he was transferred here for
further evaluation. Neurologic examination in the emergency
department demonstrates a peripheral neuropathy and a right
upper motor neuron pattern of weakness. Neurosurgery was
consulted, recommended Keppra, but did not feel that he needed
any surgical intervention. They recommended platelet transfusion
and admission to the neurology service for observation. | 98 | 117 |
17192910-DS-26 | 20,492,622 | Mr ___,
You were admitted from clinic with high blood pressure. You were
found to have an obstruction in your small intestine and your
calcium level was too high. The bowel obstruction was most
likely due to "adhesions" or scar tissue in your abdomen from a
prior surgery. You were treated with bowel rest and a tube in
your nose to decompress you intestine. With this your
obstruction resolved. You were able to tolerate a diet. However,
unfortunately the small bowel obstruction returned. You refused
an NG tube and preferred to treat with bowel rest, IV fluids,
and antiemetics. With this you improved and were able to eat
normally again. It is very important you have at least one bowel
movement a day.
You were also found to have pneumonia that was likely caused by
vomit entering your lungs. You were treated with antibiotics for
this.
Please take your medications as instructed and follow up as
below. Weigh yourself every morning, call your doctor if your
weight goes up more than 3 lbs in a day.
Best of luck with your continued healing!
Take care,
Your ___ Care Team | Summary: ___ man with a history of stage IIIA squamous
cell lung cancer, currently off any treatment, who presents with
hypertension and nausea/vomiting.
# Small Bowel Obstruction: Patient presented with N/V, abdominal
pain, and no BM in 3 days. On initial report he reported
continued flatus but then on the afternoon of ___ he vomited
feculent material. A KUB confirmed a likely SBO. NG tube was
placed and quickly self d/c'd. Replaced on morning of ___ and 2L
of feculent material was removed from his stomach with
improvement in symptoms. CT scan initially concerning for a
closed loop obstruction but on final read consistent with a
single transition point. No evidence of bowel wall ischemia on
CT scan. Treated conservatively with NG tube for decompression,
IVF and a bowel regimen. He started passing gas on ___ and had a
BM on ___. NG tube removed. He had several BMs from ___.
His diet was advanced and he did well initially. Unfortunately,
on ___, he had recurrence of nausea and vomiting. AXR was
consistent with another SBO. An NG tube was attempted to be
placed again but the patient pulled it out and refused to have
another NG tube replaced. He was treated with supportive care
including IV fluids, antiemetics, and bowel rest. His bowel
regimen was increased. He was then able to pass several stools.
His AXR improved and diet was advanced. He tolerated a regular
diet on discharge.
# Aspiration pneumonia
He had worsening leukocytosis, cough, and RLL infiltrate on CXR
concerning for aspiration pneumonia. He was started on Unasyn
(while unable to reliably take PO) on ___ for a planned 7 day
course. Once he was tolerating PO he was transitioned to
augmentin.
# Hypercalcemia: Patient presented with an elevated calcium
level to 11.4 on presentation. This in the setting of
constipation small bowel obstruction. Given his stage III lung
cancer would be concern for calcium the hypercalcemia due to
malignancy. He was given IV fluids and the Ca the significantly
improved. PTH low, vitamin D normal. PTHrP low (normal to be
low). Bone scan negative to ___ malignancy. This improved with
IV hydration and may have been related to dehydration in the
setting of small bowel obstruction. His calcium was monitored on
PO hydration and was stable.
# Hypokalemia: Likely due to GI losses. Repleted.
#Hypertensive urgency:
#Hypertension:
#Chest pain:
Was complaining of chest pain in the ED, which has resolved.
Troponins were negative x 2. ECG consistent with prior except
for T-wave changes (T waves now upright where then had been
flipped in the past). Also has a history of radiation
esophagitis which
could be contributing to chest pain. This is likely due to pain
from the SBO as well as lack of absorption of his
antihypertensives. His BP improved when he was tolerating a diet
and absorbing his medicaitons. Increased amlodipine to 5mg PO
daily for better control.
#Radiation esophagitis:
-Continued famotidine and lansoprazole
#Stage IIIA Squamous cell carcinoma:
-Currently under active surveillance and off treatment.
-Continue supportive care with tessalon pearls, inhalers. He
will have follow up with oncology as previously scheduled (on
___.
#PVD/CAD:
-Continued ASA and Plavix. Revived PR aspirin while NPO.
- Continued Statin.
#BPH:
-Continued tamsulosin once taking PO
-Continued finasteride once taking PO
#CODE: Full Code confirmed
Name of health care proxy: ___ and ___
___: both sons
Phone number: ___
___ phone: ___
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes. | 184 | 592 |
19632296-DS-7 | 25,773,719 | Dear ___, thank you very much for giving us the
opportunity to take care of you.
You were admitted to the hospital for fatigue and weakness
likely resulting from fast irregular heart rate called atrial
fibrillation. We slowed your heart rate down with a number of
medications.
Please go to the ___ lab to pick up your ___ of hearts
monitor, this will help us monitor your heart rate when you are
having symptoms as an outpatient.
Given your history of fast and irregular heart rates, we will
start you on a new regimen of heart rate-controlling
medications.
New medications:
START Verapamil 180mg twice a day
START Metoprolol succinate 100mg twice a day
START Digoxin 0.125 mg once a day | ___ with a PMH rhematic heart disease with Mitral Valve Stenosis
s/p MVR in ___ course c/b tachy-brady syndrome s/p pacemaker
placement in ___ presents with symptomatic a.fib with rvr. | 113 | 31 |
19341743-DS-27 | 27,923,777 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You were admitted for hypotension, electrolyte
abnormalities, and seizure-like activity. While you were
admitted, you were first sent to the ICU and neurology service,
where you improved after getting fluids and blood pressure
raising medicines. Several EEGs were also done, showing no
evidence of seizures. You then were transferred to the Medicine
service for medical optimization. There you were started on the
eating disorder protocol while we monitored your electrolytes,
your vital signs, and your heart rhythms. On the day of
discharge, your electrolytes were within normal limits; your EKG
was normal; your blood pressure, blood glucose, and standing
weight were stable.
We wish you the best and take care.
Sincerely,
SIRS 4 Medical Service | PRE-HOSPITAL COURSE
___ is a ___ F with bipolar disorder, anorexia/bulemia
requiring inpatient psych care, EtOH abuse with withdrawal
seizures, questionable non-epileptic events in the past, remote
h/o stroke (without residual deficit and no obvious CT
abnormalities) transferred from ___ with 4
reported GTCs,short in duration lasting 15 seconds.
The history noted here was obtained from ___
records and confirmed with her home residential facility ___
___. Due to her extensive psychiatric/eating disorder
history, she was previously admitted (___) to an
inpatient anorexia unit, recently discharged to a sober house
Day Program/ ___ Residential home. On ___ she was noted by
nursing staff to be more somnolent than usual, falling asleep
throughout the day. Her SBP at the day program was noted to be
___ and the program direct her sent her to the ___
ED. In the ED, notes indicate a questionable history of
seizure. There were 2 brief events of convulsions lasting 15
seconds with spontaneous resolution, it is unclear if these
events actually had post-ictal confusion. A third episode was
longer and she was given 2mg ativan with cessation. After a ___
event she was given another 2mg ativan and loaded with keppra
and dilatin 1mg. She was transferred to ___.
ICU COURSE
Upon arrival she was difficult to arouse due to sedating meds
and hypotensive to SBP ___. She was admitted to Neuro ICU for
pressors and IV fluids, and had good response to treatment. The
Neuro admission exam documents question of RUE weakness and gaze
abnormality but her exam a few hours later was nonfocal.
#NEUROLOGY
Prior to being connected to EEG (initially refusing) she had one
brief episode of bilateral had tremors while becoming anxious
about her hospitalization. This progressed to irregular
right-sided twitching that was nonrhythmic and sometimes
involved the left hand. These were exacerbated by movement, and
suppressed when distracted. These are all features typical of
non-epileptic events. Psychiatry was consulted for further
management, see psychiatry section below. She was continued on
her home lamictal. It was unclear if she was prescribed
valproate at home (level on admission was undetectable), this
was restarted.
In regards to the possible right upper extremity weakness, she
did have a CT and CTA at the outside hospital which were normal.
LDL 106, A1c 5.1%. This weakness was gone on our exam, and was
unlikely to be organic.
#CV - hypotensive, likely due to sedating medications and
hypovolemia (with ___, which resolved with aggressive IVF and a
very short course of pressors.
#ID: Her white cells were initially low at 3.2 and have come up
to 3.5. Blood cultures were negative, UA and CXR were clean.
#RENAL: ___ at OSH, which resolved with IVF, likely to be
pre-renal in etiology.
#FEN - evaluated by speech and swallow and failed, made NPO
until re-evaluation.
FLOOR COURSE (NEUROLOGY + MEDICINE)
#NEUROLOGY - EEG was continued, with no electrographic seizures
(no correlate with crying episodes, agitation, or jaw motion).
Depakote was discontinued (she was not taking this at home and
said it made her "sick" meaning it caused her to gain weight).
She had no change in her EEG after removing this medication.
# MEDICALLY UNSTABLE EATING DISORDER - Ms. ___ was
psychiatrically decompensated during this admission, displaying
a pseudobulbar affect, with exaggerated crying and significant
psychomotor slowing (with normal mental status testing). The
psych consult team was following, and recommended doubling her
home buspar to 20mg TID, starting standing ativan 1g TID with
meals, increasing her fluoxetine from 30 to 40 mg, and giving
Seroquel 25mg PRN for anxiety in an attempt to wean patient off
Ativan. Of note, on ___, when discussing dispo options, patient
threatened to leave AMA out of fear she would be sent to an
inpatient unit. A Code Purple was called, though the patient
voluntarily returned to her room. The next day, the patient's
lab values appeared consistent with purging, showing ___ and
hypochloremic metabolic alkalosis. She was placed on the eating
disorder protocol and these abnormalities resolved after several
days. On ___, again when discussing dispo options, patient
again tried to leave AMA and a Code Purple was called, resulting
in chemical and physical restraints due to severe agitation.
After this event pt was more cooperative, however, she was
frequently tearful when visited by primary team and exhibited
labile affect and frequent changes in her answers when asked
questions about her care plan and what she would consent to,
including simple, non-medical decisions such as how to obtain
clothes for herself. Due to her lability and evidence of
continued purging behavior even during this hospitalization, she
was deemed unable to care for herself and placed on a ___. Upon discharge, her QTc on serial EKGs were all <480 and her
electrolytes were all within normal limits. She was also
hemodynamically stable without symptomatic orthostatic
hypotension, her weight was >75% ideal body weight, and her
glucose was well controlled. Thus, she was deemed medically
stable. Patient did not show evidence of refeeding syndome
throughout hospitalization.
#NUTRITION - Speech and swallow re-evaluated the patient, and
approved her for a pureed solids and thin liquids diet. Video
swallow was performed on ___ which was largely unremarkable
except for a small focal area of "deep penetration." Nutrition
then reevaluated a third time and recommended a normal solid
diet (for eating disorder protocol) without complication. No
major aspiration events noted over the course of her admission.
#CHEST PAIN: Upon admission, patient complained of atypical
midline chest pain radiating to L shoulder, worse with palpation
of sternum. Several EKGs were obtained over the course of her
admission, which found no focal ST changes. Likely ___ to hx of
anxiety. She was continued on her home aspirin, gabapentin,
ibuprofen, tylenol, and ativan as above for pain control. | 127 | 963 |
10723086-DS-25 | 24,538,677 | Dear ___,
You were admitted to the hospital for shortness of breath and
fevers, and you were found to have a significant leg infection
that had caused bacteria to enter your blood stream. You were
started on intravenous antibiotics, which helped to treat this
infection. You will need to stay on these antibiotics for at
least one month. While on these antibiotics, you will need labs
drawn weekly for monitoring.
Changes to your medications:
START penicillin G Potassium 4 Million Units IV every 4 hours
(until ___
INCREASE oxycodone to 10 mg every 4 hours as needed for leg pain
It was a pleasure to take care of you at ___! | ___ yo morbidly obese female with h/o OSA on CPAP, obesity
hypoventilation syndrome, chronic lymphedema, HTN, who presents
with fever, chills, SOB found to have cellulitis and group G
strep bacteremia.
.
ACTIVE ISSUES BY PROBLEM:
# Cellulitis and Bacteremia - Patient presented with fever of
104, tachycardia, relatively low BPs, and WBC count of 48K.
Blood cultures on admission positive for BETA STREPTOCOCCUS
GROUP G, likely from impressive RLE cellulitis. Urine culture
negative, CXR with no infiltrate. LLE and RLE ultrasound
negative for focal fluid collection. Started on penicillin and
clindamycin IV, however clinda was stopped after 2 days.
Infectious disease was consulted, who recommended TTE to eval
for endocarditis. TTE did not show vegetations, however it was a
limited study, so TEE was recommended but patient refused.
Given the inability to rule out endocarditis, she will need to
undergo 4 weeks IV PCN therapy as empiric treatment, with
possible continued PO abx after that. Subsequent blood cultures
from ___ bottle), ___ all with no growth on
discharge. Fevers abated, WBC count came down (15K at
discharge), and ___ was placed on ___ for continued IV abx.
She will need weekly safety labs at rehab and will follow with
the ___ clinic. Decision on need for PO penicillin as
suppressive antibiotic therapy will be left to her ID team in
outpatient follow-up.
# Shortness of breath - Patient reports on day prior to
presentation was increasingly short of breath and required use
of her nebulizers. She was initially satting well on 4L of o2
which was eventually tapered to room air. She did
intermittently have wheezes on exam, so may have had component
of bronchospasm and asthma flare. She was diuresed for 2 days
with improved symptoms. Continued home flovent with albuterol
and ipratropium scheduled nebs.
# HTN: BP meds initially held on admission given SIRS. Once
clinically stable, restarted home doses of losartan, diltiazem,
metoprolol and lasix. Lasix was then decreased from 80mg BID to
80 mg daily due to incontinence issues, which is how she's been
taking at home.
# OSA/obesity hypoventilation state: continued nighttime BiPAP.
# Arthritis: continued diclofenac, tylenol, and oxycodone. | 112 | 386 |
12480792-DS-21 | 20,392,819 | You were admitted on ___ for observation/treatment of breast
cellulitis. Please follow these discharge instructions:
.
-Continue to monitor your breast area for continued improvement.
If the redness and swelling increase, please call the doctor's
office to report this.
-Should you have fevers and chills, please call the doctor's
office immediately to report.
-Continue your antibiotics until they are finished.
-You may consider eating a probiotic yogurt daily to replace the
'good' bacteria in your intestinal tract. If you cannot
tolerate yogurt then you may buy 'acidophilus' over the counter
as a supplement choice. Acidophilus is a 'friendly' bacteria
for your gut.
-If you start to experience excessive diarrhea, please call the
doctor's office to report this.
-Do not overexert yourself and no strenuous exercise for now.
-You may take either tylenol or advil (ibuprofen) for your
discomfort. Take as directed. | The patient was admitted to the plastic surgery service on
___ for breast cellulitis. The patient tolerated the
procedure well.
.
Neuro: Pain well controlled on oral medications. Pt has been
taking tylenol and dilaudid.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Pt has had good UOP and having BM. Has been on a bowel
regimen with colace.
.
ID: Pt on vanc/ancef for antibiotics and transitioned to bactrim
DS and cefadroxil at discharge.
.
Prophylaxis: The patient is low risk for VTE. Was wearing SCDs
throughout hospital stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. | 138 | 129 |
12907112-DS-15 | 25,997,539 | Dear Mr. ___,
You were admitted to the hospital with increasing seizures. You
were seen by the neurology service. During this admission we
have monitored you with eeg, which showed an increase in the
frequency of your seizures. We have adjusted your medications
for better control. You were started on a new medication
(VIMPAT, also known as lacosamide). Your Trileptal and
acetazolamide were stopped. We have imaged your brain and did
not find any acute issues. You also had brain imaging which
shows a small area of abnormality in the temporal lobes. You
are being discharged in stable condition regarding these issues.
1. Please continue all your medications as directed by this
document.
2. Please schedule a follow up appointment with your primary
care doctor in ___ weeks.
3. A follow-up appointment has been scheduled for your with Dr.
___.
4. Continue Ativan taper as follows:
- Ativan 1mg three times daily for one week
- Ativan 1mg two times per day for one week
- STOP Ativan | Mr. ___ is a ___ year-old man with h/o epilepsy since age ___
followed by Dr. ___ presented with clustering of
seizures, admitted for cvEEG monitoring.
He was monitored with cvEEG four days which showed slow
background activity and further slowing in a bitemporal
independent fashion with rightsided appearing more prominently
than the left.
There are several features playing into his increased seizure
frequency including partial medication compliance, and sleep
deprivation. During this admission we have optimized his
medications. Trileptal and acetazolamide were discontinued. He
was started on Vimpat. He was maintained on an ativan bridge.
On discharge, he was on Ativan Bridge 1mg q8h, and tapered 1mg
TID x 1 week, then 1mg BID x 1 week, lamotrigine 400mg bid,
keppra 1500mg bid, and Vimpat 150mg bid.
In terms of his labs, sodium level was monitored and upon
discharge improved to 134 from 129 on admission after stopping
trileptal.
In terms of imaging, CT Head showed no acute intracranial
process. MRI with seizure protocol performed showing multiple
scattered foci of high signal intensity in the subcortical white
matter and left temporal lobe which are non-specific but which
most likely represent early changes due to small vessel ischemic
disease. Tail and body of the hippocampus slightly more
prominent on the left. Findings suggestive of, although not
definitive for, possible mesial temporal sclerosis. These
findings were discussed with the patient, and the possibility of
surgery was discussed. He firmly refused. | 192 | 241 |
15650688-DS-3 | 26,001,900 | Ms. ___,
It was a pleasure taking care of you here at ___. You were
admitted with a skin infection (cellulitis) of your right leg as
well as a fungal infection (tinea pedis) of your right foot. You
were seen by foot specialists (Podiatrists) and we treated you
with intravenous antibiotics (Vancomycin and Unasyn) and
antifungal cream (Ketoconazole). You were transitioned to oral
antibiotics (Bactrim and Keflex) on the day of discharge. You
should take these antibiotics for the next 7 days (to end on
___.
You should also continue to apply the anti-fungal cream
(Ketoconazole) for at least the next month.
