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
|
|---|---|---|---|---|---|
16936839-DS-26 | 24,966,826 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital for medical
and surgical management of your small bowel obstruction. After
your original surgery to fix your mechanical obstruction, you
were unable to tolerate food by mouth due to slow emptying of
your stomach. You required nasogastric tube placement to help
decompress your abdomen. You underwent placement of a GJ
Feeding Tube due to your continued inability to tolerate an oral
diet. You were started on tube feedings to provide you with
nutrition.
You are now ready to be discharged to a rehabilitation facility
to continue your recovery. Please follow the instructions below
to ensure a safe recovery while at home:
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. | Mr. ___ admitted to the ___ service from the Emergency
Department on ___ following his original workup that was
most concerning for a small bowel obstruction. Initial CT
imaging was complicated given the uncertainty surrounding his
previous abdominal surgeries in the 1980s. Conservative
management was first started and the patient was made NPO,
received IVF and had a NGT placed for bowel decompression.
Nasogastric decompression originally put out 1.5 L of feculent
appearing liquid upon placement. A Foley catheter was placed to
monitor his urine output in order to optimize his hydration
status. Given Mr. ___ complicated neuropsychiatric history,
he was unable to provide any information about his past medical
history but remained pleasant throughout his stay.
On HD#2, Mr. ___ was brought back to the OR and underwent an
Exploratory Laparotomy, an extensive 2.5 hour Lysis of
Adhesions, a Stricturoplasty of what was expected to be his R-Y
Duodenojejunostomy and removal of an impacted bezoar just
proximal to the DJ anastomosis. For further information
regarding the procedure, please refer to the operative note by
Dr. ___ in the ___. Post-operatively, Mr. ___ did
well; his NGT was removed on POD#2 and he was started on sips.
However, on POD#4, he experienced increased abdominal distension
and large volume bilious emesis requiring replacement of his
NGT. On POD#5 and #6, Mr. ___ continued to have large volume
bilious emesis and underwent CT Scans of his abdomen and pelvis
on both days. CT imaging on POD#6 demonstrated contrast from the
previous exam moving through to his colon.
Over the next several days, Mr. ___ demonstrated intermittent
return of bowel function with large bowel movements, despite
continued episodes of bilious emesis requiring continued NGT
decompression. He self-removed several NG Tubes over the course
of his stay. On POD#6, he was diagnosed with a large, RUL
Pneumonia and he was started on a 7 day course of Vancomycin and
Meropenem (considering his antibiotic allergies) via a Left
Sided PICC Line. Imaging on POD#6 also demonstrated a large,
partially rim enhancing fluid collection in his LLQ which was
subsequently drained by ___ on ___ following logistic and
sedation issues required for drain placement. Cultures and gram
stains demonstrated no bacterial etiology. Mr. ___ remained on
his antibiotics for his pneumonia and serial CXR demonstrated
improvement.
Despite repeated episodes of bilious emesis and
self-discontinuation of NG tubes, Mr. ___ also continued to
have bowel movements 1 week out from his surgery. There were no
additional radiologic findings to support a continued mechanical
obstruction and it was thought that Mr. ___ partial
obstructive symptoms were secondary to severe gastroparesis. Due
to his history of ___ Disease and his additional
neuropsychiatric complications, conventional dopaminergic
prokinetic agents like Reglan were unable to be used, and he was
started on IV Azithromycin in an attempt to stimulate foregut
peristalsis. TPN was started for his moderate nutritional
deficiency.
On ___, a Dobbhoff Nasojejunal Tube was placed under
fluoroscopy and Osmolite Tube Feeds were started shortly
thereafter. Tube feeds were eventually switched to Jevity 1.5
as the patient had loose bowel movements with osmolite. Mr. ___
tolerated the tube feeds at goal but accidentally pulled out his
Dobbhoff. His abdominal clinical exams continued to slowly
improve. ___ was consulted who placed a GJ Feeding Tube under
moderate sedation on ___ and he was started on tube feeds
again on ___. The GJ tube later clogged and was replaced by
___ on ___. The patient's TPN was discontinued and his PICC
line was removed.
On ___, Neurology was consulted for recommendations
regarding restarting the patient's home management of AEDs.
Neurology recommended starting Ativan 0.5mg q8h standing as
bridge while NPO, resuming gabapentin once able to take enteral
medications (started at 800mg TID, then after 3 days, go up to
1200mg TID for 3 days,
then up to 1800-1200-1800mg TID (home dose)). The patient
received scheduled Ativan, but it was held due to patient
somnolence, and Neurology said it was ok to discontinue on
___. After holding Ativan, the patient's mental status
returned to baseline. Psychiatry was also consulted and
recommended that the patient discontinue home clozapine due to
his recent bowel obstruction. Psychiatry recommended he receive
seroquil 12.5mg prn agitation.
During the patient's stay, he received subcutaneous heparin to
prevent blood clots. Once tolerating a diet, home warfarin was
resumed for atrial fibrillation. At the time of discharge, the
patient was doing well, afebrile and hemodynamically stable.
The patient was tolerating tube feeds, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions. | 417 | 768 |
14671276-DS-86 | 20,741,784 | Dear Ms. ___,
You were admitted to the hospital for fever and found to have a
bloodstream infection. You were evaluated with blood work and
imaging to identify the source of the infection. The most likely
source of infection was your port-a-cath. We kept the
port-a-cath in place to administer IV antibiotics and treated
the port itself with antibiotics as well. We monitored your
blood for bacteria and it became clear on ___. We then
completed your course of antibiotics for 13 more days. Since
your blood likely became infected from accessing your port at
home for Demerol, we recommended switching to a different
medication for your pain that you can take by mouth. We
therefore started you on oral Dilaudid pills. Your port was
removed by your surgeon given the risk for infections in the
future.
We also made several other changes to your home medication
regimen.
For your pain medication, you must not take Demerol any longer.
We gave you prescription for a month long taper of dilaudid, to
last until you find a new primary care doctor.
We started you on a long-acting benzodiazepine called Klonopin.
You should keep taking 0.5mg twice a day for 2 weeks, then take
0.25mg twice a day for 2 weeks, in order to taper off of
benzodiazepines. You can then stop this medication. We did not
give you a prescription for lorazepam since you have this at
home; take ___ pills of lorazepam as needed only for very severe
anxiety, since you will need to taper off this medication as
well. We started you on a medication called Wellbutrin to take
once per day to help with anxiety. It is very important that you
take these medications as prescribed. There are significant
risks to stopping benzodiazepines without a taper including
seizures and death. Please discuss any medication changes with
your primary care doctor and please see a physician before you
run out of any medications.
Your buttock abscess was monitored by the surgery team, who also
changed your wound VAC as needed. You were seen by the plastic
surgery team, who you will follow-up with in clinic.
It is very important that you have a primary care doctor to
continuing prescribing medications and to monitor you due to the
medication changes we've made in the hospital. You should
contact ___ for a new primary care physician, if you
don't have one there already. We will continue to work on
finding a physician for you here at ___ at
___, but please contact ___ on ___ and ask for a
new physician in the event that we are unable to find a primary
care physician for you.
Please return to the ED if you have fever >101, shaking chills,
redness or drainage around your port site.
It was a pleasure caring for you!
Your ___ Care Team. | Ms. ___ is a ___ y/o female with chronic abdominal pain,
narcotic dependence, benzodiazepine use, gastoparesis s/p G-tube
placement, atypical chest pain, osteoporosis, depression/anxiety
and chronic open R buttock abscess s/p multiple I&D and VAC
placement who presents with fever to 103, found to have
enterococcus bacteremia.
# Bacteremia: The patient presented with fevers to ___ at home
with chills. Vital signs on presentation were notable for a temp
of 100.9 and HR 123. ___ blood cell count initially normal at
7.8. Pt was initially started on empiric cefepime and gentamicin
in the ED. The patient's R buttock abscess was considered a
possible source of infection, however only mild redness was
noted on exam and was felt unlikely to be the cause of fevers
per surgery team. On presentation she had a left-sided
port-a-cath (in place for many years), which was concerning for
line infection, especially as the patient's husband accesses the
port at home. ROS with no localizing signs of other infection.
Patient was continued on cefepime and started on clindamycin
initially on the floor. Blood cultures drawn in the ED grew
enterococcus, which was felt to be due to port infection. ID was
consulted. CT abdomen and LUE ultrasound did not reveal any
obvious source of infection. The patient's had a documented
history of red man syndrome to vancomycin, however chart review
revealed the patient had received vancomycin during a recent
hospitalization without issue. She was started on a slow
infusion of vanc, but developed an allergic reaction with hives.
The vanc was discontinued and she was treated with Benadryl. Her
symptoms resolved. ID recommended starting daptomycin with
daptomycin-heparin locks for her port-a-cath. TTE to rule-out
endocarditis was negative. The surgery team recommended not
removing the port, given her history of poor peripheral access
and need for continued IV antibiotics. Surveillance blood
cultures were drawn daily. Her blood cultures cleared on day 4
(___). She was continued on daptomycin for a 14-day course.
With her history of inappropriate access of the port-a-cath at
home for intravenous administration of a medication prescribed
IM by a non-trained individual (the patient's husband), there
were no alternative IV access options for discharge home or to
another facility to receive antibiotic treatments. The patient
therefore remained in the hospital to complete her antibiotic
course. She remained hemodynamically stable and afebrile
throughout this period. Her left port-a-cath was removed on
___ due to patient preference and risk for future infection.
# Chronic Pain/Narcotic abuse:
She has a ___ year history of multiple abdominal surgeries,
several bowel obstructions, ischemic colitis, cholecystectomy,
appendectomy, hemorrhoidectomy, TAH/BSO, and colostomy. She has
also previously been on TPN as well as tube feeds and still has
a
gastric tube in place, although this is specifically used for
venting now.
Her narcotic tolerance has increased to the point of high doses
of both benzodiazepines and narcotics have been prescribed on an
outpatient regimen.
At home, the patient self-administers a significant amount of
Demerol via her port-a-cath (equating to approx. 30mg IV
morphine Q2H). This was prescribed to her as an IM medication by
her previous PCP (Dr. ___. On admission, the patient was
placed on IV dilaudid 2mg Q2H on the floor given her significant
opioid requirement at home and initiation of this dosing regimen
in the ED per a protocol from ___. She was also continued on
Ativan 2mg Q2H (home dose of ___ Q6H), which was also started
in the ED. She was then tapered to Q4H without signs of
withdrawal, and in the final days of her hospital stay was
taking only 2 doses of lorazepam per day, in addition to
clonazepam 0.5mg BID. Chronic pain was consulted and recommended
continuing IV Dilaudid initially on admission. Psychiatry was
consulted regarding Ativan dosing and recommended not exceeding
home dose of 16mg daily. A detox program was strongly
recommended to the patient on several occasions, however the
patient consistently refused this option. After multiple
discussions with the patient, she agreed to transition to an
entirely PO pain medication and benzodiazepine regimen with a
long-acting benzo with plan to taper off both medications at
discharge. This decision was reached in consideration of the
fact that a new primary care physician would not continue
prescribing IM Demerol. The patient was started on Cymbalta 30mg
daily, however this was discontinued after the patient developed
a headache she attributed to this medication. She was then
started on Bupropion XL 150mg daily. On ___, the patient's
Ativan was changed from IV to PO at the same dose and frequency.
The following day, she was started on PO Klonopin 0.5mg BID and
her Ativan was changed to 2mg Q6H per psychiatry. On ___,
She was transitioned to PO dilaudid 10mg Q3H:PRN with IM 2mg for
breakthrough per chronic pain recommendations. The patient
reported stomach upset with the PO dilaudid, which she has
experienced in the past. Several options of managing this were
trialed including co-administering with food, anti-emetics, and
tums, however the patient refused most PO dilaudid doses. She
also refused all other options for oral pain medications and/or
patches. She was made aware that she would not receive a
prescription for IM dilaudid at discharge. We also discussed our
concern for opiate withdrawal if the patient refuses PO at home.
As the patient stated she has a "6 month supply of Demerol at
home" she was instructed NOT to continue taking this medication
and was advised of the risks of taking PO dilaudid in addition
to Demerol. She acknowledged understanding of these risks. A
taper for Klonopin of 0.5mg BID for 2 weeks, followed by 0.25mg
BID for 2 weeks was agreed upon. A Dilaudid taper was as
follows: 8mg PO Q4H x 3 days, then 8mg PO Q6H x 3 days, then 8mg
PO Q8H x 21 days, for total 30 days. She accepted prescriptions
of PO Dilaudid, Wellbutrin, and Klonopin at discharge. The risks
of stopping benzodiazepines abruptly were discussed with patient
and she acknowledged her understanding.
# Psychosocial Issues: During the patient's previous
hospitalization in ___, the patient's husband brought
meperidine into the hospital and was found at her bedside
appearing to be in the process of injecting into her port. He
was asked to leave the premises and was not permitted to return.
The patient's PCP, ___, terminated his care due to
this event. He prescribed the patient a 1 month supply of
medications while she sought out a new PCP. Several
multidisciplinary meetings were held during the present
hospitalization to discuss the visitation rights of the
patient's husband. As the steps taken in ___ were carried out
with appropriate measures in order to preserve the safety of the
patient, the case was not reviewed per the husband's request. It
was decided that he would be allowed one 30 minute visit daily,
on weekdays only, supervised by security. He did not take
advantage of this opportunity during this admission. Please see
documentation by Dr. ___ in ___ on ___ for full
details.
# Primary Care follow-up: The patient's former PCP, ___
___, terminated his care of the patient as of ___
due to the events described above. He provided her with a 1
month supply of Demerol and Ativan while she found a new PCP.
During the present hospitalization, the patient disclosed that
she had not yet found a new PCP. She did allude to a possible
new physician at ___, but refused to provide the
physician's name. We reached out to leadership at ___
___ in order to secure a new PCP for the patient, however
since the patient reported a 6-month supply of Demerol at home,
no physician would be comfortable taking on this patient and
continuing to provide opiates. This issue was discussed with the
patient and she agreed to follow-up with a PCP at ___.
# Abscess: The patient was s/p bedside I&D on ___ with VAC
placement. Pt evaluated by surgery in the ED. She was maintained
on a VAC to suction, which was changed by surgery every 3 days.
Her wound was debrided at the bedside on ___. Plastic surgery
was consulted for possible wound closure. The patient opted to
maintain the wound VAC and follow-up in plastic surgery clinic
as an outpatient. Dr. ___ agreed to act as "primary
physician" in order to obtain home ___ services for wound VAC
maintenance.
# Hx of potassium disturbances: Patient with history of both
hypokalemia and hyperkalemia during previous admissions. Last
admission with normal K and K of 3.7 on current presentation.
Electrolytes were monitored daily without need for repletion.
# Osteoporosis: The patient was continued on home calcium
supplements. | 479 | 1,441 |
17921490-DS-13 | 20,970,998 | You were admitted to the hospital with abdominal pain. An
abdominal CT scan was suggestive of possible intra-abdominal
infection, therefore, antibiotics were initiated. Your pain
subsequently improved. Additionally, your blood sugar levels
were elevated and you were evaluated by the ___ who
managed your insulin regimen while in house and have provided an
increased sliding scale. You are now preparing for discharge to
home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | The patient was admitted to the ___ surgical service on
___ with complaints of left upper quadrant abdominal
pain beginning last week with associated fever to 101.9; WBC
12.2 on admission. The patient denied chills, nausea, vomiting
or change in bowel habits. An Abd/Pelvic CT was obtained in the
ED suggesting 'mild stranding surrounding soft tissue thickening
subjacent to the left abdominal wall, extending to the greater
curvature of the stomach, minimally changed since ___ with resolution of previous abscess seen along greater
curvature of stomach.
While in house, he was inititally given intravenous levofloxacin
and metronidazole, which was transitioned to an oral regimen on
hospital day 2. His pain improved , white blood cell count
decreased to 8.1 and Tmax was 100.9 during his admission.
Additionally, the patient's blood sugars were elevated during
admission to 280s on HD1. ___ was consulted with
recommendations for increasing the patient's sliding scale while
in-house and upon discharge and keeping his glargine at 32 units
q HS; pt had not received his glargine the night of admission
accounting for some elevation in blood sugar, however, he did
remain in the 200s the following day after receiving his usual
dose. Also, metformin had been held for 48 hours following Abd
CT and was resumed upon discharge; he was maintained on a
diabetic/ consistent ___ diet upon discharge.
He was discharged on HD3 with a 2 week course of antibiotics and
follow-up scheduled with Dr. ___ next week. Following
discharge, his urine culture was finalized with yeast
10,000-100,000 organisms/mL. Pt was without complaints of
urinary symptoms, however, the patient was contacted and asked
to follow-up with his PCP ___ ___ days of discharge for a
repeat U/A and also any further management of blood sugars,
which he agreed. Additionally, the patient was encouraged to
follow-up with the ___ clinic within ___ weeks. ___ was
contacted to request appointment; pt was encouraged to call
scheduling contact number if he had not received a phone call
within 24 hours, which he agreed. | 291 | 346 |
14435214-DS-10 | 26,195,506 | Dear Mr. ___,
You were admitted to the hospital with a small bowel
obstruction. You have done well, and are now prepared to
complete your recovery outside the hospital, with the following
instructions:
ACTIVITY: Please try to remain active, and ambulate multiple
times per day.
DIET: Regular diet
MEDICATIONS: Take all the medicines you were on before. Please
be sure to follow-up as scheduled with your PCP for measuring
your INR, as you take coumadin. You have an appointment to have
your INR checked at the ___ on
___.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
Please call the ___ to make an appointment with Dr.
___. The number is ___. This is very important. | Mr. ___ was admitted to the ACS service for a small bowel
obstruction. He initially was admitted to the surgical floor
with a nasogastric tube in place, on IV fluids, and given IV
forms of his essential home medications, except for coumadin,
which was held.
He expressed significant improvement in pain and passed flatus
as well as had a bowel movement by HD#2. His NGT was removed,
and his diet was slowly advanced. He tolerated this very well.
He continued to pass flatus and have bowel movements, and
expressed having no abdominal pain.
At the time of discharge, he was tolerating a regular diet,
having no pain, and passing flatus. He expressed feeling well to
complete his recovery outside the hospital. He was discharged in
good condition with instructions to follow-up with Dr. ___ in
2 weeks. He was also set up with an appointment to have his INR
drawn at his usual Vanguard ___ clinic on ___. | 133 | 157 |
19827931-DS-10 | 27,817,804 | You were admitted to the hospital with right lower quadrant
pain. You underwent an ultrasound and you were reported to have
a dilated appendix. These findings were consistent with
appendicitis. You were taken to the operating room to have your
appendix removed. You are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Mr. ___ is a a ___ who presented ___ with a 12hr
history of abd pain initially epigastric localizing to RLQ.
Associated with nausea, chills, anorexia. ___ any vomiting.
Has been passing flatus. Did have some urinary hesitancy this am
but otherwise ___ any dysuria, hematuria. ___ any
diarrhea, bloody stools, or recent weight loss. Last meal was
dinner the preceding night. Abd ultrasound done at admission
showed a dilated, noncompressible appendix, up to 14 mm in
diameter, with surrounding free fluid, highly suggestive of
acute appendicitis. After informed consent was obtained, the
patient was taken to the OR for laparoscopic appendectomy.
Surgery and postoperative course were uncomplicated. Following
surgery the patient was admitted to the floor overnight for
observation. His diet was advanced and he tolerated this well.
He was able to void without issue, ambulate normally, and
tolerate diet. On ___ when he met appropriate criteria he was
discharged home with instructions to follow up in clinic
postopertatively in ___ weeks. | 831 | 163 |
10611631-DS-20 | 29,734,324 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with vomiting blood. You
were seen by the gastroenterologists and had an upper GI
endoscopy which did not reveal a source of bleeding. It is
important that you continue to take your protein pump inhibitor
twice daily. Your blood counts were followed and remained stable
although you are anemic. It is important that you follow-up
with Dr. ___ to resume iron infusions.
In terms of your abdominal pain, please follow-up with surgery
as previously arranged.
We wish you the best,
Your ___ Care team | Ms. ___ is a ___ woman with history of DVT/PE not on
anticoagulation due to bleeding, history of lupus anticoagulant
positivity, celiac artery stenosis, iron
deficiency anemia, previous admissions for upper GIB now
presenting with hematemesis and abdominal pain. | 104 | 38 |
15956700-DS-18 | 21,800,902 | Dear Mr. ___,
You were admitted to the hospital with concern for worsened
confusion, which can be a result of your liver disease. We did
not find any signs of infection or bleed. Your confusion was
likely due to not taking enough lactulose.
With more lactulose, you had some bowel movements and your
mental status improved, and we feel you are ready for discharge.
It is very important that you take all your medications as
prescribed, and to take enough lactulose to have ___ bowel
movements per day.
Please call a doctor if your confusion returns or worsens, if
you notice any blood or black color in your stools, if you have
fevers or chills, or for any other symptoms that concern you.
Thank you,
Your ___ Care Team | Mr. ___ is a ___ year old male with a history of HBV cirrhosis,
listed with MELD 18, portal vein thrombosis, and CKD who
presented with a confusional state consistent with past episodes
of hepatic encephalopathy. With lactulose and bowel movements,
his mental status cleared and returned to baseline.
# HEPATIC ENCEPHALOPATHY: Acute on chronic confusional state
associated with inattentiveness and altered sleep/wake cycle was
most consistent with hepatic encephalopathy, similar to his two
previous hospitalizations for encephalopathy. He was given his
lactulose and improved after having more bowel movements, both
by mental status exam and per his family's assessment. Testing
for acute triggers such as GI bleed, metabolic aberrations,
acute change in his chronic portal en thrombosis, or concurrent
infection were all negative. He had not had a bowel movement in
24 hours prior to admission, he should take enough lactulose to
have 3 BMs/day. Continued home rifaximin.
# Cirrhosis: Secondary to chronic HBV, on entecavir, recent
viral loads have been undetectable. MELD score 18, is transplant
listed. Portal vein chronically thrombosed. No ascites by
exam/ultrasound or history of SBP, no history of HRS. Home
entecavir was continued. Last EGD ___ showed 3 cords of
esophageal varices in the lower third of the esophagus, with
evidence of portal gastropathy. Home omeprazole and propanolol
were continued. CKD secondary to damage from HBV
glomerulonephritis with no evidence of ___. Pancytopenia
secondary to HBV marrow suppression as well as hypersplenism,
pneumoboots were used in lieu of heparin prophylaxis.
#Glycosuria: Glucose to 1000 on U/A, with serum glucose elevated
but only at 249. This was thought to be residual from tenofovir
induced Fanconi syndrome with disrupted proximal glucose
absorption, though tenofovir has been discontinued for ___ years.
Phosphate, bicarbonate, potassium all normal. His A1c was
elevated at 6.8, the highest it has been in years. He should
follow up as an outpatient to consider initiating treatment.
Transitional Issues
===========================
-It is important that he continue his rifaximin, and continue to
take adequate lactulose to have 3 bowel movements per day.
-A1c was 6.8, he should follow up with his PCP to consider
management of his
-follow up with liver and PCP
#CODE: Full
#CONTACT: No HCP, pt phone ___ | 126 | 367 |
18888952-DS-11 | 24,655,455 | Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a craniotomy to have blood
removed from your brain.
· After many multidisciplinary discussions including ethics,
palliative, and neurosurgery the family decided to make the
patient DNR/DNI and then he was transitioned to CMO and under
the inpatient hospice service.
Activity
· No restrictions. Comfort measures.
Medications
· Your Keppra was discontinued and you were transitioned to
scheduled Ativan q4h for comfort measures only. You may have
valium per rectal if you have a seizure that does not cease with
Ativan.
· You may use also be given Morphine for discomfort. | #___:
Mr. ___ was evaluated in the ED after transfer for an outside
hospital with a right acute on chronic subdural hematoma. His
aspirin was held and he was admitted to the neuro floor for
monitoring. His PTT was elevated and closely monitored; he
remained off subcutaneous heparin. On ___, the patient was
placed on EEG monitoring which was negative for seizure activity
and the leads were removed. On ___, the patient was taken to
the operating room and underwent a right craniotomy for
evacuation of a subdural hematoma. Post-operatively, he
recovered in the PACU and was later transferred to the ___ for
close monitoring. On ___, the patient remained neurologically
stable on examination. He underwent a scheduled head CT which
showed expected post-operative changes with a small hyperdense
right EDH in the parietal region. The subdural drain remained in
place. On ___ the patient was transfused 1 unit of platelets as
his platelet count was 95, his subdural drain was then removed.
A post pull NCHCT was stable, and did not show any residual
drain left in place. On ___ the patient was noted to be
confused and was not following commands and had LUE weakness. He
was ordered for EEG. His infectious workup continued to be
pending. Discussion held with family regarding goals of care as
they refused EEG. The patient was monitored closely and a formal
family meeting was scheduled for ___. Family was denying
neurological assessment of the patient and his meds were changed
to IV. EEG D/C'd. Repeat CT Head completed on ___ showing
stable subdural collection. During the family meeting the
___ hospital course was reviewed and options moving
forward were discussed with family. Ethics was consulted to
assist with management and social work was consulted for family
support and coping. After long discussion with the family the
patient was made DNR/DNI. On ___ he was having L arm twitching
concerning for seizures. He was given his am Keppra early and
noted to have twitching after the dose. His Keppra was increased
and he was given IV Ativan with good results. After another
discussion with the family the patient was transitioned to CMO
and palliative care was consulted to assist with management. He
was transitioned to Morphine and Ativan for comfort. On POD 7
the incision was assessed and the sutures appeared ready to be
removed however the family requested the sutures remain in place
to keep the patient comfortable. On discharge palliative, social
work, and the neurosurgery team spoke with family regarding
discontinuing keppra and increasing frequency of scheduled
Ativan with PRN Valium PR for seizures. His prescriptions were
sent to the receiving facility by ___ to expedite the lapse
between doses during transport. The patient appeared comfortable
at discharge and he was pre-medicated prior to transport.
# DELIRUM
The patient was having issues with delirium as well as an
elevated WBC count. His steroids were discontinued. A UA, CXR
and blood cultures were sent for infectious workup. He was later
transitioned to CMO. | 118 | 502 |
17437044-DS-4 | 28,688,096 | Dear Mr. ___,
You were admitted to the neurology ICU after having convulsive
seizures without clear return to your baseline. You were
initially intubated and given seizure medications intravenously.
We monitored your brain waves for evidence of seizures. We
increased your anti-epileptic drugs with resolution of your
seizures. Your mental status has been improving daily but you
had some periods of agitation for which we have prescribed
quetiapine 12.5mg twice per day. We have changed your
medications as follows:
- carbamazepine 800 mg BID
- lamotrigene 300 mg BID
- levetiracetam 1500 mg BID
- phenytoin 200 mg QHS
- seroquel 12.5 mg BID
You will need home physical therapy, an urgent appointment with
your neurologist Dr. ___, as well as follow up with your
primary care one week from discharge. Please do not hesitate to
call with questions. It has been a pleasure taking care of you.
Your ___ Neurology Team | ___ with h/o TBI, SDH s/p bilateral craniotomies and seizure
disorder reportedly on home keppra, lamictal, Dilantin, and
tegretol who presented with generalized convulsive status
epilepticus.
#Generalized Convulsive Status Epilepticus
He was witnessed to have jerking movements and gaze deviation
while mowing the lawn at his group home. He was taken to ___
___ where he was nonverbal and then had acute tonic clonic
seizure. He was intubated for airway protection, given 1000mg
Keppra and 8mg Ativan. Head CT showed no acute finding. He was
started on a propofol drip and sent to ___ for further
management. At ___ he continued to have generalized convulsive
seizures. He was given 2mg of IV Ativan x2 and loaded with
20mg/kg of phenytoin with cessation ___ seizures. He had no fever
or leukocytosis. Digoxin level and ___ level were undetectable
(rec'd as part of seizure w/u). His urine and serum tox screen
were negative. Unfortunately, AED levels were not sent at ___
___. He was admitted to Neuro ICU for further management. On
arrival to ICU he was actively seizing (GTC) on midaz 4mg/h and
prop 60. He was given 5mg of midaz bolus with immediate
cessation of tremors and increased rate of midaz from 4 to
5mg/hr. His home medications were started and uptitrated. He was
loaded w/ phenytoin as above and started on fosphenytoin 100mg
Q8H (home dose phenytoin 300mg qhs); however doses were held
d/t supratherapeutic INR. He was started on carbamazepine 400mg
bid as well as Keppra 1500mg BID (home dose 1g bid), Lorazepam
0.5mg AM, 2mg q pm (home dose) and Lamictal 200mg bid (home
dose). His EEG continue to show discharges ___ left frontal
region up to ___ Hz. He underwent an Atival trial, which did
not change his clinical status or EEG. Because his EEG was felt
to be acive, lamictal was increased to 250 mg BID and
carbamazepine was increased to 600 mg BID. On on ___ he was
transferred to the ___ for further management.
___ terms of etiology, he certainly has risk factors for status
given his prior history of TBI, SDH w/ craniotomies and prior
history of status epilepticus and there was some concern he was
not taking his medications appropriately (although, his group
home reports he is administered his meds). Additionally, there
was some concern he may have an infectious process and he was
initially placed on empiric meningitis treatment (vancomycin,
cefepime, ampicillin, acyclovir); however, CSF studies
unrevealing. He did have secretions but no overt consolidation
on CXR. Given this, all antibiotics were stopped. He underwent
on MRI on ___ which showed **************
# Acute Toxic Metabolic Encephalopathy
He was intubated for airway protection ___ the setting of status
epilepticus. Post intubation he was delirious, inattentive,
perseverative and unable to follow commands. He was pulling at
his lines and was given Haldol ___ this setting. His
encephalopathy could be attributed to post-ictal state,
infection or AEDs. He was transitioned to Seroquel 25mg QHS PRN
# History of Alcohol Abuse Disorder
EtOH level undetectable on admission and he reportedly has not
been drinking (per his sister, people from his home). He did
receive thiamine 500 mg TID x 3 days and folate initially.
# Possible COPD
Likely undiagnosed COPD. Given albuterol nebs ___ ICU.
==============================================================
NEUROLOGY FLOOR HOSPITAL COURSE
Mr. ___ is a ___ yo man with history of TBI, s/p bilateral
craniotomies, alcohol abuse, and seizure disorder managed on
multiple AEDs (phenytoin, lamotrigine, levetircetam, and
carbamazepine). He was initially admitted to the Neuro ICU with
convulsive status epilepticus and is now s/p medical management
and extubation. He's had significant clinical improvement and no
subsequent seizures. Neurologic exam notable for mild
disorientation, perseveration, and inattention but otherwise non
focal. EEG abnormal at baseline but stable without subsequent
seizures. MRI brain limited as patient unable to tolerate but
notable for significant atrophy of the cerebellum and temporal
lobes. His AEDs were increased to the following doses:
- carbamazepine 800 mg BID
- lamotrigene 300 mg BID
- levetiracetam 1500 mg BID
- phenytoin 200 mg QHS
- seroquel 12.5 mg BID
Transitional issues:
# His outpatient neurologist Dr. ___. Please call for an
appointment.
# Follow up with PCP within one week of discharge. | 153 | 693 |
14413724-DS-9 | 21,982,174 | Dear Mr. ___,
You were admitted to the hospital with dehydration and
constipation. You improved with intravenous fluids and a bowel
regimen and are being discharged home with a bowel regimen
(Colace and Senna every day, with miralax as needed). Please try
to stay hydrated. To avoid extra fluid accumulation, however, be
sure to weigh yourself every morning and contact your doctor if
your weight increases by more than 3 lbs in 1 day or 5 lbs in 1
week (your weight on discharge is 209.7 lbs).
Please continue to take your medications as prescribed. Dr.
___ should contact you within the next few days to
schedule a follow-up appointment for next week. If you haven't
heard from them by ___, please contact his office.
With best wishes,
___ Medicine | ___ man with history of CAD s/p DES, dCHF, CKD stage
III, DM, HTN, HLD, COPD presenting with failure to thrive and
hyponatremia.
# Weight loss:
# Failure to thrive:
Mr. ___ presented with failure to thrive over months, more
acute in the last few days with weakness and poor PO intake in
the setting of recent diarrhea following laxative use. His
presentation seemed most consistent with dehydration, and he
improved dramatically with IVFs alone (received approximately
1.2L IVFs in total). WBC on admission was 9.7 ->10.3 on
discharge, not thought to represent infection in the absence of
fevers, negative UA/UCx, clear CXR, and BCx without growth. Mr.
___ reported ~30 lbs weight loss over a 4-month period,
concerning for a possible undiagnosed malignancy, with no
dysphagia to suggest esophageal pathology. TSH WNL. I discussed
the possibility of a malignancy with Mr. ___, who stated that
he would not want treatment for cancer even if it were
discovered
and declined further evaluation. Further discussion around
testing for possible occult malignancy was deferred to the
patient's PCP ___ ___ years (Dr. ___ at the patient's request.
I
spoke with Dr. ___ felt that Mr. ___ may be
appropriate
for home hospice, but referral was deferred to Dr. ___ in the
absence of a clear terminal diagnosis. Mr. ___ will be
discharged home with home ___. He was tolerating a regular
diet at discharge. Dr. ___ will contact Mr. ___
with a f/u appointment within the next week.
# Hyponatremia:
# CKD stage III:
# Non-gap metabolic acidosis:
Patient presented with Na 127 and Cr 1.5 (from b/l 1.4-1.5). Na
improved to 135 and Cr to 1.4 with IVFs (total of 1.2L),
suggestive of pre-renal etiology. Mr. ___ was tolerating a
regular diet at discharge. HCO3 at discharge was 21;
consideration of sodium bicarb initiation was deferred to his
PCP.
# Constipation:
Likely secondary to poor PO intake and absence of bowel regimen.
TSH WNL. A bowel regimen was initiated, which included two
enemas. Mr. ___ had a formed bowel movement prior to
discharge, without melena/hematochezia and guaiac negative. He
was discharged on standing Colace and Senna (with instructions
to
hold for diarrhea) with Miralax PRN.
# Dyspnea on exertion:
# Hypoxia:
PCP reports transient hypoxia to 75% in clinic prior to referral
to the ED. On arrival to the ED, patient was saturating 100% on
RA, reporting only baseline dyspnea on exertion. CXR was clear,
with no evidence of PNA or pulmonary edema. Low suspicion for PE
(and V/Q scan done ___ in setting of similar and chronic DOE
low likelihood for PE). Unclear whether pulse oximetry in clinic
accurate, as patient was monitored with no recurrence of
hypoxia.
Ambulatory saturation was 92% prior to discharge, with resting
saturation of 97% RA.
# HFpEF:
EF 55%. Appeared dry to euvolemic on exam initially and received
IVFs as above. Patient reports that he was previously on Lasix,
discontinued weeks ago after a recent hospitalization for
pre-syncope. Given ongoing weight loss and poor PO intake, Lasix
had not been re-initiated as an outpatient and was not resumed
this admission. He was encouraged to monitor his weight and
contact Dr. ___ with weight gain. Standing weight at
discharge was 209.7 lbs.
# Diabetes mellitus:
A1c 7.1%. He was continued on his home 70/30 insulin 30u BID
with
sliding scale coverage.
# Hypothyroidism:
TSH WNL. Continued home levothyroxine.
# Hypertension:
Normotensive on his home lisinoipril. Patient was previously on
metoprolol, which he reports was discontinued recently (possibly
at ___ admission) in setting of pre-syncope and was not
re-initiated.
# Dysuria:
Patient reported dysuria with initiation of his urinary stream,
as well as poor urinary flow. Likely secondary to BPH. UA
negative for UTI. Deferred initiation of BPH therapy to PCP as
outpatient. PSA was not checked, given that patient would not
want treatment for cancer (see above).
# Hyperlipidemia:
Patient previously prescribed simvastatin 80mg daily, which he
has not been taking as he thinks it interferes with his sleep.
Simvastatin was not administered in house. It was kept on his
medication list at discharge, and patient was encouraged to
discuss with his PCP at his next appointment.
# CAD s/p DES:
Continued home ASA 81mg daily. Statin management as above.
# COPD:
No evidence of acute exacerbation. Advair was substituted for
home symbicort while hospitalized, with symbicort resumed on
discharge.
# OSA:
Patient declined CPAP while hospitalized. Plan to resume as
outpatient.
** TRANSITIONAL **
[ ] trend weights; may need resumption of Lasix
[ ] consider sodium bicarbonate for CKD
[ ] readdress simvastatin with patient if within GOC; consider
downtitration to 40mg daily
[ ] consider initiation of therapy for BPH
[ ] consider testing for occult malignancy, but likely not
within patient's GOC | 126 | 708 |
13051109-DS-21 | 29,206,396 | Dear Mr. ___,
You were admitted to ___
because you experienced weakness while walking up the stairs
with your son. We were worried you had an infection and a scan
identified a multifocal pneumonia (lung infection). You received
antibiotics while in the hospital (ceftriaxone and
azithromycin). We discharged you with a new antibiotic,
levofloxacin, which you should take as prescribed.
It was a pleasure taking care of you! | #Multifocal pneumonia: Patient presented with weakness. However,
the HPI and initial exam was not consistent with acute
neurologic event. Given elevated WBC to 16.1 and 90% PMN,
presentation was thought to be likely infection. Patient
appeared somewhat dehydrated based on his initial labs (elevated
BUN, all cell counts above baseline) and received 500 cc's of NS
in the ED. Mild UTI as on UA was thought unlikely to cause such
significant WBC response, but patient was treated with
ceftriaxone 1gm q24h pending other source. In setting of
increasing white count ___ AM to 18.1 and scattered rhonchi on
lung exam, we obtained thorax CT to rule out pneumonia and GI
process. CT abdomen was reassuring. ___ evening chest CT was
concerning for multifocal pneumonia, so patient was broadened
with 500mg azithromycin at 0030 on ___. He received 2 doses of
ceftriaxone (___) before eventual discharge. White blood
count improved to 10.7 as of ___. Patient remained asymptomatic
(no dyspnea, subjective fevers or chills, or any pain)
throughout hospitalization. He was discharged with a 7 day
course of levofloxacin (3 doses given q48hour, dose#1 given
in-hospital on ___. | 67 | 187 |
17342313-DS-4 | 22,597,541 | Dear Ms ___,
It was a pleasure taking care of you. You were in the hospital
because of gaze deviation to the right and left sided weakness.
You were found to have a stroke in multiple areas on the right
side of your brain. You were given a thrombolytic (for
dissolving clots) in the emergency room. You had a repeat CT
scan 24 hours after the thrombolytic and there was not bleeding
noted in your brain. Physical therapy recommended rehab.
Medication changes:
- We ADDED ASPIRIN 81 mg daily to reduce your stroke risk.
- We ADDED AMLODIPINE 5mg daily to control your high blood
pressure.
Please continue to take the rest of your home medications as
previously prescribed.
Call your doctor or go to the nearest emergency room if you
experience any of the danger signs listed below. | Mrs ___ is a ___ yo RH HF with PMH of HTN, HLD, CAD,
spinal stenosis, who had a witnessed onset of dysarthria, R gaze
preference, L weakness whilst being a passenger in her
daughter's car. She was found to have multiple lesions in the
right MCA distribution concerning for embolic infarcts.
ACTIVE ISSUES
# STROKE: Mrs ___ is a ___ yo RH HF with PMH of HTN,
HLD, CAD, spinal stenosis, who had a witnessed onset of
dysarthria, R gaze preference, L weakness whilst being a
passenger in her daughter's. On exam, she was no longer
dysarthric but had R gaze preference, L tactile and visual
neglect and very mild L weakness.
Overall, presentation was consistent with hyperacute R cortical
ischemia, in inferior division of R MCA territory. The sudden
onset suggests embolic etiology. As her initial presentation was
more severe than her current presentation, it is possible that
an embolus initially obstructed the R MCA more proximally and
then broke up. Based on her persistent deficits and NIHSS 6,
decision was made to give tPA in ED. Mrs. ___ was admitted to
the neurological ICU for post-tPA monitoring.
Her exam was stable the next morning. A repeat head CT 24 hours
post-tPA was negative for bleed; aspirin 81mg and sub-cutaneous
heparin were started. MRI showed multiple areas of acute infarct
involving the right frontal, parieto-occipital, and temporal
lobes. MRA showed a short segment of severe narrowing of the
right M1 with minimal flow signal intensity. There is also
occlusion of a right M2 branch. TTE with bubble showed no PFO or
ASD. Tele showed sinus rhythm. In terms of reisk factors
assessment: LDL 96. She was started on simvastatin 10 daily. A1c
was 5.4%.
# Hypertension: Given her acute stroke, we allowed patient's
blood pressure to autoregulate for the first few days. Her
Toprol XL dose was halved. Then, we put her back to full home
dose of her Toprol XL which is 100mg daily. Then, we added
amlodipine 5mg daily to help control her BP as her sBP runs as
high as 190's at times but ranges mostly 150's-180's. We did
not use ACE-I because of her reported allergy to enalapril.
# h/o positive PPD:
- CXR showed not evidence of TB
.
# Heterogenous thyroid gland: Noted on MRI. Follow up as
outpatient.
# Agitation: Patient had an episode of agitation/paranoia at
night time likely secondary to delirium/sundowning given recent
stroke, being in a strange environment with language barrier.
She then became attentive and orientated in the morning.
Physical restraint was required for about 12 hours. Seroquel was
ordered prn for agitation. Patient has not need physical
restraint for 3 days prior to discharge. Her mental status is
back to baseline on discharge.
TRANSITIONAL ISSUES
- consider thyroid ultrasound as an outpatient for further
evaluation of heterogenous thyroid gland.
- Please continue to work on blood pressure control. Goal is
normotension. | 137 | 485 |
10557857-DS-12 | 27,615,566 | Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You felt weak and dizzy and had black stools at home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Your blood counts were closely monitored while you were in the
hospital. You received 2 units of blood and tolerated the
transfusion well with good improvement in energy. Your blood
counts have remained stable since then, indicating that you have
not continued to bleed.
- You were found to have blood in your stool. We did a scope
study of the upper part of your GI tract, which found a
potential source of the bleed. Those vessels were cauterized,
which should keep them from bleeding again.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments. Please be
aware that you should NOT take your carvedilol and losartan at
home until you see your doctor at your follow up appointments OR
your blood pressure is too high.
- Please check your blood pressure at home. If the systolic
blood pressure (the number on top) is greater than 140, please
resume taking the losartan.
We wish you all the best!
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ gentleman with a significant past
medical history of Afib on warfarin with PPM, HFrEF (LVEF
40-45%), CAD s/p POBA, HTN, T2DM, and duodenal Dieulafoy lesion
in ___, who presented with fatigue and black stools with drop
in hgb to 6.7 from 10 in ___, found to have multiple AVMs on
EGD now cauterized.
During this admission, the patient's CBC was closely monitored.
His hgb and hct have remained stable at around 7.7 post 2 unit
pRBCs. He symptomatically improved with increased energy.
Patient also underwent an EGD and push enteroscopy to evaluate
for upper GI bleed. Multiple AVMs were found and cauterized
although they were not actively bleeding at the time of the
scope. There may have been other causes of bleed that were not
visualized. Patient was restarted on a regular diet and his home
warfarin and aspirin after the procedure and has tolerated diet
and medications well.
Patient also presented with an ___, likely prerenal in the
setting of active GI bleed, now resolved at discharge. His home
diuretics and blood pressure medications were held this
admission in the setting of possible active GI bleed. His home
diuretics and diltiazem were restarted at the time of discharge.
His carvedilol and losartan were held in the setting of normal
pressures while in the hospital. Given symptomatic improvement
and no sign of active bleeding, Mr. ___ was deemed ready to go
home.
TRANSITIONAL ISSUES:
[ ] f/u cbc within one week as there may be an additional source
of bleeding (AVMs were not bleeding at the time of EGD)
necessitating pill endoscopy or colonoscopy
[ ] Home carvedilol and losartan were held in the setting of
normal blood pressures while inpatient. Patient advised to check
blood pressures at home and restart losartan if SBP>140. Please
follow-up blood pressure and adjust medications as appropriate.
ACUTE ISSUES:
=============
# Acute blood loss anemia:
# Concern for UGIB:
Patient presented with dark stools and fatigue for 2 months
duration, seen in past for dark stools and fatigue outpatient.
Found to have drop of hemoglobin from 10 in ___ to
6.7 on admission. Transfused 2 units with appropriate response.
Home warfarin held until EGD then resumed without complication
post-procedure. Patient found to have multiple AVMs that were
not bleeding on EGD, which were cauterized. Given Pantoprazole
40mg PO BID to be continued outpatient.
# HFrEF: LVEF 40-45% (___). Arrival proBNP ~2200 (2700 ___.
Vitals stable, on room air. Denies any shortness of breath or
chest pain. Home diuretics and blood pressure medications were
held given concern for potential re-blead. Diuretics and
diltiazem were restarted on discharge. Continued to hold
carvedilol and losartan at discharge.
# ___ on CKD: Cr 1.5 on admission from baseline 1.1-1.2.
Possibly pre-renal in setting of blood loss anemia. Improved
following transfusion, back at 1.2 on discharge.
# A. fib:
# SSS s/p PPM in ___: CHADS-VASc 5.
Restarted home warfarin and aspirin following EGD. Patient
tolerated well.
CHRONIC ISSUES:
===============
# CAD s/p POBAx1: Patient was continued on home atorvastatin.
Aspirin was held until post procedure. Home carvedilol held as
per above.
#HTN: Home medications were held this admission in the setting
of GI bleed. Losartan and diltiazem were restarted at time of
discharge.
#HLD: Patient continued ___ Atorvastatin.
#T2DM: Patient continued on home glargine regime with
appropriate adjustments when NPO. Patient was also on sliding
scale insulin.
#Gout: Home allopurinol was decreased to 50mg PO daily given
___. Allopurinol dose was resumed to 100mg PO daily at discharge
given resolution of ___.
# CODE: full (presumed)
# CONTACT: ___, daughter, Phone: ___ | 222 | 586 |
10718657-DS-17 | 22,008,262 | Dear Ms. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of shortness of breath. It was determined
that you likely have a COPD exacerbation, which improved with
nebulizers, prednisone, and azithromycin. You symptoms
improved. You will continue to take prednisone for the next two
days. You will follow up with your oncologist ___ to make
sure you continue to improve.
You also have a known right lung mass. You were seen by
Radiation Oncology while you were admitted - you were seen by
radiation oncology for simulation treatment. An appointment was
scheduled with your oncologist this week. An appointment was
scheduled for radiation oncolgoy this week. It is important
that you continue to take your medications as prescribed and
follow up with the appointments listed below.
Please continue monitor your blood sugars while you are taking
prednisone as this can raise blood sugar. If your blood sugars
are >400, please contact your primary care physician. | ___ year old female with history of COPD on home oxygen with
multiple admissions for COPD exacerbations at ___, with
recent diagnosis of lung cancer (RLL), who presents with one
week of cough, fatigue, and shortness of breath consistent with
a COPD exacerbation.
ACTIVE ISSUES
-------------
# COPD: She had a CXR that did not demonstrate pneumonia. She
was treated for a COPD exacerbation with azithromycin (completed
5 days), prednisone (40mg x4 days, 20mg x2 days), and
albuterol/ipratropium nebulizers. Her symptoms improved. She
was continued on advair. She was given tessalon and guaifenesin
for cough. She was continued on supplemental oxygen at ___
liters nasal cannula. She was discharged with two days of
prednisone 20mg daily and will follow up with her oncologist on
day #3 to determine if therapy needs to be continued.
# Non-small cell Lung cancer: She was seen by radiation Oncology
during her admission and underwent simulation treatment to Lung
field on ___. She will follow up with her oncologist on
___. She will follow up with radiation oncology on ___.
MRI brain performed on ___ at ___ demonstrated small
vessel ischemic disease without evidence of metastasis.
#Diabetes: The Januvia was held during the hospitalization but
was restarted at discharge. She was maintained on an insulin
sliding scale during the hospitalization. Blood sugars were in
the 100s-200s while on prednisone 20mg. She will continue to
monitor blood sugars at home while on prednisone.
INACTIVE ISSUES
---------------
# Anemia, normocytic: Most likely anemia of chronic disease. Her
hematocrit was trended during her admission and remained stable
___. Would consider iron studies as an outpatient.
# Hypertension: patient was continued on her home amlodipine
# Depression: patient was continued on her home citalopram and
bupropion.
# Arthritis: patient was continued on her hydroxychloroquine and
leflunomide. Patient is unsure of what type of arthritis she
has.
TRANSITIONS OF CARE
-------------------
[ ] follow up with oncology ___
---[ ] consider more prolonged steroid taper at that time
[ ] follow up with radiation oncology ___
[ ] consider iron studies to further evaluate anemia | 166 | 341 |
13472144-DS-11 | 25,160,407 | 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:
- Non-weightbearing to left lower extremity in external fixator
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Pin Site Care Instructions for Patient and ___
The initial dressing may have Xeroform wrapped at the pin site
with surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Follow up with Dr. ___, NOT PA/NP
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Someone from
our office should call you to schedule this, but if you do not
hear from us within a few days after discharge, please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Activity: Activity: Activity as tolerated
Left lower extremity: Non weight bearing
Treatments Frequency:
Site: LLE
Description: external fixation, serosang oozing from pin
insertion sites
Care: pin care: ___ hydrogen peroxide, ___ NS, xeroform, guaze;
Monitor s/s infection | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L pilon and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction of left pilon and
fibula fracture with application of multiplanar external
fixator, which the patient tolerated well. He was taken back to
the operating room on ___ for application of hybrid external
fixator to his left lower extremity. For full details of the
procedure please see the separately dictated operative report.
After both surgeries, the patient was taken from the OR to the
PACU in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1 of
both surgeries. The patient was given ___ antibiotics
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. The patient
worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weightbearing in external fixator to the left lower
extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 455 | 295 |
12960939-DS-22 | 29,610,654 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
diagnosed with pancreatitis without any complicated cysts on CT
scan. We gave you fluids and pain/nausea medications, and
slowly advanced your diet, which you tolerated well.
As we discussed, please try your best to abstain from alcohol
completely, as well as to avoid fatty foods as much as possible,
to minimize the chance of future episodes of pancreatitis. | ___ h/o necrotizing pancreatitis (likely alcoholic) and
pseudocyst resected in ___ and stenting/stent removal in ___
w/ ERCP at ___ presents with abdominal pain and nausea x 1
day, consistent with recurrent pancreatitis.
# Pancreatitis: There was no evidence of pseudocyst on CT scan.
___ score 1 at admission, indicating 0-3% probability of
mortality. He was NPO on admission, and needed several doses of
morphine and zofran along with gentle IV fluids (given his
reportedly severe aortic stenosis). He felt no symptoms the
following day, when we advanced his diet to clears, then the
following day to regular, without recurrence of symptoms. He
was encouraged to abstain from alcohol completely and to avoid
fatty foods as much as possible to minimize probability of
pancreatitis recurrence.
# Aortic stenosis: We have no recent echocardiogram records in
our computer system, though ___ TTE shows 1.3cm3 aortic valve
area. Patient reports plans of valve replacement surgery in ___
months. IV fluids were given gently on the first night of
admission but discontinued when taking PO, and he never
developed symptoms related to aortic stenosis.
# Pericardial effusion: incidentally found on CT scan,
interpreted as moderate size. We did not perform an
echocardiogram given the lack of thoracic symptoms in-house. | 74 | 209 |
19727323-DS-18 | 21,047,557 | Dear Mr ___,
You were admitted to the hospital because you fell and broke
your leg. We fixed your leg with surgery. We also gave you some
blood to replace the blood that you had lost after you broke
your leg.
While you were here we also found that your kidney disease has
gotten worse, and that you will need to start dialysis soon. We
started new medications while you were in the hospital to make
sure that your body has the right amount of nutrients and
minerals like calcium, phosphate, potassium, and bicarbonate.
You improved and were sent to a rehabilitation facility in order
to help you regain your strength before going home.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
-Take all of your medications as prescribed (listed below)
-Follow up with your doctors as listed below
-___ medical atttention if you have new or concerning symptoms
or you develop
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team | ___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on
HD suffering from a displaced fractured proximal femur s/p fall
___, admitted for medical optimization prior to TFN on ___.
Pre-op course complicated by worsening renal function, metabolic
acidosis, electrolyte abnormalities, and acute-on-chronic
anemia. Patient transferred to ICU on ___ after TFN procedure
due to inability to extubate, likely secondary to medical
sedation in the setting of renal failure. Extubated successfully
on ___, and transitioned to the floor. Treated for HAP given
CXR infiltrate, fever, and leukocytosis. Should have close
follow-up after DC with nephrology for initiation of dialysis.
****************MICU COURSE******************
___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on
HD s/p fall with displaced fractured proximal femur s/p
trochanteric fixation nail on ___ with difficulty extubating
post-surgery related to the use of sedating medications in the
setting of renal failure. He was briefly on phenylephrine for
MAPs <60 while in the PACU, noted to be minimally responsive.
During the case, his estimated EBL was 100cc, his Hgb was 6.5,
and he was transfused 1 unit PRBCs.
#Hypoxemic Resp Failure
Given that the patient remained intubated and requiring pressor
support, transfer to MICU for further management was requested.
On arrival to the MICU overnight on ___, patient opened his
eyes to voice and follows commands, he was intubated and
required AC with minimal vent settings due to low tidal volumes.
Morning of ___, patient was more response, switched to pressure
support ___ with good minute ventilation and passed spontaneous
breathing trial with RISBI 32, he was extubated around 1400 on
___ maintained on shovel mask 35% with SaO2 >95%.
# ___ on CKD: In terms of his renal failure, UCx was sent,
patient made ___ cc/hr of dark yellow urine. K+ remained ___
with bicarb ___, VBG with pH 7.27 and remained euvolemic.
Renal was consulted, no urgent need for dialysis. Per renal, he
received a total of 4 g calcium gluconate for hypocalcemia, was
started on calcium acetate phos binder for hyperphosphotemia and
1300 mg BID sodium bicarbonate.
# Pneumonia
# Leukocytosis
# Fever
CXR demonstrated a consolidation and collapse of the right
lateral middle lobe concerning for aspiration with rising white
count of 20K concerning for HAP vs. CAP. Patient received 1g
vanco on ___ at 10 AM and 500 mg ceftazidime for treatment.
BCx were sent.
MEDICINE SERVICE COURSE
==========================
#Hypoxic Respiratory Failure:
#Concern for Aspiration PNA: Febrile in ICU with rising WBC
count and w/ RLL opacity on ___ CXR, likely RLL atelectasis ___
mucous plugging but aspiration PNA / aspiration pneumonitis
possible, so started on vanc/ceftazadime. CXR ___ showed marked
improvement with radiology suggesting RLL edema from
re-expansion vs. RLL infiltrate. MRSA screen, blood cx, and
urine cx x2 negative. Transitioned to renally-dosed levofloxacin
to end on ___.
# Proximal Left femur fracture: After fall at home, evaluated by
orthopedic surgery and planned for TFN after medical evaluation.
Pain initially managed with IV dilaudid, which likely
contributed to acidosis. TFN ___ complicated by difficult
extubation and MICU stay ___ for respiratory failure.
Followed by orthopedic surgery throughout admission.
# Acute on chronic normocytic anemia: Hgb nadir 6.6 on ___,
from 9.0 on admission. Etiology likely acute blood loss after
femur fracture with subsequent slow oozing around operative
site, exacerbating chronic anemia from renal failure. Hemolysis
unlikely with normal LDH, haptoglobin, and Tbili. Patient
received total 4U pRBC during admission.
# Metabolic acidosis:
# CKD Stage 5:
# Hyperkalemia: Pre-operative labs notable for hyperkalemia,
mixed respiratory and metabolic acidosis, hypocalcemia, and
hyperphosphatemia, consistent with chronic renal failure
exacerbated by respiratory suppression and volume depletion.
Hyperkalemia improved with insulin, hydration, and diuresis.
Acidosis improved with decreasing narcotics. Renal team
evaluated patient during admission and determined no indication
for acute initiation of dialysis.
# Insulin dependent T2DM: HgbA1c ___ home lantus
recently decreased from 10u to 5u qhs for concern for
hypoglycemia I/s/o good glycemic control. Home lantus held
initially; restarted after surgery in the setting of
hyperglycemia, likely from enhanced insulin clearance with
improved renal function.
# Fall: Pt reports fall near kitchen counter ___ w/o headstrike
or LOC. Most likely mechanical fall ___ visual impairment and
diabetic neuropathy or orthostatic I/s/o autonomic neuropathy;
less likely CNS cause given lack of focal symptoms, or
arrhythmia given stable ECG and tele without evens. Other
etiologies to consider include vasovagal, ACS (TropT 0.03 x2; no
STEMI), hypoglycemia. Pt and family report h/o multiple falls
and fall hazards in house where pt lives alone; preventing
future falls will necessitate adequate home services and ideally
24hr care.
# Hypertension: Home nifedipine and metoprolol held
post-operatively in the setting of hypotension but restarted
when patient became hypertensive prior to discharge. Home
lisinopril held in the setting of worsened renal function and
hyperkalemia.
TRANSITIONAL ISSUES
==========================
[] Please draw repeat CBC and Chem10 by ___ to follow-up
anemia and renal function
[] Patient will need close nephrology follow-up. Discussion
should continue with the patient and his family about initiation
of dialysis.
[] Consider starting erythropoeitin for anemia in CKD.
[] Per renal, started on calcium acetate and sodium bicarbonate
during admission.
[] Lisinopril stopped given low GFR and possible contribution to
hyperkalemia.
[] Social work and case management should continue to follow
with patient at rehab, as he could likely benefit from a home
safety evaluation
[] Post-op wound care: Please change dressing with gauze and
tegaderm every ___ days or when saturated
[] Please help patient make follow-up appointment with Dr. ___
___ (Orthopedics) on or around ___ (2 weeks
post-operation)
[] Would consider bisphosphonate therapy after optimization of
calcium and vitamin D by nephrology given likely fragility
fracture
CODE STATUS: Full Code
CONTACT: ___ (Son ___ ___ (daughter) at
same number | 167 | 930 |
15698697-DS-6 | 23,063,987 | Dear Mr. ___,
You were hospitalized and underwent treatment for perforated
diverticulitis, which required placement of an abdominal drain
and antibiotics. You have recovered in the hospital and are now
preparing for discharge to home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Also, please note the attached hand-out regarding the care of
your drain. | The patient presented to pre-op/Emergency Department on
___. Upon arrival to ED patient had acute kidney injury,
tachycardia, fever, hypotension and abdominal pain. Given
findings, the patient received a CT scan that demonstrated a
pelvic abscess. Interventional radiology placed a percutaneous
drain that expelled purulent fluid. The fluid was cultured and
found to be polymicrobial. Blood cultures drawn at admission
demonstrated streptococcus anginosus (milleri). Infectious
disease was consulted who recommended ceftriaxone and
metronidazole to cover for bacteremia secondary to
intra-abdominal abscess. A peripherally inserted central
catheter was placed and the patient was discharged on two weeks
of antibiotics. His acute kidney injury returned to baseline
(0.9-1.0) with hydration and treatment of his infection.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intravenous
pain medication and then transitioned to oral oxycodoneonce
tolerating a diet.
CV: The patient's fever, tachycardia and hypotension resolved
with antibiotics.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Post placement of
percutaneous drain his diet was advanced as tolerated to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection. His fever deffervesced with antibiotics.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. He was maintained on
subcutaneous heparin for deep vein thrombosis prophylaxis while
hospitalized.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, 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. | 268 | 327 |
15736946-DS-3 | 26,526,255 | ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Swallowing: Difficulty swallowing is not
uncommon after this type of surgery. This should resolve over
time. Please take small bites and eat slowly. Removing the
collar while eating can be helpful however, please limit your
movement of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace: You have been
given a soft collar for comfort. You may remove the collar to
take a shower or eat. Limit your motion of your neck while the
collar is off. You should wear the collar when walking,
especially in public
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic (oxycontin,
oxycodone, percocet) prescriptions to the pharmacy. In
addition, we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions. | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Physical therapy and Occupational therapy were
consulted for mobilization OOB to ambulate and ADL's.Hospital
course was otherwise unremarkable.On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet. | 699 | 111 |
19791816-DS-15 | 23,250,735 | Dear Ms. ___,
You were admitted because your right arm and leg were weak, and
you were having worsening of the tingling in your hands and
feet. Given your history of subdural hemorrhages, atrial
fibrillation, and prior stroke, we wanted to make sure that you
did not have a new stroke as the cause of your weakness. You had
a MRI of your brain and your cervical spine, which did not show
a new stroke or any problems with your spinal cord. Although we
do not know exactly why your right side is weaker and why the
tingling is worse, it is not because of a new anatomic problem
such as a stroke or a tumor.
As an outpatient, you will need another test called an EMG,
which Dr. ___ order. If the tingling in your hands
worsen, you can also start some gabapentin 100mg at night to see
if that will help.
You were also found to have a urinary tract infection. Please
take cefpodoxime twice per day for an additional 5 days.
It was such a pleasure taking care of you, and we wish you the
best!
Sincerely,
Your ___ Team | Ms. ___ is a pleasant ___ F w/ PMH b/l SDH, afib on
ASA, DLBCL s/p RCHOP, embolic infarcts, epilepsy who presents
with 1 month of progressive R sided weakness and 10 days of
worsening R sided tingling. The tingling has been happening off
and on for the last ___ years, but this time it is tingling for
longer than usual. On exam, she has a mild UMN pattern weakness
in the 4+ range in both her arm and her leg. There are no
sensory changes on formal testing with pin. Given her stroke
risk factors (ie having afib but only being on ASA given her
bleeding risk in the setting of bilateral SDH), she had an MRI
of her brain looking for a stroke that could have led to her
right sided weakness. There was no change on her MRI from her
prior MRI in ___. Chronic small bilateral occipital lobe
infarcts were noted and similar to that seen in ___ ___s
chronic small vessel changes. She also had an MRI of her
cervical spine, which did not show any abnormal cord signal
intensity. She has some degenerative changes resulting in
multilevel neural foraminal narrowing worse at R C3-C4.
Overall, it is unclear what caused her right sided weakness and
neuropathy. Given that the weakness has been going on for the
last week to 4 weeks, it may have been that she had a small left
sided stroke resulting in a mild right hemiparesis. This would
not be picked up on DWI/ADC if it happened >14 days ago, so
perhaps that could be one explanation. Regardless, she is not
someone who could be safely anticoagulated given her age and
risk of falling in the setting of a history of bilateral
subdural hemorrhages. She will remain on aspirin for the time
being and follow up with outpatient neurology. | 189 | 309 |
13443402-DS-6 | 25,568,377 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
-You were because your left arm was swollen.
What was done for me while I was here?
-You had an ultrasound and a CT that showed blood clots in your
left arm, left neck, and left chest.
-You were given a medicine through an IV, called heparin, to
stop the blood clots from growing
-You were started on warfarin, to keep the blood clots from
growing when you go home.
-You were started on a water pill (furosemide, also known as
Lasix) because fluid was backed up from your heart
What should I do when I go home?
-You should take your medications as prescribed.
-You should go to all of your doctor's appointments.
-You should weight yourself everyday and call your cardiologist
if your weight increases more than 3 lbs (229lbs) in a day or 5
lbs (231) in a week.
We wish you the best in the future!
Sincerely,
Your ___ Care Team
Discharge Diuretic - Lasix 20mg Daily
Discharge Weight - 226 lbs
Discharge Cr - 1.2
New Medications - Warfarin, Lasix, and Metoprolol | ==================
SUMMARY STATEMENT
==================
Ms. ___ is a ___ female with history of radiation to
the left breast and PPM placement in the left subclavian vein
presenting with LUE swelling and found to have thrombus in LIJ,
left subclavian vein, and two left brachial veins, now
therapeutic on coumadain. Found to have a new wall motion
abnormality on TTE with newly reduced EF, RHC w/ elevated
filling pressures (PCW 24) s/p IV diuresis with improvement in
dyspnea on exertion.
=====================
TRANSITIONAL ISSUES
=====================
[ ] Dr. ___ to manage INR as outpt via ___
clinic
[ ] Please draw next INR and Chem-7 + Mg on ___ and
fax results to ___
[ ] Consider repeat chem-7 at follow up appointment with Dr.