While you were in the ER, you were noted to have an abnormal
heart rhythm (atrial fibrillation). You were treated with
medication that help bring the heart rhythm back to normal
(Diltiazem). We also started you on Aspirin 325mg daily. Please
speak with your doctor about whether you should continue taking
asprin. | ___ y/o F PMH significant for HTN, pre-diabetes, gout who is
admitted with cellulitis and tinea pedis that has failed
outpatient treatment (5d Ceftriaxone and Bacrim/Keflex). R leg
ultrasound was negative for DVT and R leg radiograph was
negative for signs of osteo. Course c/b new onset afib w/RVR in
ED that responded well to diltiazem.
ACTIVE ISSUES
# Cellulitis: Seen by podiatry. Received 2days Vanc/Unasyn
(___) w/good effect. Started Bactrim/Keflex on ___ to cover
for community acquired MRSA. BCx neg. Vanc was given slowly for
?redman. R leg erythema/pain/edema was improving by discharge.
# Tinea Pedis: Seen by podiatry for maceration and area of
blackened skin on the toes of her right foot. Recommeded
Ketoconazole 2% cream BID with betadine dressings to
interdigital spaces for at least one month. She should follow-up
with ___ clinic in the next ___ weeks.
# Afib w/RVR to 170s. Mr. ___ says she has felt
palpitations and a racing heart race in the past, although
previous EKGs were all in sinuts. While in the ED, she received
Diltiazem with good effect and she returned to sinus rhythm.
Repeat EKGs throughout the rest of her admission were in sinus
rhythm. She was stated on Aspirin 325 given a CHADS score of 1.
I would consider whether she should continue Aspirin and whether
she needs further work-up for a-fib although ongoing infection
is most likely etiology. | 154 | 231 |
17398573-DS-22 | 25,139,888 | Dear Ms. ___,
You were admitted to ___ with an infection of your bowels and
your urine. Testing of your stool showed a gut infection called
campylobacter. This is usually caused by consuming undercooked
meats. Please be careful to consume only thoroughly cooked meats
in the future. Try to eat yogurt at every meal because this will
help your diarrhea get better.
We treated you with antibiotics and you improved. You will need
to keep taking this antibiotic (ciprofloxacin) through ___
___.
You also suffered from prolapse of your uterus. This needs to be
treated with a device called a pessary. It will be fitted by the
Uro-gynecologists at ___. You will need to call them as soon
as possible to make an appointment.
Please follow up with your primary care doctor for additional
treatment.
It was a pleasure taking care of you, best of luck.
Your ___ medical team | Summary
==================
___ y/o female with a past medical history of HTN, HLD,
peripheral neuropathy who presents with septic shock.
Acute issues
==================
# Septic shock
# UTI
# Campylobacter infection
She was found to have a UTI and signs of colitis on CT scan. She
was initially managed in the ICU with pressors and IV
antibiotics. She was stabilized and transferred to the floor.
She remained stable on oral antibiotics and was discharged home
in good condition. Stool cultures were positive for
campylobacter. She was discharged on Ciprofloxacin 500mg BID for
a 10-day course. She should continue to take ciprofloxacin
through ___. It is not clear if the source of patient's sepsis
was campylobacter colitis or occult urosepsis in the setting of
obstruction due to severe uterine prolapse (urine cultures grew
mixed flora).
Chronic issues
====================
# Normocytic anemia: does not appear to be chronic. No recent
iron panel or B12. Could also be secondary to aggressive fluid
resuscitation. B12 and iron panel were wnl. Recommend rechecking
CBC as an outpatient following resolution of acute illness.
# Uterine prolapse. Prominent prolapse on exam. Unclear
chronicity of the prolapse as patient denies having had this
evaluated in the past. Was evaluated by gynecology and will
follow with them as an outpatient.
# Hypothyroidism: chronic, stable.
- Continued home levothyroxine
# Hypertension: was normotensive during admission and home HCTZ
was held on discharge.
# Hyperlipidemia: chronic, stable.
- Continued home simvastatin and aspirin
# Peripheral neuropathy: chronic, stable.
- Continued home gabapentin
# GERD: chronic, stable.
- Continued home omeprazole | 147 | 246 |
18556017-DS-51 | 28,237,212 | Dear Ms. ___,
WHY YOU WERE HERE
- You were having burning when you pee and feeling tired.
WHAT WE DID FOR YOU
- You were found to have the same urinary tract infection as
before
- You were treated with IV antibiotics which you will continue
on discharge
WHAT YOU SHOULD DO WHEN YOU LEAVE
- You will have nursing come to the house initially to help with
antibiotic infusions
- Please take your medications as below
- Follow up with your PCP, ___, and diabetes
doctor. You will also need to see a urologist
- Please continue your excellent care of your diabetes with your
insulin pump
- Please use bolus wizard for high sugars so adjustments to
insulin pump settings can be made as needed for uncontrolled
diabetes.
- Remember, treatment with insulin requires intensive, daily
monitoring of blood glucose levels to avoid toxicity including
severe low blood sugar
that can cause neurologic changes and, potentially, impaired or
loss of consciousness.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES
==================
Discharge wt: 76.93kg or 169.6 lbs
Discharge Cr: 1.0
[] consider checking iron studies for anemia workup
[] f/u fosfomycin sensitivities on urine culture
[] needs urology outpatient f/u for urodynamic studies
[] ___ outpatient f/u
[] Transplant ID f/u with Dr. ___ outpatient (ID team
will try to set up appt ___ at 2pm); will discuss
suppressive abx regimen then
[] Renal transplant f/u with Dr. ___ | 166 | 67 |
19565358-DS-3 | 22,811,968 | Dear ___,
You were admitted to the hospital because the potassium level in
your blood was found to be high. This was felt to be due to the
lisinopril and spironolactone that you were taking. These
medications were stopped and you were given insulin, sugar, and
diuretics to decrease the potassium but it remained high. The
kidney team was consulted and they recommended some tests to
determine why your potassium remained high. These tests were
done and were still not back when you were discharged. You were
also given a medication that binds potassium in your intestine
(kayexalate) and this helped to decrease your potassium. You
should follow up with the kidney doctors as ___ outpatient to
follow up on these labs. You may need an additional medication
to treat the underlying cause of your high potassium. During
your hospitalization, it was also found that you had worsening
kidney function, which improved back to baseline at discharge.
It was also found that you had a bladder infection and you were
treated with an antibiotic (ciprofloxacin), which you should
continue taking after discharge and take your last dose on ___.
In addition your blood sugars were high during your
hospitalization. You should continue taking liraglutide,
metformin, glargine 35 units in the morning, 50 units at
bedtime, and follow up with endocrinology after discharge to
determine if your medications need to be changed.
It was a pleasure taking care of you. We wish you the best!
-Your ___ Care Team
TRANSITIONAL ISSUES
====================
-You should NOT take spironolactone and lisinopril at home until
you follow up with the kidney doctors
-___ should continue taking ciprofloxacin through ___
-You should continue to take a low-potassium diet until told
otherwise by your doctor ___ low potassium diet sheet attached)
-You will need labs drawn within 48 hours, which you have a
prescription for.
-You will need to follow up with Nephrology (Dr. ___
___ clinic ___ to follow up hyperkalemia. Please
call them on ___ to schedule this.
-You will need to follow up with your cardiologist given the
medication changes
-Your blood sugars were high during your hospitalization. You
should follow up with endocrinology (though patient says he does
not want endocrine follow up)
-Stopped medications: lisinopril, spironolactone
-New medications: Ciprofloxacin ___nd ___
-Labs pending at discharge: Renin, ___, IgG1234, Ova and
Parasites culture | Mr. ___ presented to the ED (___) after referral from his
PCP due to hyperkalemia. He had a K of 6.8 and peaked T waves on
EKG. This was felt to be secondary to his spironolactone and
lisinopril, which were held. He was given insulin and dextrose,
calcium gluconate, and he was admitted for hyperkalemia. On the
floor (___), his was given a low potassium diet and treated
with IV fluids and Lasix, however the Lasix was held after a
mild rise in Cr. He was given kayexalate and his K decreased to
5.1. Patient was also complaining of intermittent urinary
retention over the last 2 weeks and he was also found to have a
leukocytosis of 11.8 and his urine culture grew E. coli. He was
treated with ciprofloxacin and his leukocytosis resolved upon
discharge (to 9.5). Mr. ___ also presented with a 2 month
history of diarrhea, which he did not experience during his
stay. He underwent a CT abdomen scan, which showed no
hydronephrosis and was overall stable from his CTA in ___. Mr.
___ was instructed to follow up for a Chem 7 within 48 hours,
to call to schedule an appointment with nephrology, and to adopt
a low potassium diet.
TRANSITIONAL ISSUES
=======================
-K was 5.3 and Cr 1.9 on discharge, ordered chem 7 within 48
hours of discharge. Will need to be followed-up.
-Will need follow up with Nephrology (Dr. ___
clinic ___ to follow up hyperkalemia and ___ on CKD.
Patient will schedule.
-Pt should follow up with cardiology as an outpatient given new
medication changes below
-Blood sugars were 200-300 during admission on 35 glargine in
AM, 50 glargine in ___, sliding scale humalog. His liraglutide
and metformin were held initially but restarted on discharge. He
should have follow up with endocrinology
-Patient should continue to take a low-potassium diet until
potassium normalizes and remains normal
-Stopped medications: lisinopril, spironolactone
-New medications: Ciprofloxacin, 7 day course for UTI ending
___
-Labs pending at discharge: Renin, ___, IgG1234, Ova and
Parasites culture
-Instructed to make an appointment with your primary care
physician within one week of leaving the hospital. | 377 | 350 |
10662181-DS-17 | 29,664,739 | Dear Mr. ___,
You came to ___ with weakness due to a problem with your
pacemaker. We did a procedure to place a new pacemaker which
went very well. Please continue to follow with your outpatient
doctors.
It was a pleasure taking care of you, best of luck.
Your ___ medical team | Summary
___ with CAD, HFrEF, ESRD on HD TTS, and atrial fibrillation
with complete heart block s/p recent PPM explantation in the
setting of bacteremia and Micra PPM
implantationon ___ presents with bradycardia likely secondary
to Micra malfunction (possible dislodgement).
#CORONARIES: Unknown
#PUMP: EF ___
#RHYTHM: Regularized atrial fibrillation, ventricular rate 34
# Hypotension
Patient was intermittently hypotensive since admission requiring
low dose phenylephrine. Weaned off pressors slowly with normal
mentation and lactate. Unclear exactly what caused this but
likely severe aortic stenosis and CHF. Lisinopril and Metoprolol
were held and should only be restarted carefully as an
outpatient.
# Bradycardia
# Atrial fibrillation with complete heart block
Patient with history of atrial fibrillation with complete heart
block s/p PPM implantation with recent explantation in the
setting of MRSA bacteremia. Underwent placement of Micra PPM on
___ with device check 1 week later that showed acceptable
function. On presentation, was found to have bradycardia in the
setting of device not capturing initially, although it began
capturing when the rate was increased to 80. He underwent single
lead PPM placement on ___ with good results. He was
continued on outpatient warfarin.
# HFrEF
# Pulmonary hypertension complicated by cor pulmonale
TTE on ___ with EF 30% with moderate global RV free wall
hypokinesis. Severe AS and severe TR. Mild pulmonary artery
systolic hypertension. As above, held his Metoprolol and
lisinopril on discharge.
# Severe AS
Noted on echo with a valve area ~0.6 and high valve gradient
(mean 49). Should follow with ___ cardiology as outpatient for
consideration of TAVR.
# ESRD on HD TTS
Receives HD on TTS via right tunneled dialysis catheter.
Continued HD TTS per renal,
nephrocaps, sevelamer.
# CAD
Continued atorvastatin 80mg daily.
# OSA on BiPAP
On BiPAP per nursing home records, though on previous
hospitalization notes appears to be on CPAP (and consistently
refusing). Will defer BiPAP at this time and readdress if
necessary.
# COPD
On intermittent home O2. Satting well on room air on discharge.
Continued ipratropium/albuterol
# GERD
Continued famotidine 20mg PO daily.
# Anemia
Thought to be secondary to CKD. Continued ferrous sulfate 325mg
PO daily.
# Depression
Continued fluoxetine 40mg PO daily.
Transitional issues
- Will follow-up with Dr. ___ in 4 weeks for PPM followup.
- Should follow with BI cardiology for evaluation of TAVR
placement for severe aortic stenosis.
- Metoprolol and ACEi where held on discharge. Could be
restarted carefully as outpatient if blood pressures stable.
- Patient reported ride from his nursing facility to HD unit is
painful on his back. He reports better when he is able to go in
a wheelchair. I also gave him a short script of oxycodone 5mg to
be used prior to transportation for the pain.
Code: DNR/DNI (has MOLST form)
Name of health care proxy: ___
Relationship: Spouse
Phone number: ___ | 50 | 458 |
12726753-DS-34 | 29,349,815 | Dear Mr. ___,
It was a pleasure treating you at the ___
___! You were admitted for chest pain. For your chest
pain, we did some tests to see if you were having a heart
attack. We feel reassured that your symptoms resolved with your
regular home medications and additional nitroglycerin. For your
flank pain, we performed some tests to evaluate your abdomen and
kidneys. Your ultrasound showed small kidney stones that are not
obstructing your urine outflow, no signs of urine backing up to
your kidneys, and no signs of ascites (fluid in your abdomen).
You also have no signs of a urinary tract infection, including
no evidence of gonorrhea or chlamydia. We held your home
furosemide while you were here, but you should restart this upon
leaving the hospital. Please have your kidney function and blood
counts checked in one week.
You will have follow-up appointments with your primary care
physician, ___, hepatologist, and palliative care (see
below).
There have been no changes to your medications. Please continue
to take your medications as prescribed. If you have any concerns
about your medications, please contact your PCP.
Additionally, you should weigh yourself every morning, and
contact your cardiologist if you gain more than three pounds in
one day or notice worsening swelling in your feet and legs.
Best,
Your ___ Team | ___ is a ___ year old man with a history of HFpEF, 3V CAD
being medically managed, HIV, HIV medication and NASH-induced
cirrhosis, with multiple recent hospitalizations for chest pain
who presented with a 3 day history of worsening chest pain and
sudden onset flank pain, found to have elevated troponins and
stable EKGs.
#Chest pain: Mr. ___ was admitted on ___ for a 3 day history
of chest pain at rest and with exertion which acutely worsened
the night prior to admission and was not relieved by
nitroglycerin at home. His initial troponin in the ED was
negative, however repeat troponins peaked at .07 before
downtrending on ___. There were no ECG changes on serial ECGs.
During his admission, he endorsed two episodes of mild ___
chest pain which resolved with nitroglycerin and one dose of
lorazepam. He continued to be medically managed on Imdur 240mg
daily, pravastatin 80 mg, SL NTG prn, ASA 81, and nadolol 80mg
daily. Anticoagulation was not pursued due to his history of
major GI bleeds (most recently in ___. He was discharged
with close follow-up with Cardiology within the week.
#Acute kidney injury: Mr. ___ presented with a Cr of 1.7
(baseline 1.1-1.2). He was given 1L of NS in the ED and further
work-up of his ___ included a renal ultrasound, UA, and
chlamydia/gonorrhea testing. His home Lasix 20mg PO was held,
but will be resumed upon discharge. He also had a renal
ultrasound which showed nonobstructing renal stones, but no
signs of hydronephrosis. His UA was negative. GC/Chalmydia were
negative. His ___ subsequently resolved with a Cr of 1.0 prior
to discharge. He should have a repeat BMP to assess kidney
function in the setting of restarting his home dose of
furosemide.
#Cirrhosis: Mr. ___ endorsed increased abdominal distension. An
abdominal ultrasound showed no evidence of ascites. His LFTs
were within normal limits and MELD score was 6 prior to
discharge. Weight was stable/slightly decreased over his
hospitalization.
#HIV: Mr. ___ has a history of HIV on HAART with an
undetectable viral load. CD4 count was 359 during this
admission. He was continued on his home medications.
#Anemia: Mr. ___ was 8.7 on admission and was steady
through his hospitalization, thought to be related to his
chronic diseases and recent hospitalization in ___ for GI
bleeding. He was continued on his home pantoprazole and ferrous
sulfate. He should have a repeat CBC.
#Type 2 diabetes: His glucose on admission was 302 with reported
readings into 500s at home and last HbA1c on ___ was 8.0%. He
was continued on his home insulin.
#Hypothyroidism: He was continued on his home levothyroxine.
#Hypertension: He was continued on his home amlodipine. | 221 | 444 |
11250484-DS-21 | 21,600,074 | Dear Ms. ___,
It was a pleasure taking care of you. You came to the hospital
because you were having abdominal pain. We found that you had an
infection in the fluid in your abdomen, and we gave you
antibiotics to treat this. We also took fluid out of your
abdomen, and you felt better. We did not give you your water
pills while you were in the hospital in order to protect your
kidneys, but we restarted them at discharge.
New/Changed Medications:
- Start Ciprofloxacin 500 mg daily to prevent infections in your
abdomen
- Insulin decreased to 20 units NPH in the morning and 20 units
NPH at night because your blood sugars were low
- Lasix changed from 40 mg twice per day to 80 mg daily
- Carafate stopped as it is no longer needed
Please continue to take your medications as prescribed and
follow up with your liver doctors.
Sincerely,
Your ___ Team | Ms. ___ is a ___ y/o woman with history of NASH cirrhosis
complicated by ascites and varices who presented with abdominal
distension and pain and was found to have spontaneous bacterial
peritonitis (first episode). Her diuretics were initially held,
and she was treated with albumin and a 5-day course of
ceftriaxone (Last day: ___. She was then started on
ciprofloxacin for SBP prophylaxis. She had two large-volume
paracenteses (3L on ___ and 6L on ___. Her diuretics (Lasix
80 mg/Spironolactone 100 mg) were restarted on day of discharge
and should be uptitrated as appropriate as an outpatient. She
underwent CT for ___ screening, which did not show any
concerning liver lesions. However, the CT did show
intra-abdominal lymph nodes that have increased in size from
prior; the patient may require biopsy. Of additional note, the
patient's fasting blood sugars were in the ___ so her insulin
was decreased.
================= | 149 | 148 |
10777749-DS-9 | 25,925,387 | Dear Ms. ___,
You were admitted to ___ due to small bowel obstruction for
which you needed a nasogastric tube and we gave you nutrition
though an Iv route. You were also seen by surgery during the
hospital stay
You were also treated for pneumonia with a course of
antibiotics. | ___ female with metastatic ER+ breast CA, hx of SBO
(prior venting G-tube removed recent admission), PE on warfarin,
hx C.diff who presents with abdominal pain.
#Abdominal pain:
#Small bowel obstruction:
Initial CT ___ c/f SBO, unclear whether related to metastatic
breast CA or adhesions from prior radiation. Possibly
contribution from constipation given opiate use and missed doses
of bowel regimen. She was felt to be improving and then ordered
and regular diet after which she had worsening symptoms and
distension. NG tube was reinserted and connected to intermittent
suction initially and patient puled it out overnight again and
refused to have it re-inserted. ACS followed. TPN initiated on
___ due to concern for malnutrition. She remained on bowel
regimen. She began moving bowels and passing gas.
Need for long term TPN unclear as she seems to tolerate PO diet,
but that she chooses to eat small quantities and is not eager to
eat more.
# Hypoxia:
#acute on chronic hypoxic respiratory failure
#likely multifactorial from splinting, atelectasis and now
concern for
#aspiration vs HCAP: resolved
Patient at baseline 2L requirement, likely in setting of some
atelectasis and known pulmonary emboli.
# Pulmonary emboli:
Diagnosed during ___ admission. Discharged on Coumadin
(unable to afford lovenox), which is being managed by PCP. INR 2
on admission, but Coumadin was held this admit as there were
possible procedures. Ultimately she remained on lovenox 50mg
BID sc for her PE treatment. GIven that she will be discharged
to rehab, and they can help sort out if long term lovenox will
be an issue because of payment, we opted to treat with lovenox
because of malignancy. If she is unable to afford lovenox, then
Coumadin can be initiated with appropriate bridge using lovenox.
# Metastatic ER+ breast cancer:
Metastatic to bone. On doxil (monthly) and exemestane. Last
doxil dose was ___.
- Continue home exemestane
- continue tylenol and home MS ___ 60mg q12h with dilaudid IV
PRN severe pain for cancer-related pain
- f/u with Dr. ___ as outpatient | 48 | 338 |
10225793-DS-11 | 29,175,595 | You were admitted due to confusion, which possibly represented
"hepatic encephalopathy," or confusion due to liver disease.
Your exam and vital signs were reassuring, and a medical workup
showed that you do not have an infection. You slept well
overnight and are much more oriented so you are being discharged
home.
We increased your Lactulose dose to prevent confusion; you
should increase or decrease the frequency of the medication to
ensure that you have ___ bowel movements daily. Please do not
take Loperamide unless you are having >5 bowel movements in a
day.
In addition, we are giving you a small supply of Ambien
(Zolpidem) to be used in the case of severe insomnia. You can
try ___ tab and if that doesn't work you can take the other ___
tab. | ___ year old female with decompensated HCV cirrhosis complicated
by encephalopathy and ascites and chronic abdominal pain,
brought in by her daughter for disorganized speech, auditory
hallucinations, and anxiety for 3 days
# Altered mental status (Delirium): Resolved overnight. Given
her recent admission, liver failure, and particularly the
insomnia and that she's never had psych symptoms like these
before, our highest suspicion was that this is was mild hepatic
encephalopathy, with secondary possibility of an early
adjustment-type episode on underlying depression and anxiety
about her diagnosis. Patient also having severe incomnia. Other
toxic metabolic workup has been negative (including infectious).
Time course too short for mania. Patient no longer symptomatic,
and no SI/HI. Treated with lactulose/rifaximin for
encephalopathy. After discussion with patient and attending,
Ambien was chosen as sleep aid as only an occasional, prn
medication if she truly cannot sleep by 1 or 2 AM. Continued
fluoxetine. She was back at baseline by discharge after close
monitoring.
CHRONIC ISSUES
# HCV cirrhosis: Previously c/b ascites, encephalopathy. EGD
without varices. Now with bilateral ___ edema. Currently
decompensated. MELD 17. Continued lasix/spironolactone,
lactulose and rifaximin.
# Right sided colitis: biopsies without evidence of colitis, CT
findings only. Per Dr. ___ knows this patient, she
had done well whenever mesalamine has been started, and has
colitis type symptoms when it is stoppped, so continued it.
# Chronic abdominal pain: Treated with prn tylenol, less than 2
grams max per day
# h/o ___ esophagus: continued home PPI
# Hypertension: continued home atenolol | 135 | 243 |
15776313-DS-14 | 26,846,694 | Dear ___,
You were admitted to the ___ because you experienced a
seizure. You were brought to the Intensive Care Unit for careful
monitoring, EEG, and adjustment of your seizure medications. The
neurologists followed you in the hospital. When you leave the
hospital, continue taking all of your seizure medications
without skipping any doses. Please do not drive for at least 6
months. This is very important. Please follow up with your
neurologist appointment as written below.
It was a pleasure taking care of you and we wish you all the
best!
Sincerely,
Your ___ Care Team | SUMMARY:
___ year old female with complex partial seizure with secondary
generalization, admitted for further monitoring and AED
titration. | 93 | 18 |
11818671-DS-11 | 28,128,247 | You were admitted to the surgery service at ___ for diagnostic
work up on your common bile duct stricture and
hepatic/pancreatic mass. You underwent palcement of the two PTBD
drains. You have done well in the post operative period and are
now safe to return home to complete your recovery with the
following instructions:
.
Call Dr. ___ office at ___ if you have any
questions or concerns. During off hours: call Operator at
___ and ask to ___ team.
.
Please call Dr. ___ 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 large drain output, 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.
.
PTBD Drain Care x 2:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or | ___ DMII (diet), HTN, recently undergoing ERCP for obstructive
jaundice s/p stenting now presenting with increased Alk Phos and
T. Bili.
Obstructive Jaundice: The pt was admitted following a recent
ERCP bx that revealed atypical cells. A CT Scan on admission
showed a malignant appearing strictures along the CBD. The pt
was without fever, leukocytosis or other SIRS criteria to
suggest ascending cholangitis, however was empirically started
on Cipro. CA-19 slightly elevated. Patient's abdomina CTA and
MRCP demonstrated hepatic hilum lesion, common bile duct
stricture, and pancreatic tail mass.
The patient was transferred from Medicine Service to HPB Surgery
Service on ___.
His Cytology report from pancreatic mass and common bile duct
brushing was non-diagnostic. On ___ patient completed
cardiac evaluation by Medicine Service and was found to have low
risk level for cardiac complications. On ___ patient
underwent flexible bronchoscopy with mediastinal lymph node
biopsy, and bilateral PTBD placement with brushing. Patient was
empirically started on Cipro and Flagyl to prevent cholangitis.
Patient's T.Bili started to downward on ___. The patient's
diet was advanced to clears and patient tolerated diet well.
Cytology from mediastinal lymph biopsy and CBD brushing was non
diagnostic. Patient's diet was advanced to regular on ___. On
___ patient underwent cholangiography, which demonstrated liver
hilar mass extending into both lobes and a possible second area
of involvement of the mid-to-lower CBD. The patient continue to
have large daily output from his bilateral PTBDs, and his T.
Bilirubin decreased to 15. Dr. ___ PTBD catheter
upsize. On ___, patient underwent CT-guided biliary catheter
exchange to ___. Post procedure patient's diet was advanced to
regular. Patient's IGG 4 result returned back high (525). The
patient was discharged home on ___ in stable condition. He was
discharged home with open drains to gravity drainage as T. Bili
and output still high. The patient was discharged home with ___
service to check his labs on ___ and help to monitor PTBDs
output. Prior discharge the patient was educated about signs and
symptoms of dehydration and importance to drink adequate amount
of fluid while drains still open. He verbalized understanding.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 365 | 459 |
13156713-DS-15 | 28,091,694 | Dear Ms. ___,
WHY WERE YOU ADMITTED?
-You initially presented to the hospital on ___ and were
found to be in diabetic ketoacidosis
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
-You are found to have a urinary tract infection which likely
precipitated your diabetic ketoacidosis.
- You were also found to have some evidence of damage to your
heart. We do not think that this is an active heart attack at
this time, but sometimes illnesses can cause your heart to work
harder and therefore cause damage.
-You briefly had a feeding tube, but this was removed and you
were eating well prior to discharge.
-You completed a course of antibiotics for your infection
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Due to deconditioning in the hospital, you are discharged to
rehab
-We decided to change one of your blood pressure medications
-Your cardiologist will contact you to schedule an appointment
so that you can be seen as an outpatient. You may benefit from
an outpatient catheterization in the future.
-We will continue dialysis on a ___, and ___
schedule
-We encourage you to eat as much as you can to improve your
nutrition and strength
You are going to:
___ & Nursing
___
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team | Ms. ___ is a ___ year old female with history of Type I DM c/b
ESRD on HD, CAD s/p 2 MI and CABG, stroke, and CVA without
residual deficits who presents vomiting with hematemesis, found
to have UTI, DKA, NSTEMI, and encephalopathy.
# DKA:
Patient was found to have acidemia and elevated glucose on
admission. Patient was admitted to the ICU on DKA protocol and
placed on insulin drip. She was quickly transitioned to
subcutaneous insulin when the anion gap closed. Patient had
temporary feeding through NG tube. She was tolerating p.o.
intake on discharge. Her discharge insulin regimen is 3 units of
glargine in the morning and 2 units in the evening, with 2
Humalog with meals. Since the patient is going to rehab, a
appointment which also was not able to be placed. However upon
discharge from rehab, patient should have close follow-up with
___ for diabetes.
# UTI
# Sepsis:
On admission, patient required norepinephrine for hypotension
and was found to have urinary tract infection. Final cultures
grew Klebsiella, so she was briefly on cefepime and switch to
ciprofloxacin. She completed a seven-day course of antibiotics
on ___. No further antibiotics are needed.
#NSTEMI
Patient initially presented with a troponin of 0.22 which peaked
to 3.45 on ___. This was thought to be type II demand
NSTEMI. Patient was briefly maintained on heparin drip for 48
hours. She was restarted on aspirin and home statin. Her statin
was changed from her low-dose simvastatin to rosuvastatin 40,
given her history of coronary artery disease. Cardiology was
consulted, but they elected to defer cath in the setting of her
altered mental status as well as history of ___ tear
prior to presentation. She is to follow-up with cardiology as an
outpatient with consideration for outpatient catheterization.
Phone number provided in case cardiology clinic is unable to get
a hold of patient to set up appointment. Her discharge troponin
was 2.31.
# Hypertension: Patient reports that she has always been
hypertensive and has had blood pressures in the 180s at home.
She has had episodes of hypotension with dialysis in the past.
Her amlodipine was discontinued and replaced with lisinopril
10mg for renal protective and cardioprotective effect. Of note,
she reported no history of allergy to an ACE inhibitor, and it
is not documented in her chart. However she has been on losartan
in the past, so should she develop symptoms such as dry cough
related to lisinopril, consider switching to losartan if she
gets side effects. She did not have hypotension with dialysis
here.
#ESRD
Patient has known end-stage renal disease related to diabetic
nephropathy. She did receive dialysis ___ while inpatient.
#Hematemesis
Patient reportedly presented with hematemesis, likely ___
___ tear from emesis related to DKA. Her anemia remained
stable and she was briefly maintained on IV PPI while in the
hospital. This was transitioned to oral PPI. There is low
suspicion for bleeding varices due to stable hemoglobin. She
required no transfusions. | 209 | 484 |
18271325-DS-22 | 23,689,661 | Dear Mr. ___,
It was a pleasure taking care of you during your time at ___
___. You came to us because of left
groin pain. You were evaluated by Surgery and their impression
was that your pain was most likely due to a muscle strain. Your
pain improved significantly with pain medications and muscle
relaxants. We are sending you back to your rehab with a
prescription for a muscle relaxant in case you have any more
problems with groin pain.
While you were here we also managed your low sodium level. For
this, we continued to limit the amount of fluids you were
taking. You should continue to do this at rehab but you will be
able to drink a little more than you had been previously. | ___ yo M s/p pylorus-preserving Whipple discharged ___ after a
prolonged hospital course presenting from rehab with left groin
pain and hyponatremia found on admission labs. | 126 | 26 |
11536702-DS-19 | 28,269,029 | You were admitted with abdominal pain, nausea and vomiting.
Testing and imaging showed an acute liver injury likely due to a
blockage of your bile duct and resultant liver injury as well as
low blood pressures due to infection. You were treated with
antibiotics with some stabilization and then went on to have a
procedure to open your bile duct. The reason for the narrowing
of your bile duct is not clear though there is some concern
about a mass obstructing the opening of the bile duct. Samples
have been taken of this area and the results are pending.
Medication Changes:
-Started ciprofloxacin and metronidazole to treat a probable
bile duct infection. You will complete a total of 10 days of
therapy after the procedure to reopen your bile duct.
-Held Atorvastatin (LIPITOR) until liver enzyme abnormalities
resolve
-Started albuterol for possible exacerbation of underlying
asthma or URI related reactive airway disease
-Held Aspirin until seven days after sphincterotomy to prevent
bleeding (can be restarted ___ | ___ yo F with h/o cholelithiasis p/w abdominal pain, nausea,
found to have acute hepatitis and dilated bile ducts on CT.
1) Acute hepatitis, likely cholangitis: The patient presented
with an acute hepatitis of unclear etiology. Due to primarily
transaminitis initial work up appropriately focused on
infectious, toxic, and metabolic hepatitides. This work up was
negative and hepatitis serologies were negative as was work up
for celiac disease and autoimmune hepatitis. Pt was
concurrently having fevers and had initial hypotension, which
was concerning for cholangitis and patient did have abdominal
pain. Due to fevers, hypotension, and concern of cholangitis pt
received antibiotics (ciprofloxacin/metronidazole) empirically
and fluids and hemodynamic issues resolved. MRCP was not
revealing for a clear causative process and had several benign
appearing lesions. She continued to have fever and pain,
however, so decision was made to proceed to ERCP though
bilirubin remained normal. She had an ERCP that showed
obsructed ampulla with appearance of obstructing mass.
Sphincterotomy performed, fever resolved, and pain steadily
improved. She was tolerating a full diet without distress at
time of discharge. Regarding the etiology of her biliary
obstructing masses brushings and needle biopsies are pending at
time of discharge for pathological diagnosis. Doctors ___
and ___, who performed the procedure, will follow up the
pathology and plan on contacting the patient and facility to
help coordinate follow up plan as this is partially dependent on
biopsy results. She will complete 10 days of
ciprofloxacin/metronidazole post ERCP.
2) CAD, native vessel: She had no signs or symptoms of ACS
during her hospitalization and no chest pain. Her aspirin was
held around procedure and should be held until 7 days
post-sphincterotomy (can restart on ___. Her metoprolol
was help when hypotensive but then restarted without issue. Her
statin has been held given hepatitis and should ideally be
restarted after LFTs normalize.
3) Likely Viral URI/ Reactive Airway Disease: After a few days
in the hospital the patient developed nasal congestion, cough,
and some wheezing. She has a history of asthma that has been
quiesent for several years but this was felt most consistent to
mild reactive airway disease exacerbation in the setting of a
viral URI. She was managed with guaifenesin and albuterol with
good benefit. She is being discharged on standing albuterol for
a week to help treat airway reactivity around URI.
4) Diarrhea: Patient developed mild diarrhea on antibiotics but
C diff assay was negative. She may receive loperamide PRN for
symptomatic diarrhea.
5) HTN, benign: Initially she was hypotensive but this resolved
with hydration. Her BPs were well controlled on metoprolol at
home dose prior to discharge.
6) Hyperlipidemia: Statin was held given hepatitis, should be
restarted as LFTs normalize.
7) GERD: esomeprazole was converted to formulary omeprazole,
this can be converted back on discharge
8) Hypothyroidism: continued home levothyroxine
9) Depression: Sertraline was continued at home dose | 168 | 499 |
12663219-DS-15 | 29,632,772 | Dear Ms. ___,
You were admitted to ___ after you were found
to have an abnormal heart rhythm called atrial fibrillation that
was making your heart race and was causing you to be short of
breath. After being treated with a heart medication, your heart
rhythm went back to normal. While you were in the hospital, we
switched your bisopropol to a similar medication called
metoprolol, that you will take once a day from now on. This
medication will control your heart rate as well as your blood
pressure. We also started you on a blood thinner called Eliquis,
which you will also take twice a day.
You should follow up with your primary care physician and your
neurologist within a week of leaving the hospital.
It was a pleasure taking care of you!
Your ___ Team | ___ yo female with h/o L MCA stroke and hypertension who
presented with DOE + rapid heart rate, found to be in Afib with
RVR. Converted with 50 mg (20 IV, 30 PO) of diltiazem. The
patient was transitioned to metoprolol for rate control and
started on apixaban for anticoagulation.
# Paroxysmal Atrial Fibrillation with RVR: Patient presented
with DOE and palpitations, found on ECG to be in AF with RVR.
The patient was thought to have a prior history of afib, given
report of prior episodes of palpitations and tachycardia, noted
prior to immigration to the ___. No e/o infection, anemia,
obvious volume overload as trigger. Most likely secondary to
hypertension. CHADS-Vasc 6, suggesting ~10% risk of stroke per
year. Patient reverted to sinus rhythm with 20 mg IV diltiazem
and 30 mg PO diltiazem. Patient was subsequently switched from
home bisoprolol to metoprolol tartrate 12.5 mg BID, which was
then transitioned to metoprolol succinate 25 mg QD PO. She was
also started on apixaban 5 mg BID. The patient will follow up
with cardiology as outpatient for TTE to rule out structural
etiology of arrhythmia.
# Dyspnea: Patient reportedly dyspneic while in atrial
fibrillation. Dyspnea thought to be most likely secondary to
this arrhythmia as it resolved when the patient reverted to
normal sinus rhythm. Pt did have a history of possible
mild/borderline HF diagnosed in ___, which may have also
contributed to her intolerance of rapid heart rate. Her BNP was
not elevated and CXR was without evidence of pulmonary edema to
suggest acute decompensation. There was a low index of suspicion
for alternative etiologies, including CAD (as ECG unchanged and
prior stress test at ___ was negative), PE or
pulmonary process given negative CTA.
# h/o CVA: Patient without neurologic deficits in house.
Continued on rosuvastatin 5 mg qPM while in house. The patient's
CVA may have occurred due to paroxysmal atrial fibrillation
which was diagnosed on this admission. Her aspirin was
discontinued as she was anticoagulated with apixaban as above
(and her prior stroke was felt to be cardioembolic in etiology
given afib).
# HTN: On bisoprolol at home but with some elevated BPs. Patient
switched to metoprolol 12.5 mg BID PO while in house, which was
then transitioned to metoprolol succinate 25 mg PO QD.
#PUD: Patient with history of gastric ulcers. Last EGD in ___
___ showed clean based, non-bleeding gastric ulcer. Patient
continued on omeprazole while in house.
Transitional Issues:
- TTE scheduled as outpatient to establish baseline and rule out
structural cause of heart disease (previously followed by
cardiologist in ___.