___ to ensure ___ stable
[ ] Low dose BB started this admission, pt w/ soft BPs (SBPs
___ but asymptomatic, continue to titrate as outpatient
[ ] Consider restarting ACEi as outpatient. Pt had mild
improving ___ at discharge ___ diuresis in addition to softer
blood pressures, and thus was not started on ___ despite
new HFrEF
[ ] F/u BMP closely given furosemide started this admission
[ ] Ferritin 53 this admission w/ stable anemia, will likely
benefit from IV Fe repletion as outpatient given new HFrEF,
deferred this admission given hx of previous Fe infusions
[ ] Consider further workup for new onset cardiomyopathy,
possible cardiac MRI, as an outpatient
[ ] Follow up with vascular surgery as outpatient given history
of multiple provoked DVT
[ ] Will likely require anticoagulation for at least ___ months
given that this is provoked, and consider evaluation for further
anticoagulation as an outpatient given that this is her second
DVT
Discharge Diuretic - Lasix 20mg Daily
Discharge Weight - 226 lbs
Discharge Cr - 1.2
NEW MEDICATIONS
Warfarin 5mg daily
Furosemide 20mg daily
Metoprolol XL 12.5 daily
===========================
HOSPITAL COURSE BY PROBLEM
===========================
ACUTE ISSUES:
=============
#Heart Failure with Reduced Ejection Fraction
Patient complaining of dyspnea on exertion for the past several
weeks prompting TTE that showed newly depressed EF of 39% (EF
>55% in ___ with regional wall motion abnormalities.
Troponins were negative. Had LHC/RHC without coronary artery
disease, but elevated filling pressures w/ PCW 24. Pacemaker
interrogated w/o acute events. Etiology of heart failure may be
secondary to adriamycin toxicity or a stress cardiomyopathy in
light of her acute clot burden as below. Successful IV diuresis,
switched to PO ___.
- Preload: Continue Lasix 20mg PO
- Afterload: None, holding home ACEi in setting of ___, consider
re-starting as outpatient
- NHBK: Started on metoprolol succinate 12.5mg
#LIJ, left subclavian, left brachial DVT
Presented with sudden onset LUE swelling and LUE U/S showed
extensive thrombus in LIJ, L subclavian vein, and two left
brachial veins. Thought to be precipitated by recent PPM
placement. No concern for compartment syndrome this admission.
Was bridged initially w/ lovenox and then hep gtt given
borderline kidney function. Discharged on warfarin with
therapeutic INR.
- Discharge INR 2.4
- Anticoagulation will be managed by ___
clinic and Dr. ___
# ___ on CKD, resolved:
History of CKD stage III. Cr 1.2 in ___ with intermittent ___
to 1.5 this admission while diuresing. Discharge Cr 1.2. | 185 | 514 |
13895555-DS-15 | 21,516,179 | Dear Mr ___,
You were admitted to the Stroke Service at ___
___ after presenting with nausea, slurred speech,
diplopia, ataxia and flucuating right-sided weakness. Emergent
imaging showed strokes in multiples areas at the base of your
brain and clots in the arteries that supply the base of your
brain. An attempt was made to remove the clot; however, the
clot could not be reached. You were therefore started on a
blood thinner. You were admitted initially to the ICU for close
monitoring. You required medications to keep your blood
pressure high enough to allow blood to flow past the clots in
the arteries supplying your brain. You were eventually able to
wean off the medications that required intravenous
administration. At that point you were transferred to the
floor. You were switched from an intravenous blood thinner to
an oral blood thinner which you will continue long-term. You
had significant difficulty with swallowing while in the ICU.
You therefore had a feeding tube placed. You were re-evaluated
after transfer to the floor and it was felt that you were safe
for ground solids and thickened liquids. You were also treated
twice for urinary tract infections during your admission. In
addition, you required an enema the day of discharge due to a
significant amount of stool in your bowels. | ICU Course:
Mr. ___ was admitted to the neurology ICU with basilar
artery occlusion that was thought to be due to embolization from
the left vertebral artery origin or from in situ thrombosis of
the basilar artery. He had frequent pressure and posture
dependent changes in his exam. At his best he was awake and
alert and oriented x3 with some mild LUE and LLE weakness and
ataxia. With drops in blood pressure and sitting up his exam
worsened with increase somnolence and worsening left sided
plegia. In the setting of worsening exams, he had serial NCHCTs
which did not show signs of edema or hemorrhage. For this reason
he was continued on norepinephrine for blood pressure support
and the HOB was kept flat. He was started on midodrine in
attempt to wean off IV pressors. He slowly improved. Blood
pressure goals were weaned down slowly and HOB was gradually
increased as tolerated by his neurologic exam. By ___ he was
able to get out of bed to the chair and tolerate SBP as low as
120.
Mr. ___ was evaluated multiple times by speech and swallow
therapy and was unfortunately unable to tolerate a PO diet
safely. Therefore a PEG tube was placed on ___. Following PEG
placement he was started on coumadin.
On ___, he was found to have a UTI and was started on
ceftriaxone for a planned ___ultures grew E.Coli. | 231 | 232 |
17100483-DS-10 | 25,157,512 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for cellulitis (an infection
of your skin and soft tissue) of your face and treated with IV
antibiotics. Your cellulitis improved and you will go home with
antibiotics for 7 more days to complete a 10 day course. You
should stop your antibiotics on ___.
Please refrain from using any new topical creams or ointments on
your face, and continue to see your dermatologist. Please
refrain from scratching your skin, as it makes you more prone to
infection. | Mr ___ is a ___ year old Male with a past medical history of
DM, hypertension, atrial fibrillation on coumadin, ___ admitted
for diffuse facial swelling worsening over 3 days.
ACUTE ISSUES
============
#Cellulitis: Patient presented with diffuse facial swelling that
began 3 days prior to admission after 5 days of itchy eyes and
use of new eye drops. CT showed preseptal cellulitis with no
postseptal involvement. He was started on IV antibiotics then
transitioned to PO clindamycin to complete a 10 day course
- follow up with dermatologist Dr. ___.
CHRONIC ISSUES
==============
#Atrial fibrillation- Stable during admission. Patient has
history of A fib with chads score of 3, currently rhythm
controlled. Continued home amiodarone and warfarin.
#DM- Stable during admission, not on medication regimen,
continued diet control
#dCHF- No clinical signs or symptoms of heart failure. Continued
home torsemide.
#CAD: History of CAD
-continued valsartan, lipitor, amlodipine,
#Gout: Continued home allopurinol.
TRANSITIONAL ISSUES
=================== | 94 | 142 |
11954526-DS-5 | 23,100,143 | You were admitted s/p fall. You were seen by ___ and did well and
now you will go to rehab for further strength. A ___ has been
left in place to help with your difficulty urinating. Please
follow-up with Uro-Gyneocology next week, as planned. | # s/p unwitnessed fall: details unknown but pt deconditioned,
possible mild delirium secondary to UTI. Wound care was
provided for knees and LUE skin tears, and she was started on
vitamin D 1000U to decrease risk of falls. ___ evaluated pt and
recommended rehab.
# recurrent UTI: likely secondary to intermittent urinary
retention, plus some fecal incontinence. Started empirically on
vancomycin, as current infection occurred through ciprofloxacin,
and last UTI in OMR was pansensitive enterococcus. She is
allergic to PCN, Keflex, and Sulfa. Urine cx from ED grew mixed
flora, so urine cx was repeated. Urine culture was negative and
antibiotics stopped prior to discharge.
# urinary retention: She consistently had high PVR on bladder
scan, so ___ was placed. She will keep ___ until f/u with
her uro-gynecologist Dr ___.
# fecal incontinence: stool softeners were discontinued, and she
was given Metamucil to add bulk. Consider probiotics as well. | 44 | 150 |
14018526-DS-7 | 22,711,435 | You presented to the hospital after removing your GJ-tube. You
had the GJ-tube replaced successfully. Due to bleeding from the
GJ-tube site, you received 3 units of red blood cells with good
effect. You were successfully restarted on tube feeds. You had
some diarrhea, but there was no evidence of C. diff infection.
The diarrhea is likely due to the tube feeds and improved with
addition of banana flakes. You also developed a new rash, which
is most likely a fungal rash. The rash is improving with a
steroid ointment and an antifungal ointment.
. | ASSESSMENT
================================
___ male w/PMHx including severe aortic stenosis s/p ___
___, CAD w/systolic CHF, afib on warfarin, diabetes with
complications, smoldering multiple myeloma, stage III CKD,
anemia and thrombocytopenia, peptic ulcer disease s/p Billroth
II
anastomosis with known lymphangiectasia with gastric remnant
(with bleeding in the past associated with aspirin), history of
colon cancer ___ ___'s B2 with right colectomy, last
colonoscopy in ___, s/p recent GJ tube placement on ___. He
is now presenting with bleeding after he pulled out his GJ-tube
on ___. Now s/p replacement of his GJ tube by ___ on ___.
.
PLAN by PROBLEMS
================================
# Diarrhea
He was noted to have diarrhea, but per his son, this has
happened in the past and has been attributed to tube feeds.
Banana flakes were added with some improvement in his diarrhea.
Stool C. diff was sent and was NEGATIVE.
.
# Rash
Patient was noted to have a rash on his trunk, that spared his
limbs, palms / soles and mucosal surfaces. He had DFA for HSV
and VZV, both which were negative. He had a wound swab with a
negative Gram stain and no growth on culture to date. He also
had a fungal culture, with no growth to date. Blood cultures
also with no growth (FINAL). Most likely this is a fungal
folliculitis. He was started on a steroid ointment and an
anti-fungal ointment with improvement. Of note, his son-in-law,
Dr. ___, is a local dermat___ and examined pt
on a frequent basis.
.
# Traumatic removal of GJ tube in the setting of dysphagia and
significant aspiration risk, with acute blood loss anemia,
stable
___ was able to replace the GJ tube on ___ successfully. He
was able to tolerate TF's at goal. He did require 3 units PRBC
transfusion before stabilization of his Hct.
.
# Anemia, acute blood loss
Most likely related to dislodging GJ-tube and replacing GJ-tube.
He is s/p 3 unit PRBC transfusion with stable post-transfusion
Hct check. He had no evidence of active bleeding after blood
transfusion
.
# Severe aortic stenosis s/p ___ ___, CAD w/systolic CHF,
afib on warfarin, HTN, HL
He was continued on home ASA, atorvastatin, furosemide. His
Coumadin had been held prior to admission due to anticipated
need for replacement of GJ tube. On admission, he was placed on
heparin GTT. After replacement of his GJ tube, he was restarted
on Coumadin. He is on anticoagulation for his Atrial
fibrillation. Per his Cardiologist, Dr. ___ his ___, he
does not require Coumadin. ASA is adequate for his ___. He is
currently with therapeutic INR. Most recent Coumadin dose has
been 3mg daily for the past few days. Will need INR check on
___.
.
# Diabetes mellitus, c/b retinopathy, neuropathy
BS in good range, he was on gentle HISS
.
# Stage III CKD
- avoid nephrotoxins, monitor Cr/UOP/lytes while here, with
stable Cr.
.
# Smoldering multiple myeloma, monoclonal gammopathy, anemia and
thrombocytopenia
He received 3 units PRBC for acute blood loss anemia, otherwise
his count remained low but stable.
.
# Peptic ulcer disease s/p Billroth II anastomosis with known
lymphangiectasia with gastric remnant (with bleeding in the past
associated with aspirin)
When his GJ tube was out, he was placed on IV Protonix. He was
resumed on lansoprazole once GJ tube replaced.
.
# Hypothyroidism
Continued home levothyroxine via GJ-tube
.
# Possible history of depression
Continued home sertraline via GJ-tube
.
# Possible history of bronchospasm vs. COPD
Was previously discharged with PRN albuterol and ipratropium for
unclear
reasons. These were continued but he did not require frequent
treatments.
.
# FEN
Continued TF's at goal. He is strict NPO
.
# Code Status: FULL CODE
# CONTACT INFORMATION:
HCP ___ (daughter) ___
Alternate ___ (wife) ___
Alternate Dr. ___ (son) ___
. | 101 | 615 |
19738181-DS-18 | 26,287,919 | Dear Ms. ___,
It was pleasure caring for you at ___
___. You were admitted for fainint in the bathroom. We
assessed conduction system of your heart with EKG, and it was
normal. We also put you on telemetry to continously monitor your
heart, and you had no undesirable event. You were found to have
low blood pressure when you were standing relative to when you
were sitting. We call this orthostasis hypotension, and it could
have been a reason that caused you to faint. We treated this by
giving you some intravenous fluid. You were also found to have
an infection of your urinary tract, which could also have
contributed to your passing out. We started you on a 5-day
course of antibiotics (first day ___.
We are glad you are feeling better, and we wish you the best of
luck!
Regards,
___ Team | ___ with h/o dementia, HTN, and HLD presented from a nursing
home with syncope. | 141 | 15 |
17421215-DS-21 | 25,178,640 | You have been transitioned from Rapamycin (Sirolimus) to
Tacrolimus to help with wound healing.
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, increased abdominal
pain, incisional redness, drainage or bleeding, dizziness or
weakness, decreased urine output or dark, constipation or
diarrhrea or any other concerning symptoms.
You will have labwork drawn as arranged by the transplant
clinic, with results to the transplant clinic (Fax ___
. CBC, Chem 10, AST, T Bili, Trough Tacro level, Urinalysis.
On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacro with you
so you may take your medication as soon as your labwork has been
drawn.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotion or powder near the incision.
You may leave the incision open to the air.
The staples are removed approximately 3 weeks following your
surgery
No tub baths or swimming
No driving if taking narcotic pain medications
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure.
Check your blood sugars and blood pressure at home. Report
consistently elevated values to the transplant clinic. Follow
insulin scale as ordered
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise | ___ y/o male s/p kidney transplant ___ presented with left lower
quadrant pain and change in bowel habits, new anemia and melena.
He was scanned and CT demonstrated a mass in the small bowel in
the left lower quadrant at the site of the patient's pain.
Given h/o metastatic squamous cell carcinoma it was suspected
that mass was likely a metastatis and the plan was to take him
to the OR. Prior to OR, he was given PRBC for anemia (hct 22%)
with increase.
GI was consulted for EGD to rule out upper GI causes of blood
loss. EGD was performed on ___ showing: atypical appearing
erosion of the mucosa in the distal gastric body. Cold forceps
biopsies were performed for histology. Duodenum appeared normal.
Biopsy was consistent with iron stained gastritis.
On ___, he underwent small bowel resection for tumor. Surgeon
was Dr. ___. Please refer to operative note for complete
details. He did well and there were no complications. NG needed
to be replaced and then he didn't do well with clamping due to
nausea. NG was replaced to suction. Clamp trials were then tried
and residuals were low (15cc). NG was removed on ___. Clear
diet was started. He was passing flatus and had BMs on ___.
Diet was advanced and tolerated. Abdomen was non-distended.
Incision was intact and without redness or drainage.
Pain was initially managed with PCA. Once diet was started, he
was transitioned to po pain medication -ultram and Tylenol. He
did get a few doses of oxycodone as well.
___ Clinic was consulted for hyperglycemia. He was started on
Lantus (home insulin was Levemir/Humalog SS) with improved
control. Metformin was resumed.
___ evaluated and found that he had no acute ___ needs. ___ was
not indicated. He was discharged to home in stable condition.
Of note, Rapamune was stopped preop in anticipation of surgery
(potential to impair wound healing). Tacrolimus was started and
dose adjusted to 3mg bid with troughs in the 4.9 range.
Tacrolimus was ordered and filled by ___. | 280 | 338 |
13931815-DS-16 | 20,311,561 | Ms. ___,
You were hospitalized due to symptoms of SLURRED SPEECH. This is
likely due to your new Alprazolam medication. However, you were
found to have a small ACUTE ISCHEMIC STROKE for which you
fortunately have not developed severe symptoms. This stroke
developed while you were not taking Clopidogrel regularly. In
order to prevent stroke, you need to take this medication to
prevent the formation of clots.
We are changing your medications as follows:
1. We are increasing your ATORVASTATIN to 40 MG (from the prior
10 MG dose) to better control your cholesterol.
2. Please take CLOPIDOGREL 75 mg daily as prescribed to prevent
future stroke.
3. Please take your other medications as prescribed.
Please followup with your Neurologist as listed below as well as
your PCP.
If you experience any of the symptoms below, please seek medical
attention.
It was a pleasure providing you with medical care during this
hospitalization. | ___ h/o ischemic stroke, L cavernous ICA saccular aneurysm,
HTN, HL, DM, AAA, DVT, R ulnar neuropathy, cervical and lumbar
polyradiculopathy, polyneuropathy now p/w slurred speech for
three days in the setting of oral morphine therapy for
pancreatitis, here for evaluation for possible cerebral
ischemia. Found to have a small tiny R frontal cortical stroke
while noncompliant with clopidogrel therapy. Her slurred speech
was not apparent on reexamination and is likely due to her new
alprazolam therapy. She was restarted on Clopidogrel and her
risk factors were reassessed. Her Atorvastatin was increased to
40 mg from 10 mg when her LDL was found to be 101 (goal < 70).
Given the embolic appearance of her small stroke, a TEE was
performed (in the setting of a negative TTE) which shows a
simple atheroma in the descending thoracic aorta but no other
major abnormalities (this atheroma is distal to the R
brachiocephalic/carotid artery takeoff, so it is not the
explanation for her symptoms). She was assessed by ___ who
recommended acute rehab given a mild gait instability.
.
PENDING STUDIES: None
. | 144 | 178 |
14396180-DS-15 | 24,959,591 | Dear Mr. ___,
You were admitted to ___ for evaluation of a rash. This rash
is likely an infection that affected the lymph (drainage system)
for your arm. We started you on an IV antibiotic, and would
like you to continue to take oral antibiotics for the next 7
days. The medication we would like you start is called
Clindamycin. Please take this three times a day for the full 7
days, and follow up with your primary care doctor.
If you develop worsening redness, pain, or weakness, please
return to the hospital. | ___ with PMH of HCV (last viral load ___ HCV 896,000), IVDU
(last use 4 months ago), anxiety, depression presents with rash
on R hand and streaks up his arm.
# Lymphangitis: Patient relays history of minor trauma in distal
skin area (bed bugs leading to exoriations and open lesions in
fingers and dorsum area of hand) and characteristic streaks
leading to proximal lymph nodes, which was suspicious for
lymphangitis. Patient had a low grade fever and leukocytosis but
was hemodynamically stable. Contact dermatitis from gloves less
likely as rash is only unilateral and not in distribution of
gloves. Necrotizing fasciitis in differential but has no signs
of tissue gas formation on x-ray and no pain. He received two
doses of vancomycin with quick resolution of erythema and
streaking. He was discharged on Clindamycin 300mg PO TID, plan
for 7 day course (d1 = ___. Tylenol was used as needed
for pain.
# Rash: from bed bugs lesions. Was on hydrocortisone cream as
outpatient. Hydrocortisone 1% BID PRN was continued for
symptomatic relief. He has had his room evaluated and treated by
an exterminator.
# Hepatitis C: genotype 1, has not responded to Rebetron or
Ribavirin in the past. He has a scheduled appointment with liver
in ___ for retreatment with the newer drugs.
# History of Substance Abuse: including cocaine, heroine,
methadone, and benzodiazepines. Reports last use of illicit
drugs was ___.
# Depression: continued home celexa and doxepin
# GERD: continued home famotidine
TRANSITIONAL ISSUES
- Complete course of clindamycin | 95 | 253 |
12577235-DS-4 | 29,020,376 | Dear Mr. ___,
It was a pleasure caring for you! You came to the hospital
because you were feeling unwell and having difficulty breathing.
You were found to have fluid around your lungs, which was
infected. A tube was placed in your chest to drain the infected
fluid. You were also given medicine to treat the infection. You
improved with the medicine and tube in your chest. The tube was
removed and you did very well. You were able to go home with a
medicine that will help you continue to treat your infection.
You will also be using supplemental oxygen at home during the
day started during your hospitalization.
It is very important that you finish all of the medicine that we
have prescribed you.
It is also very important that you follow-up with your primary
doctor and the lung doctors. ___ have scheduled the appointments
for you and you can see the details below.
It was a pleasure caring for you!
Sincerely,
Your Medical Team | ___ PMHx down syndrome, dementia, PNA (in ___ c/b effusions
requiring drainage, presented with 1 week of fevers, chills,
SOB, admitted for strep viridians empyema requiring chest tube
placement.
# EMPYEMA
# SEPSIS
Patient presented to ___ with malaise, cough,
dyspnea and subjective fever x 1 week. He was hypoxemic w/ SpO2
to low ___, WBC count > 30. Imaging showed left-sided empyema
with loculations. Received Zosyn and Levoquin and was
transferred to ___. Patient was continued on vancomycin/Zosyn
on arrival to ___. He had a chest tube placed on ___ with >
1.4L purulent drainage. Cultures grew Strep Viridans so his abx
coverage was narrowed to ceftriaxone on ___. Patient clinically
improved. His white cell count decreased (11 on discharge from
30 on admission). His chest tube was removed on ___. Patient
was discharged on a course of augmentin for 14 days. He will
follow-up with interventional pulmonology in two weeks after
discharge.
[ ] Continue augmentin for 14 days, consider extending to 4 to 6
weeks
[ ] Follow-up WBC count
# HYPOXEMIA: Patient presented with SpO2 in the low 80%s
secondary to his empyema. He initially required 4L nasal cannula
which was able to be reduced to 2L nasal cannula after chest
tube placement. Patient remained on 2L O2 during remainder of
hospitalization and discharged with home oxygen.
[ ] Follow-up oxygen saturation and wean oxygen supplementation
as tolerated for goal O2>92%
# Increased INR:
INR was 1.4 on admission. It was thought to be related to his
acute infection. INR downtrended with treatment of infection to
1.2 at time of discharge.
[ ] Follow-up INR as outpatient
CHRONIC ISSUES:
# Gout: continued allopurinol
# Hypothyroidism: continued synthroid
# Down syndrome: Continued Aricept
# Peripheral edema: held furosemide ISO infection
======================
TRANSITIONAL ISSUES:
======================
NEW MEDICATIONS:
[ ] Amoxicillin-Clavulanic Acid ___ mg PO Q12H for 14 days,
consider extending to 4 to 6 weeks
MEDICATION CHANGES:
[ ] Furosemide HELD due to infection and low blood pressures,
re-start as outpatient
ITEMS FOR FOLLOW-UP:
[ ] Follow-up WBC count as outpatient (11 on discharge)
[ ] Follow-up INR as outpatient (1.2 on discharge)
[ ] Follow-up oxygen saturation and wean oxygen supplementation
as tolerated
# CODE: full (presumed)
# CONTACT: ___ - house ___ of ___ -
___ | 167 | 379 |
12970119-DS-24 | 22,233,281 | Mr. ___,
You were admitted at ___ for management of bloody stools. We
transfused blood products and performed endoscopy (EGD) to look
for a source of the bleeding. While we found some enlarged blood
vessels in your esophagus (varices) and a nodular area in the
duodenum, we did not find a definite source of your bleeding.
Because of this, we would like to look again in ___ months. We
recommend changing your blood thinner due to the difficulties of
warfarin. | #GIB
#Acute blood loss anemia on anemia of chronic disease
(originally w/ melena and hematochezia): In the setting of C.
difficile infection. EGD was preformed which did not find a
source of bleeding. No biopsy taken of duodenal nodularity so as
not to confound bleeding situation. Stool H. pylori was negative
(though patient on PPI). As the bleeding has stopped,
anticoagulation was restarted and the patient monitored. No
further bleeding was seen. He will continue high dose omeprazole
for 8 weeks before resuming his home dose. He received 3 U pRBC
total.
#EtOH cirrhosis: Decompensated by grade I EV and GAVE ___.
With ongoing EtOH use. Has not kept outpt hepatology
appointments. RUQ US shows cirrhotic liver with suspected
sequela of portal hypertension including
mild splenomegaly and trace ascites in the right lower quadrant.
V: trace ascites on US
I: no known prior hx SBP
B: Small and moderate varices, started coreg, currently 6.25 mg
BID
E: no current or known prior hx HE
S: US for ___ screening as above (noncon CT done ___
insensitive)
- Hep A/B immune
#Recurrent C. difficile enterocolitis: Previously treated w/
Vanc in ___. Back on Vanc 125 mg PO QID for 14- day course.
Bowel movements have improved. CT AP w/out any acute finding.
#Acute on chronic renal failure III: ___ due to volume loss. Cr
now back to baseline. Avoid nephrotoxins.
# Chr. thrombocytopenia: Secondary to splenomegaly and use.
# A.fib/ flutter: Changed to coreg as above given varices.
Anticoagulation changed to apixaban 5 mg BID as patient was not
adherent to warfarin and INR testing (presented with
supratherapeutic INR)
# DM II: Adjusted Lantus and meal-time Humalog to 12 U and 4 U,
respectively.
# Chronic systolic CHF: Resuming torsemide given improvement in
bowel movements. Metoprolol changed to Coreg as above. Also on
isosorbde and hydral. Patient has not been on ACE-I/ ___ per
cardiology notes
# Hx CAD: Continue statin. Okay to resume ASA per hepatology.
Patient no longer on ticagrelor per last ___ discharge summary
# Alcohol abuse: Counselled. On acamprosate as outpatient
# Tobacco abuse: Counselled. Declines nicotine patch
Mr. ___. was seen and examined on the day of discharge and
is clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. | 79 | 370 |
19860038-DS-20 | 21,195,941 | Dear Ms ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED?
========================
You were brought to the hospital with confusion. We believe that
the confusion was caused by your trouble breathing from all of
the fluid in your lungs.
WHAT HAPPENED WHILE I WAS HERE?
=================================
We treated you for pneumonia, in case you also have a pneumonia.
We gave you medications to help eliminate the fluid from your
lungs.
You were discharged back to ___ where you have been living.
We wish you the very best,
Your ___ Care team | ___ year old Farsi speaking female with a history of HFpEF, AS,
MR, multifactorial gait disorder, and hypothyroidism presenting
with ethargy and dyspnea from ___ being admitted to ___
for HFpEF exacerbation. Being treated for aspiration pneumonia
vs HFpEF exacerbation.
ACUTE ISSUE
============
# HFpEF Exacerbation
# Possible Aspiration PNA
# Altered mental status
Patient with history of HFpEF (last EF 55% in ___ found to
be dyspneic at her nursing home with new oxygen requirement. CXR
significant for moderate edema and possible left lower lobe
consolidation. Bibasilar crackles present on exam with a new
oxygen requirement likely representing CHF exacerbation. Could
also be PNA in setting of aspiration given fluctuating mental
status. She was noted to be hypercarbic as well. A CXR was
performed which did not show any new process aside from known
edema. A NCHCT was negative for any acute changes. Troponins and
BNP were elevated, likely in the setting of demand ischemia.
A bumex drip was initiated, with boluses in addition to help
with diuresis, and over the 24 hours that she was here, her
mental status did slightly improve however she became
progressively hypercarbic.
Her HCP was notified of the situation, and did NOT want the
patient to receive supplemental positive pressure ventilation.
She was therefore diuresed as aggressively as possible to aid in
her oxygenation. We did continue broad treatment for aspiration
PNA vs CAP as the patient was noted to be continuously
aspirating while here, and after further conversation from the
living facility, she has been aspirating for some time.
The patients HCP requested a transfer back to ___ with
hospice services as she expressed that the patient would not
want to be in the hospital at all, even if we were to be able to
remove additional volume with IV diuresis as the hypercarbia
needs positive pressure ventilation and this is not within her
goals of care, and that she wanted the patient to be transferred
back to ___ as expeditiously as possible. IV access was lost
overnight in the hospital as the patient was and was not
replaced in keeping with her goals of care.
A careful and thoughtful review of her medications was done with
the pharmacist, patient's daughter and the hospice agency in
order to maximize the smoothest transition.
================
CHRONIC ISSUES:
===============
#Coronary artery disease
#Hyperlipidemia
Discontinue home aspirin and statin
#Hypothyroid
- Continue home levothyroxine
#GERD
Discontinue home famotidine (dose reduced given CrCl)
#B12 deficiency/nutrition
Hold Cyanocobalamin 1000 mcg IM/SC QMONTHLY
Discontinue Multivitamins W/minerals 1 TAB PO DAILY
CODE: DNR/DNI/NO TRANSFER TO THE ICU. NO ESCALATION OF CARE
CONTACT: Daughter ___ ___ | 88 | 442 |
19763129-DS-18 | 26,964,023 | You have been admitted with an enlarged spleen and increased
white blood count that could be chronic lymphocytic leukemia.
You have been seen by an oncologist who has recommended further
testing that will be followed up as an outpatient. You will be
contacted by ___ oncology for a follow-up appointment this
week. | ___ yoM with h/o TMJ who presents with leukocytosis to 173K,
splenomegaly, and pelvic adenopathy.
# Leukocytosis: Most likely CLL given constellation of
leukocytosis that is lymphocyte-predominant, splenomegaly and
adenopathy. Heme/onc reviewed peripheral smear and is c/w this.
Other potential diagnoses are hairy cell leukemia, mantle cell
lymphoma, lymphoplasmacytic lymphoma. No current signs of
leukostasis or tumor lysis. ___ have aggressive disease given
likely short doubling time given near normal CBC ___ year ago.
Uric acid, LDH, LFTs normal. SPEP and flow cytometry pending.
___ heme/onc was consulted and recommended sending DAT, HCV and
HBV serologies, peripheral cytogenetics and FISH, and HIV. If
diagnosis is uncertain as ___ be considered for bone
marrow biopsy.
# TM: Home Vicodin, gabapentin
# FEN: No IVF, replete electrolytes, regular diet
# PPX: Subcutaneous heparin, senna/colace, pain meds
# ACCESS: Peripherals
# CODE: Full code
# CONTACT: ___ is friend ___ in ___ ___
# DISPO: Home | 52 | 160 |
10189149-DS-18 | 20,717,975 | Dear Ms. ___,
You were hospitalized due to symptoms of confusion resulting
from an ACUTE HEMORRHAGIC STROKE, a condition where a blood
vessel bleeds into your brain. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High Blood Pressure.
Please take your other medications as prescribed. We have
stopped your cholesterol medication pravastatin as this can
increase your risk of bleeding for the next three months. We
will re-start this medication in 3-months when you come to see
us in the neurology clinic.
We have scheduled you for a neurology appointment with Dr.
___ on ___.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is an ___ woman with Alzheimer's disease,
hypertension, diastolic heart failure, type A aortic dissection
s/p endovascular stent graft c/b popliteal artery occlusion,
lumbar spinal stenosis and osteoarthritis presenting with one
week of altered mental status and found to have a right lobar
intraparenchymal hemorrhage.
#Right temporoparietal IPH
Patient presented with one week of altered mental status and was
found to have right lobar intraparenchymal hemorrhage. Given
history of Alzheimer's, there was concern for amyloid angiopathy
though MRI did not show any evidence of microbleeds. Suspect
hypertensive bleed given SBP 190s on admission to ED. CT also
with chronic microvascular angiopathy and encephalomalacia in
the
left parietal and occipital lobes. Continued on home
antihypertensives for goal SBP<150. Hold ASA, NSAIDs, other
anti-platelet agents
-Her statin was also held and should not be re-started until 3
months post bleed.
#Alzheimer's Dementia
Physical examination notable for waxing and waning mental
status. She was continued on donepezil 5mg daily and gabapentin
100mg qHS. She was also given quietapine 6.25mg PRN for
agitation. She was given a one time dose of 12.5mg Seroquel
which caused too much sedation.
#Lumbar stenosis
Physical examination notable for lower extremity hyperreflexia
likely secondary to severe lumbar spinal stenosis. Concern for
deconditioning secondary to pain, age and generalized weakness
on
exam. Will need rehabilitation for physical therapy.
#Hypertension
SBP 190s on admission briefly requiring nicarpine gtt. SBPs have
been 100s on home medications of carvedilol 25mg BID, furosemide
40mg daily and losartan 100mg daily. His furosemide was stopped
while she was refusing PO. Resume when patient is taking
adequate fluids.
#Type A Aortic dissection s/p endovascular repair
- Continue afterload reduction with carvedilol. Holding
pravastatin given her hemorrhage
#ID
UA dirty without leuks; urine culture ___
negative. Discontinued nitrofurantoin. | 306 | 273 |
13365002-DS-29 | 23,428,029 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for abdominal pain and decreased
oral intake. You were treated with IV fluids, bowel rest and
pain medication and your symptoms improved. You had an endoscopy
and a colonoscopy which found an ulcer in your esophagus as well
as at the site of your previous gastric bypass. This may be
contributing to your abdominal pain and decreased ability to
eat.