- Consider repeat evaluation for CAD (prior stress test done at
___ reportedly negative) | 134 | 441 |
19626086-DS-14 | 20,573,860 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing in Right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin daily for 4 weeks
WOUND CARE:
- You may shower but do NOT get cast wet. Your cast must be left
on until follow up appointment unless otherwise instructed.
- 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. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have fracture of the right ankle, and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of R ankle, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report.
After the procedure 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. The patient
was given ___ antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. She was also closely monitored
on CIWA protocol and treated with Ativan for concern of EtOH
withdrawal.
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
touch down weight bearing in the right lower extremity, and will
be discharged on Aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 191 | 255 |
12897175-DS-14 | 29,072,158 | Dear ___,
It was a pleasure taking care of you at the ___
___. You were admitted for chest pain. A
scan of your chest showed that there was no lung clot. It showed
a possible pneumonia. You were treated for this pneumonia and
you continued treatment for your skin infection. You completed
your antibiotic treatment while here.
We are discharging you to a day program to help you with your
alcohol addiction. You have an appointment at ___ on
___ with your PCP.
We wish you all the best | ___ year old female with a history of frequent inpatient
admissions for alcohol intoxication and withdrawal ((>10
withdrawal seizures and DTs) who was recently discharged on ___
with seizure in the setting of alcohol abutse who re-presented 1
day later with chest pain and possible pneumonia on imaging.
Immediately after leaving the hospital, she drank alcohol, then
went to her scheduled ___ appointment, and later to the
emergency room complaining of chest pain and worsening cough.
CTPA showed no evidence of PE, but a possible left upper lobe
pneumonia. Her cellulitis over right antecubital fossa was also
very inflammed. She was started on azithromycin and ceftriaxone
for pneumonia and cellulitis. She was monitored on telemetry and
CIWA protocol during stay, although she was on the phenobarbital
protocol during previous admission with some residual effect of
phenobarbital remaining. Her cellulitis improved, her cough
persisted, but she remained afebrile and without leukocytosis.
She completed antibiotic course for pneumonia and cellulitis
before discharge. | 89 | 161 |
13297743-DS-104 | 23,769,508 | Dear Ms. ___,
You were admitted to the ___
because you were having abdominal pain and vomiting from your
chronic pancreatitis. You were given intravenous fluids and
medications to control your pain and nausea using the protocol
that you discussed with your primary care doctor. During your
hospital course, your pain improved and you were able to
tolerate a solid food diet without feeling nauseous. You were
discharged with a plan to take the oral pain medications that
you take at home.
We recommend that you follow up with your primary care doctor
after leaving the hospital.
You should call your doctor or return to the emergency
department if you develop worsening abdominal pain, fevers,
chills, bloody stools, vomiting, diarrhea, or are unable to eat
food without feeling nausea or vomiting.
It was a pleasure caring for you here at ___, and we wish you
the best in your recovery.
Sincerely,
Your ___ Medicine Team | Ms. ___ is a ___ woman with a history of CFTR mutation
complicated by chronic pancreatitis (with frequent admissions)
without pulmonary symptoms, acute ischemic colitis, chronic
pain, polysubstance abuse, and depression with prior suicide
attempts who presented to the ED with 2 days of vomiting and
epigastric abdominal pain radiating to the back similar to prior
episodes of pancreatitis. The patient was made NPO and treated
with continuous intravenous fluids and intravenous pain and
anti-emetic according to her outlined ___ pain protocol. The
patient initially did not tolerate PO and her diet was slowly
advanced. She was continued on IV pain medication, Ativan, and
anti-nausea medication until discharge. She tolerated a full
diet the day prior to and the day of discharge without nausea or
vomiting. Of note, there was difficulty accessing patient's port
(similar to last admission), TPA was administered, and patient
should plan to visit clinic every ___ weeks for flushes of the
port.
# Chronic pancreatitis - Patient with a history of CFTR mutation
with frequent admissions for chronic pancreatitis. Her
presentation on this admission was consistent with previous
pancreatitis flares, however labs (including lipase) were normal
on admission. There was no concern for infectious process or
other etiology. She was started on her pancreatitis pain control
protocol in ED. She was able to tolerate POs after a few days
and her PO regimen was restarted.
# Normocytic Anemia - Hb at baseline. Most likely ACD, though
there may be some component of malabsorption as well. Hb 8.7 at
time of discharge.
# Migraine Headaches: Continued home Fiorocet
# Depression/Anxiety - Prior history of suicide attempts,
patient denies any current SI/HI. Continued
lorazepam/quetiapine/lamotrigene.
# GERD: Of note, patient has history of Cdiff. Continued
Omeprazole
TRANSITIONAL ISSUES
=================
[ ] Patient required TPA to access port due to difficulty
drawing back, will need clinic appointments Q4-6weeks for port
flushes
[ ] Discussion regarding outpatient pain regimen to prevent
frequent hospital readmissions, with consideration to celiac
plexus block.
# Code Status: Full
# Contact: ___ (wife), home ___, cell
___ | 149 | 334 |
12952913-DS-18 | 29,513,458 | Dear Ms. ___,
You were admitted to the hospital for fevers and malaise. We
did a CT scan of your abdomen which showed a possible infection
around the area you were treated for your cancer. We discussed
this at our liver cancer conference and felt that the best
course of action would be to discharge you on antibiotics. You
are being discharged on an antibiotic called Augmentin which you
should take for 1 week.
When you were admitted to the hospital you were also found to
have a rapid heart rate and irregular rhythm called atrial
fibrillation. We increased one of your home medications,
metoprolol, to help control your heart rate. You will need to
discuss starting a blood thinner with your primary care doctor.
At the time of your discharge, your heart was no longer in
atrial fibrillation.
We made several changes to your medications which are detailed
in your discharge paperwork. You should review this carefully
and go over it with your visiting nurse to make sure you are
taking the correct medications. You should also follow-up with
your doctors as detailed below.
It was a pleasure taking care of you.
Sincerely,
Your ___ care team. | Patient is a ___ female with h/o primary biliary
cirrhosis, large ___ status post TACE, and recent admission for
SBP who was admitted for low-grade fevers and malaise as well as
atrial fibrillation with RVR.
#Fevers, malaise
She had negative blood cultures, negative C. difficile test,
negative stool cultures, no SBP, and urine with coag negative
staph (likely contaminant or colonization given lack of pyuria).
She underwent a triphasic CT of the abdomen which found a
ring-enhancing lesion just below the dome of the right diaphragm
concerning for an abscess. She was discussed at the
multidisciplinary liver tumor conference and it was felt like
this represented expected post-TACE changes rather than a true
abscess amenable to drainage, but that she may have micro
abscesses as result of the procedure. She was initially treated
with levofloxacin but transitioned to amoxicillin/clavulanate
prior to discharge. Her fevers resolved.
#Atrial fibrillation with rapid ventricular response
Her atrial fibrillation resolved spontaneously and her heart
rate was well controlled on an increased dose of metoprolol.
This was likely triggered by her infection. A discussion of
anticoagulation was deferred to the outpatient setting given the
concern for bleeding risk with the ___.
#Primary biliary cirrhosis
Her lactulose was stopped and she was started on miralax given
significant abdominal discomfort. Her diuretics were restarted.
#GAVE with chronic GI bleeding and iron deficiency anemia
She was given an infusion of IV ferric gluconate 125 mg on ___.
#Hypertension
Her losartan and verapamil were both held in the setting of
normal blood pressures and good heart rate control with the
increased dose of metoprolol. | 200 | 256 |
19005323-DS-18 | 26,727,014 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. As you know you were
admitted with abdominal distension and an elevated white count.
You were treated for an infection of the fluid in your abdomen
called spontaneous bacterial peritonitis (SBP) with five days of
intravenous antibiotics. You were also given albumin to help
reduce the fluid in your abdomen. Fluid from your abdomen was
removed with a procedure called a therapeutic parenthesis.
Finally, you had a screening test for dilated blood vessels in
your esophagus and stomach (called varices) using a tube with a
camera called an EGD. At the time of discharge, your abdominal
swelling improved and your white count levels returned to
normal.
Please take your medications as instructed. Please followup with
your primary care physician and hepatologist Dr. ___.
Sincerely,
Your ___ Care Team | ___ with HCV and EtOH cirrhosis, ___ s/p TACE ___, RFA
___ who presents with increasing abdominal distension and
was referred by outpatient hepatologist due to leukocytosis,
elevated Cr concerning for SBP.
# Worsening ascites: Concern for SBP with elevated WBC however
no evidence from diagnostic paracentesis that this is the source
of infection. Last paracentesis ___ removed 8L, received
37.5g albumin at the time, also with >250 PMNs in that sample,
culture negative. Per patient, he experienced little relief
after paracentesis but after that day did not notice much of a
difference in the size of his abdomen. Denies abdominal pain,
feels oxycodone helps his back pain primarily. Concern for
potential malignant component to his ascites but will likely
require large volume tap during this admission. Currently
comfortable, no urgent need and would avoid given renal
function. Gave 1.5 g/kg 25% albumin x 1 (137.5g) Day ___= ___,
and 1 g/kg 25% albumin x1 (92g) on Day 3. Restarted
lasix/spironolactone at half home dose as well as metoprolol
once renal function stabilized. continued CTX 2g Q24H for 5
days (Day 1= ___ treat SBP. Pt had therapeutic parancetesis
___ prior to discharge; 6 L removed.
# Leukocytosis: Most likely source was SBP given large ascites,
cirrhosis. No respiratory symptoms, GI symptoms, fevers, chills,
urinary symptoms to suggest another source of infection. urine,
blood cultures were negative. f/u peritoneal fluid culture.
# ___: Baseline Cr 0.6, increased to 1.3-1.4 post-large volume
paracentesis. There was also concern for HRS, but will need to
rule out other etiologies. Trended Cr, which trended down to 0.9
on day of discharge.
# HCV and EtOH Cirrhosis: No known varices but no EGD in our
system. No history of hepatic encephalopathy per patient, no
record in OMR. Not on home lactulose but is taking Mg oxide BID.
MELD 10 and has just initiated transplant eval. Screening EGD
done ___ showed low-grade esophageal varices. Will need to
follow up pending transplant eval labs
# ___ s/p TACE, RFA: No acute issues at this time. Pending
transplant.
# Coagulopathy: INR stable at 1.4, no previous episodes of
bleeding.
# Back pain: Continued home oxycodone 5mg q4h:prn
# Nutrition: Vitamin D deficiency noted, started weekly vitamin
D supplementation with 50,000 units.
# HTN: Held lasix and spironolactone due to renal function,
restarted them at half dose once kidney function recovered;
continued metoprolol and could continue to uptitrate metoprolol
for further BP control, though not a potent antihypertensive
medication. Continued amlodipine 5 mg PO daily, consider
increase to 10mg from 5mg PO daily. | 141 | 438 |
10928511-DS-31 | 28,191,606 | Dear Ms. ___,
You were admitted to the hospital for leg swelling. Our vascular
surgeons saw you and recommended changes in your leg wraps. They
recommend using juxtalite to compress your legs. We also
coordinated with home nursing so that we can hopefully prevent
you from having to come back into the hospital again.
Your medications were unchanged. The details of your follow up
appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ hx of chronic venous stasis, lymphedema and cellulitis
treated in the past with Unna boot and mechanical compressions
presents from home with complaint of increased swelling in her
legs since ___ that has been diuretic resistant.
# Bilateral lower extremity lymphedema: Ms. ___ has a long
history of bilateral lymphedema, and has followed with cariology
and vascular in the past for this. She reports that sh was not
able to compress her legs adequately on her own and reports that
her home services have not been wrapping her well for some time.
Because of this, she accumulated fluids in her legs which has
been painful and limiting her mobility at home. She was seen by
vascular surgery who recommended changing her compression to
juxtalyte for ease at home. New home services were arranged. Of
note, patient known what works ___ for her and just needs help
with the application of her compression. Future caregivers
should take her input seriously. She will be discharged home
with PCP and ___ clinic follow ups.
# ___: Cr 1.3 from baseline of ~1. BUN:Cr >20. Likely prerenal
in the setting of over diuresis. She reports that she was
instructed to take double dose of home diuretic in the week
prior to admission. She was discharged with a reduced dose of
diuretic and PCP follow up. | 77 | 222 |
13626021-DS-13 | 28,411,816 | Ms. ___,
You were admitted to ___
because you were short of breath and your mouth hurt.
While you were here:
-We extracted your teeth
-We gave you the IV water pill to improve your breathing
-You felt better by the time you left the hospital
When you go home:
-Please continue all medications as directed
-Please follow-up with the below doctors
-___ yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best,
Your ___ care team | ___ with PMH asthma/COPD 3L home O2, PE (___) on apixaban,
interstitial lung disease on prednisone, DM, and HFpEF
presenting with subacute progressive SOB and mouth pain.
#Dyspnea:
#HFpEF:
#Asthma/ILD:
The patient presented with dyspnea worse than baseline, although
on her home oxygen requirement. She was found to be wheezing and
with volume overload. She was diuresed with IV Lasix to
euvolemia. Her oxygen requirement decreased to 2 L (3 L when
ambulating up stairs). She was continued on home prednisone,
Lasix, albuterol, zafirlukast, and fluticasone. Breathing
improved to baseline before discharge.
#Mouth Pain:
Initially concerning for deep space infection given swelling.
OMFS was consulted. CT was negative for deep space infection.
Panorex without evidence of obvious infection. The patient had
extraction of all remaining teeth ___. She was restarted on
apixaban without bleeding. Her mouth pain improved after
extraction. She should continue chlorhexidine mouthwash for 7
days (END: ___. Follow-up with OMFS and dental.
#Urinary tract infection:
Urinalysis suggestive of bacteriuria. Difficult history and
uncertain if she was symptomatic. She was treated with a course
of ceftriaxone in house.
#Herpetic lesions:
Found to have lesions on R buttock suggestive of VZV. Started on
acyclovir course for VZV for 7 days (END: ___. Follow-up with
dermatology as outpatient if indicated.
#Pulmonary embolism. Diagnosed ___, thought to be
unprovoked. However, the patient does have a history of colon
cancer and melanoma. She was placed on apixaban for life.
Apixaban was held ___ and resumed without
bleeding.
#Postmenopausal vaginal bleeding: Patient endorsed vaginal
bleeding a few weeks prior to admission. No active bleeding
during admission. She should follow with OB/GYN for endometrial
biopsy and ultrasound.
#Immature WBC forms:
The patient has had laboratory evidence of immature white blood
cell forms that are chronic. Hematology/oncology was consulted
during hospital lesion. Likely represents response to infection
versus MDS. ___ repeat CBC with differential as
outpatient as well as at annual visits with referral to
outpatient hematology/oncology if CBC shows rising immature
cells or new cytopenias.
#Iron deficiency anemia:
Iron deficient by labs. No evidence of active bleeding.
Hemodynamically stable. However, the patient does have a history
of vaginal bleeding as above, as well as a history of colon
cancer in the past. Recommend repeat CBC as outpatient as well
as GI/gyn onc follow-up. The patient was started on iron
repletion.
#Diabetes mellitus:
Glucose was dramatically elevated on admission likely due to
dose of IV steroids at presentation. Her last hemoglobin A1c was
9.8% in ___. Glargine was increased to 18U. Recommend
glucose check and A1c in clinic with titration of regimen as
appropriate.
# HTN: Continued home lisinopril 10 mg PO daily.
# HLD: Continued Atorvastatin 10 mg PO/NG DAILY.
# Osteoporosis:
# Vitamin deficiency: Continued home calcium, vit D/B, MVI. | 75 | 439 |
13215699-DS-24 | 25,838,726 | Dear ___,
___ was a pleasure taking care of you at ___
___. You were admitted for treatment of your
lightheadedness and evaluation by physical therapy and
occupational therapy. Our ___ team felt that you were safe to
go home with additional treatments there.
Also, while you were here you were evaluted by the surgeons who
work with the surgeon who performed your recent carpal tunnel
release. They felt that the surgical site on your left hand was
healing well and is without any evidence of infection. | ___ w/ hx of TIA, DMII, chronic vertigo, recent carpal tunnel
surgery who presents with lightheadedness.
# Lightheadedness: Occurred intermittently during this
hospitalization. She was offered meclazine as needed, which she
only took once. She was seen by neurology in the ED, who felt
that her symptoms were consistent with peripheral vertigo, of
which she has a history. She was seen by both ___ and OT to
evaluate her functionality and ability to be at home. Based on
their assessment, she was discharged with both ___ and OT home
services, as well as home nursing and evaluation for home health
aide.
# S/P Carpal Tunnel Release Surgery: Patient reported pain over
the surgical site. Examination of the wound revealed a black
eschar. She was seen by the orthopedic surgery service, who felt
that the wound was healing well. She was discharged with ___ for
wound checks, and with close follow-up in ___ clinic.
# Bacteriuria: Denied any urinary symptoms. Was found to have
Enterococcus 10,000-100,000 CFU on urine culture, which was read
as contaminated with mixed flora. We did not treat her with
antibiotics. | 87 | 182 |
15665415-DS-8 | 20,835,875 | You were admitted to the surgery service at ___ for fevers.
You improved on antibiotic therapy and are now safe to be
discharged to rehab to complete your recovery with the following
instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. You need to take the
antibiotics (ciprofloxacin and metronidazole) until ___ to
treat your infection.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your surgical wound was opened and packed with wet-to-dry
dressing, which needs to be changed three times a day.
*You have steri-strips. They will fall off on their own. Please
remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
G/J-tube: Keep G-tube capped. J-tube with cycling tubefeed,
flush tube Q6H with 30 cc of tap water. Monitor for signs and
symptoms of occlusion or dislocation. Change drain sponge daily. | Ms. ___ is a ___ female s/p Whipple procedure for duodenal
adenocarcinoma (moderately differentiated, T2NO) who presented
to the ED from the rehab facility 3 days after discharge with
fevers. On presentation, she had an elevated white count,
positive UA, and opacities on CXR concerning for developing
infection. She was started on IV antibiotics (vancomycin and
levofloxacin) in the ED then admitted to the surgical service
for further evaluation and management.
IV antibiotics were continued on admission - vancomycin,
cefepime, and metronidazole per recommendations from Infectious
Disease. Blood cultures drawn at presentation and on HD2
(___) when she spiked a temperature of 102.4 were pending on
day of discharge. Despite a positive UA, urine culture showed no
growth. Her surgical wound was opened at bedside with drainage
of thick, purulent material -culture showed GNRs on Gram stain
and growth of mixed bacterial flora. The viscous, murky quality
of the drainage suggested a pancreatic leak even with a normal
JP amylase (10). CT abd/pelvis and RUQ ultrasound showed
expected post-operative changes but no intra-abdominal fluid
collections or abscesses. Her WBC normalized on HD2. On HD3
(___), given her improving clinical status and non-convincing
culture data, she was transitioned off the IV antibiotics and
started on oral ciprofloxacin and flagyl to complete a two week
total course of antibiotic therapy (___) per ID
recommendations.