You were started on twice daily Protonix and sucralfate slurry
four times a day which are new medications for you to treat your
ulcers. Please add these to the medications you take daily. You
were given an iron infusion before you left the hospital to help
with your anemia. Please continue to take your other medications
as you have been doing. Attend all follow up appointments as
below. | ___ hx of gastric bypass ___ with recent intraabdominal fluid
collect s/p IV abx and recent tachycardia, weight loss,
dizziness, and weakness consistent with failure to thrive.
# Failure to thrive, nausea: Pt reports severe nausea w/ PO
intake and reports loss of 10lb over the last ___ weeks. General
surgery saw Pt in ED and felt that she was stable and did not
require surgical intervention. They felt that CT abdomen was not
necessary. Also, her pain seems be in a similar location to her
prior fluid collection. GI was consulted and an ___ was
performed which showed clean-based ulcer in esophagus and at
anastomosis. Recommendations following procedure include twice
daily PPI and sucralfate. Nutrition consult was placed and
recommended Ensure TID with meals. The patient's symptoms
gradually improved with hydration and bowel rest. She will
follow up with Dr. ___ as an outpatient.
# Suboxone therapy/h/o addiction: Pt states that she is taking
her suboxone 4x daily rather than the 1x daily that she is
recorded as having been prescribed, although this is prescribed
by a ___ practitioner, Dr. ___ at ___. If she is
indeed taking 4x her prescribed dose of suboxone, opiate
toxicity could potentially be an exacerbant of her nausea. Her
dose was clarified with outpatient provider ___ at
___ to be 8mg q6 hours and the patient was continued on
this dose while inpatient.
# Palpitations: unclear etiology, but Pt was tachycardic on
presentation and on the floor. She was monitored on telemetry
# gastric wall edema/esophageal thickening: EGD and colonoscopy
were performed, results described above.
# normocytic anemia: Hct currently at 32.9; recent baseline
___, low ___ for much of ___. Pt's Hct may be
hemoconcentrated given dehydrated appearance. Recent iron
studies w/ low iron at 11, low normal ferritin at 16, low TRF
110, suggestive of iron deficiency / malnutrition. The patient's
hematocrit was monitored during admission and she was given an
Fe transfusion prior to discharge.
# smoking history / COPD: home albuterol and
fluticasone-salmeterol. She was given a nicotine patch while
inpatient
# GERD: home pantoprazole, increased to BID dosing with findings
on EGD.
# muscles cramps: home methocarbamol
# depression: home buspirone, duloxetine, quetiapine
# anxiety: home haloperidol prn, although Pt's tremulousness may
be a reflection of extrapyramidal side-effects of long-term
antipsychotic use.
# insomnia: home trazodone
TRANSITIONAL ISSUES:
-will need biopsies followed up with Dr. ___ need to continue outpatient iron transfusions | 145 | 393 |
13201364-DS-7 | 28,822,655 | Dear Mr. ___,
It was a pleasure taking care of you.
You were admitted to the ___
for chest discomfort and shortness of breath. We performed a
stress test to evaluate the condition of your heart which came
back normal. Your chest discomfort resolved and you were well
enough to be discharged home. You will follow up with your
primary care doctor within the next week.
Please continue to take all of your medications as previously
prescribed. | [] BRIEF CLINICAL COURSE:
___ y/o Male w/ PMH of HTN who presented to the ___ after onset of
an episode in which he experienced chest pressure, bilateral
upper extremity numbness and tingling, shortness of breath, and
diaphoresis while in the car with his son. CTA chest was
negative for PE, and stress echo was normal.
.
#Chest Pain NOS: unclear etiology of event. ___ represent
episode of angina, but patient has no history of such episodes.
Hypertension is his only CAD risk factor ___ his normal HgA1C
and normal lipid panel and no history of tobacco use. As such
there was no indication for heparin gtt in setting of negative
cardiac enzymes. No evidence of pulmonary embolism on CTA of
the chest. Alternatively could represent anxiety vs other
neurologic process, although the history is not consistent with
complex seizure ___ lack of post ictal period. The patient
was prophylactically placed on ASA 325mg daily while
hospitalized. Stress Echo testing on the day of discharge was
normal. Thus, the patient was discharged home in good
condition, asymptomatic, with PCP follow ___. ___ his lack of
cardiac risk factors, he was not started on prophylactic ASA or
other anticoagulation
.
#HTN: We continued the patient on his home dose of 25mg PO HCTZ
daily. During this admission, the patient remained normotensive
on floor with SBPs in the range of 110-135.
.
[]TRANSITIONAL ISSUES:
NONE | 79 | 242 |
17160384-DS-20 | 20,831,443 | You were admitted for cellulitis of your fight foot and leg.
You were also found to have an abscess which was drained by
podiatry. You were treated with antibiotics. Your blood sugars
were also very high and your insulin dosing was adjusted. | ___ yo man with IDDM, CAD s/p stent, with recurrent bilateral
foot infections presents with at cellulitis of right foot
extending up leg and abscess s/p drainage on ___.
# Diabetic Foot Cellulitis with abscess, growing out MRSA and
pseudomonas: Presents with marked cellulitis and fluid
collection near right hallux. S/p abscess drainage of right
foot by podiatry on ___. ESR only mildly elevated to 31. Xray
shows no acute osteo. Podiatry thinks that MRI not necessary.
No probe to bone on exam. Started on vanco and unasyn with
marked improvement of cellulitis. Cultures returned with MRSA
sensitive to bactrim and pseudomonas sensitive to cipro.
Switched on ___ to bactrim and cipro. Bactrim to take through
___. Cipro to take through ___.
- ___ off loading shoe
- Outpt follow up with podiatry
# IDDM w/ complications: Very uncontrolled ___ setting of dietary
noncompliance, frequent snacking, and infection. Pt followed by
___ as outpt and seen by ___ here. Pt was switched to
lantus BID, and increased to more aggressive carb counting and
correction factor ratios. Glucoses very much improved
# CAD s/p MI and stent:
- Plavix and aspirin
- Metoprolol
- Lisinopril
- Statin
# HX GI bleed: Continue PPI
# Psoriasis: Continue home creams
# BPH: Continue flomax
# Anemia: Chronic.
# CKD: Baseline is 1.6
Transitional: Follow up of right groin enlarged LN, most likely
due to infection
FEN: Diabetic diet
Prophy: Heparin SQ
Code: Full confirmed
Dispo: Screening for placement tomorrow
___
___ | 45 | 240 |
11294494-DS-15 | 27,744,412 | Dear Mr. ___,
You were admitted to ___
after experiencing shortness of breath and cough. You underwent
imaging of you chest (CT Scan) which showed a blood clot ___ your
lungs (pulmonary embolus). ___ order to treat the blood clot we
will send you home on a medicine called enoxoparin. You will
need to give yourself injections twice a day. This helped
stabilize the blood clot ___ your lung. Your breathing improved
significantly with this medication. Please continue with the
injections of the enoxoparin twice a day.
During the hospitalization we also treated you for an infection
___ your lung or pneumonia. ___ order to treat the pneumonia you
were started on intravenous antibiotics and transitioned you to
oral antibiotics why the time you left. You were seen by the
lung doctors (___) as well as infectious disease
specialists. They recommended you continue augmentin twice a
day. We would like you to continue this medication with end date
___. Additionally to determine what was the cause of the
cavitary lesion, the interventional pulmonologists would like
you to undergo another imaging of your chest (CT imaging) ___
approximately three weeks. They would also like to follow-up
with you ___ the interventional pulmonology clinic following the
repeat imaging of your chest. They will help schedule the CT
imaging as well as the clinic appointment. They would also like
you to follow-up with the general lung doctor (___)
___ approximately 5 weeks.
It is very important that you obtain the repeat imaging and
attend every follow-up appointment as the cause of the cavitary
lesion ___ the lung is currently not known without an
interventional procedure. Possible causes include infection
versus a cancer. Thus it is very important to follow-up with
these appointments ___ the coming weeks.
We stopped your prednisone as well as enbrel for your rheumatoid
arthritis as you were suspected to have had an infection.
Please follow up with your rheumatologist and primary care
physician to determine if it is appropriate to restart these
medications.
It was a pleasure taking care of you during your
hospitalization!
Sincerely,
Your ___ Team | Mr. ___ is a ___ gentleman with a hx of CAD, RA on
Enbril, presenting from an outside hospital found to have PE and
cavitary pneumonia.
# RIGHT SIDED PULMONARY EMBOLUS: Mr. ___ had a CT imaging
consistent with pulmonary embolus. This PE was on the right
side. ___ order to treat the PE, he was started on a heparin drip
with subsequent bridging to warfarin. At the time of discharge
his INR was 3.2, with greater than 24 hours of therapeutic range
INR. At the time of discharge he was transitioned to lovenox
given that we expected that he would need to return for IP
procedure ___ a few weeks and we felt that it would be easier to
bridge with lovenox than warfarin. He received lovenox teaching
___ the hospital, and was discharged on lovenox for
anticoagulation ___ the setting of the pulmonary embolus. He was
told not to stop anticoagulation without speaking to a physician
and also told that he would be switched to oral anticoagulation
after the procedure. Of note, he did undergo duplex ultrasound
of the lower extremities which did not reveal any thrombus
present. No heart strain on ECG.
# CAVITARY LESION: Patient's CT and CXR showed cavitary lesion
___ the right lung. Initially thought to be due to cavitary
pneumonia superinfected after lung necrosis from the pulmonary
embolus. However there is also concern for malignancy. CT
findings indicated "Pulmonary embolism within the right main
pulmonary artery extending intosegmental branches. Large right
upper lobe cavitary lesion measuring 6.3 x 5.3 cm, diffuse
patchy ground-glass opacities ___ the bilateral lobes and
multiple enlargedmediastinal lymph nodes. Constellation of
findings is suspicious forinfectious process including
tuberculosis though malignancy such as squamouscell carcinoma is
not fully excluded." He was started on vancomycin and
piperacillin-tazobactam. Given his rheumatoid arthritis therapy
with enbrel and prednisone, risk for fungal infection was
present. Both interventional pulmonology and general pulmonology
were consulted. Sputum smears were negative for acid fast
bacilli. Quantiferon gold was indeterminate. Cryptococcal
antigen was negative. Aspergillus galactomannan antigen
negative. Beta glucan was positive although patient was on a
beta lactam (piperacillin-tazobactam), which could lead to false
positive result. Histoplasma antigen was pending. Sputum culture
showed sparse growth commensal respiratory flora. Blood cultures
showed no fungus or mycobacterium present. CMV IgG and IgM were
negative. Sputum ___ showed budding yeast with pseudohyphae with
preliminary fungal culture growing yeast. Preliminary nocardia
culture showed no nocardia isolated. MTB direct amplification
was sent to state lab for further identification. Acid fast
smear was negative. Interventional pulmonary was consulted and
recommended a repeat CT image of the chest (scheduled for
___ to determine if the cavitary lesion improved
with antibiotics. At that time, consideration for a bronchoscopy
with biopsy of the lesion/lymph nodes will be critical to
determine etiology of the cavitary lesion and mediastinal
lymphadenopathy. Additionally obtaining sputum cytology may be
critical ___ the future to determine the cause of the lesion.
Decision was made not to do bronchoscopy with lymph node biopsy
___ the hospital setting given the acute pulmonary embolus and
risk for progression while holding anticoagulation for the
procedure. Infectious disease was consulted who recommended
transition from vancomycin/piperacillin-tazobactam to Augmentin
875 mg PO BID for a total antibiotic course of 14 days (end date
___. Follow-up on this cavitary lesion will be
critical, as there is still concern for malignancy given his
smoking history and CT findings concerning for squamous cell
cancer.
# Odynophagia/Dysphagia: Patient reported significant substernal
discomfort after eating as well as significant weight loss over
the past four months. Concern for malignancy was present given
the CT findings and dysphagia with weight loss.We obtained video
swallow and barium esophagram which only showed distal
esophageal spasm without obstruction or stricture. His PCPs
office was called and noted that he had a EGD one month prior
that did not show obstruction or mass.
# RHEUMATOID ARTHRITIS: Patient was on enbrel and prednisone for
rheumatoid arthritis. Initially he was continued on these
medications, however, given the possibility of infection, they
were stopped. The prednisone was restarted on discharge (pt was
called and asked to restart the med, although not listed on dc
med list).
# CORONARY ARTERY DISEASE: patient has history of CAD with 2
previous MIs with stent placements. These occurred ___ ___ and
___. Continued home dose aspirin, metoprolol, and atorvastatin.
# CHRONIC PAIN: continued with his home dose gabapentin 800 mg
Q8H as well as his home oxycodone-acetaminophen.
# GASTROESOPHAGEAL REFLUX DISEASE: continued home omeprazole 20
mg PO daily.
# OBSTRUCTIVE SLEEP APNEA: Uses CPAP at home. Continued with
CPAP during hospitalization.
TRANSITIONAL
============
#Please follow-up with appointment for your CT scan of your
chest which will be scheduled by the Interventional Pulmonology
team (___). Please also follow up with the
Interventional Pulmonary team ___ clinic. They will help schedule
all of these appointments for your within the next three weeks.
It will be critical to follow-up with these appointments as
malignancy is still on the differential of this cavitary lung
lesion.
#There are numerous oustanding laboratory data as noted above.
Please follow-up the results of the Quantiferon-TB Gold,
Histoplasma antigen, Sputum fungal culture; nocardia culture,
MTB direct amplification, Acid Fast Smear, Acid Fast Culture,
Blood CMV AB, CMV IgG antibody, CMV IgM antibody, sputum acid
fast cultures, as well as blood cultures.
#INTERVENTIONAL PULMONARY: When biopsy is done, please ensure
gram stain, aerobic + anaerobic cultures, fungal culture,
acid-fast bacilli smear and culture, MTB PCR, Nocardia smear and
culture.
#FOLLOW-UP RESULTS: Please follow-up results of the fungal
culture as was growing budding yeast with pseudohyphae.
#HYPERCOAGULABLE WORKUP: please consider hypercoagulable workup
given the lack of inciting factor for the pulmonary embolus.
#ANTICOAGULATION: pt will need to be transitioned from lovenox
to coumadin after biopsy.
#CODE STATUS: FULL CODE
#CONTACT: ___ (wife) ___ | 345 | 975 |
18605511-DS-7 | 21,984,987 | Dear Mr. ___,
You were hospitalized due to symptoms of left sided 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. You underwent a procedure called
thrombectomy where a catheter was used to unclog the clot
blocking the blood supply in your brain. Your symptoms
significantly improved following the procedure.
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:
Atrial septal defect/PFO
After the above procedure for your stroke, you were found to
have seizures involving your left side of face and arm. Seizures
are abnormal electrical activity in your brain for which you
were taking medication at home. We suspected that this was due
to you missing a dose of your seizure medications prior to
arrival and in the setting of a new stroke. You required
assistance with breathing and a breathing tube was placed and
were closely monitored in an ICU. You were started on your home
medications Lamotrigine, Topamax and a medication called
Leviteracetam (KEPPRA) was added. Your seizures were well
controlled with these medications.
We are changing your medications as follows:
Added:
Keppra 1000mg oral twice daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | This is a ___ year old man with history of developmental delay
and lasting cognitive impairment, prior brain abscess, epilepsy,
bipolar disorder, and drug-induced parkinsonism who presented to
the hospital with left facial and left-sided weakness. Imaging
on arrival showed right M1 thrombus and he underwent mechanical
thrombectomy with subsequent TICI IIB reperfusion. His motor
deficit improved after the procedure. etiology of stroke
unclear, likely cardio-embolic given clear carotids.
# Right M1 Thrombus s/p thrombectomy at ___ at 1249PM
His deficit significantly improved following thrombectomy. He
was intubated for seizure control following the procedure and
neurological exam after extubation showed improvement compared
to previous. He had residual left upper extremity proximal
greater than distal weakness and left facial droop, mild
dysarthria. He was started on aspirin, Plavix and atorvastatin.
Stroke work-up showed HgbA1c -5.4%, LDL 114, TTE showed atrial
septal defect with right-to-left shunt, no visible thrombus.
Normal EF and PA pressures. lower extremity Dopplers ultrasound
and pelvic CTV did not show any evidence of DVT. TEE was
obtained which showed large ASD-atrial septal aneurysm with
large PFO, measurements taken. We will refer to structural
heart disease clinic for follow-up as outpatient. No evidence
of atrial fibrillation on telemetry monitoring, ZIO Patch
ordered at discharge. ___ OT and speech therapy were consulted,
he participated well. Initially he was on a modified diet,
later advanced to regular consistency with thin liquids,
one-to-one supervision and meds crushed per speech therapy
recommendation. He is being transferred to inpatient rehab for
continuation of ___ OT. He will continue on ASA and Plavix.
#Seizure disorder with breakthrough seizure
Post-procedure he developed breakthrough seizures, likely
etiology related to stroke and lower seizure threshold given
missed AM seizure medications. He developed a cluster of focal
seizures with left facial and left arm twitching, received
multiple doses of IV Ativan and was intubated for further
control of seizures. His home medications lamotrigine and
Topamax were resumed per NG tube and he was started on IV Keppra
with good seizure control and ultimately was switched to PO (see
medications). Continuing all 3 antiepileptics at discharge.
#Respiratory failure
-Needed intubation for seizure control but also developed acute
pulmonary edema and vent associated pneumonia prolonging vent
requirement. He received PRN Lasix with improvement, did not
require any further doses after extubation. He was initially on
broad-spectrum antibiotics and sputum/BAL cultures grew MSSA.
Antibiotics tailored to cefazolin and completed a total 7-day
course during his stay in the hospital. He was asymptomatic,
breathing comfortably at room air at discharge | 371 | 432 |
13998526-DS-5 | 23,807,008 | discharge instructions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 4 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing in unlocked ___
Physical Therapy:
touch down weight bearing in unlocked ___
Treatments Frequency:
Dressing changes BID until wound is dry and clean | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF right femur, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is TDWB in unlocked ___ in the
RLE extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 175 | 237 |
13178657-DS-8 | 24,727,619 | Dear ___,
___ were hospitalized due to symptoms of speech difficulty
resulting from an TRANSIENT ISCHEMIC ATTACK, a condition where a
blood vessel providing oxygen and nutrients to the brain is
temporarily 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 ___ 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
-Artery plaque
We are changing your medications as follows:
-Starting aspirin 81mg daily for prevention of future stroke (we
have contacted your hepatologist and PCP about the addition of
this medication)
Please also:
-Attempt to eat low fat and salt foods to prevent artery plaque
formation
Please take your other medications as prescribed.
Please follow-up with Neurology and your primary care physician.
If ___ 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
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ with a past medical history of hepatitis C
and hypertension who presented ___ with acute onset aphasia (vs.
speech apraxia) and received tPA at an outside hospital (see HPI
for further details). She was then transferred to ___ for
further management. In the ED, pt had a STAT CTA/H/N which
showed mild plaque at aortic arch and ICA bifurcation
bilaterally but no high-grade stenosis or clot. Pt was then
admitted to the neurologic ICU for post-tPA care.
Overnight, pt clinically improved. On hospital day #2 (___),
pt's speech difficulties had resolved entirely and she had a
non-focal neurological examination. MRI did not reveal an acute
infarct and only showed small vessel ischemic
disease. At the time of discharge, it was felt that pt likely
had a TIA.
Her TIA was felt to be possibly due to an athero-embolus given
her plaque on CTA. Her echo was unremarkable and telemetry did
not show atrial fibrillation. She was discharged with ___ of
Hearts monitor to assess for paroxysmal atrial fibrillation.
At the time of discharge, for secondary stroke prevention, she
was started on aspirin 81mg daily. Both her hepatologist and PCP
were notified of this medication addition given her history of
cirrhosis (LFTs, coags, and platelets were normal). She was not
started on a statin due to her history of liver disease and her
LDL being only ___.
=
=
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 88) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
=========================
TRANSITIONS OF CARE
=========================
-Mrs. ___ presented with symptoms of speech difficulty
(expressive aphasia vs. speech apraxia). She received tPA and
symptoms notably improved. MRI did not reveal an acute infarct.
-She was presumed to have a TIA and was started on aspirin 81mg
at discharge for secondary stroke prevention. This information
was provided to Ms. ___ hepatologist, as Ms. ___ stated
she had not been on aspirin in the past due to hepatitis C
cirrhosis. Liver function tests and CBC were normal while in the
hospital.
-Source of her stroke was felt to be an embolus from either
atherosclerosis (there was mild plaque on her CTA head and neck)
or a cardiac source. Ms. ___ was discharged with ___ of
___ monitor to evaluate for paroxysmal arrhythmias; echo was
unremarkable and there was no arrhythmia on telemetry during her
hospitalization. LDL was 88; Ms. ___ was not started on a
statin due to her LDL not being significantly elevated and her
concurrent liver disease. | 293 | 615 |
17822224-DS-8 | 21,212,208 | Dear Mr ___,
You were admitted with symptoms of double vision and after a
clot was found in your right internal carotid artery. We tried
to get an MRI of your head and your neck arteries for further
evaluation, but since you were unable to lay flat for this, we
decided to perform an ultrasound of your carotid arteries
instead. This showed there was a soft plaque vs. thrombus in the
right internal carotid artery. You were started on Coumadin,
which you should take for 3 months, to help lower the stroke
risk from this clot. You will then need a repeat CT scan of the
arteries in your neck to see if the clot has stabilized.
Your double vision is due to ___ nerve palsy, which is likely
due to diabetes. You can use an eye patch, alternating between
eyes to help with the double vision. Dr. ___
neuro-ophthalmologist may also give you prism glasses.
Your shoulder pain and right sided proximal weakness is likely
from your diabetes resulting in a condition called diabetic
amytrophy. You were started on Percoet and Gabapentin to help
with pain control. You may need an EMG/NCS (nerve conduction
study) to help with diagnosis (though this should be done when
you are not on Coumadin).
Your diabetes is very poorly controlled and you will need to
make lifestyle, and likely medication changes as well. You were
started on insulin while in the hospital and you should schedule
___ follow-up as outpatient. | Mr ___ is a ___ yo RHM w/PMH of obesity (250 pounds), NIDDM,
HTN, HL,
Bell's palsy (not sure anymore which side of his face was
affected), now presenting with a dual chief complaint of
binocular diplopia (subjectively getting worse when he looks at
something in the distance) and R arm pain (in a stripe like
fashion from his neck over his shoulder into the back of his
upper arm), and incidentally discovered thrombus or soft plaque
in the R ICA, starting just prior to the bifurcation, followed
by a loop distally. He also has an anomaly in his posterior
circulation with having two connections between the right
vertebral artery and basilar artery. These three processes
appear to be independent from each other.
1. Regarding the ICA thrombus we wanted to perform MRI of the
head and MRA of the neck, but as he could not stay flat , it was
attemped, but he was not able to complete the MRI. Instead, we
performed carotid US which showed: soft plaque vs. thrombus in
the right internal carotid artery. He was started on Coumadin
and needs to continue that for 3 months with INR goal of ___
which will be managed by PCP.
2. Double vision: after evaluating the patient we found that he
has RIGHT ___ nerve palsy, most likely due to DM. He will also
be seen in ___ clinic after discharge to see if he
requires any additional management for this.
3. Right shoulder pain and proximal weakness: after he was
evaluated for other cause, we think it is due to diabetic
amyotrophy. He was started on Gabapentin and Percocet for pain
control.He may need EMG/NCV as an outpatient if his pain does
not improve and if he develops weakness.
4. DM: HbA1C: 10.6 which showed that his DM is poorly
controlled, we controlled his DM in hospital with insulin. He
needs to be followed in Justlin as an outpatient.
5. HTN: we continued home medications to control the BP and ASA | 252 | 333 |
12332796-DS-15 | 25,252,511 | Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hosptial with very high
blood pressures. We have been able to better control your blood
pressures using the current medication regimen we have
prescribed for you. It is important that you continue to take
your medications on a daily basis. We found that you have a mass
in your right adrenal gland. This is likely contributing to your
high blood pressure. We have scheduled follow up appointments
for you with the Endocrine and Kidney doctors that ___ have been
seeing in the hosptial. Dr. ___ (the surgeon you
met while in the hospital) will be contacting you with a follow
up appointment as well as scheduling you for an appointment with
a cardiologist for pre-operative clearance.
The following changes have been made to your medications:
NEW medications:
- Clonidine 0.1mg by mouth twice per day for blood pressure
control
CHANGES:
- Increased spironolactone to 200mg by mouth twice per day for
blood pressure control
It is very important that you keep your follow up appointments. | Mr. ___ is a ___ gentleman with HTN, DM2, CAD, recent
admission for HTN urgency who presents again in hypertensive
urgency.
# Hypertensive crisis: The pt was admitted with sbp's in 200s.
He had no new evidence of end organ damage. The pt had no EKG
changes, though he has CAD history and admited to chest pain
prior to admission. He was ruled out by cardiac enzymes. He did
complain of headache on admission but his neuro exam showed no
focal deficits and a head CT was negative for any acute process.
His creatinine on admission was at his baseline of 1.3-1.4. On
recent admission, he underwent work up for secondary causes of
hypertension. MRI/MRA of kidneys were preformed and showed renal
artery stenosis but Nephrology did not think the amount of
stenosis was clinically significant. He also underwent workup
for hyperaldosteronism due to hypokalemia and resistant
hypertension, which showed supppressed plasma renin activity.
Normal cosyntropin stimulated cortisol and aldosterone levels in
the serum, however, selective adrenal vein blood sampling
revealed massively elevated baseline and stimulated levels on
the right side, concerning for adrenal tumor. An CT of Ab/pelvis
showed a right adrenal adenoma measuring 11 x 9 x 9 mm. During
this admission his blood pressure was difficult to control.
Initially he was restarted on home dose labetalol 400 mg TID,
Lisinopril 20 mg BID (max dose), Amlodipine 10 mg QHS (max
dose), and Spironolactone 100 mg daily without adequate control
with BP continuing to be in 190/90s. Renal was consulted and
recommended increasing spironolactone to 200mg BID and we added
clonidine 0.1mg BID as well. Endocrine was consulted and
recommended we send out a plasma metanephrine to rule out a
pheochromocytoma. Surgery was also consulted and decided to
perform the surgery on an outpatient basis after
pheochromocytoma has been ruled out. Dr. ___
will be arranging follow up for surgery.
# Coronary Artery Disease, native vessel: Initially the pt was
complaining of chest pain. He was ruled out for having an MI
with negative cardiac enzymes and EKG. We continued him on
Lisinopril 20mg BID, Labetalol 400mg q8, Simvastatin 20mg and
ASA 81mg. His chest pain resolved once his blood pressure was
better controlled.
# Psych: Pt recently was admitted to psych hospital for suicide
attempt. During this hospitalization he denied any suicidal
intentions. We continued citalopram 30mg, trazodone 300mg qhs.
# DM2, uncontrolled, with complications: His glucose levels were
controlled using a Humalog insulin sliding scale during this
hospital admission.
# Anemia: Hct stably in mid ___ during this admission. MCV 85,
normal iron studies.
# Transitional issues: A plasma metanephrine level was ordered
during this admission and will need to be followed up after
discharge to rule out pheochromocytoma prior to surgery. He has
follow up appointments with endocrine and nephrology. Dr.
___ will contact pt on ___ following
discharge to arrange office appt for surgical scheduling and
also will arrange for cardiology pre-op as well. His office
number is ___.
***Would recommend follow-up of anemia (Hct 34.1 on discharge)
and creatinine (1.7 on discharge) in outpatient setting. | 176 | 516 |
19662586-DS-4 | 23,040,121 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were admitted with swelling in
your left foot and pain in your right foot. You were given
steroids and your symptoms improved. The Rheumatologists sampled
the fluid in your ankle and this showed signs consistent with
gout. Please continue taking the Prednisone according to the
following taper:
___: 50mg (5 pills)
___: 40mg (4 pills)
___: 30mg (3 pills)
___: 20mg (2 pills)
___: 10mg (1 pill)
___: 5mg ___ pill)
___: Stop
You will also start taking the medications Colchicine and
Allopurinol daily, which will help to prevent gout attacks in
the future.
Please follow up with your nephrologist on ___ and
discuss whether or not it is safe to resume taking your NSAIDs.
If you are in pain, it is safe to take Tylenol.
We wish you the best,
Your ___ Treatment Team | ___ year old with chronic C4 glomerulopathy and proteinuria
presenting with a polyarticular inflammatory arthritis, also
found to have ___.
ACTIVE ISSUES
=============
# Acute Gouty Polyrthritis: Left foot swelling with isolated
tenderness to left MTP and also right MTP joints was most
consistent with gout. He was evaluated by orthopedics and
vascular surgery in the ED, given elevated D dimer on outpatient
labs. Left lower extremity dopplers were negative for DVT. There
was low suspicion for septic joint. Rheumatology was consulted.
Arthrocenteis was performed with negative ___, <50,000 WBC, and
needle Monosodium Urate Crystals with negative birefrig
consistent with gout flare. He was given 60mg PO Prednisone with
improvement in his swelling and pain. He was discharged on a PO
prednisone taper, with initiation of colchicine and allopurinol
daily for gout prophylaxis. He will have follow up with a
rheumatologist at ___ as an outpatient. CCP was negative (<16),
RF was 20 and Urine GC/Chlamydia was negative. Joint fluid
culture results were pending at the time of discharge but were
preliminarily no growth.
# ___ on CKD, C3 GN: Pt presented with Cr 1.6 from baseline 1.3
in the setting of recent NSAID use and inflammatory arthritis.
Cr returned to baseline s/p IVF and holding NSAIDS. Home
lisinopril was restarted and he was set up to see a nephrologist
in the outpatient setting on ___. Protein/Cr ratio was elevated
at 12.3 on admission, to be follow up on the day after discharge
in Nephrology as an outpatient.
CHRONIC ISSUES
==============
# Hypertension: Continued home lisinopril
# Nasal congestion: Continued home Flonase
TRANSITIONAL ISSUES
===================
# Gout/Rheumatology
- Final joint fluid culture pending at discharge
- Patient will need Rheumatology follow up upon discharge, to be
arranged by PCP through ___.
- Started on daily colchicine 0.6mg and allopurinol ___ for
prophylaxis. To be continued daily unless otherwise directed in
Rheumatology follow up.
- Recommend eating red meat and drinking alcohol in moderation
to avoid precipitating gout attacks.
- Prednisone taper
___: 50mg
___: 40mg
___: 30mg
___: 20mg
___: 10mg
___: 5mg
___: Stop
# C3 glomerulopathy and proteinuria
- Patient with scheduled Nephrology follow up on ___
- Holing NSAIDs on discharge
# CONTACT: ___ (partner) ___
# CODE STATUS: Full code | 146 | 370 |
13431504-DS-10 | 29,736,114 | Dear ___,
You were admitted with severe abdominal pain after not taking
your stool softeners for two days. As you are taking opioid pain
medications, you are at significant risk of getting constipated.
Please follow up with your primary care provider to continue to
address this problem.
Please take your stool softeners daily. If you start to have
constipation, speak with your primary care doctor before
stopping your stool softeners.
It was a pleasure taking care of you,
Your ___ Team | Summary: ___ hx scleroderma, hypertension, hyperlipidemia, gout,
chronic back pain, chronic abdominal pain p/w acute abdominal
pain also found to have acute kidney injury.
#Abdominal pain - Patient presented with more severe abdominal
pain than baseline in the setting of stopping his home stool
softeners. CT A/P with no evidence of rupture of his known
abdominal aneurysms. He reported his pain as chronic and
episodic. He was given an aggressive bowel regimen that included
magnesium citrate, enemas (soap ___ and tap water) and
methylnaltrexone. He had soft bowel movements and resolution of
his abdominal distension on the morning of ___. His distension
increased but then improved on ___ after more bowel movements.
While constipated, patient was put on standing IVF. His pain was
controlled with his home Dilaudid and Fentanyl patch. His back
spasms were controlled with his home Flexeril.
#Testicular discomfort: On ___, patient developed sharp, sudden
testicular pain that radiated to his abdomen and back. He
reports that this pain is also chronic and intermittent and
feels as "if someone is kicking him in the testes." UA/Urine
gonorrhea/chlamydia were sent and were negative. Pain was
managed with his home medications, and pain receded by the end
of the day. No masses palpated, no testicular swelling.
#Scleroderma: Continued patient on home Plaquenil 200 mg PO
daily.
#Acute kidney injury - Paient's creatinine was 2.3 at admission
up from his baseline of 0.9. His creatinine improved with
fluids, patient counseled on staying hydrated during pain
episodes. UA was negative and blood pressure was within normal
limits so was not initially concerning for a scleroderma renal
crisis. Lisinopril was held in the setting of kidney injury.