She was maintained on a clear liquid diet and tube feeds (Vital
1.5) were continued. On ___, tube feed rate was
increased to 70cc/hour, cycled 6pm to 10am, as her pre-albumin
was low (14). She continued on her outpatient medications,
including Lovenox. Her opened wound received TID dressing
changes with WTD gauze; it continued to express small amounts of
thick, purulent material. After HD2, she had no additional
fevers and WBC was normal. Her vital signs were stable
throughout her course. She was discharged back to rehab on HD4
(___) to continue her post-operative convalescence. | 363 | 318 |
14080988-DS-13 | 21,858,669 | Dear Ms. ___,
Thank you for allowing us to participate in your care during
your recent stay at ___. You were hospitalized for a right
toe skin infection. During your stay, you were treated with IV
antibiotics prior to being switched to oral antibiotics. Your
toe improved throughout your stay, and you were able to walk on
it prior to discharge.
During your stay we also had you speak with social work, who
provided you with a list of therapists. It is important to call
and make an appointment to see one of these therapists when you
return home. You will also have follow up with rheumatology, in
order to reestablish care and reevaluate many of your other
concerns.
You will be discharged on oral antibiotics (clindamycin).
Please take as directed. If you notice that your toe is
worsening, it is important that you return to care. You are
scheduled for an appointment with Podiatry in 1 weeks time to
evaluate your progress.
You were also seen by vascular surgery during your stay to
evaluate for blood flow to your legs. The studies that they did
looked appropriate, however, you will need to follow up with Dr.
___ in ___ in 1 months time.
While hospitalized your atenolol and triamterene-HCTZ were
stopped. Please follow up with your PCP prior to restarting
these medications. | Ms. ___ is a ___ with unclear autoimmune history and hx of
scalp MRSA currently on doxycycline who presents for R hallux
cellulitis, concern for vascular insufficiency, and bilateral
foot pain.
# R hallux cellulitis: On presentation R hallux appeared
erythematous, swollen, and tender, with no exudate or
fluctuance, concerning for cellulitis. Pt was treated
empirically for MRSA with IV vancomycin given hx of recent MRSA
infection and failure of outpatient IV Ceftriaxone, Augementin,
and doxycycline. Pt improved rapidly and was transitioned to PO
clindamycin 450mg TID for a 7 day course. She was discharged
with planned follow up with podiatry.
# Concern for vascular insufficiency: Right DP pulse by doppler
only, ___ palpable. Initial concern for vascular insufficiency,
particularly given dusky discoloration of foot. Pt was seen by
vascular surgery and underwent non-invasive arterial studies
which were normal. She was discharged with instructions to call
for follow up appointment with Dr. ___ in one months time.
# Toe fractures: Unclear chronicity, although likely from
earlier trauma. Unlikely osteo given negative Xrays x2 and
timeliness of improvement on antibiotics. Podiatry consulted,
recommended post-op boot temporarily for 1 week upon discharge,
will re-evaluate in clinic during scheduled follow up on ___.
# Bilateral foot pain and discoloration: Unclear etiology. Given
acute nature of her infection and potential fractures, it was
decided to focus on the more acute problems, recognizing that
she merits a full workup as an outpatient for her more chronic
concerns. Pt has seen rheumatology at ___ in the past, but not
for many years, and requests that she be provided with
rheumatologist at ___ as she is hoping to transition her care.
Pt provided with follow up appointment with rheumatology.
# HTN: During hospitalization pt's home atenolol and
triamterene-HCTZ were discontinued. Her BP's remained stable
without meds in the 110-130's.
# Diabetes: Metformin held during hospitalization, restarted on
discharge.
# CODE STATUS: Full code, confirmed
# CONTACT: sister, ___, ___ | 231 | 333 |
12641004-DS-35 | 20,074,676 | Dear Mr. ___,
It was a pleasure participating in your care. Please read
through the following information.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had discomfort and
white color discharge from the site of insertion of your central
line port.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You central line was removed.
- We sent for blood and wound cultures. The catheter was also
sent for culture.
- The wound site was infected; however, we did not find evidence
of an infection in your blood stream, which is good news!!
- You were started on IV antibiotics initially and transitioned
to oral antibiotics on discharge.
- A new central line was inserted on ___
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Take ciprofloxacin 500mg twice daily (last day: ___
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is 77.2
kg (170.1 pounds). Please seek medical attention if your weight
goes up more than 3 pounds in 2 days or 5 pounds in one week.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
-Your ___ Care Team
- Heart failure service fax number ___ | SUMMARY
========
Mr. ___ is a ___ year old male with history of dilated
cardiomyopathy thought to be secondary to lymphocytic
myocarditis s/p HeartMate II LVAD implant at ___ in ___ with
subsequent device explant ___ due to pump failure and
driveline infection in setting of decreased compliance, now on
palliative milrinone with last EF 17%, presenting with ___
line site infection.
==============
ACTIVE ISSUES:
==============
#Infected ___ site cellulitis
Patient admitted on ___ with ___ day of progressively
worsening discomfort around ___ line. Also recently
developed purulent drainage coming from this line. Reassuringly
without systemic symptoms. ___ contacted and the line was removed
and sent for cultures. Swab cultures around the skin grew
pan-sensitive pseudomonas. The patient was started on Vancomycin
and Ceftazidime while in-house pending blood culture results.
Blood and catheter tip cultures remained negative. The patient
is thought to have site infection without systemic/blood stream
seeding. Per infectious disease team recommendations, the
patient was started on ciprofloxacin 500mg PO q12h for a total
of 2 weeks (day 14: ___. On ___, a double-lumen
___ tunneled line was successfully placed via the left
internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use
after the procedure.
#Chronic systolic heart failure on Palliative Milrinone
Patient with known reduced EF to 17% w/ tenuous volume status
and
recent admissions for both volume overload/depletion. On
admission, the patient was volume overloaded with JVP of 13-14
cm. He was continued on home torsemide 100mg BID. Milrinone
infusion was continued at a rate of 0.5 mcg/kg/min using PIV
prior to ___ placement. His weight on discharge was
77.2 kg (170.1 pounds). | 249 | 271 |
13989641-DS-16 | 29,327,334 | -ALWAYS follow-up with your referring provider ___ your PCP
to discuss and review your post-operative course and
medications. Any NEW medications should also be reviewed with
your pharmacist.
-Resume your pre-admission medications except as noted AND you
note that you NO longer need to take medications that shrink
your prostate (Hytrin, Avodart, Flomax, etc.)
-You may take ibuprofen and the prescribed narcotic together for
pain control. FIRST, use Tylenol and Ibuprofen. Add the
prescribed narcotic (examples: Oxycodone, Dilaudid,
Hydromorphone) for break through pain that is >4 on the pain
scale.
-The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from
ALL sources) PER DAY.
-Ibuprofen should always be taken with food. If you develop
stomach pain or note black stool, stop the Ibuprofen. Ibuprofen
works best when taken around the clock.
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Do NOT drive while Foley catheter is in place.
-AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up. Generally about
FOUR weeks. Light household chores are generally ok. Do not
vacuum.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks
-If you had a drain removed from your abdomen, bandage strips
called steristrips have been applied to close the wound. Allow
these bandage strips to fall off on their own ___ days).
PLEASE REMOVE any remaining dressings w/ gauze within 2 days of
discharge. You may get the steristrips wet.
-resume regular home diet and remember to drink plenty of fluids
to keep hydrated and to minimize risk of constipation. For the
first few days at home, you should eat SMALL PORTIONS. Avoid
high fat, bulky or fried foods. | Mr. ___ was transferred from OSH with refractory hematuria
(prostatic origin) for consideration of ___ embolization verse
simple prostatectomy. He was evaluated and ultimately optimized
for the robot-assisted laparoscopic simple prostatectomy that
was completed on ___. No concerning intra-operative events
occurred; please see dictated operative note for full details.
Mr. ___ received ___ antibiotic prophylaxis. At
the end of the procedure the patient was extubated and
transported to the PACU for further recovery before being
transferred to the general surgical floor. He was transferred
from the PACU in stable condition. His post-operative course was
complicated by delayed return of bowel functions, postoperative
ileus requiring nasogastric placement (twice) and placement of a
PICC for nutritional support with TPN. His pain was well
controlled, initially with PCA, then with oral pain medications.
He was continued on DVT/PE prohpylaxis with SQH and SCDs. With
the eventual passage of flatus and bowel movements, his diet was
slowly advanced to regular and TPN was discontinued. He
underwent a void trial prior to discharge and his drain was also
removed. Mr. ___ was discharged in stable condition, eating
well, ambulating independently, and with pain control on oral
analgesics. On exam, incision was clean, dry, and intact, with
no evidence of hematoma collection or infection. Mr. ___ was
given explicit instructions to follow-up with Dr. ___
post-operative evaluation and pathology findings. | 420 | 229 |
13648483-DS-16 | 20,208,430 | Dear Ms. ___,
You were admitted to the hospital with abdominal pain and an
elevated white blood cell count which is a marker of infection.
You had an ultrasound that was concerning for in an infection in
your abdomen. You were taken to the operating room and found to
have a normal gallbladder but appeared to have a ruptured
ovarian cyst. The OBGYN team was consulted during surgery and
send samples from the fluid to the lab to test for bacteria. You
then had a CT scan which showed an ovarian cyst/mass. You will
need to follow-up with the Ob/Gyn service for further management
of this, pending culture results.
You are now doing better, tolerating a regular diet, and ready
to be discharged to home to continue your recovery. Please note
the following discharge instructions:
Please 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.
Best Wishes,
Your ___ Surgery Team | Ms. ___ is a ___ year old female who presented to urgent care
with right upper quadrant pain, nausea/vomiting, and
chills/sweats x1 day. She was mildly tachycardic at 107 bpm but
otherwise hemodynamically stable. Labs were remarkable for white
count elevated at 20 with normal LFTs and lipase. Liver
ultrasound showed sludge in the gallbladder. She was referred to
the Emergency Department and evaluated by Acute Care Surgery and
her signs and symptoms were concerning for acute cholecystitis.
Informed consent was obtained and she was taken to the operating
room and underwent an aborted Laparoscopic Cholecystectomy after
noting a normal appearing gallbladder and drainage of a right
ovarian cyst via an intra-operative consult by ob/gyn. The gram
stain of the fluid collected was noted to have PMNs with no
growth on culture or pelvic washings. She was initially started
on vacomycin, ciprofloxacin, and flagyl for a presumed
tuboovarian abscess. A JP was placed in her left lower quadrant
for drainage of the mass.
Patient was subsequently admitted for further evaluation and
management of her mass. During her inpatient stay, tumor markers
were collected and notable for a CA 125: 3550. CEA and ___
were within normal limits. She underwent further imaging. A CT
Abdomen & Pelvis was notable for a heterogeneously enhancing
lower abdominal mass likely arises from the right adnexa. Due to
concern for malignancy vs an infectious process, her antibiotics
were discontinued and was consented for surgical exploration.
On ___, she underwent a Total Laparoscopic
Hysterectomy, bilateral salpingo-oophorectomy, para-aortic and
pelvic lymph node dissection, omentectomy for endometrioid
ovarian cancer that was confirmed by frozen section
intra-operatively. Please see the operative report for full
details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with dilaudid and
toradol. Her diet was advanced without difficulty and she was
transitioned to oral pain medications. On post-operative day #1,
her urine output was adequate so her Foley catheter was removed
and she voided after a formal trial of void. She was ambulating
independently, and pain was controlled with oral medications.
She met with Social Work to discuss coping strategies regarding
her new cancer diagnosis. She was then discharged home in stable
condition with outpatient follow-up scheduled. | 827 | 368 |
13900699-DS-3 | 29,346,852 | Dear Mr. ___,
You came in after you had a seizure at home. We believe this was
due to a small spot of cancer on your brain. We started you on a
new medication to prevent further seizures.
You were also seen by our neuro-oncologist Dr. ___
recommended radiation treatment. You had your planning session
here in the hospital and will need to return next week for your
treatment.
We are working on scheduling follow up with the neuro-oncologist
Dr. ___. You should also follow up with Dr. ___
leaving the hospital.
It was a pleasure taking care of you, and we are happy that
you're feeling better! | Mr. ___ is a ___ y/o M w/ metastatic melanoma followed by
Dr. ___ ___ ___, locally advanced SCC of the right
orbit s/p extensive resection by Dr. ___ ___
___, who presented with at least one unwitnessed and
one witnessed syncopal episodes that seem most consistent with
seizure. MRI brain showed new hemorrhagic focus and metastatic
lesion in addition to previously noted abnormalities. He was
started on IV Keppra in the emergency department. He was seen by
neuro-oncology who recommended radiation therapy. He underwent
initial planning session while hospitalized, and will receive
cyber knife treatment as an outpatient. He was discharged on
keppra 1g BID. He was counseled that due to the seizures he is
not allowed to drive, but he reports that he already stopped
driving prior to this.
> 30 minutes spent on discharge coordination and planning | 104 | 140 |
10785570-DS-23 | 25,503,241 | Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaluation and management of cancer with brain involvement. You
were given whole brain radiation and steroids to help alleviate
your symptoms. You will need to continue the steroids after
discharge, but the dose will be slowly decreased. Follow up
appointments have been scheduled with your primary care
physician as well as your oncologist. Please take your
medications and keep your follow up appointments as scheduled.
We wish you all the best.
- Your ___ Team | Ms ___ is a ___ yr old female with history of breast
cancer s/p L mastectomy and axillary LND, 4 cycles chemotherapy
and adjuvant XRT who presented with left ___ nerve palsy, found
to have innumerable brain mets on MRI. Patient received 5 cycles
of whole brain radiation during her admission and was started on
steroids. There was no change in her ___ nerve palsy with
consistent paralysis of her left lateral gaze. With regards to
her pain control regimen, she was seen by palliative care team.
Her pain was mainly due to headache and retro-orbital pain. Her
opiod regimen was adjusted to standing MS ___ 15 mg q12 hours
and PRN ___ morphine. She also received tylenol. Her pain control
was good prior to discharge. She was also noted to have some
intermittent hallucinations / agitation which were thought
likely secondary to her steroids. She was started on olanzapine
2.5 mg daily. There was a family discussion regarding
disposition. It was determined that given her brain mets and
risk for resumption of alcohol consumption at home, that she be
discharged to a facility where she could receive assistance and
be more closely monitored. | 96 | 194 |
18979146-DS-24 | 25,506,996 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for chest pain, side pain,
and abdominal pain and you also had a very sick liver
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- To help your liver heal, you required nutrition and vitamins,
and we gave this to you through a tube
- We put a tube through your nose that went into your stomach to
help your liver
- You removed the tube because it was making you sneeze and
cough
- We explained that it is very important for you to have this
tube in through your nose to help your nutrition
- You were very concerned about your employment status and your
children, and you wanted to go to work even though we said it
was very dangerous to leave the hospital
- You communicated your understanding of the risks associated
with your liver disease and understand that you need to avoid
alcohol and focus on nutrition to recover
- With all the information we gave you, you decided to leave the
hospital despite our recommendation
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Please avoid drinking alcohol as it is extremely harmful to
your liver
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- It is very important to keep track of your health.
- If you notice your skin or your eyes turning yellow, you need
to go to the hospital
- If you start feeling nauseous or start vomiting, you need to
go to the hospital
- If you notice your belly becoming bigger or you have trouble
breathing, you need to go to the hospital
We wish you the best!
Sincerely,
Your ___ Team | ___ with a history of alcohol use disorder complicated by
withdrawal, hepatic steatosis, hypertension, tobacco use, and
GERD who presented with chest pain and flank pain found to have
hyperbilirubinemia and AST predominant transaminitis consistent
with alcoholic hepatitis.
TRANSITIONAL ISSUES
===================
[] Vaccinate for HBV
[] Will need EGD screening for varices as outpatient
[] Consider re-introduction of furosemide and spironolactone as
___ outpatient. This was held at discharge as patient with
unclear follow up due to his leaving prematurely
[] Will need intensive nutrition rehabilitation to manage his
alcoholic hepatitis
[] Patient counseled to avoid alcohol and should continue to
receive support for this | 306 | 99 |
11297219-DS-11 | 27,230,370 | Mr ___,
It was a pleasure treating you during this hospitalization. You
were aditted initially for a syncopal episode. You were found to
have an abnormal heart rhythm and had a pacemaker lead replaced.
You also experienced a heart arrhythmia known as ventricular
tachycardia. This arrhythmia likely caused an acute-on-chronic
injury to your kidney. You were started on both amiodarone and
mexilitine to control these abnormal rhythms. In addition, you
were found to have an exacerbation of your heart failure and
treated with diuresis to remove fluid. Your blood pressure was
quite high through out much of your hospital stay and we
adjusted your medications accordingly to control your blood
pressure.
Please Weigh yourself every morning, call MD if weight goes up
more than 3 lbs. Your weight upon discharge is 101.9 kg.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team | ___ year-old ___ man with a history of CAD s/p DES ___,
afib on coumadin, Systolic CHF with LVEF 35%, s/p ICD also with
CKD baseline Cr around 2.8 admitted for syncopal event.
# VT: History with corroboration from wife initially seemed
consistent with a vasovagal event. EKG at baseline, trops at
baseline, no new significant lab changes. Neuro consulted by ED
who also agreed with this assessment. Orthostatics negative and
patient had no events on tele in 24 hours of initial
observation. No additional testing was pursued given history.
However given presence of ICD, EP interrogated device on ___,
which revealed an episode of VTach, which degenerated into vfib
and then shock. Pacer was previously set at rate of 40 which was
increased to 50 on ___ by EP. On ___, when ___ was placed
for UOP monitoring, pt was found to have clots and required
placement of 2-way catheter by Urology. On ___, he had
worsening R flank pain. His ICD was adjusted to pace in ___ and
pt was placed on Dobutamin gtt for renal perfusion. He developed
multiple runs of sustained VT. During one such episode, a code
was called, and pt was transferred to CCU. In CCU, pt had
several episodes of VT, one of which terminated in ICD shock. He
was evaluated EP, who recommended DC Dobutamine which resulted
in improvement in his VT. He was transferred to the floor where
he had symptomatic 60-100 beat runs of VTach overnight. He was
transferred back to the CCU for monitoring and started on
lidocaine drip and switched him to mexilitine after numerous
runs of NSVT, these stabilized and he was transferred back to
___. He then went for a lead revision procedure to help control
his VTach. He tolerated the procedure well and his VTach
improved.