#Eosinophilia - ABS eosinophil count >1000. Not clear etiology,
possibly related to scleroderma. Patient denies allergies,
unlikely parasitic infection. Eosinophlia resolved.
#Leukocytosis - no clear signs or symp of infection or acute
intra-abdominal process. CXR and UA clear. Likely reactive in
the
setting of pain and constipation, and has trended down with IVF
likely was dry/concentrated initially.
#Anemia - Hg now down to 10.5 (which appears to be patient's
baseline). As above likely was dry on admit, notably he is
anemic. Last c-scope was about ___ years ago. No signs or
symptoms of bleeding.
-continue ferrous sulfate 325 mg PO daily
-continue folic acid 1 mg daily
#Hyperlipidemia - c/w pravastatin 20 mg qpm
#Hypertension - Patient initially with low blood pressures and
some of his home medications were held. By discharge he was
restarted on all of his home medications including:
-c/w clonidine 0.1 mg PO BID
-continue labetalol 600 mg TID
-continue torsemide 20 mg daily
-continue lisinopril 40 mg daily
#Gout
-allopurinol ___ mg daily
#Chronic back and abdominal pain - as above c/w fentanyl,
dilaudid 4 mg PO q6h PRN, flexeril prn, venlafaxine 112.5 mg PO
daily,gabapentin 300 mg PO BID
#GERD - c/w omeprazole 20 mg daily
#Tobacco use
-continue nicotine patch 21 mg daily
#BPH
-continue tamsulosin 0.4 mg PO qhs
TRANSITIONAL ISSUES
-continued control of elevated blood pressure
-outpatient workup for anemia (likely ___ chronic inflammation
with scleroderma)
-repeat CBC w/differential to monitor eosinophil count
(currently wnl at discharge)
CONTINUE TAKING
Allopurinol ___ mg daily
Clonidine 0.1 mg PO BID
Cyclobenzaprine 20 mg TID PRN pain/back spasm
Fentanyl patch 100 mcg/hour every 72 hours
Folic Acid 1 mg daily
Gabapentin 300 mg BID
Dilaudid 4 mg every 6 hours PRN severe pain
Plaquenil 200 mg daily
Labetalol 600 mg TID
Lisinopril 40 mg daily
Nicotine Patch 21 mg daily
Omeprazole 20 mg daily
Miralax daily
Pravastatin 20 mg daily
Tamsulosin 0.4 mg at bedtime
Venlafazine XR 112.5 mg PO daily
CHANGED MEDICATIONS
Ferrous Sulfate 325 mg daily (not twice a day)
Restasis every 12 hours
Torsemide 20 mg daily
NEW MEDICATIONS
Senna
Bisacodyl PR
HOLD MEDICATIONS
Spironolactone 100 mg daily - in setting of hyperkalemia
More than 30 minutes were spent on discharge planning for this
page | 81 | 608 |
18252692-DS-9 | 23,548,797 | Dear Ms ___,
You were admitted to the hospital for the treatment of your
abdominal pain. You have underwent treatment and are now safe to
continue your recovery at home.
You were found to have hernias during this admission. A surgical
correction of the hernia is recommended and you have been
scheduled for surgery on ___. Please remain on bariatric
stage 5 diet through your surgery.
Please resume all of your medications unless specifically told
by your doctor to do otherwise.
Please call your surgeon or return to the Emergency Department
if you develop a fever greater than ___ F, shaking chills, chest
pain, difficulty breathing, pain with breathing, cough, a rapid
heartbeat, dizziness, severe abdominal pain, pain unrelieved by
your pain medication, a change in the nature or severity of your
pain, severe nausea, vomiting, abdominal bloating, severe
diarrhea, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness, swelling from your
incisions, or any other symptoms which are concerning to you.
Diet: Stay on Stage 5 diet until your follow up appointment;
please refer to your work book for detailed instructions. Do not
self- advance your diet and avoid drinking with a straw or
chewing gum. To avoid dehydration, remember to sip small amounts
of fluid frequently throughout the day to reach a goal of
approximately ___ mL per day. Please note the following signs
of dehydration: dry mouth, rapid heartbeat, feeling dizzy or
faint, dark colored urine, infrequent urination. | The patient presented to the ED on ___ for epigastric pain and
associated nausea/emesis. The patient was known to have multiple
incisional hernias and was seen by Dr. ___. She was scheduled
for the incisional hernia repair on ___. She stay in the
hospital until the day of the procedure for conservative
management of her epigastric pain and nausea/emesis.
The patient presented to pre-op on ___. Patient was evaluated
by anaesthesia. She was given a thoracic epidural prior to the
procedure for pain control.
The patient was taken to the operating room for a incisional
hernia repair with mesh underlay. There were no adverse events
in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and
epidural. Pain was well controlled. The patient was then
transitioned to a regular diet once she was able to tolerate it.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Afterwards, the
patient was started on a stage 3 bariatric diet, which the
patient tolerated well. Subsequently, the patient was advanced
to regular diet which the patient was tolerating on day of
discharge.
ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The epidural was removed on ___ and patient was
able to tolerate her pain on PO medications. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 245 | 392 |
16130199-DS-15 | 27,137,501 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with fever and worsening neck
pain shortly after diagnosis of a blood clot in your right
jugular vein. We started you on IV antibiotics because of
concern the clot was infected and continued you on
anticoagulation medication. After your your port was removed you
had significant improvement in your symptoms. There was growth
of bacteria on your port so will you be treated for a total of 4
weeks of IV antibiotics. You had a PICC line placed so this
could be done at home.
Please continue your home medications. Your simvastatin dose was
reduced to 10mg due to potential interaction with the antibiotic
(daptomycin).
Please follow up with your primary care doctor and your
oncologist.
Sincerely,
Your ___ Care Team | ___ PMH of MDS ___ 2 cycles of Decitabine, while awaiting
possible allogeneic transplant) ___ right IJ port (___) and
very recent diagnosis of right jugular vein thrombosis who was
admitted with fever, neck pain, and thrombophlebitis of the
right jugular vein. Imaging found extension of clot with
significant peripheral inflammation and reactive lymph nodes.
She was started on IV heparin and antibiotics. She had her port
removed on ___. After port removal she had significant
improvement in her symptoms. She was transitioned back to
lovenox. Culture from port tip grew coag neg staph >15 colonies,
indicating line was colonized with staph, oxacillin sensitive.
Treating for 4 weeks from removal of port on ___ (Day ___,
to be completed ___ with IV daptomycin for ease of
administration and team preference.
# Neck Pain secondary to Acute IJ Thrombus:
# Port Infection: She was started on Vanc/CTX/Flagyl given
concern for clot superinfection. Port removed on ___ with
improvement in symptoms. Port catheter tip now growing coag
negative Staph. She was discharged to complete 4-week course of
daptomycin.
# RUQ Pain: Developed mild RUQ pain with normal LFT's and
negative RUQ US. Continue to monitor.
# Constipation: Bowel regimen.
# HLD: Continued statin.
# Hypothyroidism: Continued synthroid.
# MDS:
# Anemia in Malignancy: On decitabine ___ 2 cycles. Awaiting
possible upcoming allogeneic transplant in ___. She should
follow up with her ___ oncologists and with the ___ transplant
team at ___.
# Billing: 45 minutes spent coordinating and executing this
discharge plan.
==================== | 135 | 241 |
10933622-DS-26 | 29,957,117 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for a right dislocated hip. It is
normal to feel tired or "washed out" after hospitalization, and
this feeling should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated always with hip abduction brace
on, in 30 degrees of abduction and ___ degrees of flexion
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:
- N/A
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___ in
the ___ Clinic in ___ weeks for evaluation, see ___
___ for first follow up visit. Call ___ to
schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weight bearing as tolerated in the right lower extremity, always
with hip abduction brace on, 30 degrees of abduction and ___
degrees of flexion
Treatments Frequency:
No wound care needed. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a recurrent right prosthetic hip dislocation. A
reduction was attempted and successful overnight in the ED. The
patient was admitted to the orthopedic surgery service for
fitting of an abduction brace. The patient was given
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated with strict instructions to remain
in the abduction brace at all times when ambulating, in 30
degrees of abduction and ___ degrees of flexion in the right
lower extremity. Abduction pillow when laying down or sleeping
The patient will follow up with Dr. ___ in ___ weeks. 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. | 290 | 217 |
18633532-DS-15 | 26,885,518 | Division of Vascular and Endovascular Surgery
Endovascular Aneurysm Repair Discharge Instructions
MEDICATIONS:
Take Aspirin 81mg (enteric coated) once daily
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
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
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 go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications | After reviewing the OSH CT findings, it was recommended the
patient go urgently to the OR for repair of her ruptured
thoracic aorta by an endovascular approach. The patient's family
was notified and the patient herself gave informed consent. She
underwent TEVAR on ___. Please refer to the dictated
operative report for further details. The patient tolerated the
procedure well and there were no complications.
Postoperatively, she was brought intubated to the CVICU for
continued resuscitation. The remainder of her hospital stay is
as follows, by systems:
NEURO: Preoperatively, it was decided against placing a lumbar
drain due to the length of time it would require to place one.
Postop, while intubated, the patient was sedated with propofol
and her pain was treated with a fentanyl drip. Immediately upon
transfer to the CVICU postop, she was noted to be moving all
four extremities spontaneously and she never developed any
neurologic sequelae as a result of the TEVAR. The patient did
develop delirium/sundowning on POD#3, insisting that she was at
home and trying to climb out of bed and walk out of her room
while still attached to all her lines and drains. This improved
over the hospital course but she continues to be
confused/slightly agitated especially at night but easily
reoriented.
___: The patient was transferred to ___ on an esmolol gtt.
This was continued intra- and postop for BP control, with an SBP
goal range between 120-140. The patient developed tachycardia
with HRs into the 130-140s on POD1. She complained only of vague
chest/epigastric soreness and pain that radiated into her back.
Cardiac enzymes were found to be elevated and cycled. Because
they continued to climb (trop eventually peaking at 2.13),
cardiology was called, who recommended full anticoagulation.
They felt that her perioperative MI with transient lateral ST-T
changes and increase troponin was secondary to her critical
illness and need for multiple pressors. She was started on a
heparin drip which we transitioned to plavix when she
stabilized. A TTE was obtained on POD2, which showed an LVEF
50-55% and dyskinetic apical cap. Comparison with her old echos
at ___ revealed these findings to be pre-existing.
She was eventually transitioned to PO metoprolol. She was
restarted on her home coumadin dose on POD 7.
PULM: A non-con CT of the chest was obtained on POD1 to evaluate
the extent of hemothorax and hemomediastinum present. Initially,
it was decided against placing chest tubes. However, in the late
afternoon of POD1, the patient developed acute desaturations and
respiratory distress consistent with flash pulmonary edema.
Therefore chest tubes were placed bilaterally and lasix was
given with subsequent resolution of symptoms and improved
oxygenation. The chest tubes initially drained close to a liter
each the first 24 hours but the output dropped off thereafter.
They were placed to water seal POD#3 and subsequent CXRs showed
markedly improved aeration of the lung. They were both
discontinued by POD#6.
FEN/GI: The patient was allowed to have clear liquids POD#2.
This was advanced to a regular diet on POD#3 and tolerated well.
GU: The patient had a Foley catheter for UOP monitoring. She had
preserved renal function and her UOP was appropriate.
HEME: The patient's EBL was 500cc and she received 4U pRBC in
the OR. Postop, her hcts remained stable. She did not require
any further transfusions thereafter. She was started on a
heparin gtt on POD#1 for her acute coronary syndrome, which was
continued for 48 hours. She was then transitioned to plavix.
DISPO:She worked with ___ who recommended rehab prior to
returning home secondary to deconditioning and unsteady gait.
She is instructed to follow up her cardiologist, Dr. ___
discharge from rehab and with Dr. ___ in one month with CTA of
the torso. | 252 | 623 |
17122832-DS-11 | 28,761,837 | You were admitted with L knee and thigh pain, complete workup
was negative for clots, bleeding, infection, but it was felt you
have a sprain. You will wear a brace, use ibuprofen and
oxycodone for pain, and follow up with orthopedics. | ___ y/o F with ___ Danlos syndrome, multiple orthopedic joint
surgeries, asthma, recent ovarian hyperstimulation (now
resolved) who presented with new onset L thigh pain and
subjective swelling.
.
# Leg extremity pain and swelling: Throughough workup in ED
including doppler u/s, knee films and CT showed no evidence of
clots, bleeds, infection or other etiology for her swelling.
-orthopedics was consulted and thought this could be a
ligamentous injury. A ___ brace was prescribed and she was
started on Ibuprofen. She was also seen by Physical therapy.
-pain initially requiring IV dilaudid, and then tolerable with
oxycodone prn
-she will f/u with orthopedics
-given omeprazole for GERD and especially while taking
Ibuprofen, colace for narcotic induced constipation
.
# Chronic muscle pain: continued on flexeril
.
# Insomnia: continued on trazodone
.
# Low grade temperature: with h/o UTI, U/A was checked and was
negative, no fever | 42 | 141 |
13656933-DS-14 | 27,354,905 | You are being discharged from ___
___ after undergoing an above the knee amputation of your
right leg for an infected below the knee amputation site
incision. You have recovered from your surgery well and are now
being discharged to rehab.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s) .
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover youre amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE | The patient presented to ___ on ___ with an infected BKA
stump (performed on ___. The decision was made to perform an
AKA. On ___, the patient was taken to the OR for an AKA.
Please see operative report for further details. After a brief
stay in the PACU, the patient was transferred to the vascular
floor for further management.
Neuro: The patient received IV pain medications for pain control
while NPO and was advanced to an oral regimen once taking a
diet. She was complaining of immense pain on POD1 but continued
titration of pain meds and time improved her symptoms. She was
discharged with good pain relief.
CV: The patient had no cardiac issues during her hospitalization
Pulm: The patient had no pulmonary issues during her
hospitalization
GI: The patient was given a bowel regimen and was regularly
passing stools during her hospitalization.
GU: The patient received hemodialysis on ___, and
___ while she was in house. Kayexalate was held while in
house but was restarted at discharge to manage potassium levels
when patient resumes her normal diet. She will have potassium
levels drawn in the coming days.
Heme: The patient was monitored for anemia and blood loss. On
POD3 the patient had a hematocrit drop of 5 from 28 to 23 and
was given 1U of PRBC.
ID: The patient was initially on vancomycin, ciprofloxacin, and
flagyl for her infected BKA stump though she did not have an
elevated white count. After her AKA, her new stump did not show
any erythema or signs of infection and antibiotics were stopped.
Endocrine: The patient was admitted on a regimen of sliding
scale and 70/30 insulin. She was kept on this regimen and was
given half doses post-operatively due to reduced PO intake. She
will be discharged on her regular regimen and will titrate as an
outpatient as necessary.
On ___, the patient was tolerating a regular diet, pain was
controlled, she was voiding independently and passing bowel
movements. She will return to rehab for further physical therapy
after her AKA. Discharge plans were communicated to the patient
and she was in agreement. She will follow up with Dr. ___
in the clinic in ___ weeks. | 598 | 367 |
11747567-DS-4 | 25,131,792 | Dear ___,
___ were seen in the hospital because of recurrent fevers likely
associated with a recurrence of your Macrophage Activating
Sydrome. ___ underwent chemotherapy for this and your
hospitalization was complicated by a bacteria called
enterococcus and a virus called CMV in your blood, treated with
antibiotics and antiviral medications. ___ also had an irregular
heart rhythm called atrial fibrillation which resolved. Your
sugars were very high because of the steroids in your
chemotherapy regimen, so ___ will need insulin at least while
still on steroids at home. Also, ___ were started on a pill
called lasix for your leg swelling.
Please have your home nurse draw the following labs on ___:
Cyclosporine level, CMV Viral load, CBC with Diff, Na, K, Cl,
HCO3, BUN, Cr, Glucose, Ca, Mg, Phosphate, AST, ALT, Alk phos,
LDH, total protein, albumin, ___, PTT.
We have made the following changes to your medications:
START artificial tears as needed
START atovaquone
START cyanocobalamin
START cyclosporin
START dexamethasone
START diltiazem
START fexofenadine
START fluconazole
START furosemide
START NPH insulin
START humalog
START lansoprazole
START oseltamivir
START oxycodone as needed
START valgancyclovir
INCREASE folic acid
INCREASE metformin
STOP valsartan
STOP etodolac | ___ year old female with DMII, HTN, insulinoma, HBV, HCV
presented with fevers, altered mental status after a urinary
tract infection found to have recurrence of hemophagocytic
lymphohistiocytosis (HLH). Course complicated by Afib with RVR
requiring MICU stay, enterococcus bacteremia, CMV viremia.
# Macrophage Activating Syndrome/HLH
Hematology/Oncology was consulted by general medicine admitting
team, and the patient was deemed to meet criteria for
hemophagocytic lymphohistiocytosis (HLH), and she was
transferred to the bone marrow transplant service to start the
HLH94 protocol (etoposide and dexamethasone).
Day 1 of the HLH94 protocol was ___. After her first dose of
etoposide, the fever broke, vancomycin was stopped on ___, and
she was maintained on cefepime. Judged likely an infection
driving HLH. No obvious malignancy; CEA was elevated, team did
consider obtaining breast MRI and/or colonoscopy, deferred for
now. Currently CT showed no obvious masses. Pt unlikely to have
genetic cause for her disease at her advanced age. Hep B VL
undetectable, HCV VL has been very high likely bc of
immunosuppression, but ID and Hepatology felt HCV unlikely
trigger of HLH. EBV and Hep B undetectable on most recent viral
loads. EBV, however, initially detected, cleared quickly. Pt
received several courses of etoposide and was maintained on PO
dexamethasone. Ferritin was trended, initially downtrending but
then variable as treatment progressed. Had doxycycline PO for ___mpirically as appeared to help patient on initial
presentation.
Pt started on several prophylactic medications while
immunosuppressed: atovaquone (reportedly had fever with bactrim
in past), acyclovir, nystatin swish & swallow, lansoprazole for
GI prophylaxis while on corticosteroids, Fluconazole 200 mg QD
and Tamiflu 75 QD (several patients on service w/ flu).
She was continued on dexamethasone 5mg throughout the rest of
her stay and received 8 cycles of etoposide. She was started on
cyclosporine on ___ for additional immunosuppresion, which
she tolerated well. Her fevers finally subsided and she felt
subjectively better after each cycle.
# VRE bacteremia: Blood cultures for febrile neutropenia showed
VRE sensitive to daptomycin on ___. She was started on
daptomycin which was continued through ___ with no subsequent
fevers.
# CMV viremia: CMV virema noted on ___, ID was consulted,
treatment started with ganciclovir on ___. Her CMV VL
decreased nicely over several weeks. She was transitioned to PO
valganciclovir prior to discharge. She will follow up with Dr.
___ in ___ clinic as an outpatient.
# Hepatitis B and C. H/o hepatitis B, but neg viral load, so it
not appear that reactivation of disease triggering HLH. She was
continued on LaMIVudine 100 mg PO DAILY for h/o Hep B. Some case
reports of Hep C as trigger. Pt is Hep C genotype 2 but cannot
take interferon, as IFN could potentially exacerbate HLH. ID saw
pt, and reminded team that while increasing viral load is likely
___ neutropenia, VL is not relevant marker of this disease. Her
HCV VL was trended weekly and stayed >69K per lab results.
# Upper Odynophagia and dysphagia: Patient c/o pain with
swallowing on admission. Likely yeast esophagitis given long
term high dose steroids. Symptoms improved on miracle mouthwash
and Nystatin swish and swallow, and PPI.
# Rash: patient with petechaiae from thrombocytopenia,
excoriations from pruritis and flushing of the skin likely from
histamine release during an inflammatory process. Relieved with
sarna lotion. Rash improved with etoposide.
# Afib with RVR: The patient developed afib with RVR on ___ in
the setting of fever, was transferred to the MICU, rate
controlled with IV metop/dilt, then converted to sinus rhythm.
On ___, went back into afib with RVR, which persisted for 48
hours despite fevers resolving, so we started anticoagulation
with lovenox, suspended while thrombocytopenic.
# Chest pain / SOB: Patient had several episodes of chest
discomfort / shortness of breath ruled out for MI several times,
and ruled out for PE. It is thought that she had fluid overload
from afib with RVR, hypoalbuminemia, mitral regurg. Imaging
revealed pleural effusion and required lasix daily. TTE ___
showed larger effusion, but no tamponade. Pericarditis was
considered; not a candidate for NSAIDs, on steroids already.
Maintained euvolemia on 20mg PO lasix daily during admission.
# UTI: Patient with + urine culture on ___ grew out
pansensitive E. coli. Had been on broad spectrum antibiotics at
OSH x 5 days. U/A mildly positive on admission, urine culture
negative. Further abx were held until the patient started to
decompensate on HD 5 as above.
# Diabetes: Held metformin and started insulin, ___ consulted
followed as sugars were difficult to control on steroids. She
was discharged on an insulin regimen with NPH and Humalog SS.
She received diabetes teaching by ___ prior to discharge.
She has been instructed to f/u with ___ after d/c. | 173 | 787 |
19576216-DS-8 | 27,675,565 | Dear Mr. ___,
You came in because your creatinine, a blood test that tells us
about the function of your kidneys was abnormal. It improved
when we gave you fluids. You will be going to ___ for
inpatient physical therapy. There you can have your blood drawn
so that doctors ___ continue to watch your kidneys. You will
follow up with your nephrologist and primary care doctor. It was
a pleasure taking care of you. | ___ with hx of CRI, mental retardation, anemia, who was recently
admitted for difficulty walking and started on treatment for
prostatitis with cipro, now readmitted with acute on chronic
kidney injury, cr 3.6-->6.0.
# Acute on chronic kidney injury: Pt with baseline cr 3.6, found
to have asymptomatic increase to 6.0 at ___ following
being discharged from the previous hospital admission
(___). ___ likely prerenal due to recent decrease PO
intake and diarrhea with labs suggestive of intrinsic renal
injury as well. Urine sediment was negative for ATN. Renal u/s
was negative for hydronephrosis. The patient's furosemide was
held throughout the hospitalization and started at a lower dose
prior to discharge. With fluids, creatinine improved and at
discharge was 4.1.
# CKD: The inpatient renal team representing his outpatient
nephrologist Dr. ___ recommendations and followed
closely throughout the hospitalization. Patient continued on
calcitrol and sodium bicarbonate. He will follow up with Chem
10 and albumin lab draws the upcoming ___ and next ___
for surveillance at ___. These labs should be sent to
his PCP as well as faxed to Dr. ___ at ___.
# Prostatitis: Pt started on cipro x28d in his previous
hospitalization for prostatitis. Given that he was asymptomatic,
a u/a here in ___ that was normal and concern for potential
kidney injury, ciprofloxacin was discontinued at admission and
will not be continued at discharge.
# Venous stasis ulcers: Chronic. Wound care followed.
# HTN: continued home metoprolol.
# Anemia: chronic. continued home iron
# Transitional issues
- Patient's HCP ___ need to make appointment with Dr.
___, by phone at ___
- Patient's HCP ___ also need to call to make an
appointment with PCP
-___ check daily weights, Chemistry 10 panel with albumin on
___ and ___. Will need these labs drawn qweekly after
this. Please fax results to the PCP as well as Dr. ___ at
___
-If albumin still low, please obtain nutrition consult | 75 | 319 |
10069871-DS-20 | 26,257,265 | Dear Ms. ___,
You were admitted to ___.
WHY WERE YOU ADMITTED?
You were admitted for evaluation and management of chest pain,
shortness of breath, and an episode of losing consciousness, in
addition to wanting to receive another opinion on management of
your tricuspid valve endocarditis.
WHAT DID WE DO FOR YOU?
- To manage your endocarditis, we continued the antibiotics
(Augmentin, Rifampin, and Bactrim) that you had left ___ with.
We then switched you to intravenous Cefazolin after speaking
with our infectious disease team. Our infectious disease team
determined that you had completed your antibiotic course, and
did not need other antibiotics at home.
- We managed your chest pain with an IV anti-inflammatory drug,
and then continued you on methadone to manage both pain and your
previous opioid use. You were discharged on a dose of 60mg once
daily. The last dose of your methadone was given at 9:52AM on
___.
- We obtained an echo image of your heart to evaluate whether
surgery (tricuspid valve replacement) would be appropriate at
this point. Our cardiac surgery team agreed with your operative
plan at ___, that you would need to demonstrate 6 months of not
using drugs in order to be re-considered for valve replacement
WHAT SHOULD YOU DO FOR FOLLOW-UP?
- Set up follow-up with a primary care physician at ___:
___, or online
___/
- Follow up with the ___ clinic (Habit Opco) as scheduled
below.
- Follow up with Dr. ___ office as scheduled below.
- Follow up with our infectious disease team as scheduled below.
It was a pleasure taking care of you. We wish you all the best.
-Your ___ team | ___ y/o F w/ h/o IVDU, hepatitis C, infective endocarditis c/b R
hip septic arthritis s/p washout and s/p TV replacement (stented
bioprosthetic Epic; ___ at ___ c/b
reinfection of new bioprosthetic valve who presented with
pleuritic chest pain and SOB 2 days after leaving AMA from ___,
where she was being treated for recurrent TV endocarditis. She
presented to ___ with hopes of being evaluated for candidacy
for a TV replacement. During this hospitalization, we obtained a
CTA and Echo to evaluate possibly worsening pulmonary emboli or
worsening tricuspid vegetations compared to her findings at ___.
We determined that both the emboli and vegetations were stable,
and determined that she completed an appropriate antibiotic
course and no longer needs further antibiotic suppression. Our
CT surgery team agreed with the operative plan established at
___ by Dr. ___ (6 months of abstinence from drugs prior to
re-evaluation for TV replacement). She was discharged with plans
to follow-up with primary care and CT surgery at ___, and with
plans to follow-up with a ___ clinic. | 268 | 174 |
15497465-DS-23 | 21,062,510 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated LLE with anterior hip precautions
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 Coumadin daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Physical Therapy:
WBAT LLE
Anterior hip precautions
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Dressing change as needed daily starting ___, after POD 7,
may leave open to air if not draining
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left hip hemiarthroplasty, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity with
anterior hip precautions, and will be discharged on her home
coumadin 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. | 347 | 260 |
15052495-DS-10 | 21,738,409 | You presented to the hospital with hoarseness and difficulty
swallowing. You were found to have an infection of your
tonsillar cavity. You were treated with steroids and
antibiotics. Your symptoms improved and should continue to
improve over the next several days. You can alternate taking
Tylenol and ibuprofen for pain. You also need to take the
steroids and antibiotic you were prescribed. Please finish all
doses of those.
You need to follow-up with your PCP on ___ ___ at 9:30am.
Please call Dr. ___ office on ___ to make a follow-up
appointment for ___ weeks from now. | #supraglottitis/pharyngitis
Following ENT evaluation, she was admitted to the ICU for airway
observation. She was started on IV antibiotics and steroids. The
patient was initially placed on droplet precautions for c/f
viral infection; however multiple exams were notable for right
tonsillar pillar with erythema and exudative plaque, more
concerning for bacterial infection. Pain improving markedly by
time of discharge, tolerating adequate PO, ambulating
independently and making adequate urine.
.
.
#hypothyroidism: continued home-dose levothyroxine
.
.
#anxiety: continued home Wellbutrin
.
.
#HTN: anti-hypertensives held in ICU, SBP consistently 120-140,
restarted day of discharge
.
. | 96 | 86 |
15485853-DS-20 | 26,045,891 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having a
harder time breathing and were coughing more. You were given
antibiotics and more steroids to treat a pneumonia.
Interventional Pulmonology saw you, rescheduled your surgery,
and you were discharged to rehab to make you stronger before the
surgery. Best of luck to you in your future health.
Discharge weight 93kg or 205 lbs. Please weigh yourself every
day and call a physician if you gain more than 3 pounds in one
day. Please take all medications and therapies as directed,
attend all physician appointments as directed, follow a diabetic
heart healthy diet, and call a doctor if you have any questions
or concerns. | Mr. ___ is a ___ w/ Hx of tracheobronchomalacea on 3L home ___
s/p multiple IP interventions including silicone Y-stent and
recurrent bronchoscopies for mucous plugging, CHF (EF 40%),
adrenal insufficiency on chronic prednisone and other issues who
presents from rehab with productive cough and SOB concerning for
HCAP. He was started on vancomycin/cefepime, increased his
prednisone, he clinically improved, and he was discharged to
___ rehab pending tracheobronchoplasty in the future.
# Cough/SOB/Tracheobronchomalacea: This patient likely has many
contributors to his respiratory distress: tracheobronchomalacia,
HCAP, mucous plugging, airway reactivity, and possibly volume
overload given CHF and peripheral edema. Ultimately felt to be
secondary to HCAP in the setting of TBM with lower of steroids.
Interventional Pulmonology was following him throughout his
hospital course and recommended IV antibiotics for 8 days,
amoxicillin-clavulanate PO until the surgery, and a future IP
appointment to discuss the exact timing of the surgery. He was
continued on home nocturnal BiPAP, benzonatate, guaifenasin,
montelukast, and was given albuterol/ipratropium nebulizer
treatments.
# HCAP: IP evaluated pt in ED and felt his Sx were more likely
due to infection than TBM. Respiratory status currently stable
on 4L NC. No culture data from previous admission to guide
antibiotic selection (only yeast grew from bronchial washings).
Per IP, no known MDR organisms and minimal past microbiology
data. LDH in 200s. Sputum cultures x2 were heavily
contaminated with oropharyngeal flora. He was discharged on
vancomycin/cefepime on an 8 day total course (last day ___.
# Adrenal Insufficiency on chronic corticosteroids: Patient with
long history of steroid dependence for adrenal insufficiency.
Received Methylprednisolone 80 mg IV in ED. In the setting of
acute stress, prednisone was increased to 60mg x2 days then put
to 40mg daily on a taper (course 30 mg x1 day, then 20mg
thereafter). He was also placed on PCP prophylaxis with ___
DS 3x/week on ___.
# CHF: Patient with peripheral edema that per him is around his
baseline. There are no crackles on exam, no significant pulm
edema on CXR, and no overt JVD. Mr. ___ was continued on his
home dose of furosemide 40mg PO BID. Discharge weight 92.7 kg.
# Chronic Pain: Patient has chronic back and abdominal pain
secondary to various injuries. He was maintained on home
fentanyl patch and morphine sulfate ___ PO ___ q6 hours while
in hospital and then switched back to his home regimen on
discharge.
# CAD: Chronic stable issue on home carvedilol, simvastatin, and
aspirin.
# DM2: Chronic stable issue on home insulin glargine 35 units
and insulin sliding scale. FSBG was between 130 and 260 during
this hospital stay.
# BPH: Chronic stable issue continued on home terazosin.
# ___ Esophagus: Continuing home pantoprazole but
sucralfate discontinued for medication interactions.
# Depression/Anxiety: Chronic stable issue continued on home
mirtazapine and diazepam
# Hypogonadism: Chronic stable issue continued on home Androgel®
# Constipation: Chronic stable issue continue on home
polyethylene glycol PO daily
# Code Status: Full Code confirmed with patient. Emergency
contact is his wife ___ at ___. | 130 | 507 |
13141418-DS-20 | 28,640,503 | You were admitted to the hospital after you were assaulted.
Your received swelling around your left eye and a left 3rd rib
fracture. You have received pain medication for your injuries.
You were seen by the Social Worker and you have been cleared for
discharge home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
You sustained a left sided rib fracture, which puts you at risk
for pneumonia, please use the incentive spirometer, every 4
hours. If you develop fever, cough, chills, night sweats please
call the clinic at ___. If you have other questions,
do not hesitate to call the clinic # ___
Please schedule an appointment with the Opthomology service so
you can be seen in 1 week. The telephone number is #
___. | ___ year old male who was admitted to the hospital after being
assaulted by his roommate. He reported that he was repeatedly
struck in the right eye waking him up. The patient reportedly
fell on his left side during the altercation. Upon admission,
the patient reported left chest and left back pain as well as
spinal tenderness. He was evaluated at an OSH where a cat scan
of the head was done which showed no acute intracranial
abnormality. He was reported to have right ___
swelling. Because of swelling, he was reportedly evaluated by
the Ophthalmology service who recommended non-operative
intervention. The patient was reportedly prescribed eye drops.
There was no globe injury or acute fracture. The patient
remained hemo-dynamically stable. A cat scan of the chest
showed one acute non-displaced 3rd rib fracture.