# Abdominal Pain: Patient described right sided flank pain
radiating to shoulder which is very similar to presentation in
___ where he described "left-sided lateral chest wall pain
extending to his mid-back". There is tenderness on exam
reproducible but without ___ sign. Troponins and EKG
completed in the ED at baseline. CXR negative for PNA as cause
of pleuritic type pain, no rib fractures seen. This has been an
ongoing issue for several years and already extensive work up
has been completed, see OMR and HPI for details. During
admission he had recurrence of symptoms but more localized to
paraspinal muscles and lat dorsi reproducible with palpation of
muscle consistent with muscle spasm related pain. Started on
standing tylenol and tizanidine with good effect. Celiac's ruled
out by tTg IgA, UA without blood to invoke kidney stones, LFTs
relatively normal. Prior upper endoscopy biopsy negative for
HPylori so Ag testing likely of low yield. Prior normal Renal
US, RUQ US and rib film during admission for similar symptoms so
did not repeat this work up. After reviewing workup, his pain
was felt to be related to constipation though unclear
precipitant to event. No recent narcotic use (did receive some
Oxycodone during admission for extreme back pain but
constipation started prior to narcotic). KUB completed and
showed large fecal load and without obstruction. No recent
abdominal surgeries (appendectomy ___ years ago). Given an
aggressive bowel regimen including Senna, Colace, Miralax,
Bisacodyl supp, Mag Citrate and Fleet enemas with good effect.
# ___ Chronic Kidney Disease: Stage IV with baseline Cr around
2.5-2.8. Admitted at baseline thought Cr up trended during
hospitalization which was that to be consistent with renal
disfunction secondary to hemodynamic changes. His bradycardia in
the setting of low EF was thought to cause to low effective
arterial volume and increased in renal venous pressures. His BP
in the hospital was labile, ranging from 180-90mmHg (systolic).
The change in renal function occured 3 days after admission with
no evidence of nephrotoxic meds or contrast exposure. His Cr
gradually downtrended to 1.9 on discharge.
# Chronic Systolic CHF: with LVEF ___ secondary to ischemic
cardiomyopathy. He developed evidence of decompensated diastolic
heart failure with hypoxia in the setting of monomorphic VT. His
repeat echocardiogram demonstrated improved left ventricualar
function from prior, with low normal RV function and moderate
pulmonary hypertension. In the past, right heart catheterization
has demonstrated elevated biventricular filling pressures,
suggesting that pulmonary hypertension may be secondary to CHF,
but suspect that untreated OSA is contributing. His response to
diuretics was confounded by development of urinary obstruction
from blood clots. His urinary output improved with relieved
obstruction. He was weaned from supplemental O2 following . He
was taken again for another right heart catheterization on this
admission which confirmed elevated filling pressures in both the
left and right heart confirming his heart failure. He continued
diursesis with furosemide and transitioned to torsemide PO.
Discharge weight 101.9 kg.
# Atrial fibrillation: Chronic, rate controlled and
anticoagulated. CHADS2 score of 4. Continued Coumadin,
Amiodarone at reduced dose per PCP, ___.
# Coronary artery disease: s/p DES to LCX in ___, most recent
cath ___ with 2VD. Continued ASA, pravastatin 80 mg,
carvedilol, hydral and Imdur.
# DM II. Chronic insulin dependent DM II, poorly controlled and
complicated. Last A1c 8.9%. Continued glargine and pre-meal
humalog | 143 | 878 |
10760122-DS-26 | 22,048,195 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were transferred to ___ because of worsening abdominal
pain. The pain was severe enough to wake you from sleep.
WHAT HAPPENED IN THE HOSPITAL?
- You had another diagnostic paracentesis performed which showed
an infection in your abdomen.
- You were given antibiotics to treat the infection and your
pain improved.
- You had a shoulder X-ray which showed that there was some
progression of the lytic lesion in the acromion of your left
shoulder.
- Your pain medications were increased to better control your
pain.
- You had another paracentesis performed to make sure that the
infection in your abdomen got better. This showed that the
infection is gone.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You should continue to take all of your medications as
prescribed.
- You can now start the chemotherapy medicine that was
prescribed previously.
- You should follow up with your doctors as ___ below.
- IF you notice the size of your belly increasing, call your
liver doctor to discuss increasing the frequency of your Lasix
or scheduling an appointment to have fluid taken off.
We wish you the best,
Your ___ Care Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ year old gentleman with history of HCV
cirrhosis (Child C/___, MELD 24) in the setting of HIV
coinfection, complicated by portal hypertension (rectal varices,
ascites, hepatic encephalopathy), and metastatic HCC with mets
to shoulder s/p resection and palliative XRT, who presented with
recurrent abdominal pain following recent admission for
RUQ/epigastric abdominal pain and refractory ascites s/p LVP. | 202 | 63 |
15192547-DS-13 | 23,602,940 | Dear Ms. ___,
It was a pleasure taking care of you a ___. You were admitted
for nausea and vomiting. We performed a work up to evaluate you
for an infection or a problem related to your surgery and
unfortunately we did not find any cause for your nausea and
vomiting but there does not appear to be any life threatening
condition that wound require immediate surgery or continued
admission. We gave you a medication called reglan for your
nausea and will send you home with a prescription for this
medication. While you were in the ___ we had the
gastroenterologist evaluate you and they perfromed a endoscopy
to look at you stomach and upper intestines. This was normal. We
scheduled you for a out patient gastric emptying study for
___ to further investigate your nausea and vomiting. In
preparation for your appointment on ___, please do not eat
or drink anything after midnight on ___. You should not take
any oxycodone when you get home. Please also stop taking your
Reglan on ___ night in preparation for your appointment on
___. You also had poorly controlled blood sugar. We
controlled you with a long lasting type of insulin. Please
continue your usual insulin dose at home but it is very
important you follow up with your primary doctor to improve your
blood sugar control. Elevated blood sugar can contribue to your
intenstinal symptoms. We also treated you for a thrush infection
in your mouth. This is caused by a fungus. Please use the
nystatin as directed.
Follow up: See your scheduled appointments below and please
follow up with your primary doctor as soon as possible. | This is a ___ year old female with a history of type two
diabetes, coronary artery disease, and systolic congestive heart
failure (Ejection fraction <25% in ___ who underwent a recent
left salpingoopherectomy (discharged ___ for an enlarged
adnexal mass. Now admitted with tachycardia and vomiting.
# Nausea and Vomiting: Initial concern for small bowel
obstruction although imaging was not consistent with this
diagnosis. Patient was found to have a large right sided fecal
load seen on her xray, which may explain some of her symptoms,
however her nausea and vomiting persited even after regualr
bowel movements. She had no infectious signs or symptoms and she
remained afebrile. Her symptoms improved with reglan but did not
completely resolve. Zofran was avoided due to a prolonged QT on
EKG. A endoscopy with gastroenterology was unremakable. She was
discharged home with a out patient gastric emptying study for
___ to further evaluate her motility. Her abdomen remained
tender but non-peritonitic. She was placed on an agressive bowel
regimen with bisacodyl, colace, senna, and milk of magnesium.
# Tachycardia and Chest Pain: The patient had consistently been
tachycardic on admission to 110-140. This tachycardia resolved
with hydration. The patient had chest pain while in the
emergency department and there was concern for ACS, she was
given nitro with complete resolution of symptoms. Troponins were
negative and an EKG was unchanged. The cardiology attending in
the emergency department felt that the patient was likely
experiencing demand ischemia in the setting of dehydration. Her
EKG does not meet Scarbossa Criteria for acute coronary syndrome
in a left bundle branch block. While inpatient and with IV
fluids here tachycardia and chest pain completely resolved. We
continued her home aspirin and home metoprolol.
# Urinary tract Infection: Positive urinalysis for infection.
The patient is completed her course of macrobid on ___
# Acute Kidney Injury: Baseline creatine is 1.0; currently 1.3,
which is likely in the setting of dehydration. During the
patient's hospitalization, fluids improved her creatitine back
to baseline of 1.0.
# Oral thrush: White inta oral exudtate. Thought to be thrush.
Unclear why a immunocompentant patient would develop thrush
unless diabetes is poorly controlled. Discharged with nystatin.
# Asthma: This is a chronic stable issue. We continued her home
Advair and albuterol.
# Hypertension: This is a chronic stable issue. We continued her
home isosorbide dinitrate, metoprolol, and valsartan
# Type Two diabetes: This is a chronic issue however during her
admission her blood sugars were markedly elevated. We placed her
on lantus and a sliding scale with good blood sugar control.
She will need close follow up for this issue. We did not
discharge her on lantus given concern for hypoglycemia when she
resumes her home insulin. | 276 | 462 |
18291850-DS-13 | 27,305,823 | Dear Mr. ___,
You were transferred to our hospital for evaluation of some
bleeding into your left thigh which had been progressing over
the past week. You were evaluated by our surgery team and there
was no reason to surgically fix this bleed. We monitored your
blood counts for a few days and they were stable. You are safe
to return home but you should probably be supported with a less
constricting ___ lift harness to prevent further trauma.
The following changes were made to your medications:
1. START LEVOFLOXACIN 750mg daily for ___ and ___. START FLAGYL 500mg three times a day ending in the evening of
___
Please continue all other previously prescribed medications | Mr. ___ is a ___ with mental retardation, previous CVA/TIA,
previous aspiration pneumonias who was admitted with a left
thigh hematoma which stabilized without intervention.
1. LEFT THIGH INTRAMUSCULAR HEMATOMA: He developed a hematoma
in the left obturator externus and adductor magnus muscles about
a week prior to presentation that was worsening. CT and plain
films in the ED showed no evidence of fracture. He was evaluated
by vascular surgery in the ED who felt no need for urgent
intervention. He was admitted for serial HCT, which were stable
over the next ___ hr. His caretakers suspect the hematoma was
incited by the straps of his ___ lift causing local trauma to
the left thigh. They purchased a different harness to alleviate
the problem. There was no suspicion for physical abuse. His
aspirin was continued due to multiple CVA/TIA in the past.
2. LEFT LOWER LOBE PNEUMONIA: A LLL consolidation was discovered
incidentally on CT ABD/PELVIS done to evaluate the thigh
hematoma. Because he was coughing more frequently, we chose to
treat a community acquired pneumonia as well as an aspiration
pneumonia with levofloxacin and flagyl. He was afebrile with
excellent oxygen saturations. | 116 | 199 |
13000142-DS-13 | 21,329,407 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted because your
liver doctor was concerned about your liver function. You were
started on a new medication called Imuran in addition to the
prednisone in order to control your liver disease. You liver
function numbers improved while you were here. Please continue
both of these medications.
Thank you for allowing us to participate in your care. | Impression: Ms. ___ is a ___ yo F with a history of asthma,
fibromyalgia who presents with acute severe hepatitis, most
likely ___ autoimmune hepatitis.
**ACUTE ISSUES**
# Acute severe hepatitis: Most likely ___ autoimmune hepatitis:
Patient initially presented to OSH 1 month prior with
transaminitis to 3000. Liver biopsy at that time was consistent
with autoimmune hepatitis and patient was initiated on 40mg
prednisone. This dose was confirmed with patient's pharmacy and
on visual inspection of the pills. She was referred to ___ for
persistently elevated LFTs to 1000. Repeat workup revealed
negative hepatitis serologies, normal immunoglobulin levels,
positive ___, negative anti-smooth muscle,
anti-liver-kidney-microsome antibody, HSV, and equivocal VZV.
RUQ u/s showed patent vasculature. Infectious work-up was
unrevealing. Patient continued on 40mg prednisone and started on
imuran 50mg daily. Her LFTs were downtrending at discharge.
# Diarrhea: Unclear etiology. Patient presented with reported 1
month history of diarrhea. It improved with cholestyramine
initially, but worsened when cholestyramine was transitioned to
ursodiol. C. diff was negative. Ttg-IgA also within normal
limits. Would recommend outpatient EGD and colonoscopy for
continued work-up.
# Pruritis: Most likely ___ hyperbilirubinemia. Initially
controlled with cholesytramine, which helped, but then
transitioned to ursodiol. Ursodiol discontinued when patient
developed increasing diarrhea and she was discharged with
cholesytramine.
**CHRONIC ISSUES**
# Asthma: Well controlled during hospitalization, particularly
in the setting of prednisone.
**TRANSITIONAL ISSUES**
- Patient initiated on Imuran 50mg in addition to 40mg
prednisone. Would continue monitoring LFTs for continued reponse
and prednisone taper.
- TPMT genotype pending at discharge
- Will need immunization for hepatitis B and hepatitis A
- Will likely need endoscopy and/or colonoscopy to evaluate for
causes of diarrhea, such as Celiac's | 74 | 271 |
16240694-DS-20 | 21,213,236 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for an exacerbation of your MS
in the setting of a pneumonia. You were treated for pneumonia
with antibiotics and for MS with steroids and you got better. At
discharged you felt much stronger and were discharged home.
It is important that you take all medications as prescribed, and
keep all follow up appointments. | Ms. ___ was admitted to the general neurology service for an MS
exacerbation. MRI brain and spine was performed, there were new
nonenhancing cord lesions at left C4 and right C5 levels. She
was started on IV solumedrol for a 5 day course (last two days
will be given at home). Her exam improved significantly with
steroids, and by day 3 she was able to transfer to chair on her
own. She was also found to have pneumonia, and was treated with
a 7 day course of levaquin, started here to be continued as
outpatient.
On the day of discharge, she was noted to be mildly tachycardic
(sinus), which resolved with 1L of IVF.
She was discharged home with home ___, and has close follow up
with Dr. ___. | 68 | 127 |
16073325-DS-38 | 22,449,598 | Mr ___,
You were admitted to the hospital with infection of your non
healing left great toe ulcer. Your infection and pain did not
improve with medications and antibiotics so we need to remove
the infected tissue in the OR. You needed to return to the OR
for closure of the stump after the infection improved. You are
now doing well and are ready to be discharge to rehab. Please
follow the instructions below to insure a speedy recovery.
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
LOWER EXTREMITY AMPUTATION
DISCHARGE INSTRUCTIONS
ACTIVITY
You should keep your amputation site elevated and straight
whenever possible. This will prevent swelling of the stump and
maintain flexibility in your joint.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until the incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage,
you may leave the incision open to air.
Your staples will remain in your stump for at least 4 weeks.
At your followup appointment, we will see if the incision has
healed enough to remove the staples.
Before you can be fitted for prosthesis (a man-made limb to
replace the limb that was removed) your incision needs to be
fully healed.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
YOUR VASCULAR SURGEON WILL DETERMINE WHEN/IF THE STAPLES ARE
READY TO BE REMOVED FROM YOUR STUMP! IF THERE ARE ANY
QUESTIONS ABOUT THIS, YOUR OTHER PROVIDERS SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
STAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT. | Mr. ___ is a ___ y/o male with dry gangrene of the left great
toe with osteomyelitis and nonhealing left heel ulcer with
persistent cellulitis on outpatient vancomycin p/w increased
left lower extremity erythema and pain concerning for worsening
infection. He was treated with IV antibiotics with some
improvement however required left BKA on ___ for definitive
source control.
# Acute on Chronic Left Great Toe Gangrene and LLE Cellulitis:
Patient recently admitted in late ___ where he was started on
vancomycin for planned 6 week course (due to end ___. MRI on
___ showed evidence of osteomeylitis of the distal phalanx of
the left first toe with dry gangrene on exam. Venous ulcer on
LLE with poor wound healing likely related to severe PVD. As he
was a poor revascularization candidate as there were no adequate
distal targets. While on the medicine service he was covered
broadly with Vancomcyin and Ceftazidime with mild improvement of
his LLE.
He remained hemodynamically stable and blood cultures returned
negative. Pain was controlled with oral dilaudid in the pre-op
period. He was evaluated by the Cardiology consult service with
assessment that he was moderate risk surgical candidate for high
risk vascular procedure however benefits of surgery outweighed
the risks. He eventually underwent left guillotine amputation
on ___ for source control. After we were confident the
infection was cleared, he was brought to the operating room for
closure on ___.
Post-operatively, patient did have a few episodes of hypotension
especially with HD and was started on midodrine with good
results.
Patient was seen by Cardiology post-operatively given his
complicated cardiac history who felt that patient was
progressing well. Patient worked with ___ who recommended rehab
and was discharged to rehab in stable condition on post
operative day 5 after the ___ closure. | 390 | 303 |
11618548-DS-11 | 27,759,027 | -Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
*It was a pleasure to have worked with you, and we wish you the
best of health.* | PSYCHIATRIC
#Depressive symptoms/Anxiety: On admission, patient was acutely
depressed in setting of long history of treatment-refractory
depression, with active suicidal ideation with plan (though
patient refused to specify plan details).
During hospitalization, we continued patient's home medications
of lamictal 250mg PO QD, seroquel 37.5mg QHS, modafinil 300mg
qAM, and fetzima 80mg PO QD. We stopped the patient's topamax in
setting of recent decreased appetite with weight loss.
Additionally, we added hydroxyzine PRN for anxiety, with poor
effect, which was then changed to seroquel PRN for anxiety with
fair effect. Given her difficulty with sleep and appetite,
mirtazapine 7.5mg was started. She was also started on Adderall
2.5 mg at 8am and 2pm. She did well with these medications. Also
given she did well with risperdal in the past, the seroquel was
changed to risperdal. The patient consented to ECT treatments
for management of her acute on chronic depressive episode. She
underwent 8 treatments, with good improvement in her mood and
appetite, as well as resolution of her active suicidal ideation.
On discharge, mood was "better", and mental status exam was
pertinent for bright affect.
Safety: The patient remained in good behavioral control
throughout this hospitalization and did not require physical or
chemical restraint. The patient remained on 15 minute checks,
which is our lowest acuity level of checks.
GENERAL MEDICAL CONDITIONS
#)Hypertension: Patient's HTN inadequately treated at home/on
initial presentation to the unit. Medicine was consulted, and
recommended atenolol 25mg PO AD, amlodipine 10mg PO QD, and HCTZ
12.5mg PO QD, with good effect while on the unit.
-Recommend f/u with outpt providers as clinically indicated
#)HLD: continued home statin
-Recommend f/u with outpt providers as clinically indicated
#)
-Recommend f/u with outpt providers as clinically indicated
PSYCHOSOCIAL
#) MILIEU/GROUPS
The patient was euthymic, and participatory in the milieu. The
patient was very visible on the unit and frequently had
conversations with her peers. She attended some groups. She
never engaged in any unsafe behaviors. The pt ate all meals in
the milieu, slept well, and cooperated with unit rules.