The patient's pain was controlled with oral analgesia. He was
instructed in the use of the incentive spirometer. He was
tolerating a regular diet and voiding without difficulty. He
did not experience any visual changes. Prior to discharge, the
patient was evaluated by the Social worker, who after discussion
with the patient, felt safe returning home. The patient was
discharged home on HD #1 with stable vital signs. The patient
was informed of the need for follow-up with the Ophthalmology
service in 1 week and he was prescribed eye drops until his
follow-up visit. He also has an appointment scheduled with his
primary care provider. Discharge instructions were reviewed and
questions answered. | 309 | 266 |
13719737-DS-18 | 22,508,570 | You were admitted to the hospital after a drug overdose in a
suicide attempt. You were stabilized initially in the intensive
care unit and monitored closely. Toxicology was involved and
monitored you until the drugs had left your system.
Initially were having high heart rate but over your
hospitalization you improved and now your heart rate has
remained normal. You are being discharged to an inpatient
psychiatric facility for further help. We wish you the best in
your recovery
Your medical team | ___ with history of PTSD, anxiety, and depression, presents with
altered mental status after an intentional overdose. Tylenol
level positive and received 21hr of NAC now medically stable for
inpatient psychiatric care | 84 | 32 |
19611909-DS-10 | 26,061,152 | Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to. | The patient was admitted to neurosurgery on ___. He was found
to have a left IPH and SDH with 11mm of midline shift. He found
to have a left frontal AVM on CTA. He was taken to angio for
embolization of the AVM. He was then taken to the OR for left
craniotomy for ___ evacuation. Subgaleal JP drain was placed.
The patient was taken to SICU post op. Post op head CT showed
evacuation of SDH with stable frontal IPH, embolization material
was seen in left frontal region of AVM malformation. The patient
remained intubated overnight. On ___ NCHCT was stable. JP drain
was removed. Keppra was increased to 1,000 mg BID. Systolic
blood pressure was kept strict less than 140. On ___ the patient
was febrile to 100.9F. Sputum gram stain showed GNR, GPC culture
was still pending. The patient was not started on antibiotics
while awaiting culture results. WBC was 9.3. He was extubated
successfully. He was preoped for angio on ___. On ___ his exam
was slightly improved as he was able to lift his RUE
antigravity. He underwent a portable head CT which was stable
and after review it was determined that he would undergo
cerebral angiogram for embolization. On ___, the patient's exam
remained stable. He underwent a cerebral angiogram with
embolization without complication.
On the morning of ___, Mr. ___ was found to be more somnolent on
exam and intermittently following commands. A portable CT head
was ordered, which was stable. On the same day, his bilateral
femoral sheaths were discontinued.
On ___ he was brighter on exam, and was mobilized with ___.
On ___ patient had a decline in his mental status, on
examination in the morning, he was unable to answer questions
about place and date, a CT was performed that showed a larger
left frontal hemorrhage. Patient was transferred to the ICU.
On ___ patient remained in the ICU. EEG was placed. Systolic
blood pressure was liberalized to less than 160. He continued to
work with physical therapy. speech and swallow evaluated the
patient and cleared him for a soft solid nectar thick liquid
diet. A multipodus boot was also applied to his RLE for foot
drop.
On ___ patient was slightly brighter on exam. EEG results
showed no seizure or epileptiform activity. The EEG leads were
removed. His Keppra was continued to 1 gram BID. On ___, the
patient continued to do well. His motor exam remained stable,
but notable for ___ strength in his anterior tibialis,
gastrocnemius, and extensor hallus longus. He was seen by
speech and swallow and due to continued improvement, his diet
was advanced to regular solids and thin liquids. He was
transferred to the inpatient ward that afternoon.
On ___ Speech upgrade to thin liquids, regular solids. Patient
transferred to floor.
On ___ Dr. ___ was stable, ___ showed no interval
changes, Anesthesia performed pre-op tests and the patient was
consented by both Neurosurgery and Anesthesia.
On ___ No events for Dr. ___ the day.
At the time of discharge on ___ he is tolerating a regular
diet, afebrile with stable vital signs.
He will return on ___ for surgical resection of the AVM. | 124 | 534 |
16214743-DS-21 | 28,813,723 | Ms. ___, you were admitted to the ___
___ with confusion, fevers and tremors. You were
found to have a urinary tract infection and were treated with
antibiotics to complete a seven day course.
It was a pleasure caring for you and we wish you a speedy
recovery! | ASSESSMENT/PLAN
___ with PMH BRCA (dx with relapse ___ yr ago pt refuse surgery or
tx), HTN, Dementia who presents from her nursing home with
symptoms of rigors and fever to 101.3 with large leuks in urine
c/f UTI. | 48 | 38 |
15548837-DS-2 | 24,449,182 | Dear Mr. ___,
You were admitted to ___ for
evaluation of two episodes of unresponsiveness. Monitoring of
your EEG did not show signs of ongoing seizure activity, and you
did not have further episodes during your stay. Testing did not
show signs of infection. No medication changes needed to be
made.
It was a pleasure taking care of you at ___.
Sincerely,
___ Neurology | 1. Episodes of unresponsiveness, low likelihood of seizures:
Patient's episode of unresponsiveness at his ALF was noted to
resolve shortly after administration of fluids at ___,
with non-contrast head CT negative at that time. Patient was
transferred to ___ to investigate possible underlying seizure
activity; continuous video EEG monitoring for 24 hours
preliminarily did not reveal active seizures. Although patient
was noted to have an episode of somnolence and decreased
responsiveness to questions and commands one day prior to
discharge, no seizure activity was noted at that time; these
symptoms resolved in a few hours without intervention. No
infectious process was identified on laboratory testing or chest
imaging. Based on the absence of a clear worsening of underlying
seizure disorder, antiepileptic regimen was not changed.
Symptoms may have been related to symptomatic hypovolemia given
poor oral intake at baseline and response to IV fluids. | 60 | 144 |
18935958-DS-13 | 22,409,845 | * You were admitted to the hospital for observation as you
developed another left pneumothorax. Your pain has improved and
your chest xray has remained about the same.
* You will likely need to have this problem corrected with
surgery, when you are ready. You have a follow up appointment
with Dr. ___ to review your xrays and discuss firther plans.
* If you develop any increase in chest pain, shortness of breath
please return to the Emergency Room. If you have any new
symptoms that concern you, call Dr. ___ at ___ | Mr. ___ was admitted to the hospital and was placed on oxygen
at 5 LPM to attempt to resolve the small left pneumothorax. His
left shoulder pain resolved and a repeat chest xray was done on
___ which showed a small left apical pneumothorax, maybe
slightly larger than the prior film on ___. He had minimal
pain and his room air ambulatory saturations were 96%. A repeat
chest xray was done 7 hours later and there remained a stable
left apical pneumothorax. As he wishes to postpone any surgical
treatment until he has a break from college, he was discharged
on ___ and will follow up with Dr. ___ in 2 weeks with
another chest xray. If he has any increased chest/shoulder pain
or shortness of breath he will return to the Emergency Room. | 92 | 137 |
19143018-DS-10 | 29,117,512 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted to the hospital with worsening abdominal pain. You had
an umbilical hernia, which was repaired by surgery, and also
excessive fluid in your abdomen, which required two paracentesis
procedures to remove the fluid. You also developed a fever and
some redness around your surgical site, and you received
antibiotics for a skin infection.
It is very important that you avoid salt in your diet and do
not take in too much fluid. We also recommend that you stop
drinking alcohol and seek assistance in ways to do this safely
if you choose to do it. Please make sure you complete all of
your antibiotics so your infection thoroughly improves.
Your ___ Team | Ms ___ is a ___ year old woman with history of ETOH cirrhosis
(complicated by GAVE, ascites, Hepatic Encephalopathy, SMV
thrombosis subsequently resolved), alcohol abuse, and HTN,
presenting with abdominal pain, vomiting, and diarrhea and
umbilical hernia, s/p hernia repair on ___.
#Abdominal pain:
Likely secondary to umbilical hernia and distention initially
secondary to ascites. Patient admitted with 1 wk hx of abdominal
pain associated with nausea, vomiting, and diarrhea. Spontaneous
bacterial peritonitis ruled out in ED with diagnostic
paracentesis. Patient taken to OR by transplant surgery ___ for
repair of umbilical hernia. Also received paracentesis in OR
removing 4L fluid, was given 25% albumin. On day 1 post-op,
patient developed fever to 101.5 which resolved. Patient
subsequently developed erythema surrounding the surgical site
concerning for cellulitis vs secondary bacterial peritonitis.
Was started on empiric vanc/zosyn and underwent
diagnostic/therapeutic ___ paracentesis ___ removing 2L,
was negative for bacterial peritonitis. Patient transitioned
briefly to PO Bactrim given negative para but then rebroadened
to IV vanc/zosyn due to worsening induration at surgical site.
CT abdomen ___ consistent with phlegmon vs hematoma. Per
discussion with surgery there was no indication for further
surgical management and area noted on CT was not drainable.
Patient was transitioned to PO augmentin on ___ for a 10 day
course.
Patient's pain was managed initially with IV dilaudid and
gradually transitioned to PO oxycodone. Patient was provided
with short term course of PO oxycodone until follow up with PCP.
Should consider pain clinic referral if ongoing pain.
#ETOH Cirrhosis:
Child's class B, MELD 14 on admission. Patient has history of
hepatic encephalopathy but there was no evidence of
encephalopathy during hospital course. INR and TBili stable
during hospital course, and patient was on home regimen of
Lasix, spironlactone, rifaxamin, and lactulose.
#ETOH Abuse:
Given patient's active drinking status, she was placed on CIWA
protocol with lorazepam. CIWA protocol was discharged after 5
days, and patient received 0.5mg lorazepam Q12H PRN anxiety
given continued anxiety. Patient should follow up alcohol abuse
and treatment with PCP as outpatient.
TRANSITIONAL ISSUES
========================
-Patient discharged with 10 day course of Augmentin to be
completed on ___
-please follow up surgical site and ensure it is improving
-patient should follow up with transplant surgery in clinic for
monitoring as well (appointment listed)
-Continue to discuss alcohol abuse and rehabilitation
-patient discharged with short term supply of oxycodone and
Ativan. Need for these medications should be re-evaluated at
follow up appointment.
-consider referral to pain clinic
-IMPRESSION:
1. 2.3 x 5.1 x 7.9 cm structure of heterogenous density with few
gas bubbles just deep to the umbilicus, either related to
hematoma or phlegmon/early abscess. It does not appear drainable
at the current time.
2. Heterogenous liver, at least partially due to some steatotic
changes. There are a few nodular hypodense areas seen in the
posterior aspects of segments 6 and 7, which could be due to the
overlying heterogeneity of the liver parenchyma, although given
the underlying cirrhotic change dedicated cross-sectional
imaging of the liver (either by CT or MRI) is recommended to
exclude underlying lesion.
3. Diffuse mild dilation of the small bowel loops, compatible
with ileus.
RECOMMENDATION(S): Dedicated liver protocol CT or MRI, after the
acute episode has resolved. | 127 | 529 |
19444188-DS-3 | 28,258,080 | Dear ___
___ was a pleasure taking care of you at ___. You were admitted
for abdominal pain with poor appetite, nausea, and a few
episodes of diarrhea in the emergency department. We performed
imaging of your abdomen, which showed inflammation of your
colon. We treated you with fluids given through your veins and
antibiotics in case your pain was from an infection. You
improved during your stay, and we discharged you after you were
able to eat. Please continue to take the antibiotics as
prescribed through ___.
We would like you to follow-up with you primary care doctor to
further discuss whether you should undergo colonoscopy to
evaluation your colon more closely. | ___ with PMH sigmoid diverticulosis, hypothryoidism presents
with 2 weeks of abd pain, new onset diarrhea, and transient
nausea with elevated WBC ct, concentrated urine, and imaging
colitis in ileal-cecal area c/f infectious vs. ischemic colitis. | 111 | 36 |
13726322-DS-2 | 20,250,992 | Dear Mr. ___,
You were hospitalized due to symptoms of left leg weakness
resulting from a TRANSIENT ISCHEMIC ATTACK, oxygen and nutrients
temporarily do not get to the brain because the vessel 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 cholesterol
snoring with concern for sleep apnea
Obesity
Pre-diabetes
Poor diet with low fiber, high simple sugar intake
Lack of exercise
We are changing your medications as follows:
Start ___ 10 mg nightly
Start Fish Oil 1000 mg BID
Please take your other medications as prescribed.
Please follow up with your primary care physician as listed
below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ year old many with hyperlipidemia who
presented with left leg weakness and dysarthria who was admitted
to the Neurology stroke service. Fortunately, his symptoms
improved and by the time that he was examined on rounds, he had
returned to his baseline. Thus, this is most likely a TIA
secondary to vascular risk factors. He does have significant
vascular risk factors and received detailed education about his
risk factors and what the appropriate treatment for each of his
risk factors is. His LDL was significantly elevated to 173. We
started ___ 10 mg for this, considering that he had
previously proximal muscle pain when he was on a low dose of
Atorvastatin . HbA1c 6.3. TSH slightly elevated at 7.4, T3 and
free T4 were normal. Emphasized the importance of healthy diet,
daily exercise, preventative health care and routine primary
care follow up.
His stroke risk factors include the following:
1) DM: A1c 6.3%
2) Hyperlipidemia: LDL 173, ___ started
3) Obesity BMI 32.5
4) Snoring with suspected sleep apnea
Transitional issues:
[ ] Hg A1c 6.3%
[ ] PCP to ___ as tolerated, goal LDL <70
[ ] no follow up is needed for incidentally found colloid cyst
seen on MR brain
[ ] needs sleep study to evaluate for sleep apnea
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - (x) No
4. LDL documented? (x) Yes (LDL = 173 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 304 | 496 |
15417534-DS-11 | 27,388,264 | Dear Mr. ___,
You were admitted to the hospital for confusion and
hallucinations. You underwent an extensive infectious workup
which was unremarkable. You also underwent a CT head which did
not reveal any acute process. Your confusion ultimately resolved
and your are being discharged home.
Please do NOT take the following medications until told to do so
by your primary care doctor:
- metformin
- simvastatin
Please call your primary care doctor tomorrow to try and move up
your appointment scheduled for ___.
With best wishes,
___ Medicine | ___ ___ speaking man with hx diabetes mellitus,
dementia, blindness and hearing loss, recent admission ___
for UTI and otitis externa presenting with encephalopathy and
visual/tactile hallucinations x 3 weeks, found to have elevated
lactate of unclear etiology and mild rhabdomyolysis for which he
was initially monitored in the FICU, transferred to the floor on
___.
# Toxic metabolic encephalopathy:
# Visual/tactile hallucinations:
# Dementia:
Presented with worsening confusion and visual/tactile
hallucinations over 3 weeks. There was initial c/f sepsis given
presenting tachycardia and elevated lactate (see below),
although
he remained afebrile, without a leukocytosis, and with no
obvious
infectious source (no e/o otitis media/externa, CXR without
clear
PNA, UA positive but UCx subsequently negative, BCx NGTD, HIV
negative, and CT A/P without intra-abdominal pathology). NCHCT
was negative, and there was no headache or meningismus to
suggest
CNS infection. Treponemal Ab pending at the time of discharge.
B12, TSH WNL. No clear medication culprits, and no history of
intoxication or e/o withdrawal syndrome. Initially treated with
empiric CTX (___), cefepmine (___), and azithromycin
(___) - ultimately discontinued in the absence of clear
infectious source. Etiology for his presenting encephalopathy
and
hallucinations ultimately unclear, possibly delirium in setting
of underlying dementia, but both had resolved by the time of
discharge; confirmed to be back to baseline by son/HCP at the
bedside (AOx1-2, pleasant and minimally conversant in setting of
blindness and deafness). Seen by ___, who found him to be at his
mobility baseline and recommended home without services (has ___
family caregivers and supervision). Home risperidone 2mg QHS
continued in hospital and on discharge.
# Elevated lactate:
Lactate peaked at 6.4 on admission. In setting of encephalopathy
and sinus tachycardia, initially concerning for sepsis, but
infectious w/u was ultimately negative as above and empiric
antibiotics were discontinued. CT A/P without evidence of bowel
ischemia. ___ have been secondary to dehydration in setting of
encephalopathy vs metformin effect and resolved with IVFs and
holding home metformin. Given A1c of 6.0%, home metformin held
on
discharge pending PCP ___.
# Mild rhabdomyolysis:
CK 380 on admission and peaked at 1100 on ___. No e/o
renal/liver dysfunction or cardiac ischemia. ___ have been
secondary to dehydration/immobility vs drug effect (possibly
home
simvastatin) and resolved with IVFs. Home simvastatin was held
in
hospital and on discharge pending PCP ___.
# Type 2 diabetes mellitus:
A1c 6.0%, with fingersticks well-controlled this admission. In
setting of elevated lactate, home metformin held in hospital and
on discharge pending PCP ___.
# Constipation:
No e/o ileus or obstruction. Initiated bowel regimen with senna
daily and miralax PRN on discharge.
# GERD:
Continued home omeprazole.
# BPH
Continued home Tamsulosin.
# Microscopic hematuria:
Repeat UA as outpatient to document resolution if within GOC.
# Contacts/HCP/Surrogate and Communication: ___ (son)
___
# Code Status/ACP: DNR/ok to intubate
** TRANSITIONAL **
[ ] ___ Trep Ab, pending at discharge
[ ] ___ BCx, pending at discharge
[ ] metformin held on discharge in setting of elevated lactate
and well-controlled diabetes; ___ diabetes mellitus off this
medication
[ ] simvastatin held on discharge in setting of mild
rhabdomyolysis; defer resumption to PCP
[ ] ___ constipation; discharged on bowel regimen
[ ] repeat UA as outpatient to document resolution of
microscopic
hematuria, if within ___ | 82 | 473 |
18663430-DS-8 | 20,294,483 | Patient Instructions
- Please do the following after discharge:
- Continue daily showers/rinses with warm soapy water three
times a day
- Continue daily packing of the wound after each shower rinse
Physical Therapy:
- WBAT ROMAT RUE
Treatments Frequency:
Please do the following wound care:
- continue daily showers/rinses for 10 min three times a day
- continue packing your wound after each showering
- continue to dress your wound in dry gauze after each
shower/rinse | Pt was admitted to the hospital for the above diagnosis, dorsal
hand abscess. She underwent bedside I&D and washout on ___
and the wound was packed and dressed with dry sterile gauze.
Cultures from that wound eventually grew out Strep Anginosis and
her antibiotics which were initially Vancomycin (trough 12) and
Cipro were switched to PO erythromycin which she tolerated well.
On HD2 the packing was removed and the pt was instructed on how
to rinse her wound with soap and water for 20 min, three times
per day. After each rinse, the wound was repacked by nursing
care.
By HD3 the patient's pain was well controlled on her home
suboxone, she was tolerating dressing changes, and she was
ambulating and voiding independently and tolerating a regular
diet. She expressed her readiness for home and she was
discharged in a healthy condition. | 69 | 148 |
14674376-DS-6 | 26,368,538 | Ms. ___,
You were admitted with shortness of breath and decreased oxygen
saturation. We think your symptoms are likely due to a viral
infection worsened by your underlying lung disease, but
pneumonia could not be ruled out. You were treated with
antibiotics as well as various medications and chest therapy to
improve your breathing. You were transferred to the ICU for a
brief period for difficulty breathing. You were also started on
BiPAP at night given the results of previous sleep studies.
.
Please follow-up with your PCP, an appointment has been made on
your behalf. You should also follow-up with your outpatient
pulmonologist.
.
Your medication reconcilliation can be found as part of this
discharge packet -- it has been updated to include your new and
old medications.
.
It was a pleasure participating in your care, thank you for
choosing ___! | The patient is a ___ with history of restrictive lung disease,
unknown degenerative neuromuscular disease, and baseline
collapsed RLL presenting with one week of chest congestion and
cough, found to be hypoxic at clinic, with opacities on CXR,
likely viral URI.
.
ACUTE ISSUES
#Hypercarbic respiratory failure:
Patient with history of pulmonary disease (restrictive
[secondary to neuromuscular disease?] and decreased diffusion
capacity), presented with hypoxia in setting of recent URI. The
patient did not have leukocytosis or fever upon admission. There
were opacities on CXR thought to be atelectasis, though
pneumonia could not be excluded. Her bicarb was elevated to 37,
though this is thought to be chronic. Her O2 sat remains lower
than baseline of high-80's to low-90's on RA. Not thought to be
PE given negative d-dimer and no ___ findings. Patient was
treated for CAP with levofloxacin given hypoxemia and history of
lung disease. She was also started on a regimen of
albuterol/ipratropium and acetylcysteine nebs, and was given
intensive chest ___. The patient was transferred to the MICU
after being found lethargic one morning, with a CO2 of 115. She
was immediately placed on BiPAP and continued throughout the day
with a steady downtrending of her CO2. BiPAP was removed the
following morning and she was able to tolerate nasal cannula
while awake. She required BiPAP during naps and overnight.
Settings were initially titrated by vent, then transferred to a
home machine. The patient was evaluated by both Pulmonology and
Sleep Medicine who recommended bipap for sleep with settings of
___ H2O with 4L O2 with SpO2 maintained >88% and <95%. She
was intermittantly requiring NCO2 during the day; this can also
be titrated to 88%<O2 sat<95%. An appointment has been made for
outpatient Sleep Medicine follow-up. The patient will require
follow-up with her outpatient pulmonologist. Patient received
pneumococcal vaccine prior to discharge.
.
#Conjunctivitis
Patient with injection of right eye since initiation of nightly
Bipap. This was thought to be related to her Bipap mask
irritating her eye at night. Patient without symptoms other than
mild foreign-body sensation. She was given artificial tears, as
needed.
.
CHRONIC ISSUES
# GERD:
The patient has a history of GERD, she was continued on her
home-dose omeprazole.
.
# Depression:
The patient has a history of depression. She was not reporting
sign or symptoms of depression during her hospitalization. She
was continued on her home-dose sertraline.
.
TRANSITIONAL ISSUES
#Patient had a marginally abnormal UA during hospitalization.
This should be repeated by PCP.
#Patient will require outpatient follow-up with Sleep Medicine
for evaluation of home BiPap services. An initial inpatient
evaluation made recommendeds for interim home BiPap.
#Patient is at high risk for complications of influenza.
Prophylaxis should be considered at acute rehab should active
cases of influenza or ILI be at facility.
#A TSH is pending at the time of discharge. | 136 | 465 |
15773840-DS-13 | 20,417,140 | Dear Mr. ___,
You were admitted to ___.
WHY WERE YOU IN THE HOSPITAL?
==============================
- You had blood clots in your legs.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
==============================================
- You were given a blood thinner though the IV.
- You had imaging of your abdomen/pelvis which showed that the
blood clots extend to the large veins of your abdomen.
- You were seen by the vascular surgeons, who recommended a
follow-up appointment in the clinic if you have additional
symptoms. There is no need for immediate surgery at this time.
- We started you on a new medication called Eliquis (Apixiban)
that helps to thin your blood and prevent stroke. We discussed
the side effects of Apixaban and symptoms that would be
concerning.
Please call your primary care physician or come to the emergency
department if you have:
- Changes in your mental status (e.g. increased sleepiness or
confusion)
- Headaches worse than usual
- Severe skin bruising
- Abnormal bleeding
- Blood in stool or dark/black tarry stool
- Blood in your urine
WHAT YOU NEED TO DO WHEN YOU GO HOME?
======================================
- Please continue to take all of your medicines as prescribed.
- Follow up with your primary care doctor
___ avoid taking aspirin or ibuprofen for pain, as these will
further increase your bleeding risk. Tylenol (up to 3 grams per
day) is acceptable.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ year old male with history of quadriplegia
after diving accident in ___ and prior PE (s/p IVC filter ___
and 6mon course warfarin) who was found at ___ to
have b/l DVTs and started on a heparin drip. A CTA showed no
evidence of PE. He was then transferred to the ___ for further
management. At ___, he was continued on the heparin drip and
placement of his IVC filter was confirmed by ___. Vascular
surgery was consulted, who recommended a CTV which showed
filling defects in IVC from level of IVC filter to distal
femoral veins. No surgical interventions were warranted at the
time. He was then started on apixaban. Throughout the
hospitalization, he was hemodynamically stable and did not show
any signs of bleeding.
# Bilateral DVT: Patient with history of b/l DVTs s/p IVC filter
placement and 6mon course Coumadin in ___. IVC filter still in
place as seen on KUB. DVTs likely ___ IVC filter, which
increased venous stasis in lower extremities and therefore risk
of DVTs. CTA negative for PE. No family history of clotting
disorder. Vascular surgery was consulted, who recommended a CTV
which showed filling defects in IVC from level of IVC filter to
distal femoral veins. No surgical interventions were warranted
at the time. Patient was switched to apixaban and heparin gtt
was discontinued. He was discharged home with vascular surgery
follow-up.
# UTI: patient with suprapubic catheter, with recurrent UTIs.
Diagnosed with UTI by urologist on ___ and being
treated with 7-day course of Cephalexin. Caphalexin was
continued during course of admission. | 230 | 268 |
19272859-DS-17 | 29,450,359 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with low blood pressure after drinking alcohol and smoking
marijuana. Your blood pressure was so low that you needed to be
in the ICU, where you received medications to increase your
blood pressure. You were seen by cardiologists and
toxicologists who were reassured that this was not caused by a
problem with your heart or by a medication overdose. You were
monitored and improved. You are now ready for discharge home.
Of note, during your hospital stay, your liver tests were mildly
elevated, but they improved. We think this was due to your
alcohol and drug use. We recommend that you have your liver
tests rechecked at your primary care appointment.
We recommend avoiding alcohol and additional drug use. | This is a ___ year old female with past medical history of atrial
fibrillation on sotalol and pradaxa who was admitted ___ to
the ICU with hypotension following alcohol and marijuana use,
initially requiring peripheral vasopressors, complicated by LFT
abnormalities attributed to hypotension, subsequently improving
with supportive measures, able to be discharged home
#Hypotension: Patient presented with SBP 50mmHg with elevated
lactate, initially requiring peripheral pressors in the ICU,
subsequently improved with IV fluid boluses and supportive care.
No infection, bleeding or acute cardiac event identified.
There was initial question of sotalol toxicity by the ICU team,
but per toxicology evaluation clinical picture was not
consistent with this toxidrome. EP interrogation of pacer was
unrevealing. TTE without obvious new wall motion defect or
valvulopathy. Symptoms were likely secondary to excess alcohol
and marijuana use complicated by her underlying comorbidities.
Blood pressure normalized as above, and patient was montiored x
24 hours without event. Ramipril held at discharge, to be
reassessed at PCP ___.
# Atrial fibrillation - Patient on chronic sotalol with
pacemaker. As above, initially concern for sotalol toxicity but
this was exonerated. Per discussion with EP and outpatient
cardiologist, sotalol was restarted at prior dose with repeat
EKG 2 hours later without significant change. Continued
pradaxa.
# Transaminitis - secondary to mild shock liver in setting of
hypotension. Peaked at ALT 114, AST 130, AP 71, Tbili 0.9.
Improving to ALT 50, AST 27, AP 58, Tbili 0.8 at discharge.
Would repeat at ___
# Hypothyroidism - continued levothyroxine
# GERD - continued pantoprazole
# HLD - continued rosuvastatin
# Complex sleep apnea ___ muscular dystrophy - continued CPAP
# Hypertension - held ramipril
# Bladder spasm - continued oxybutynin
Transitional Issues
- Would consider recheck of LFTs to ensure continue
normalization (LFTs at discharge were ALT 50, AST 27, AP 58,
Tbili 0.8)
- Ramipril held in setting of hypotension; could consider
restarting at ___
> 30 minutes spent on this discharge | 138 | 331 |
18040115-DS-22 | 28,172,969 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because your heart was
beating fast and your knee was hurting more and swelling a
little more.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital we continued your antibiotic regimen and
increased the medication which slows your heart rate. The
orthopedic surgeons saw you and did not think you needed to have
a sample of your knee fluid as it was healing as expected.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue working hard in rehab.
- Continue to take all your medicines and keep your
appointments.
We wish you the ___!
Sincerely,
Your ___ Team | Mr ___ is a ___ year old male with DM2, OSA, recent left
knee PJI, s/p explant
and placement of antibiotic spacer with Dr. ___ on ___ (on
vanc/cipro), recent pAF diagnosis (on apixaban), presenting from
rehab with rapid AF, now in sinus, admitted for w/u of mild
leukocytosis and elevated CRP.
#Prosthetic joint infection
#Leukocytosis
#CRP elevation from baseline
Mr ___ currently has an antibiotic spacer in his left knee
after his prosthetic joint had to be removed for infection. He
has been on vancomycin and ciprofloxacin managed by ID in rehab.
He presented with a slight uptrend in CRP from prior (84 from
70.5 on ___ and leukocytosis with WBC 11 from 6.8 on ___.
Aside from knee pain, he had no localizing symptoms/exam/lab
findings. CXR without pneumonia, UA without evidence of UTI. No
evidence of PICC-associated infection. Given no culture data,
difficult to know if antibiotics have appropriate
coverage--possible that switch from CTX to ciprofloxacin is
responsible for presentation, although this switch happened on
___ and he was clinically stable for ~2 weeks on this regimen.
Without any change to the antibiotics, his CRP trended down to
54 and his white count to 7.3.
#Paroxysmal atrial fibrillation: CHADS2VASC: 2 (Age, HTN).
Mr ___ presented with rates to 170s and spontaneously
cardioverted while on
diltiazem gtt. His metoprolol was increased from 25 daily to 50
daily (fractionated into Q6 dosing). He will be discharged on
this higher dose of metoprolol. He has remained in the ___ HR.
Apixaban held for possible procedure. Restarted upon discharge.
CHRONIC ISSUES
================
#DM2:
-Held home metformin, insulin sliding scale while in the
hospital
#GERD: Continued home omeprazole
#Anxiety/depression: Continued home escitalopram, alprazolam
#BPH: Continued home Flomax
#HLD: Increased simvastatin to 40mg given ASCVD risk of 20.9% | 134 | 280 |
13043906-DS-17 | 22,469,153 | Dear Mr ___,
It was a pleasure caring for you at the ___
___. You were admitted for a fever. We performed
blood cultures that showed no bateria in your blood. We feel
your fever was due to a small infection around your ___ site.
We removed your PICC and replaced it with a new line. We feel
you are safe to return home on antibioitcs.
During this admission, we made no changes to your medications. | Primary Reason for Admission: Mr ___ is a ___ with h/o
poorly controlled DM2 and right ankle osteomyelitis ___ fracture
in ___, sternum osteomyelitis ___ CPR, currently on
dapto/flagyl/cipro, who presents with right ankle pain, "redness
around and drainage" from the PICC area, and +SIRS criteria.
. | 76 | 47 |
11563811-DS-17 | 23,117,072 | Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
*** You must wear the hard cervical collar at all times.
Medications
Please do NOT take any blood thinning medication (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.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
*** Continue to take Aspirin 325mg by mouth daily for
concern for arterial injury to the V3 segment.
When to Call Your Doctor at ___ for:
Fever greater than 101.5 degrees Fahrenheit.
New weakness or changes in sensation in your arms or legs. | Ms. ___ was admitted to the neurosurgical service on
___ after suffering a trip and fall while at home. She
was transferred from ___ with a Type II dens
fracture. She underwent a CTA of the head which showed a
possible V3 segment injury. The imaging was reviewed by Dr.
___ she was started on a full strength Aspirin daily. She
was placed in a hard cervical collar to be worn at all times.
On ___, the patient remained neurologically intact on
examination. She underwent a MRI of the cervical spine which was
negative for ligamentous injury.
On ___, the patient remained neurologically stable on
examination. Prophylactic subcutaneous Heparin was held as she
was ambulatory per Dr. ___. She was re-evaluated by
physical and occupational therapy and it was determined she
would be discharged to a skilled nursing facility with a plan to
follow-up with Drs. ___ of ___
Neurosurgery in 1-month. | 173 | 152 |
15379960-DS-21 | 24,839,160 | Dear Mr. ___,
You were admitted for a change in your mental status. We also
found that you were likely aspirating oral contents and that
this led to a pneumonia. We treated you with antibiotics and
your mental status is currently improving.
We have also continued your Lamictal and changed your Dilantin
dosages as recommended by your outpatient neurologist Dr. ___.