#) FAMILY CONTACTS
Family meeting was held with the patient's ex-husband and
daughter and was notable for discharge planning. They understand
and are in agreement with the current treatment and discharge
plan.
#) COLLATERAL We spoke with the patient's therapist and
psychiatrist, who both agreed with plan.
LEGAL STATUS
The pt remained on a CV throughout the duration of this
admission. | 97 | 386 |
17639084-DS-18 | 20,489,835 | ___ were admitted to the hospital with GI bleeding. ___ were
monitored in the intensive care unit. ___ required blood
transfusions and ___ required medication to support your blood
pressure. On further testing ___ were found to have bleeding
from ___ ileum and ___ had embolization to the vessel where the
bleeding was recurrring. Despite this, the bleeding continued
and the surgery team was consulted. ___ were taken to the
operating room for an exploratory laparotomy, and a resection of
the part of the bowel which was bleeding. Your hematocrit has
been stable and ___ have had no further bleeding. Your vitgal
signs have been stable. ___ were seen by physical therapy and
recommendations made for discharge to a rehabilitation faciity. | Ms. ___ is a ___ year old female with history of diastolic
heart failure, atrial fibrillation on aspirin, chronic MSK pain,
celiac disease, and multiple admissions for lower GI bleed with
negative EGDs and colonoscopies within the past month,
presenting with hemodynamically unstable active GI bleeding.
The patient presented with recurrent bright red blood per rectum
and dizziness. Previous workup during recent hospitalizations
had been largely negative. EGD demonstrated abnormal antral
mucosa but no obvious source of bleeding. MRE demonstrated
1.9cm infrarenal AAA with no small bowel mass or inflammation.
___ colonosopy limited by poor prep but no obvious bleeding
source.
The patient was admitted to the medical intensive care unit on
the evening of ___ after receiving 5 units pRBCs in the
emergency room. A GI consult in the emergency room recommended
CTA if hemorrhage recurred. ___ in the intensive care unit,
the hematocrit dropped from 27 to 16, massive transfusion
protocol was initiated, a stat CTA showed small bowel bleeding,
and the patient was taken for mesenteric angiography. ___ placed
a coil on the morning of ___. The patient was stable in the
intensive care unit for most of the day, however hct dropped
again in the evening (32 -> 20). The patient returned to
___, was intubated for airway protection, and further
coils were placed due to ongoing bleeding in the same vicinity
as prior. Unfortunately, due to collateral flow, hemostasis
could not be achieved by endovascular approach. The surgery
service was consulted and the patient was taken for a small
bowel resection on ___. At the time of transfer from MICU to
the OR (and onto surgical service), the pt had received 24 units
pRBCs, 10 units FFP, 4 units of platelets, and 4 units of cryo.
The operative findings were notable for multiple subcentimeter
and 2 cm small bowel masses
throughout the entire small intestine. Blood was noted
throughout the small bowel from the jejunum to the ileocecal
valve. Active hemorrhage was seen intraluminally via endoscopy
at the site of the coils and mesenteric hematoma in
the proximal jejunum. She had a 200 cc blood loss during the
procedure and was transported to the intensive care unit for
monitoring. After stabilization of her vital signs the patient
was extubated.
She was transferred to the surgical floor on ___. Her
hematocrit continued to be monitored and after it remained
stable, she was started on her sc heparin. She resumed clear
liquids. She did have a bout of bloody stool on ___ and
underwent a cat scan of the abdomen which showed a large amount
of extravasated contrast throughout the colon and terminal
ileum. The source of active extravasation is not identified.
She continued to have occasional episodes of bloody stool, but
her pa vital signs remained stable. No intervention was
indicated unless she had recurrent bleeding resulting in
cardiovascular instability. She was also reported to have
episodes of mild confusion which occurred mostly at night and
resolved with re-orientation. During her hospitalization, she
was noted to have swelling in her left upper arm. Because of
this, she underwent an ultrasound of her left arm which showed a
thrombus in the mid and distal left basilic vein. No additional
thrombus. Her arms were wrapped with ace bandages.
The patient was evaluated by physical therapy and because of her
physical status, recommendations were made for discharge to an
extended care facility where she can further regain her strength
and mobility. Upon discharge, she was tolerating a regular
diet. Her vital signs were stable with a hematocrit of 28. She
was voiding without difficulty. Of note, she was started on a 1
week course of ciprofloxacin for a urinary tract infection. The
course should be completed on ___. The patient was discharged
to a ___ facility on HD #10 in stable condition.
Follow-up appoinments were made with the GI, acute care service,
and recommendations made to follow-up with her cardiologist.
Anticipated lenght of stay at rehab: < 30 days
CHADS2 = 3. Pt had been on Coumadin in recent past, although
since her prior hospitalization Coumadin had been held due to GI
bleed. She had been taking 325 ASA daily in the days leading up
to this hospitalization.
Plan for anticoagulation given CHADS2 = 3. | 127 | 737 |
19045429-DS-12 | 24,622,757 | Mr. ___,
You were hospitalized due to concern for tuberculosis. You were
found to have pneumonia, you will complete a course of
antibiotics for community acquired pneumonia.
Please follow-up with pulmonary and your primary care physician
after discharge. We wish you all the best in your recovery.
Best wishes,
Your ___ team | Mr. ___ is a ___ male with past medical history of
PUD, CAD, hypothyroid, latent TB, who
presented with low grade fever and abdominal pain improved with
bowel movement during his visit in the ED. He was also noted to
have interval change on CT chest and given his history with
concern for latent TB and fever, he was admitted for r/o TB.
During his stay, he was unable to produce more than one sputum
for AFB/NAAT, which was found to be negative. He was continued
on Ceftriaxone IV daily and Azithromycin for three days while
hospitalized for community acquired pneumonia, and discharged
with oral Cefpodoxime and Azithromycin to complete a 5 day
course of antibiotics. He will follow-up with outpatient
pulmonary to reassess for further evaluation and repeat CT
imaging as outpatient with next pulmonary appointment. | 48 | 137 |
14083140-DS-22 | 23,537,797 | Dear ___,
___ were admitted with a viral infection that was complicated by
a pneumonia. ___ fortunately are not having issues with your
breathing and stopped having fevers once we started antibiotics.
___ will be able to continue to recover at home. Please continue
your antibiotic through ___.
It was pleasure to take care of ___.
Your ___ Team | Mrs. ___ is ___ female with a history of breast
cancer currently on weekly paclitaxel and trastuzumab presenting
with fever and severe cough suggestive of viral bronchitis with
bacterial pneumonia.
#Bronchitis
#Community Acquired Pneumonia
Patient presented initially with non-productive cough as her
family went througha could but then had significant fevers up
to 101.7. CXR cannot exclude pneumonia. She defervesced after
starting antibiotics but continued to feel and appear ill
prompting additional 24h of observation. To complete at 5 day
course of levofloxacin on ___.
#Breast Cancer: Will be seen in clinic on day after discharge to
evaluate whether OK to get next dose of chemotherapy. Underwent
radiation mapping while in-house on ___.
#T2DM: Held metformin in favor of lispro ISS
#Hypothyroidism: Continued on levothyroxin.
TRANSITIONAL ISSUES
===================
1. Antibiotic course of levofloxacin through ___.
35 minutes spent formulating and coordinating this patient's
discharge plan | 57 | 138 |
19800337-DS-3 | 21,535,326 | -Continue to slowly increase po intake as tolerated
-Please take Bactrim and Keflex daily as prescribed for ten
days.
-No heavy lifting or strenuous activity for at least one week
-Return to the clinic for follow up with Dr. ___ in
___ days | This is a ___ yo F who underwent right level II lymph node
dissection on ___. She was doing well at home but two days
later she developed worsening dysphagia and erythema of the
neck. She presented to ___ after 24 hours of these symptoms
(morning of ___ for evaluation. She was readmitted that day
for IV antibiotics. She was started on Levo/clinda but was
switched to cipro/clinda due to what appeared to be an allergic
rash to the Levofloxacin.
A CT scan of her neck revealed Post-surgical changes right upper
neck with foci of air and fat stranding most pronounced between
the sternocleidomastoid muscle and the submandibular gland and
extending medially to the parapharyngeal space with mild
narrowing of the hypopharyngeal airways. There appeared to be no
vascular injury and no abscess formation, and no evidence of a
prevertebral or retropharyngeal abscess.
She remained afebrile and her condition improved on IV
antibiotics over the next three days, with reduction of
aryepiglottic fold edema on FOE exam and improvement of her R
neck swelling/erythema.
She was discharged on po Bactrim and Kelex on ___ in stable
condition, and a follow up Dr. ___ was planned for the
next week. | 41 | 199 |
18313899-DS-2 | 24,467,969 | Dear Ms. ___,
Thank you for coming to ___!
Why were you admitted?
- You were admitted for worsening left hand pain and swelling
- You were found to have a left dorsal hand abscess and
cellulitis
What happened while you were ___ the hospital?
- You had an incision and drainage ___ the OR
- We gave you IV antibiotics for your infection
- We recommended that you stay for IV antibiotics, but you
declined. We switched you to two new oral antibiotics on
discharge.
- You had a normal chest x-ray at bedside
- We also recommended that you stay to have your hand swelling
monitored, since the pressure ___ your hand can increase
significantly and cause loss of pulse and sensation. This is
known as compartment syndrome. It is possible that you could
even lose your hand. However, you declined to stay for serial
surgery exam monitoring and accept this risk.
What should you do when you leave the hospital?
- It is important for you to continue taking these antibiotics.
We recommend that you take them until your hand surgery
appointment. They will tell you how long to continue them. We
have given you a two week supply.
- We recommend that you follow up with your PCP or ___ ___
clinic.
- We also recommend that you keep your hand wound clean and dry.
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team | Ms. ___ is a ___ female with history significant
for current active IV drug use who presents with several days of
worsening left hand swelling and pain, found to have left dorsal
hand abscess and cellulitis without features of sepsis, now s/p
OR I&D. She left AMA because she did not want to stay ___
hospital for IV antibiotics. She was evaluated by psychiatry who
felt she had capacity to leave. | 233 | 67 |
15228166-DS-18 | 25,014,197 | Dear ___,
You came to the hospital because you were having chest pain. All
your tests for signs of blood clots in your lungs did not show
any clots. You were started on heparin to thin your blood as we
were restarting you on Coumadin, but you left against medical
advance before your INR was at a safely thin level.
When you leave, it is important you find a primary care provider
to help with your blood disorder. You are at high risk of future
clots.
We wish you the best of luck,
Your ___ Care Team | ___ is a ___ year old male-to-female transgender with
an extremely complicated social history and psychiatric history
with medical history further complicated by history of
prothrombin mutation, ? seizures, PE ___, most recently ___
on V/Q scan in ___, chronic pain, who presented to the ED
for elevation of chest pain. Workup for serious etiologies
remained negative. Heparin drip was started with the goal of
bridging to Coumadin on discharge, though patient left AMA prior
to a therapeutic level. Anticoagulation on discharge was
deferred because of the patient's lack of safe follow-up
monitoring as outpatient and reported increased rates of falls
as an outpatient. She was encouraged to establish care with a
PCP and was given ___ number at discharge.
#Chest Pain
Unclear etiology. Reassuringly normal CXR, normal BNP, and
negative trop. While she is hypercoagulable and is non-compliant
to anticoagulation, no signs of PE. Most likely musculoskeletal
in nature. After extensive discussion, we let ___ know that
narcotics would not be an appropriate medication for her pain.
We discussed ___ alternative medications to which she
reports previous allergies, including NSAIDs and Tylenol, and
she deferred. We also counseled that pain management
consultation would not be necessary at this time, to which she
expressed
extreme frustrated, including requesting to fire her medical
team and to speak to the social worker. She ultimately left AMA
and expressed her motivation for this was lack of adequate pain
control.
#Hx of DVT
#Hx of Prothrombin deficiency
Per patient - her INR goal is 3.5. This was established by a
physician in ___ in the setting of HRT. Multiple MI,
strokes, and PEs per patient report. Has not been on
anticoagulation as an outpatient for several weeks as she has
run out. She does warrant life-long therapy in this setting, but
due to her difficulty obtaining primary care and the frequency
monitoring of Coumadin, a NOAC would be more ideal. Per patient,
she has had several strokes and PEs through this, though we do
not have records at this time to confirm. Does endorse abdominal
discomfort to lovenox and she deferred this. She was initially
started on a heparin drip for bridging with started heparin
7.5mg, but she left AMA prior to therapeutic levels.
#Threatening behavior toward staff
During stay, patient bit the phone cord and broke the phone and
continues to make threatening comments towards staff, including
threatening to strangle ucos and requiring security to come to
bedside. Also refuses majority of care, including physical
exams, PTT monitoring, and iron infusions. Multiple attempts
were made to form therapeutic alliances with her, though she
expressed ongoing frustration and anger due to lack of pain
control with narcotic medications.
#Frequent falls
Patient feels ___ to spine issue, no dizziness or pre-syncope
with this. Neuro exam was limited due to participation at this
time, but declines any bowel or bladder dysfunction. She
deferred ___ evaluation during her hospital stay
#iron deficiency anemia
Patient has a history of anemia with a hemoglobin baseline of 9.
She with hemoglobin of 7.7. No evidence of ongoing upper or
lower GI bleeds. Discussed this with patient and she refused
iron infusions, due to the belief it would make her at increased
risk of clotting. It was explained this would not increase her
risk of clotting, but she deferred treatment while in house
#Hx of seizure disorder
Patient had not taken this at home as she had run out of
prescriptions for this. Continued keppra 750mg while in house.
#Hormone therapy
At higher risk of blood clots I/s/o hereditary clotting disorder
and current smoking. This was discussed with ___, though she
said the risk of thrombosis was outweighed by the benefit of the
estrogen treatment. estrogen patches were non formulary, so
Estradiol PO 0.3mg twice a week were used and she was continued
on finasteride.
#Housing insecurity
A social work consult was placed, but the patient would not
discuss resources during this time.
I have seen and examined the patient and agree with the note by
the medical resident on the day she chose to leave the hospital
against medical advice.
TRANSITIONAL ISSUES
-==================
[] In the future, would defer anticoagulation initiation while
in house until patient has a safe plan for follow-up due to the
risk of unmonitored anticoagulation
[] Needs iron transfusion or PO for severe iron deficiency
anemia
[] Ongoing discussion around risk of estrogen therapy with
hypercoagulable condition | 93 | 711 |
13813803-DS-24 | 27,353,447 | You were admitted to the hospital with abdominal pain after
tripping on your G-tube and we were concerned that you might
have dislodged your G-tube, or worse, suffered a perforation.
We performed a G-tube sinogram and contrast was seen to enter
your stomach without difficulty. We restarted your tube feeds
which you tolerated well. You may need repositioning of your
G-tube by Dr. ___ in clinic. | Ms. ___ presented on ___ with abdominal pain and
increasing g-tube discharge since tripping on it three days
prior. She was admitted for observation and radiographic
imaging to rule out a gastric leak. She had no peritoneal
signs, and her abdomen had signs consistent with poor dressing
care with significant g-tube site discharge including
rash-appearing erythema.
She was made NPO with cessation of TF, placed on IVF, and given
intermittent dilaudid for pain control. She had a g-tube study
that indicated no free air in the abdomen, as well as passage of
20cc of contrast into the gastric body that extended into the
small bowel with no evidence of leakage. The g-tube appeared to
be well positioned per this study. Her TF was restarted which
she tolerated well without nausea or vomiting. Her rash nearly
resolved with proper dressing changes and wound care. She
continued to have abdominal pain at the site of granulation
tissue of the g-tube. She had persistent g-tube site discharge
well managed with dressing changes.
On the day of discharge, she was tolerating her TF and her pain
was well controlled. She was ambulating without assistance and
voiding freely. She will follow up with Dr. ___ at his
next available appointment in two weeks. | 69 | 218 |
18901084-DS-9 | 20,753,750 | Dear Mr. ___,
It was a pleasure taking ___ of you during this admission. You
were admitted for severe back and hip pain. MRI of your spine
showed some enhancement of your spinal cord, so we followed up
with an MRI of your brain and checked your spinal fluid. Both of
these were normal. The MRI of your hips was also normal. We
changed your pain medications by stopping your fentanyl patch
and starting you on a new medicine MS ___. Your pain
improved.
Please make the following changes to your medications:
-START MS ___
-STOP the Fentanyl Patch
-STOP Olanzapine
-DECREASE your Prednisone dose to 5mg every other day starting
___
Resume the other medications you were taking prior to this
admission.
Please remember to take your dexamethasone starting on ___
___ prior to starting chemotherapy. | Brief Course:
Mr. ___ is a ___ with history of metastatic NSCLC to
T-spine and adrenal who presents with back pain and bilateral
hip pain. | 129 | 25 |
16743676-DS-26 | 20,178,728 | Dear ___,
___ were admitted to ___ after a fall at home. The fall was
felt to be consistent with a mechanical fall. Evaluation with
CAT scan of head and neck showed no new abnormalities. ___ were
initially treated for a urinary tract infection, however further
evaluation showed that ___ had no infection.
It was also noted that your decubitus ulcer was unchanged.
Finally, your coumadin was temporarily held due to high levels
of INR.
___ were discharged to a skilled nursing facility with hopes of
improving your strength and ability to move around to prevent
further falls. This was discussed and decided upon with your
daughter.
The following changes were made to your medications:
Should ___ develop any symptoms concerning to ___, please call
the doctor on call and Dr. ___, ___. | ___ yo W w/ ___ Body dementia, Afib on coumadin, hx of frequent
UTIs and other chronic medical problems presents to ___ s/p
fall at home. She was found to have head laceration,
supratherapeutic INR, and a positive UA.
.
# Fall. Mechanical fall by history as there were no symptoms of
presyncope, no witnessed LOC and no systemic infectious
symptoms. Although she has a history of diagnoses of
asymptomatic UTIs in the past (Proteus, VRE) and was found to
have positive UA, it was unclear how much suspected UTI
contributed to her fall (see below). There was no clinical
evidence for seizure activity. Imaging evaluation in the ED
revealed no acute abnormalities. It appears that she has had
progressively more difficulty with safe ambulation, despite the
___ care at home with the family. After ___ evaluation and
discussion with her daughter, a decision was made to pursue a
short course of rehabilitation in hopes of having the patient
return to home with 24 hour care and improved gait/mobility.
# Head laceration: Pt with head lac s/p fall, stitches placed in
ED.