Please have your rehab center check your Dilantin level on
___ and report the results to Dr. ___ ___.
You will see ___ (nurse in Dr. ___ on
___, and will see Dr. ___ on ___ (see below).
Please call your doctor or go to an emergency room if you have
another change in your mental status, develop a new fever, or
have trouble breathing. | ___ male with a past medical history notable for cavernous
hemangiomas of brain, SDHs s/p TBI, and aspiration pneumonias
presenting with cough and fevers from a rehab facility.
#Sepsis: Attributed to aspiration pneumonia given the patient's
cough, hypoxemia, history of aspiration and CXR/CT
abnormalities. Blood cultures and urine cultures were negative.
Patient improved with supplemental oxygen, aggressive suctioning
and broad spectrum antibiotic coverage not requiring pressor
support. Initially started on Vancomycin and Zosyn with eventual
narrowing to Zosyn alone. Completed 8 day course of zosyn on
___. Last febrile on ___. On discharge, blood cultures
from ___ were still pending.
#Altered mental status: The patient's mental status is severely
compromised at baseline secondary to prior strokes, SDH, and
ICHs. Head CT on last admission ___ after ___ showed a small
increase in chronic bilateral SDHs with mixed attenuation and
new hemorrhage in the posterior horn of the left lateral
ventricle. Prior to this admission he was speaking words and
physically interactive with family. His presentation was most
consistent with hypoactive delirium secondary to concurrent
infection. His mental status gradually improved over the course
of the hospital stay. At the time of discharge, he is more
physically interactive with his wife and the medical team,
though was not verbal, but when compared to the physical exam
during the admission, this appears to be new baseline.
#Hypoxemia, oxygen requirement: On admission, was requiring 10L
supplemental oxygen. Oxygen requirement improved throughout
admission with treatment of PNA, chest ___, aspiration
precautions, and frequent nasotracheal and orotracheal
suctioning. Saturating well on room air, with occasional ___
requirement likely due to infiltrate from resolving PNA,
micro-aspirations, atelectasis, and small left pleural effusion.
Occasional micro-aspirations due to chronic neurological
impairment causing inability to protect airway, causing
occasional short periods of tachypnea, however resolved quickly
with deep suctioning and decreased in frequency with regular
oral suctioning. On day of discharge, patient was on room air
using shovel mask overnight with humidifed oxygen.
Unfortunately, patient will continue to have micro-aspiration
events.
#Hematuria: Developed hematuria on day of discharge. UA with no
e/o infection. Hematuria likely due to foley trauma.
#Tachycardia: Heart rate up to 120s during admission, likely due
to infection and hypovolemia. HRs returned to his baseline
95-105 on discharge with treatment of his infection and volume
repletion with tube feeds and free water flushes through his
PEG.
#Seizure disorder: Last known seizure ___. He is currently on
lamotrigine and phenytoin. Dosages recently changed at rehab;
change does not appear to have been approved by outpatient
neurologist (Dr. ___. Returned patient to home doses of
phenytoin and lamictal, however remained subtherapeutic
(phenytoin level 6.6 on ___. Per outpatient neurologist, on
___, patient given 500mg phenytoin x1 and increased dose to
200mg QAM and 250mg QPM. Patient will follow-up with outpatient
neurology. Throughout admission, patient had slight muscle
twitches at rest, no overt seizure activity, and no evidence of
non-convulsive seizure activity on EEG during this admission.
#Cavernous hemangiomas of brain/SDH/ICH: Most recent bleed after
fall in ___. No signs of bleed at present, and no evidence
of bleed on head CT ___. Held all ASA, NSAIDS and
anticoagulation (including DVT PPX) during hospitalization.
#Hyponatremia: Patient has a history of hyponatremia. Per wife,
the patient has been having weekly sodium checks. Plan to resume
weekly sodium checks and send results to rehab MD for review.
TRANSITIONAL ISSUES
# Code: ___
-___ rehab draw phenytoin level prior to AM dose on ___ and
fax results to Dr. ___ (fax ___
-Follow up appointment with outpatient neurologist (Dr. ___
___ for management of partial complex epilepsy and AED dosage
titration.
-Follow up final results of ___ blood cultures
-Voiding trial and discontinuation of Foley catheter. Montoring
urine output for continued hematuria.
-Chest ___, oral suction TID.
-Weekly serum sodium checks, please send reports to rehab MD.
-___ up imaging findings with PCP:
1. Expansile lucent lesion in T7 with mild wedge compression
fracture, possibly complicated vertebral hemangioma. MRI may be
considered for further assessment, if not already done.
2. Incompletely imaged suspected pathologically enlarged left
axillary lymph node. | 124 | 667 |
19474302-DS-15 | 27,956,280 | Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
You were transferred to ___ because your abdominal aortic
aneurysm appeared bigger on scans you had, and you needed to see
vascular surgery.
WHAT HAPPENED IN THE HOSPITAL?
-You were seen by vascular surgery for your aneurysm. This will
need to further management by vascular surgery, and we have
arranged a clinic appointment for you
-You were seen by neurosurgery for your weakness. This was felt
to be due to narrowing of your spinal cord and you have an
appointment for further follow-up
-You were treated for antibiotics for a pneumonia
-Physical therapy recommended rehab to help you get stronger
-You had a catheter placed because you were having difficulty
urinating
WHAT SHOULD I DO AFTER LEAVING THE HOSPITAL:
-Work with the therapists at your rehab to help regain your
strength
-Please follow-up with your vascular surgery and neurosurgery
appointments as scheduled below
-Please see your primary doctor after leaving rehab
___ wish you the best!
-Your Care Team at ___ | ___ with PMH CKD III (Cr baseline 1.8), DM (on insulin),
paroxysmal atrial fibrillation, HLD (not on statin ___ rhabdo),
stable AAA last checked ___ presents to the ER for fatigue,
low back pain and subjective leg weakness, found to have stable
but 5.7cm AAA, spinal stenosis causing weakness, treated for
community-acquired pneumonia.
#Leg weakness:
#Lumbar stenosis:
Patient with transient leg weakness on admission. Neurosurgery
and neurology consulted. MRI showed "spinal canal stenosis at
the L3-4 level" and "Multilevel significant neural foraminal
narrowing" and there was no indication for urgent surgical
intervention as not consistent with cord compression. His exam
showed ___ strength except for 4+ plantar/dorsiflexion
suggestive of lower motor neuron deficit consistent with imaging
level. His weakness resolved. He worked with physical therapy
and was discharged with neurosurgery follow up.
#AAA:
Prior to transfer, imaging showed possible expansion of known
AAA. 4.6 cm ___ -> 4.8 cm ___ -> 5cm ___ Was to have
outpatient vascular work up. Surgery was advised for >5.5 cm or
increase of >0.5 cm in 6 months. On CT non-con at OSH was 5.7.
Although different modalities (ultrasound, CT) there was concern
for acute change in size and he was transferred to ___ for
vascular surgery evaluation, who recommended CTA for assessment
and surgical planning. Underwent CTA, vascular surgery
evaluation and will follow-up with vascular surgery at scheduled
clinic appointment.
#Toxic metabolic encephalopathy:
#MCI:
Concern for TME vs. TIA/stroke on initial presentation due to
confusion. NCHCT without acute findings. Neurological exam
largely non-specific but did show some frontal (changes in
behavior) and cerebellar (tremor.) Delirium resolved morning
after admission, most likely due to metabolic(hyponatremia to
129), infectious causes(untreated pneumonia,) urinary retention,
with aspect of sundowning. TSH, B12, folate within normal
limits. Further work up of possible mild cognitive impairment
deferred to outpatient.
#Urinary retention:
#Likely BPH:
Patient with post void residuals 700-1000ml. No cord
compression, suspected element of overflow incontinence. He was
straight catherized in hospital but indwelling was placed as it
was felt patient could not reliably straight cath at home.
Tamsulosin started, uptitrate as tolerated as outpatient. Please
discontinue foley and perform voiding trial in 1 week at rehab.
If fails would recommend intermittent straight cath and arrange
urology evaluation.
#Pneumonia, bacterial: Patient with RML pneumonia on OSH CT
scan. Patient asymptomatic, but did have fever to 103 at OSH.
Completed 5 day course for CAP: azithromycin (___)
and ___
#Hyponatremia:
Patient's baseline Na is 135 from prior ___ records. Admitted
with Na 129 on ___. Improved to 135 with out specific
intervention. | 176 | 414 |
14480817-DS-10 | 23,545,320 | Dear Mr. ___,
It was a pleasure to be part of your care.
You were admitted to the hospital because you were found to be
very confused at home.
In the hospital you were found to have a lung infection which
was likely contributing to this change, and which was treated
with antibiotics. The sudden confusion improved with
antibiotics, however you remained confused about some facts
during your stay and both your family and the doctors were
concerned based on this confusion that you wouldn't be able to
take care of yourself at home.
We also adjusted your anticoagulation drugs, used to prevent new
drug clots in your legs. Please follow up with your appointments
as listed below.
We found a longer-term care facility that can help take care of
you while you are still confused.
We wish you the best,
Your ___ Team | Mr. ___ is a ___ with a history of HIV (on ART, no detectable
viral load ___, chronic low back pain (on opiates) recently
admitted for DVT/PNA (___) who presented with AMS likely ___
toxic metabolic encephalopathy iso infection and sepsis
attributed to PNA. Pt was initially transferred to the ICU iso
severe agitation requiring precede but agitation has resolved
and pt was transferred back to the floor. Pt received IV
antibiotics for presumed PNA and encephalopathy improved.
# Encephalopathy. Pt initially p/w toxic metabolic
encephalopathy iso sepsis from PNA described below. Delirium was
notable for severe agitation requiring MICU admission for
precede administration. Delirium improved significantly with IV
antibiotics and upon readmission to the floor pt was AOx3 and
generally calm. At time of discharge pt demonstrated persistent
confusion/inattention (AOx3 but unable to state president ___
backwards). Pt likely has persistent delirium. He possibly pt
has underlying dementia or less likely is persistently altered
___ underlying psychiatric conditions. Pt received Depakote 500
mg BID while inpatient and was re-started on zyprexa 5 mg upon
discharge given QTC ___ of 397. Per psychiatry evaluate, home
fetzima should be restarted as an outpatient. Psychiatry advised
that benzos should be avoided. They suggested starting ramelteon
to regulate sleep/wake cycle.
# Pneumonia: Pt p/w AMS, leukocytosis and sepsis with CT Chest
c/f PNA. Pt was treated for 8D course of HAP with vanc/cefepime,
transitioned to zosyn/azithromycin. Pt will require repeat CT
chest in ___ weeks.
# Chronic pain. Hx of chronic back pain on Percocet (5 mg-325
mg) TID, MS contin 100 mg BID and gabapentin 800 mg QID:PRN.
Home pain medications were initially held iso AMS and then
restarted gradually. Pt was discharged on home regimen with
exception of gabapentin, discharge dose 300 mg TID.
# Afib: Noted to have Afib on ___ with RVR up to 170s-180s
which resolved with IV metoprolol 5 mg x1. No prior history of
afib, however CHADS Vasc of ___oes not require long term
anticoagulation for atrial fibrillation. Pt was continued on
metoprolol for history of NSVT/HTN and anticoagulation for DVT,
described below.
# Weight loss: 30 lb documented weight loss in our records.
Unprovoked DVT last year, cachectic on exam. Concerning for
underlying malignancy. Outpatient providers should discuss with
patient/HCP cancer screening.
RESOLVED/CHRONIC
# Transaminitis: (resolved). Elevated transaminases noted on
admission likely ___ sepsis, ascites/edema of abdomen and
increased attenuation of the liver noted on CT abd ___.
Transaminitis resolved during admission.
# Type II NSTEMI: Pt w/new TWI on EKG on admission. Had NSTEMI
II w/trop elevation on last admission. Trops slightly elevated
at 0.06, stable upon recheck. Likely demand ischemia in setting
of sepsis.
# CAD: Continue ASA 81 mg, atorvastatin 80 mg QPM
# Deep vein thrombosis: Of note, during admission
___ pt was found to have presumed unprovoked
bilateral DVTs (non-occlusive in R common femoral extending to
the popliteal, L superficial femoral). Per PCP, ___
for 6 month AC with warfarin (ending ___ per anticoagulation
tab note, however 6 months from initiation would be ___,
however pt has been sub-therapeutic on admission and in
outpatient clinic for approximately 50% of course. Pt was
discharged to rehab on Enoxaparin 60 mg SC Q12H as it was
difficult to achieve therapeutic INR and titration will be
affected by restarting ART.
# HIV: Diagnosed ___, VL ___ undetectable. Previously on
combivir and nevirapine. Stopped taking medications for one
month prior to admission. Low c/f ___ given CD4 330s. HIV VL
3.1 (log10 value). ART will be restarted in outpatient ___
clinic, once it can be confirmed that pt will reliably take home
medications.
# Malnutrition: Albumin 2.8 on admit. Per family, pt has
difficulty feeding himself at home. Pt received daily MVA and
ensure TID with meals.
# HTN: SBPs elevated up to 170s during admission. Pt was
restarted on home metoprolol succinate 100 mg PO QD and home
lisinopril 5 mg PO QD which was up-titrated to 10 mg QD during
admission. SBP 100-110s on discharge so pt was discharged on 5
mg lisinopril.
# Depression/Anxiety. Psychiatry recommended that pt restart
home fetzima as an outpatient. They also recommended Depakote as
discussed above.
# Thyroid Nodule. H/o thyroid nodule status post
hemithyroidectomy in ___ with benign pathology. TSH
mildly elevated at 4.3 however Free T4 1.1 wnl.
TRANSITIONAL ISSUES
[] Restart home fetzima
[] Consider utility of ramelteon, started to regulate sleep/wake
cycle
[] Repeat CT in ___ weeks after discharge
[] Discharged on lovenox 60 mg SC BID. End date ___ per
anticoagulation tab in OMR (Of note 6 months from initiation
would be ___. Decision about whether to restart warfarin
should be considered at time of discharge from rehab as pt may
complete planned course of AC at rehab
[] Titrate back gabapentin (home 800 mg QID:PRN)
[] F/u with outpatient HIV provider ___: restarting ART. Pt will
need appointment set up in infectious disease clinic at ___.
[] Continue ensure TID as pt p/w malnutrition
[] Monitor QTC as zyprexa was restarted on discharge (QTC 397 on
___
# CODE: full
# CONTACT:
Brother: ___. ___
Niece: ___ ___ (HCP) | 140 | 848 |
16882993-DS-18 | 27,876,419 | Dear Mr. ___,
You presented to the hospital with tongue weakness and you were
found to have a nerve problem (a hypoglossal nerve palsy). It is
unclear what caused this; brain imaging did not show a stroke or
vascular abnormality. We checked a variety of bloodwork that was
pending at the time of your discharge; please follow-up as an
outpatient to go over these results.
We wish you all the best! | Mr. ___ is a ___ year-old man with a past medical history
including hypertension who presented to the ___ ED ___ with
tongue weakness. CT/CTA conducted in the ED did not demonstrate
any acute intracranial hemorrhage or hemodynamically significant
stenosis or large vessel occlusion. Mr. ___ was admitted to the
stroke neurology service for further management.
# NEUROLOOGY
Symptoms persisted while in the hospital. Mr. ___ was admitted to
the stroke service as there was concern for stroke. He was
initially placed on telemetry, fall precautions and aspiration
precautions. He had a bedside swallow assessment prior to
eating. Fortunately, his head MRI was negative for any acute
ischemia or intracranial hemorrhage. Following this result,
multiple labs were checked to assess for the etiology of his
peripheral cranial nerve XII palsy. Labs were negative or
pending at time of discharge. There was not a clear etiology to
his cranial nerve XII palsy. Mr. ___ will follow-up with his
primary care doctor at his previously scheduled appointment.
# CARDIOVASCULAR
As there was initial concern for stroke, a fasting lipid panel
was checked. This showed elevated triglycerides to 383 and
elevated total cholesterol to 230. Mr. ___ should follow-up with
his primary care doctor regarding these findings.
# GLOBAL
Mr. ___ was placed on heparin SQ for DVT prophylaxis while in the
hospital.
==============================
TRANSITIONS OF CARE
==============================
- Mr. ___ was diagnosed with a CN XII (hypoglossal) nerve palsy
during hospital stay. MRI and CTA head and neck did not show any
abnormalities. Etiology of this nerve palsy was unclear at time
of discharge. Mr. ___ declined a lumbar puncture. Please
follow-up the pending labs at time of discharge to further
clarify the etiology of this nerve palsy.
- Mr. ___ was also found to have elevated total cholesterol to
230 and triglycerides to 383 on fasting lipid panel. He may need
additional medications as an outpatient. | 69 | 304 |
13945586-DS-24 | 23,145,496 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted
___. You were admitted because of complications with
hemodialysis yesterday. Your AV fistula was evaluated here and
found to be working well. You should resume your home cycle of
dialysis on ___. There were no changes
made to your medications. You should follow up with your PCP and
nephrologist at your scheduled appointments. | Mr. ___ is a ___ year old male with ESRD who presented from
hemodialysis center after an unsuccessful attempt to use AVF. | 72 | 22 |
19147811-DS-5 | 21,891,113 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abnormal liver tests.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a CT scan that showed worsening of biliary dilatation
due to an obstruction that we believe is secondary to your
pancreatic cancer.
- You underwent an ERCP and had a stent placed in your common
bile duct.
- You were given IV fluids after the procedure and then
transitioned to a clear liquid diet.
- The CT scan also showed an infection in your bladder, and we
gave you antibiotics.
- Given your vaginal bleeding, you had a vaginal ultrasound that
showed that you could have an abnormal connection between your
vagina and intestinal tract or inflammatory changes. This
finding requires further workup as an outpatient by your primary
care provider.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Followup with your primary care doctor and your oncologist.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman PMH of HTN, PE, Borderline resectable
pancreatic cancer (s/p ___ neoadjuvant cycles FOLFOX), who
presented with ___ c/b biliary obstruction. She
underwent a CT scan which showed biliary duct dilitation ___
obstruction near pancreatic head. | 197 | 42 |
11118087-DS-21 | 23,349,716 | 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 activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
Please remember that you received contrast during your
angiogram and that you should pump and throw away the breast
milk x 48 hours. | ___ y/o F with whooshing sound in L ear since delivering her
baby, MRI/A shows concern for L dural AVF. Patient was admitted
to neurosurgery for a diagnostic angiogram. Patient was neuro
intact on examination. On ___, patient was taken to angiogram
with no intraoperative complications. She was diagnosed with a L
dural AV fistula. Once angiogram was completed, patient was
transferred to the floor with flat bedrest for 2 hours. Patient
reported blurried vision for approximately 2 minutes which
resolved on it's own. Post angio exam was stable and no further
episodes of changes in vision. On ___, patient was discharged
home with directions to pump her breast milk and discard it for
48 hours. | 291 | 117 |
16820602-DS-31 | 27,370,748 | Dear Mr. ___,
You were admitted to the hospital with rectal pain. You
underwent an MRI in the emergency department which demonstrated
a perirectal abscess. This abscess spontaneously drained and you
did not require surgical intervention. You are tolerating a
regular diet, passing gas and your pain is controlled with pain
medications by mouth.
If you have any of the following symptoms, please call the
office 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, we wish
you all the best! | Mr. ___ presented to ___ ED at ___ on ___ with ___
anal pain. He was admitted and observed. His pain was
controlled, and the abscess/fistula output was observed. He had
an MRI (see separate report) and no further intervention was
needed
Neuro: Pain was well controlled on Tylenol and Dilaudid for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored.
GI: The patient was initially kept NPO in case he'd need to be
taken to the OR, but was then advanced to a regular diet.
Patient's intake and output were closely monitored.
GU: The patient was voiding without difficulty. Urine output
was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none.
Heme: The patient received enoxaparin and ___ dyne boots
during this stay. He was encouraged to get up and ambulate as
early as possible.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently, the pain was controlled. He will
follow-up in the clinic in ___ weeks. This information was
communicated to the patient directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge. | 111 | 422 |
16201176-DS-11 | 25,968,257 | You were admitted to the hospital after the car in which you
were driving was t-boned by another car. You sustained rib
fractures as well as a collection of blood around your spleen.
You were admitted to the intensive care unit for monitoring.
Because of your rib fractures, you had a catheter placed in your
back for pain management which has since been removed. You have
been transitioned to oral medication with control of your pain.
You have been evaluated by physical therapy and cleared for
discharge to a rehabilitation facility to futher regain your
strength. | The patient was admitted to the hospital after he was involved
in a motor vehicle accident. Upon admission, he was made NPO,
given intravenous fluids, and and underwent imaging. He
sustained left sided fractured ribs ___, a splenic laceration,
and a small left hemo-pneumothorax. He was admitted to the
intensive care unit for pulmonary toilet and pain managment.
Because of his multiple fractured ribs, the Pain service was
consulted and the patient underwent placement of an epidural
catheter. He was monitored in the intensive care unit for 24
hours where he remained stable. He was transferred to the
surgical floor on HD #3.
The patient's vital signs remained stable. The epidural
catheter was removed and the patient was started on oral
analgesia. His pulmonary status remained stable and he
maintained adequate saturation. He was passing clear urine out
of his supra-pubic tube. His hematocrit remained stable at 36
with a normal white blood cell count. Prior to discharge, he
was evaluated by Physical therapy and recommendations were made
for discharge to a rehabilation center where the patient could
regain his strength and mobility. The patient was discharged on
HD # 6 in stable condition. An appointment to follow-up in the
acute care clinic will be arranged at a later date by the
clinic.
******review u/a results at follow-up | 101 | 233 |
14501935-DS-7 | 23,098,630 | You were admitted to ___ with abdominal pain and vomiting up
blood. Please continue to take all of your medications. | ___ with chronic abdominal pain, admitted with hematemesis in
the setting of abdominal pain and vomiting.
.
ACTIVE ISSUES
# Mild Hematemesis secondary to ___: Specks of blood
in vomiting x15. DDx include ___, less likely large
acute GIB secondary to borhaves, dulefoys, AVMs, mass. The pt
was treated supportively with IV PPI, 2 large bore PIVs, but
there were no further episodes in house.
- NPO
.
# Chronic Abdominal Pain: Unclear etiology. Has been evaluated
at ___ on multiple occasions. Case discussed with PCP today and
confirms history. Working diagnosis for now is gastris and
duodenitis. Gastropersis is possible although not typically
associated with abdominal pain. Biliary colic in differential.
No evidence for pancreatitis, peritonitis, mesenteric ischemia,
SBO, LBO, appendicitis, cholecystitis, diverticulitis, peptic
ulcer disesae, colitis, hypercalcemia, AAA, adrenal
insufficiency, toxins (lead, iron), vasculitis (per PCP ___
WNL), FMF (no fevers), constipation, UTI. No evidence for mass
or abdominal lymphaenopathy. The patients diet was advanced, he
was treated with GI cocktail and PPI as well as low dose
narcotics for chronic pain, and was discharged the next day.
.
CHRONIC ISSUES
# Back Pain: Chronic in nature. Hold meds.
. | 20 | 198 |
18319079-DS-6 | 23,965,571 | Dear ___,
It was a pleaseure taking care of you at ___
___!
You were admitted for abdominal pain. You were found to have a
urinary tract infection, that was initially treated with IV
antibiotics and converted to antibiotics by mouth. Your foley
catheter was also replaced while admitted. Your pain improved.
While here, your port was clotted and was treated with
fibrinolytics and successfuly reaccessed. | ___ with rectal cancer stage IV and SVT admitted with fevers,
worsening lower abdominal pain and evidence of a urinary tract
infection.
Active Issue
# Urinary tract infection: patient complained of abdominal pain
and fevers on admission. He was found to have mixed flora on
urine culture. He was started on ceftriaxone and his foley was
changed. He was converted to PO bactrim and continued to be
afebrile during the course of his stay. Patient previously
declined offer of suprapubic catheter.
# Stage IV Rectal adenocarcinoma: patient recently completed ___
and radiation treatment. His port was accessed and found to
have clotted. 24hr alteplase was placed and was flushed
successfuly therafter. Port documents were solicited from the
hospital in PR in which it was placed, but were unsuccessful at
the time of discharge.
Chronic Issues
# AVNRT s/p ablation: patient was recently ablated for multipleo
episodes of AVNRT despite beta blockade. Patient was initiated
thereafter on sotalol and continued on 80mg sotalol BID while
admitted
Transitional Issues
- Please obtain records regarding port placed in ___
- Please follow up on blood cultures, pending at time of
discharge | 67 | 187 |
15772069-DS-18 | 20,236,265 | - continue daily weights and lasix as needed for gain of more
than 1 kg
- continue monitoring hg/hct weekly and transfuse blood PRN for
Hg <7.0
- cont IV vancomycin to 750 mg q 12 h thru ___ with trough am
___, goal trough ___
- Please obtain weekly cbc w/diff, BMP, LFTs while on vancomycin | ___ w/ CLL/SLL (unfavorable cytogenetics), breast cancer in
remission, and recent diagnosis of NSCLC IIIa admitted w/
improving rash but worsening anasarca after outpt blood
transfusion, which has improved but now w/ MRSA bacteremia.
# Anasarca/lower extremity edema - Pt reports chronic ___ for
almost ___ but admitted w/ worsening ___ with
blood transfusion. Etiology most likely
seems related to volume overload. Weight stable at 151.3 lb. She
did not require Lasix during the last week of her
hospitalization. She notes that her ___ is chronic and despite
many interventions, never has ever fully resolved.
# CLASBI
Developed F ___ and growing GPCs in ___ bottles on ___. PICC
was originally placed ___ was removed ___. TTE and TEE neg for
endocarditis. She was seen by ID team. Vancomycin was started ___.
She needs total of 2 weeks of abx since ___ negative culture
through ___. ALl cultures subsequent to initiation of
vancomycin were negative. Vanco trough was persistently slightly
high just above 20 so dose decreased to 750mg day of discharge.
Repeat trough should be checked on am ___.
# Anemia/Pancytopenia
She has hypoproliferative anemia, no evidence of hemolysis or
bleeding.
Last transfusion ___ then again ___, Likely ___ CLL compounded
by cytotoxic effect of prior bendamustine. While DAT is
positive, LDH/haptoglobin/smear not suggestive of hemolysis.
Low retic count supports anemia of underprodcution likely ___
CLL and chemotherapy.
# Distal DVT
Found in R peroneal vein, a distal vein. Given high risk of
propagation in context of host, outpatient team decided to
proceed with anticoagulation. Risks and benefits discussed.
Due to pancytopenia, it was felt that BID Lovenox would be best
medication for her.
- cont Lovenox BID. Plt have been stable
# Lung Ca:
Currently not chemo-rads candidate given pancytopenia, per Dr.
___ would have severe bone marrow suppressive
effect and radiation alone not likely to alter quality of life
and would have severe toxicities. Pt herself shying away from
wishing to pursue any aggressive options as well.
# CLL
She has profound cytopenia limiting therapy per oncologist
Pt's sister in law and brother discussed raising the idea of
hospice and feel like this would be in line with the patient's
goals. Pt is in agreement though would still like treatment for
infections, etc, not fully CMO. She will need to f/u with her
primary oncology team.
# Hypertension/Hypotension
BP stable, low to normal range. Here ACEI and CCB were d/ced.
Since ___, outpatient SBPs have been ___.
Prior to that SBPs in 140s-160s range. Likely due
to vascular insufficiency. Cortisol stimulation test did not
suggest adrenal insufficiency.
# Constipation
Chronic and per her report, due to our food. +flatus
- cont senna/colace/duloclax/MOM
# ___: Improving. Does not require neutropenic
precautions
# Breast Cancer: continue anastrozole
# Depression: sw consult given passive SI as outpt but she
denied this inpatient
# Seizure disorder: continue valproic acid, keppra, lamictal
# Rash: per derm, most likely ___ blood transfusion. Almost
completely resolved. We continued her home claritin
# COPD: stable, continue home inhalers | 54 | 490 |
13477858-DS-20 | 27,346,558 | Dear Ms. ___,
You were admitted to the hospital after having a fracture of
your right femur which was caused by cancer that has spread to
your bones. We'd like to keep you in the hospital to treat you
for the cancer, the fracture, and pain. However, you wanted to
leave against medical advice. We recommend that you follow up
with your own doctors as ___ as you leave the hospital and that
you come back to the hospital if at any point you develop
worsening symptoms or any concerning symptoms to you. | ___ y/o F w/ untreated, slow-growing breast cancer since ___ p/w
right hip/thigh pain due to bone mets and pathologic right
femoral neck fracture. Extremely challenging hospitalization in
which she has essentially refused all efforts to palliate her
hip pain other than oral pain medications.
# Right femoral neck fracture (pathologic)
# Right hip/thigh pain: Consulted RadOnc, Onc, Ortho,
Palliative.
-Gave Pamidronate 90 mg IV x1 on ___ per Onc recs.
-Ortho-Trauma saw her on admission. Patient delayed decision on
surgery. So was maintained NWB RLE on bedrest pending her
decision. She ultimately declined palliative right
hemi-arthroplasty for reasons including not wanting a male
surgeon, wanting to talk to an ___ MD first, and wanting
more time to consider her options. Ortho-Trauma advised NWB
RLE, and ROM as tolerated (no longer on bedrest).
-Radiation Oncology evaluated and recommended palliative
radiation therapy. She was initially in agreement with this, and
went for the planning session on ___, but when they called for
her to go down for the first treatment session on ___, she
refused. She said she didn't want to be rushed into it, and
would prefer to do it as an outpatient. She said she wanted to
be seen by ___ and be seen by ___ prior to undergoing any
radiation therapy. We had ___ evaluate her and a female surgeon
from ___ also met with her.
-___ saw her on ___: she declined palliative surgical tx
offered by them. Said that she understood from their discussion
that there was a chance that the hip could heal on its own over
the next 6 weeks, so she did not want to pursue surgery at this
time. She said she was not "in a psychological state" to have
surgery and described herself as "a very indecsive person."
___ upgraded her weight-bearing restrictions to touch down
weight bearing of the RLE, so that she could more easily manage
transfers and other aspects of mobility. They cautioned her that
there is a substantial chance that the fracture does not heal on
its own and instead progresses/worsens.
-She worked with ___, who advised rehab given her significant
need for assistance with transfers and any mobility. The
patient refused rehab and said she would want to go home. She
refused home services.
-On arrival to the hospital, she was extremely uncomfortable and
highly resistant to any ROM of the right hip. She would lay on
her left side and keep the hip flexed. Any attempted movement
prompted severe anxiety, panic, and pain. The pain would
resolve rapidly, but attempted transfers and/or bed
repositioning maneuvers were very challenging due to her
anxiety. She was initiated on a pain regimen of standing
Tylenol, PRN toradol (prior to liver met biopsy, stopped after
that), standing & PRN oxycodone, and IV morphine
pre-procedurally/prior to planned transfers. The pain regimen
seemed to work well, and the IV morphine was discontinued. In
the last ___ days of hospital course, she was mostly pain free
at rest, only seemed to have pain during actual movement of the
right hip, which itself seemed to resolve very quickly. Her
pain regimen was adjusted during the course of her
hospitalization with the help of the palliative care team. See
reported that the pain with hip aROM had improved from ___
initially to ___ on the day she left AMA.
# Metastatic breast carcinoma: Known prior breast Ca, which is
now a large and ulcerating right breast mass, so this was the
presumed primary. CT c/a/p done showed widely metastatic
disease to liver and bones. ___ did biopsy of liver met (___).
Path confirmed the dx of metastatic breast carcinoma. Oncology
discussed treatment options with her and they advised
anastrazole 1 mg PO daily, which she said she would be willing
to take, and was initiated prior to the patient leaving AMA on
___. An appointment was made for her in ___ clinic
with Dr. ___ for ___, should she choose to
attend.
# Dural enhancement: on MRI. Evaluated by Neuro-Oncology (Dr.
___, who felt this was most consistent with metastatic
carcinomatosis. The treatment of diffuse dural metastasis is
systemic chemotherapy, which the patient was not interested in
initiating during this hospitalization, but which she can
discuss with her primary Oncologist at her upcoming ___
appointment.
# Blurry vision w/ right lateral rectus muscle paresis and
facial asymmetry: CT head without ICH or large stroke, but many
skull mets one of which might be the culprit (may be pressing on
CN 6). MRI brain without any brain mets. Consulted
Neuro-Oncology at the recommendation of the Oncology team.
# Blindness: due to longstanding cataracts/glaucoma that she did
not seek ___ for. She has a large magnifying
glass and flashlight that she uses to read things.