Remove stitches s/p 1 week.
# ? UTI. Positive UA and we were unable to ascertain any
symptoms. She was treated with CFTX empirically x 3 days. UCx
grew strep viridans, felt to be a contaminant from foley
placement, removed on admission. ABx were discotinued. Patient
had a low grade fever (___) that evening. UA was repeated and
was felt to be contaminated, UCx pending at time of discharge.
CFTX was discontinued on ___. Patient remained afebrile for
over 36 hours prior to discharge without clinical signs of UTI.
Should she develop sx of UTI or a fever, it is recommended to
repeat a UA and UCx and call her PCP, ___ at
___, ___.
# Afib on Coumadin. Initailly with supratherapeutic INR.
Coumadin was held and restarted on ___ at 5mg (INR 1.8). No
bridge was felt to be required. INR at time of d/c was 1.2,
coumadin was increased to 7.5mg on ___. INR increase prior was
felt to be due to ABx. Will need monitoring EOD and dose
adjustment.
# Coccygeal ulcer was approx 1.4 x 1 x 0.2cm with yellow wound
bed and moderate serous drainage with no erythema and the
dressing was intact despite urinary incontinence. Right gluteal
ulcer exhibited fresh epithelial tissue. Care as per orders in
discharge plan.
# ___ Body Dementia: continued on home risperdal and donepezil.
Of note, mirtazapine was recently started by PCP with some
improvement in sleep pattern. This may need further
optimization.
# ARF on CKD. Cr peaked at 1.5 and baseline 1.3. Likely due to
decreased PO intake and home lasix dose. Due to fever, lasix
was decreased to 40mg daily. Cr. returned to 1.1. She had mild
___ edema at time of d/c. She was discharged on home lasix at
80mg daily.
# Diastolic heart failure: Pt with mitral regurgitation that
worsened in severity between ___ and ___ on echo, but EF
remained >55%. Discharge weight was 143lbs.
- see above
# Seizure disorder. Stable. Patient continued on home phenobarb
and phenytoin
.
# Code: DNR/DNI | 133 | 551 |
13717469-DS-8 | 25,579,555 | Dear Mr. ___,
You came to hospital because you were having increasing swelling
and pain in your stomach.
While you were here, you had the extra fluid on your stomach
removed and had a feeding tube placed. You kept getting more
fluid in your stomach, so a permanent drain was placed in your
stomach to help drain it. You also were able to eat food by
mouth, so your feeding tube was removed. You also received
radiation to your cancer.
Because of your worsening cancer and worsening health, you were
discharged home with help from hospice.
When you leave the hospital, you should make sure to take your
medications as prescribed.
If you have any worsening abdominal pain, nausea, vomiting,
fevers or chills, please call you hospice care team to help
figure out the best plan.
It was our pleasure to take care of you, and we wish you the
best!
Your ___ Care Team | ___ yo male with a history of gastric cancer, Her2 not over
expressed, MSS, metastatic to peritoneum, admitted with
increasing abdominal pain and distension. Was initially
concerned for SBP, but culture negative and stable without
treatment. Had pleurx placed for comfort with continuing
drainage requirement and underwent 5 fractions of palliative
radiation to gastric outlet. Also temporarily had enteral
nutrition. Was discharged home with hospice care services.
Active Issues
========
#Abdominal Pain
#Ascites
The patient originally presented with signs and symptoms
concerning for SBP. Because of his abdominal pain, worsening
swelling, and leukocytosis, he was started on ceftriaxone
empirically. A diagnostic tap was done and the cell counts were
not consistent with SBP. Pt also had remained afebrile, appeared
clinically stable, and blood cultures remained negative, so
treatment was stopped. Pt also had a therapeutic tap, at which
time 3L were removed. The pt continued to have abdominal pain
and swelling, with worsening ascites, so for improved comfort, a
pleurX catheter was placed for daily drainage. The patient
required twice-daily drainage of fluid of ___ liters each
drainage. On discharge, the patient can do larger volume
removals once daily in the morning to improve comfort. His wife,
___, also received education on how to utilize the drainage
symptom and plans to continue to do so at home.
#Pain control
#constipation
Pt was experiencing pain prior to admission, but was not taking
his home dose morphine secondary to constipation and nausea. He
was originally transitioned to oxycodone 10mg q3h PRN pain and
morphine IV ___ PRN for breakthrough. Pallative care was
consulted and recommended fentanyl patches for longer acting
pain regimen. He was slowly titrated up from 12mcg/h to 25mcg/h
to 37.5mcg/hour with good response. He was continued on
oxycodone 10mg a3h PRN breakthrough pain. The patient also
experienced a great deal of pain relief with the pleurx drainage
as above. The patient was started on a bowel regimen of
scheduled miralax, senna, bisacodyl, and lactulose with daily
bowel movements and improved discomfort.
#Nutrition
Pt had experienced weight loss at home secondary to poor
appetite in the setting of increasing abdominal pain and
distention. He had also experienced gastric outlet obstruction
symptoms and had previous duodenal stent placement and repair.
In order to optimize nutrition, a NG tube was place at bedside
and advanced post-pyloric by ___. Nutrition was consulted and
their recommendation for tube feeds were followed. The tube came
out of place several times and started to malfunction later in
the course. After a meeting with the patient and his HCP ___,
it was decided to discontinue the tube feeds and encourage PO
intake with liquid supplements and not to place another tube.
The patient was discharged home able to tolerate PO intake.
#Stage IV Gastric Adenocarinoma
Pt diagnosed in ___ and has continued to progress in the
setting of treatment with FOLFOX and Ramucirumab/Taxol. Not
currently on treatment. His outpatient oncologist discussed
treatment options with patient throughout the hospital stay. The
patient wished to further pursue treatment at this point.
Radiation oncology was consulted for palliative radiation to the
tumor where it caused gastric outlet obstruction. The patient
received 5 fractions of radiation therapy ___,
___, and ___ without complication. The post pyloric feeding
tube was placed as above to optimize nutrition and was d/c'd
after it stopped functioning. A goals of care meeting was had
with the patient and his wife ___, and it was agreed that the
patient would be best cared for at home with home hospice care.
The pt hoped to utilize this service and eventually pursue
further chemotherapy, if his functional status improved. He was
discharged home with directions to call his oncologist as
needed.
#Social Issues
Pt is was without health insurance and had been using a bike to
get himself to and from appointments. Also has issues affording
medications at home. Social work, case management, and
palliative care helped to get patient hospice care on discharge
to help with nursing issues and supplies. Also, patient was
given extra supplies for his pleurx and plans were made for the
patient to be able to obtain medications, including fentanyl, on
discharge.
Transitional Issues
============
[]New medications: Fentanyl 37.5 mcg/h, oxycodone 10mg q3h PRN
pain
[]Stopped medicines: Morphine (replaced with oxycodone)
[]Pt had a pleurX catheter placed inpatient, which could
increase his risk of SBP. Careful monitoring should be done
[] Pt had severe nausea with morphine, avoid if possible in pain
regimens.
[]Pt did have severe constipation on admission, can add
lactulose to bowel reg if needed
[] Patient has Pleur-X catheter in place, and has the phone
number to call if he needs more supplies
CODE STATUS: Full code
EMERGENCY CONTACT HCP: ___ ___ | 148 | 760 |
12873065-DS-12 | 23,148,076 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with symptoms of back pain,
headache and urinary frequency. Based on a urine analysis and
blood tests you were found to have kidney infection
(pyelonephritis). You were treated initially with the antibiotic
ceftriaxone, though you will take ciprofloxacin when you go
home. An ultrasound of your kidneys showed that there was no
stone blocking your urinary tract, but there were small stones
in both your kidneys. We recommend that you see an outpatient
urologist because it is important to make sure that the
infection is cleared from those stones.
We also gave you a pain reliever for your headache, and this
improved by the time you went home.
Please continue your antibiotics through ___ and keep all
your follow-up appointments.
We wish you the best,
Your ___ Team | Ms. ___ is a ___ woman with a history of nephrolithiasis,
chronic headache and myofascial pain syndrome admitted with
pyelonephritis and worsening headache.
.
>> ACTIVE ISSUES:
# Acute complicated pyelonephritis: Ms. ___ was found to have
acute complicated pyelonephritis based on clinical presentation,
urinalysis, and renal ultrasound demonstrating bilateral renal
stones. She was treated with IV fluids and ceftriaxone and
transitioned to PO ciprofloxacin before discharge to complete a
10-day course. Patient urine culture grew pan-sensitive E. coli.
Her chills/rigors resolved and flank pain improved significantly
with antibiotics. For her pain, she did receive limited supply
of toradol and then was discharged with limited number of
ibuprofen.
.
# Headache: Patient presented with ___ headache. Of note, she
has a history of chronic headaches, but they are usually
intermittent and less severe. The pattern of pain was deemed to
be consistent with a tension-type headache and thought to be
triggered by active infection. Her headache was treated with her
home duloxetine, tramadol and tylenol with ketorolac as needed
for breakthrough pain.
.
>> CHRONIC ISSUES:
# Anemia: Patient was found to have a Hb of 9.6 which remained
stable during hospitalization. She mentioned that she has
chronic anemia, though our hospital has no records of previous
CBCs to confirm this. CBC was trended but otherwise no
intervention was performed.
.
# Myofascial pain syndrome: Patient has a history of myofascial
pain syndrome, with exacerbation of back pain early in the
hospitalization. This improved on her home medications plus
ketorolac, and she did not experience significant back pain at
the time of discharge.
.
>> TRANSITIONAL ISSUES:
# E. coli pyelonephritis: Urine cultures grew pan-sensitive E.
coli. Please continue antibiotics through ___ for 10-day
course. Patient will need a negative U/A to confirm clearance of
infection and should follow up in urology given bilateral kidney
stones.
# Anemia: Hb was stable at 9.7 at discharge. Recommend
re-checking H/H and pursuing anemia workup as outpatient.
# EMERGENCY CONTACT HCP: husband ___ ___
# Code Status: Full | 140 | 321 |
13139336-DS-19 | 27,693,760 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital with
gallstone disease. You were taken to the operating room and had
your gallbladder removed laparoscopically. During this
operation, there was concern for a retained bile duct stone and
so you underwent an ERCP to help open and clear your bile ducts.
You were started on a course of an antibiotic called
Ciprofloxacin which you will continue to take at home.
You were noted to have skin breakdown on your backside and a
medication called Santyl (collagenase) was ordered to help with
wound healing. You will have a Visiting Nurse come to your home
to help you with wound care.
You are now tolerating a regular diet and your pain is better
controlled. You are now ready to be discharged home to continue
your recovery. Please follow the discharge instructions below
to ensure a safe recovery at home:
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 a ___ y/o F w/ hx of HTN & seizure disorder who
presented to ___ with nausea/vomiting & abdominal pain x5 days
with decreased PO intake. Upon presentation to the ED, she
underwent CT Abdomen which noted diffuse gallbladder wall edema
with minimal peripancreatic fat stranding. She subsequently
underwent RUQ US which showed cholelithiasis but no gallbladder
distension or wall thickening. Labs were notable for
transaminitis. The Acute Care Surgery service was consulted and
recommended ERCP for gallstone pancreatitis. The patient was
initially admitted to the Medical Service and ERCP was
consulted.
On HD1, the patient was started on IVF, IV abx, pain medication
and anti-emetics as needed. Carbamazepine was continued for the
patient's known seizure disorder and home baclofen was ordered.
HCTZ was temporarily held as the patient was hypotensive on
presentation to her PCP's. The patient was noted to have a
Stage III Decubitus ulcer. A wound nursing care consult was
placed and santyl was applied to the wound.
The patient's LFTs continued to improve and there was the
possibility that she had passed a gallstone. MRCP revealed no
ductal dilation or choledocholithiasis, so no ERCP was warranted
at the time.
On HD2, the patient was taken to the operating room and
underwent laparoscopic cholecystectomy with intraoperative
cholangiogram (IOC). IOC was concerning for a small filling
defect within the distal CBD which may have represented a focus
of air, however a small stone could not be entirely excluded.
The patient tolerated the surgery well (reader, please refer to
operative note for further details). After remaining
hemodynamically stable in the PACU, the patient was transferred
to the surgical floor. ERCP was reconsulted and ___ the
patient had an ERCP with sphincterotomy and sludge swept. The
patient tolerated this procedure well. LFTs and lipase were
trended.
The patient was kept NPO after her ERCP and then diet was
advanced to regular which was well-tolerated. She was
prescribed a 5 day course of ciprofloxacin. The patient was
alert and oriented throughout hospitalization; pain was managed
with acetaminophen and oxycodone (although the patient reported
pain was well controlled without pain medication). The patient
remained stable from a cardiovascular and pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet, and
incentive spirometry were encouraged throughout hospitalization.
Patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 849 | 504 |
13312840-DS-23 | 22,083,147 | You were admitted to the hospital for a small bowel obstruction
related to a parastomal hernia which is next to your stoma. You
were given bowel rest and intravenous fluids and a nasogastric
tube was placed in your stomach to decompress your bowels. Your
obstruction has subsequently resolved after conservative
management. You have tolerated a regular diet, are passing gas
and your pain is controlled with pain medications by mouth. You
may return home to finish your recovery. The parastomal hernia
will need to be repaired and Dr. ___ like to do this in
the near future. Our office will be in touch with you to discuss
this.
You should continue to care for the stoma as you have been at
home. Please wear the stoma belt provided to you by the wound
ostomy nurses. ___ is important to continue the pyoderma
treatment you were doing prior to admission. There is a new
steroid ointment that should be applied to the ulcers next to
your ileostomy when you change your ileostomy appliance.
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.
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! | The patient was admitted to the colorectal surgery service for
management of small bowel obstruction secondary to a parastomal
hernia. He presented with abdominal pain, nausea/vomiting, and
cessation of ostomy output. CT imaging showed small bowel
obstruction with transition point in the parastomal hernia. He
underwent placement of an NGT in the ER for decompression and
manual reduction of the hernia in the ER. He was admitted to the
surgical floor and treated conservatively with NGT, IVF, and
bowel rest. He was closely monitored with serial abdominal exams
and manually reduced once more for recurrent incarceration with
worsening abdominal pain. On HD2, he started having stool per
ostomy and increased NGT output, with improvement in his
abdominal pain and tenderness on exam. He was bolused with
fluids as needed given high NGT output to maintain adequate
urine output. On HD3, he had flatus per the stoma and felt
significantly improved. His NGT was clamped then removed after
the clamp trial was tolerated well. He was started on clear
liquid diet, which he tolerate well, then advanced to regular
diet on HD4. He ambulated and voided appropriately. He was
afebrile and hemodynamically stable throughout his stay. He
additionally was noted to have erythema around his stoma, for
which he was seem by dermatology and had a kenalog injection
performed for pyoderma gangrenosum prior to discharge. He will
be seen in follow up in colorectal surgery clinic in ___ weeks. | 245 | 239 |
19360345-DS-17 | 23,667,399 | Dear Ms. ___,
You were admitted to the hospital for management of abdominal
pain. You were found to have acute gangrenous appendicitis. You
underwent an open ileocectomy. You are at risk of developing an
intraabdominal abscess, so please beware of any fevers or
abdominal pain.
You will be discharge with 4 more days of antibiotics. Please
take as directed.
Please refer to the following directions below regarding
post-operative management.
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:
___ services will be provided to manage your abdominal wound.
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Staples will be removed at your follow-up appointment.
Sincerely,
___ acute care surgery | Patient underwent diagnostic laparoscopy, open ileocecectomy for
gangrenous appendicitis, resection of mesenteric nodule, and JP
drain placement. Pathology report of surgical specimens
identified necrotizing appendicitis with perforation,
unremarkable colon and small intestine. Specimen labeled
mesenteric nodule consisted of encapsualted fat necrosis,
consistent with infarcted epiploic appendage. Please see
operative note for further details regarding the operation.
Post operatively, patient received 500cc fluid bolus x2 for low
urine output. She was started on IV Cipro/Flagyl. On POD2, NGT
and foley were removed. On POD3, patient was triggered for low
urine output and a foley was replaced for close urine
monitoring. Urine output was adequate and foley was removed the
following day. On POD6, she had flatus and she was given sips.
On POD7, she was noted to have a elevated WBC (13.6-18.4). UA
and Urine culture were negative. She was also noted to have
bilateral leg swelling and left upper arm swelling (IV site).
She has history of left leg swelling ___ chronic lymphedema. She
underwent noninvasive venous duplex studies of bilateral lower
legs and left arm, which were all negative for deep vein
thrombosis.
By POD8, she was having bowel movements and her leukocytosis was
resolving (18.4-16.7). She was advanced to regular diet and
transitioned to PO Cipro/Flagyl. However, she had an episode of
bilious vomiting at dinnertime. She was transitioned back to
clears. On POD9, her leukocytosis continued to decrease (WBC
16.7-15.8). On POD 10, she was given a regular diet which she
tolerated with no complications of nauseas, vomiting, or
abdominal pain. JP drain was removed as output was minimal for
multiple days. At time of discharge, she was tolerating regular
diet, having normal bowel movement, and ambulating. She
understood the risks of developing an abscess after a perforated
gangrenous appendix and is aware of concerning signs and
symptoms. She was discharged on 4 more days of PO Cipro/Flagyl
to complete a 2 week antibiotic course. She was arranged ___
services for midline abdominal wound (moist-to-dry) and close
follow-up in ___ clinic. | 342 | 335 |
17240150-DS-12 | 28,873,125 | You were admitted to the hospital after you were punched in the
jaw. You sustained a fracture to your mandible. You were taken
to the operating room to have it repaired. Your vital signs
have been stable. You are now preparing for discharge home with
the following instructions:
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Showering: You may shower ___ days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help. | The patient was admitted to the hospital after he was punched in
the jaw. Upon admission, he was made NPO, given intravenous
fluids, and underwent imaging. The patient was reported to have
fractures through the body of the mandible on both sides with
displacement on the right. The patient was taken to the
operating room on HD # 2 where he underwent an ORIF of he left
and right manibular fractures. His operative course was stable
with a 100 cc blood loss. At the close of the procedure, a
drain was placed. The patient was extubated after the procedure
and monitored in the recovery room.
His post-operative course has been stable. He resumed a full
liquid diet. His vital signs have been stable and he has been
afebrile. His surgical drain was removed prior to discharge.
The patient was discharged home on POD # 2. He will continue a
full liquid diet for ___ weeks, per OMFS. He will be discharged
on peridex mouth rinse and 1 week of keflex, per OMFS. He will
follow up with OMFS. This was communicated to the patient prior
to discharge. | 680 | 198 |
Subsets and Splits