# Goals of care: It was very challenging to fully understand and
help Ms ___ to achieve her goals. She initially indicated that
she wanted palliative interventions for her severe right hip
pain, however aside from pain medications,with their relatively
immediate effects on the pain, she ultimately turned down all of
the palliative interventions we could offer that required a
greater degree or process of decision-making. She seems to have
a combination of strongly avoidant and obsessive personality
traits. She is extremely anxious and, in her own words
"paralyzed with indecision" at times, but refused both talk
therapy and psychopharmacotherapy for anxiety when evaluated by
the Psychiatry consult & liason service. She is intensely
private, won't share any information about friends/family with
us, and won't allow us to reach out to anyone on her behalf.
She is also distrusting of both her condition and our motives.
She requested at times that we print out all of her imaging
studies, labs, and DNR/DNI order. On ___, I did this,
highlighted all the key parts (name of study, findings, etc.),
and gave them to her to help alleviate some of her
anxiety/distrust. When I asked her today (___) if she had read
any of these, she said no, because she has been interrupted so
much in the past 24 hours, which is fair, but I have also gone
in and found her sitting by herself, doing nothing, on multiple
occasions today. Unclear to me if she is actually able to read
the reports, even with her magnifying glass/light/etc. She
demonstrated circular reasoning at times, was often non-linear
in her thinking, and at times demonstrated poor recall.
However, with frequent repetition, she gradually integrated new
information, and was able to demonstrate understanding of the
risks of refusing palliative interventions (e.g. palliative hip
hemi-arthroplasty, palliative radiation therapy), as well as
additional diagnostic evaluations (e.g. CTPA to evaluate for PE)
or medical interventions (e.g. possible anticoagulation for PE,
if found). Palliative care, SW, and I all talked with her
extensively and did our best to understand her goals of care and
help her achieve them. Her long history of avoiding medical
interventions and allowing her medical conditions (breast
cancer, left hip metastatic lesions, and cataracts/glaucoma) to
follow their natural course was considered by our
multi-disciplinary team, to be an integral part of her
personality, and so we did our best to work within this
conceptual framework to offer her palliative interventions that
would limit the potential side effects that she seemed to be
much more afraid of than the disease processes themselves.
# Disposition: patient left AMA on ___. Earlier that day
she told us that she felt like she was being imprisoned and
wanted to go home. We reviewed our concerns about her safety at
home in her current condition with limited personal mobility
(evaluated by ___ & OT), and she was dismissive of our concerns.
She expressed that she would be just fine at home, but also
requested that we provide her with a wheelchair. We explained
that although we would absolutely not keep her against her will,
we were at the same time not under an obligation to facilitate
putting her in an unsafe situation. Along those same lines, I
explained that I did not feel comfortable prescribing her
narcotic pain medications for unsupervised home use due to the
combination of her severe vision impairment and her high risk of
falling without assistance. I asked her if she would consider
staying to continue working with ___ in the hospital to get
stronger & more capable of safe transfers on her own, so she
could go home safely. She declined. She said she would call a
friend to pick her up. Ultimately someone did come to pick her
up from the hospital at around 10 ___, and the patient refused to
allow the night team to reveal any details of her
condition/illness with this person. We provided her with a
prescription for anastrazole on discharge.
# Code status: DNR/DNI (confirmed with patient). | 92 | 1,477 |
11915451-DS-11 | 29,039,029 | Dear ___,
___ was a pleasure caring for you at ___. You were admitted
because you had a blood stream infection. Your infection was
most likely caused by your dialysis line, and you were treated
with IV antibiotics. Because your infection appeared to be
associated with your line, we removed your dialysis line. You
instead received dialysis through your right thigh AV graft.
Because of your infection, your blood pressures have been lower
than normal so we have not given you your blood pressure
medications (amlodipine and metoprolol).
You will continue taking ciprofloxacin through ___. Please
continue taking vancomycin through ___.
Thank you for allowing us to participate in your care. All best
wishes for your recovery. | PLAN AND ASSESSMENT:
Pt is a ___ with PMH ESRD on HD with multiple failed/infected
accesses, multiple hospitalizations for recurrent vanc sensitive
enterococcal line infections, now presenting with fevers and
chills concerning for cath-associated blood stream infection.
ACTIVE ISSUES
# Serratia/Enterococci Septicemia. Pt was septic ___ Serratia
bacteremia likely due to CRBSI. Line pulled by ___ on ___. The
patient was evaluated by Nephrology and Infectious Disease and
the pt was started on IV Cefepime with significant clinical
improvement. Patient also had a single blood culture from ___
grow enterococcus (became positive on ___. Pt's amlodipine and
metoprolol were held given his recent sepsis and SBPs in the low
100s-120s. TTE on ___ showed no sign of vegetations; however,
the pt received TEE for worsening TR noted compared to prior
echo in ___. TEE on ___ showed no sign of vegetation.
For this reason, pt was d/c'ed on 2 week course of PO Cipro and
IV vancomycin. | 120 | 159 |
16602058-DS-21 | 26,299,910 | Dear Ms. ___,
You were admitted to the gynecology oncology service for a small
bowel obstruction. Over the course of your stay, your small
bowel obstruction was treated with bowel rest, nasogastric tube
placement for stomach decompression and antiemetics. At this
time, you have recovered well and the team now feels it is safe
for you to be discharged home.
Please follow these instructions:
* Take your home medications as prescribed.
* You may alternate between Tylenol and ibuprofen for your pain.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* Please continue on your low residual diet until ___.
Please follow up with Dr. ___ in ___ weeks. An
appointment has been made for you for ___. Do not
hesitate to call the Gynecology ___ clinic if you have any
questions. | Ms. ___ is ___ year with a history of stage IIIc ovarian
cancer with metastatic recurrence who underwent multiple
treatments of chemotherapy with progression of disease,
currently on rucaparib with plan to start Avastin who was
transferred from an outside hospital for treatment of small
bowel obstruction. A CT abdomen and pelvis from the outside
hospital demonstrated a high-grade small bowel obstruction with
a transition point in the right lower quadrant, likely related
to adhesions. No obstructing mass was noted on CT. There were
also unchanged pulmonary metastasis, hepatic metastasis, and
peritoneal nodes as well as an increasing small pericardial
effusion.
Upon arrival to the ED,gynecology oncology was consulted and,
given the patient's overall well appearance and after reviewing
the imaging, the decision was made to manage the small bowel
obstruction conservatively. An nasogastric tube was placed in
the ED and the patient was made NPO with IV fluids. General
surgery was consulted and the patient was monitored with serial
abdominal exams.
On hospital day 2, patient's abdominal exam showed no peritoneal
signs during her stay and she remained afebrile with a normal
white blood cell counts. At that time, patient passed flatus and
her NG tube output decreased. An NG tube clamping trial was
performed and there was minimal residual after four hours. Her
NGT was thus removed and patient was kept NPO overnight. On
hospital day 3, patient was advanced to clears in the morning
without issue. At noon, patient tolerated crackers and toast.
She continued to pass flatus and had a bowel movement. Her
abdominal exam was normal. She was subsequently discharged home
in stable condition on hospital day 3. | 146 | 277 |
18676440-DS-15 | 28,397,111 | You were admitted with abdominal pain and vomiting. It is not
clear what caused your symptoms but they may be due to a problem
with the motility of your gastrointestinal tract or irritation
in your stomach. You were treated symptomatically and your
symptoms improved. You were evaluated by the GI service and had
an endoscopy that showed a fungal infection which is being
treated with anti-fungal. Brain MRI showed nothing that would
cause your symptoms. You had a swallow study which was normal
and without spasm of your esophagus. You should follow up with
your PCP and gastroenterologist. You were evaluated by social
work as well.
Please speak with your PCP to see ___ Psychologist to help treat
your anxiety. Your anxiety may not be the sole cause, but may be
contributing to your physical symptoms of abdominal pain and
vomiting. | ___ with history of asthma, recent admission for suspected
alcoholic gastrits presents with LUQ abdominal pain and
vomiting.
#Abdominal pain, LUQ
#Vomiting
Unclear etiology of pain. Alcoholic gastritis seems unlikely
given patient has recently stopped drinking. Recurrent nature
makes viral gastroenteritis less likely. While lipase is
elevated, doubt this is pancreatitis given normal CT findings.
Functional dyspepsia and impaired motility also on differential.
Seen by gastroenterology who recommended bowel regimen. The
patient was treated symptomatically with improvement in
symptoms. The GI service was consulted and performed an EGD
which revealed antral gastritis and esophageal candidiasis. He
was discharged on treatment with fluconazole and omeprazole for
a planned 3 week and 2 month course respectively. Brain MRI done
given hypertension/bradycardia which showed findings that could
be consistent with pseudotumor though he was experiencing no
symptoms suggestive of such. He should follow up with his
gastroenterologist for consideration of gastric emptying study
after discharge. A barium swallow was negative for esophageal
spasm. TSH, cortisol unrevealing. It was recommended that he
seek treatment for his anxiety as a contributing factor in his
nausea/vomiting.
# MRI findsings
Brain MRI ordered and without significant findings that would
cause his symptoms. Given the absence of symptoms of increased
ICP and lack of headache, visual changes, or palsy, and that
nausea only happens with food intake, will not assess further.
Should be evaluated by ophtho as an outpatient.
#Asthma
Noncompliant with medications at home and currently stable
#Anemia
Iron studies were normal.
#Anxiety
Recommend close outpatient follow up. Pt seen by social work. | 140 | 251 |
14440691-DS-14 | 21,842,272 | Dear Ms. ___,
You were sent from your nursing home to the hospital with fever,
elevated white blood cell count and concern for pneumonia. You
were started on broad-spectrum antibiotics. You were found to
have a urinary tract infection. Your Foley catheter was
exchanged. You antibiotics were tapered to the results of your
urine culture. You had a PICC line placed so that you can
receive antibiotics at home.
.
We noted that your sodium levels are high sometimes, suggesting
you don't drink enough water. We recommend that you increase
your water intake. | ___ year old F with vascular dementia, on chronic Coumadin for
prior DVT, chronic Foley recurrent UTI's here with fever and
altered mental status. Likely infectious source is urine given
normal CXR and lack of pulmonary symptoms. AMS likely ___
infection given fever and WBC. Elevated INR, does warrant CT
head though, suprisingly not done in ED.
1. Fever/Leukocytosis/somnolence ---> complicated UTI (ESBL and
chronic Foley)
She had received IM CTX at her nursing home. She initially
received IV CTX and Azithromycin in the ED for presumed PNA.
However, her CXR did not show clear infiltrate and she lacked
pulmonary symptoms. Her urine was very suspicious for UTI,
especially given chronic Foley and previous UTI's. She was
started on Vancomycin and Ceftriaxone to cover for GNR's and
possible enterococcus. Her Foley catheter was exchanged. She
did not have further fevers and her mental status improved to
baseline. Her WBC returned to normal limits. Her urine culture
returned positive for >100K CFU ESBL E. coli and ___
enterococcus. Her antibiotics were changed to Meropenem, with
plan for 10 day course for complicated UTI. She will complete
her antibiotic course at home via a PICC line. Interestingly,
her symptoms resolved prior to administration of the correct
antibiotic regimen. Given the lower colony count for the
enterococcus, did not choose to treat as true pathogen, more
likely colonization in setting of Foley catheter.
She changed to ertapenem 1g daily on the day of discharge,
___, and will finish antibiotics on ___.
2. AMS
Most likely toxic-metabolic encephalopathy from underlying
infection/UTI. However, given elevated INR on admission and
AMS, head imaging is warranted.
- obtain CT head - NEGATIVE for bleed
- treat infection as above
- improved with treatment of infection
3. Supratherapeutuic INR
- hold coumadin
- check Head CT for bleed
- no reversal given no active bleeding or high-risk of bleeding
- she was discharged on 2mg daily, with INR of 2.0 on the day of
discharge
4. DM2
- SSI with home lantus 5units
- fingersticks q6 while altered, revert to meal time sliding
scale once she starts eating
5. ___
Elevated BUN/Cr on admission, with Cr of 1.1, baseline <1.
Resolved with IVF. Most c/w pre-renal ___ from hypovolemia in
the setting of acute infection.
6. Hypernatremia
Pt had elevated Na of 149. She was given some free H2O via IV
while NPO. This improved her Na level. Encouraged free H2O
intake, and Na levels returned to normal. She is at risk for
limited access to free H20 given her baseline status and is at
risk for developing hypernatremia. Encourage access to free
H2O at nursing home to permit drinking to thirst.
FEN - NPO, LR at 100
PPX - INR > 2
Code - DNR /DNI per documentation from ECF | 96 | 462 |
16620730-DS-13 | 26,306,514 | Dear Ms. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
because you were found to have an appendix abscess. You had a
drain placed by Interventional Radiology on ___ without
complications. You tolerated the procedure well and are
ambulating, stooling, tolerating a regular diet, and your pain
is controlled by pain medications by mouth. You are taking
antibiotics to help with the abscess infection. You are now
ready to be discharged to home. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
IMPORTANT: CONTINUE YOUR ABTIBIOTICS TILL ___
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond ___ an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for several weeks. You might
want to nap often. Simple tasks may exhaust you.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- With antibiotics, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- You may take Tylenol as directed, not to exceed 3500mg ___ 24
hours. Take regularly for a few days after surgery but you may
skip a dose or increase time between doses if you are not having
pain until you no longer need it.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change ___ nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change ___ your symptoms or any symptoms that concern you
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.
Drain Care:
==============
You are being discharged with drains ___ place. Drain care is a
clean procedure. Wash your hands with soap and warm water before
performing your drain care, which you should do ___ times a day.
Try to empty the drain at the same time each day. Pull the
stopper out of the bottle and empty the drainage fluid into the
measuring cup. Record the amount of fluid on the record sheet,
and reestablish drain suction. **--A visiting nurse ___ help
you with your drain care.--**
- Clean around the drain site(s) where the tubing exits the skin
with soap and water. Be sure to secure your drains so they don't
hang down loosely and pull out.
-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).
-Note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-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 ___
water.
- If you develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10cc/ml for 2 days ___ a
row, please have the ___ call Interventional Radiology at ___
at ___ and page ___. This is the Radiology fellow on
call who can assist you.
Please call with any questions or concerns. Thank you for
allowing us to participate ___ your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team | Ms. ___ is a ___ with history of perforated appendicitis who
present on ___ with persistent RLQ pain found on imaging to
have (recurrent) perforated appendicitis with abscess,
leukocytosis of 17, but otherwise hemodynamically stable.
Patient was admitted to the general surgery service for abscess
drainage and IV antibiotics (cipro/flagyl).
#SURGICAL COURSE: Interventional Radiology was consulted for
drain placement at abscess. ___ did a CT-guided placement of an
___ pigtail catheter into the
collection with a JP bulb placed. Patient tolerated the
procedure well symptoms improved there-after. Initially
exudative light brown appearing material drained was collected
and sent for culture. Patient received daily catheter flushes by
nursing. On discharge, drain continued to drain some minimal
serosanguinous material.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with Tylenol. Pain
was very well controlled.
#CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
#PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: Initially patient presented with some dysuria. Her
UA/UC were negative. Pelvic ultrasound was significant for
fibroid uterus with notice of a lower abdominal abscess. CT
findings consistent with perforated appendicitis with right
lower quadrant multi-lobulated abscess measuring approximately
7.0 x 4.3 x 5.9 cm. There was also note of secondary thickening
of the urinary bladder and cecum, likely inflammatory due to the
nearby abscess. Her abdominal pain improved significantly after
starting IV antibiotics, taking Tylenol, and getting the drain
placed. The patient was NPO prior to her ___ procedure;
there-after patient was advanced to a regular diet which she
tolerated well. She had several loose bowel movements after
starting IV antibiotics, which was likely a side effect consider
she had no further leukocytosis or other infectious symptoms
prompting workup.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none. Patient was started on
IV ciprofloxacin and flagyl on admission. Her WBC on discharge
was normal at 5.8. She was discharged on PO Ciprofloxacin and
Flagyl.
#HEME: Patient received BID SQH for DVT prophylaxis, ___ addition
to encouraging early ambulation and Venodyne compression
devices.
#OTHER: Case management helped set up ___ services for the
patient to go home with for her abscess drain care. | 808 | 393 |
18204000-DS-7 | 26,710,254 | Dear Ms ___,
It was a pleasure to care for ___ at the ___.
___ were admitted for diverticulitis - an inflammation of the
outpouchings along your colon. ___ were given antibiotics for
this condition which ___ should continue after discharge. Please
continue to eat soft foods for another few days after discharge
(bananas, boiled rice, apple sauce and toast), then advance your
diet as ___ can tolerate without pain.
During your stay, ___ had a CT scan that showed a cyst in your
pancreas and a thickened area along your left pelvic wall. We
talked to your oncologist's office about these findings, who
feels they can be followed up as an outpatient. Please be sure
to ask your oncologist about a MRI study to evaluate these
findings.
MEDICATION CHANGES
- Start ciprofloxacin
- Start metronidazole (Flagyl) | Ms. ___ is an ___ woman with a history of
endometrial cancer, s/p robotic TAH-BSO and undergoing
chemotherapy with carboplatin (due to begin cycle 5 on ___,
received Taxol with cycle 1). She presented with left flank pain
and her clinical exam, lab results, and radiologic findings were
consistent with diverticulitis. | 133 | 51 |
10692690-DS-15 | 21,037,848 | Dear Ms. ___,
You were hospitalized for an episode of ischemic colitis likely
brought about by diabetic ketoacidosis. While in the hospital,
you received intravenous fluids and antibiotics. Once your
digestive tract had rested for a day, we resumed your diet to
facilitate its healing. We were reassured that your blood levels
were stable and did not think a colonoscopy would be needed at
this time.
When you leave the hospital, please continue to take your
medications, including the antibiotics we have prescribed for
you this hospitalization, and please follow-up with your primary
care physician.
If you have increased amounts of bleeding, we would recommend
that you return to the emergency room!
It was a pleasure to take part in your care!
Sincerely,
Your ___ Care Team | Patient Summary
===============
___ year-old woman with T2DM ___ A1C 9.3), HTN, Afib on
warfarin, and CAD w/ drug-eluting stent who presented with
nausea, vomiting, abdominal pain, and BRBPR.
Acute Issues
============
# Ischemic colitis: Developed gradual onset abdominal pain and
BRBPR in the ED. Admission CTAP demonstrating colonic wall
thickening and fat stranding most compatible with colitis. This
most likely represents ischemic colitis as the distribution is
consistent with watershed reasons. Cause of ischemic colitis is
likely from poor PO intake and DKA. Patient was made NPO for
bowel rest for 24 hours and then started on diet. She had a
second small episode of BRBPR on ___ AM (24 hours after the
first episode), which likely is residual from the first episode.
She was started on ceftriaxone/flagyl for empiric antibiotics.
She should continue antibiotic therapy with cefpodoxime 400 mg
PO q12h and metronidazole 500 mg PO q8h for a one-week course
(___). Warfarin was held on admission but resumed prior to
discharge. Last colonoscopy in ___ showed normal colon, and
as hemoglobin and hemodynamics remained stable, we did not feel
inpatient colonoscopy would add further value. She was educated
on return precautions.
# Type 2 DM
# DKA: Patient with longstanding diabetes, last A1C 9.3. Has had
end organ damage with autonomic neuropathy and diabetic
retinopathy. Had anion gap and glucose levels in 300s in the ED
concerning for DKA, which was treated with 4L IVFs. Anion gap
resolved in the ED. The patient should continue her home insulin
regimen: Lantus 35U qAM and qHS + HISS.
Chronic Issues
==============
# Afib: History of ___ in ___. CHADS2 score of 2, does
not meet criteria for bridging as per bridge trial. Last
warfarin dose on ___. The patient was continued on her home
sotalol 100 mg BID. Her home warfarin was held for one day given
BRBPR and resumed at a reduced dose of 3mg daily on ___. She
should have her INR checked on ___ with her PCP with warfarin
dose re-evaluated at that time.
# HTN: The patient was continued on her home losartan 100 mg
daily with holding parameters.
# Hypothyroid: The patient was continued on her home
levothyroxine 100 mcg daily.
# Peripheral neuropathy: The patient was continued on her home
duloxetine 60 mg daily.
# HLD: The patient was continued on her home rosuvastatin 20 mg
daily and home aspirin 81 mg daily.
# Mood: The patient was continued on her home buproprion 300 mg
daily.
# Other: The patient was continued on her home vitamin D 5000U
daily and home pantoprazole 20 mg daily.
Transitional Issues
===================
# Post-menopausal bleeding: CT on admission showed endometrial
thickening. This is already being worked up as an outpatient.
Patient will need endometrial biopsy, which has been scheduled.
- CONTINUE cefpodoxime 400 mg PO q12h and metronidazole 500 mg
PO q8h for 1 week (___).
- CONTINUE warfarin at 3mg PO daily (reduced dose due to being
on metronidazole). Next INR check on ___ at ___
___, confirmed by phone.
- Discharge INR 1.7. | 123 | 491 |
18699523-DS-36 | 26,640,297 | As you know, you were admitted with concern of drainage from the
R PICC line. This PICC line was evaluated by an IV nurse here
and repositioned. There was no evidence of infection or
drainage. Please continue with the TPN as scheduled.
There was question of pneumonia on a CXR, although this was
not a definitive diagnosis - since there was no fever or
significant rise in white blood cell count in the blood. You
may continue to take the antibiotics (Levoflox) for a short
course of treatment.
There are no changes to your medication otherwise. | ASSESSMENT AND PLAN: ___ w/chronic pancreatitis recently started
on TPN presents for ___ eval and found to have PNA.
# PNA: no fever or hypoxia: levaquin x5 days although suspicion
for pneumonia was relatively low.
# Concern for PICC Infection: she was eval by ___ team in ED
and determined there was no evidence of infection. It was
repositioned and dressed to ensure adequate placement and
consistency
# Chronic Pancreatitis: pt reports increased pain but denies any
PO intake. If this is true there is no reason for her to have a
flare of pancreatitis. All labs wnl. No signs of dehydration.
Multiple documented concerns for medication ___ in
the past. Of note, PCP is in the process of tapering home oral
dilaudid.
She was given dilaudid IV overnight, although there was no
clear evidence of significant exacerbation. She did not get a
prescription for dilaudid at discharge, she has appointment with
PCP ___ ___ | 109 | 161 |
11667815-DS-21 | 29,900,797 | Mrs. ___,
___ were admitted for evaluation of dizziness and left leg
weakness. MRI of your brain did not show any evidence of stroke
or structural abnormalities as potential causes of your
symptoms.
We recommend that ___ follow-up with your PCP, ___ can
also return to the Neurology Clinic ___ may call Dr. ___
___ below) for evaluation if symptoms persists.
We are not ordering any new prescriptions for ___ at this time.
It was a pleasure providing care for ___ during this
hospitalization. | She was admitted for further evaluation of vertigo, transient
facial sensory symptoms, and left leg weakness. Her symptoms
resolved overnight. She received an MRI Brain and MRA Neck which
were unrevealing of acute ischemia or structural
lesions/abnormalities that could explain her symptoms. Her
cardiac telemetry did not reveal any arrythmias. She was
discharged home with a recommendation to followup with Neurology
should her symptoms recur or persist.
PENDING STUDIES: None | 84 | 69 |
15950208-DS-16 | 22,698,938 | Dear Mr. ___,
It was a pleasure participating in your care. Please read
through the following information.
WHY WAS I ADMITTED TO THE HOSPITAL?
Your admitted to the hospital due to worsening shortness of
breath and increased fluid buildup. We were concerned he was
had an exacerbation of your heart failure.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
We gave you medications to help her move excess fluid from the
body. Originally you required intravenous medications, however
as your symptoms started to improve, we switched you to oral
medications.
We were also concerned that you may have developed a mild
upper respiratory infection. Given that you did not have any
fevers and your lab work otherwise looked fine, we did not feel
that you needed antibiotics.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Get labs drawn on ___
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is
212.96 lbs (96.6 kg). Please seek medical attention if your
weight goes up more than 3 lbs (increases to a weight of 215
lbs).
- 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 | ___ man with iCM with chronic systolic heart failure
(LVEF 10% in ___ s/p ___ ICD, prior LV thrombus on
warfarin, CAD s/p DES to LCx (___), presenting now for CHF
exacerbation.
TRANSITIONAL ISSUES
===================
[] Patient is not on a beta blocker outpatient. It may be
beneficial to have further discussions regarding the benefits of
attempting to reinitiate therapy versus the risks of decreasing
heart function given his low ejection fraction at baseline.
[] While inpatient, there were initial discussions regarding
whether CardioMEMS would be of benefit for this patient. He was
agreeable to this, and thus it should be followed up at his next
cardiology appointment.
[] Patient has reported history of hyperkalemia with
spironolactone. However, he also has reported history of
hyperkalemia with Lisinopril, but seemed to tolerate this well
inpatient. It may be of benefit to trial spironolactone again,
and consider potassium reducing agents if he becomes
hyperkalemic again.
[] Patient's Imdur was decreased to 30mg daily in the setting of
introducing lisinopril. Please continue to monitor his blood
pressures to ensure this is an adequate dose.
[] Please follow up INR and Chem10 from ___
ACUTE ISSUES
============
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
Patient presented with home with history of signs and symptoms
concerning for volume overload. After review of his HPI, it was
thought his symptoms were likely secondary to dietary
indiscretion as well as an inadequate medication regimen in the
setting of as needed torsemide. Patient was started on IV
diuretics, and responded well. Once he was thought to be
euvolemic, he was transitioned to oral Torsemide and was able to
maintain euvolemia on this dose. For afterload reduction,
patient's nitrate was decreased, and he had an increase in dose
of hydralazine as his blood pressures appeared to be able to
tolerate this. He was also newly started on lisinopril, and
monitored closely for hyperkalemia, which he did not have.
Patient was continued on home acetazolamide and digoxin.
[] Consider beta-blocker if blood pressures can tolerate
[] Consider CardioMEMS
[] Patient has reported history of hyperkalemia with
spironolactone. However, he also has reported history of
hyperkalemia with Lisinopril, but seemed to tolerate this well
inpatient. It may be of benefit to trial spironolactone again,
and consider potassium reducing agents if he becomes
hyperkalemic again.
[] Patient's Imdur was decreased to 30mg daily in the setting of
introducing lisinopril. Please continue to monitor his blood
pressures to ensure this is an adequate dose.
CHRONIC / STABLE ISSUES
=======================
# LV THROMBUS
Previously noted on echo from ___, and started on
warfarin. Again redemonstrated on echo from ___. Patient
presented with subtherapeutic INR, and thus given his active
thrombus, he was initiated on heparin while awaiting INR to
become therapeutic. Heparin was discontinued once INR was in
therapeutic range, so patient was continued on his doses of
warfarin.
# CORONARY ARTERY DISEASE
Most recent cath ___ with DES to LCx. No recent chest pain
or other ischemic symptoms. Patient was on triple therapy with
Plavix, aspirin, and warfarin, however based on the WOEST trial
and that the patient was more than ___ year out since stent
placement, Plavix was discontinued in favor of simply continuing
dual therapy with aspirin and warfarin. He was continued on home
rosuvastatin.
# Chronic Kidney Disease
Baseline appears to be around 1.6. Slightly elevated at time of
admission, suspect secondary to cardio-renal disease vs
progression of his underlying kidney disease. ___ also appear
worse during hospitalization due to initiation of lisinopril.
Stabilized at time of discharge.
# DIABETES
Continued Lantus 44u bedtime with mealtime sliding scale
# HYPOTHYROIDISM
Continued levothyroxine Sodium 112 mcg PO/NG DAILY
# GOUT
Continued allopurinol ___ mg PO/NG DAILY | 241 | 594 |
17916721-DS-21 | 23,431,052 | Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted after your fall and were found to have bleeding in to
your thigh. You were monitored closely and given blood
transfusions. Your blood levels have remained stable and thus
appears that you have stopped bleeding. You were also treated
for a urinary tract infection.
You will need to restart your anticoagulation in about 2 weeks,
but will need to speak to a physician regarding the risks and
benefits of this type of medications. We hope you continue to
improve. | ___ with h/o dementia, dCHF, BPH, Afib on coumadin, MV repair,
with recent complicated course including CVA ___, recurrent
UTIs, and recurrent C.diff who presents with gluteal hematoma
after a mechanical fall on systemic anticoagulation and
hypotension. | 101 | 37 |
12324075-DS-8 | 24,304,637 | You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. . Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office ___ and
make an appointment for 2 weeks after the day of your operation
if this has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Activity as tolerated w/ C-collar on.
Treatments Frequency:
Location: Sacrum
Type: unstageable pressure ulcer
Size: 1.0 X 0.8cm
Wound Bed: 100% yellow slough
Exudate: minimal
Odor: none
Wound Edges: pink, new epithelial tissue, intact
Periwound Tissue: intact, no issues
Wound Pain: ___
Wound Progress: Wound is decreasing in size with healthy new
epithelial tissue around borders. Wound center appears to be
superficial in depth.
patient is incontinent of stool and his perineal area was
erythematous with scattered rashy areas.
Recommendations:
Continue pressure relief measures per pressure ulcer
guidelines.
( X )Continue with current wound care as per previous note.
Commercial wound cleanser or normal saline cleanse
all open wounds.
Pat the tissue dry.
Apply DuoDerm wound gel to wound
Cover with 4 X ___ Mepilex Border
Change every 3 days
Apply thin layer of Critic Aid Anti-fungal moisture
barrier
lotion to perineal area with every ___ cleaning of perineal
area.
Support nutrition/hydration.
___ MD or wound care nurse if wound or skin deteriorates | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. In PACU, pt. developed hypoxia was
re-intubated and subsequently taken to the trauma ICU for close
monitoring. Pt. had a complicated hospital course detailed
below. He remained in the ICU until discharge and was discharged
directly to rehab from the ICU. | 853 | 88 |
12568708-DS-22 | 29,015,301 | Dear Ms ___,
You were admitted to ___ for confusion. We think you had
build-up of toxins from your liver disease. We gave you some
extra doses of your lactulose medicine.
While you were here, we ruled out active tuberculosis infection.
However it appears you have a latent infection with
tuberculosis.
You also underwent a biopsy of a lesion in your lung. The
results of this are pending at the time of discharge. Dr. ___
will follow up with you with the results.
Please continue you to take this and your other medicines at
home. You should have ___ bowel movements per day at home.
It was a pleasure taking care of you!
Wishing you the best,
Your care team at ___ | This is a ___ year old woman with a PMH significant for NASH
cirrhosis (c/b grade I EV, EGD ___, and HE), MELD-Na of 9,
who presents with ___ days of confusion concerning for hepatic
encephalopathy, resolved with lactulose & rifaximin, as well as
known cavitating lesion in lung undergoing workup for lung
cancer.
ACTIVE ISSUES
# HEPATIC ENCEPHALOPATHY: No leukocytosis or fevers; bland UA;
CXR without obvious infection; blood cultures pending. Suspect
encephalopathy was likely due to insufficient lactulose. No
evidence of PVT on ultrasound. Resolved with increased
lactulose. Discharged with lactulose TID (goal ___ BM) as well
as rifaximin 550 mg BID.
#LUNG MASS: With cavities vs. dilated bronchi, on ___ CT chest.
Concerning for TB vs. fungal process vs. possible lung cancer,
given radiographic description as spiculated and involving the
pleura. She is of ___ origin, with regular travel to ___.
QuantGold positive, with negative AFB smear x3 from induced
sputum. Galactomannan negative. Beta-glucan positive, at 162
(threshold >80).
- Will need to follow up biopsy
- Consider treatment for latent tuberculosis
CHRONIC ISSUES
# CIRRHOSIS: secondary to NASH. Grade I EVs identified on EVD in
___ given small size, not on nadolol. No prior history of
ascites or SBP. Encephalopathy in the past and on admission,
resolved within a few days of admission.
# COAGULOPATHY, and
# THROMBOCYTOPENIA : INR mildly elevated to 1.2. No signs of
bleeding. Secondary to cirrhosis.
# DIABETES MELLITUS: diet-controlled. Hb A1C 5%, ___.
# HYPOTHYROIDISM: continued him home levothyroxine.
==============================================
TRANSITIONAL ISSUES
==============================================
- Positive Quantiferon Gold (IGRA) test; consider latent
tuberculosis treatment
- Positive beta-glucan; follow up lung mass biopsy
- Lung mass: follow up biopsy. Preliminary read: positive for
adenocarcinoma. | 117 | 275 |
Subsets and Splits