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17549476-DS-12 | 28,386,451 | Dear Mr. ___,
You were admitted to ___ after you had an
episode where you lost consciousness, were shaking, and vomited.
You first went to ___, where a CT of your head looked
normal but a potential blood clot in the vessels going to your
bowel was seen on a CT scan. To treat this, you were transferred
to our hospital.
When you arrived here, you felt fine, and had no abdominal pain,
chest pain, shortness of breath, or lightheadedness. However,
your labs did suggest you were dehydrated, so we started you on
fluids delivered through your vein. Meanwhile, the vascular
surgery team saw you and suggested we start you on a blood
thinner delivered through your vein. Because your blood pressure
was low initially, we did not give you your blood pressure
medications while you were in the hospital.
We also got a picture of your heart called an "Echo," which
showed that the valve through which blood flows from your heart
to your body is severely narrowed. You should follow up with
your cardiologist about this.
Finally, we got an ultrasound of the vessels in your belly,
which showed a small tear in one of the vessels. To avoid a clot
forming within this tear, we started you on a blood thinner
called XXX.... You should take this medication every day, and
follow up with our vascular surgeons in one month about any
further testing and whether you need to continue your blood
thinners. You should also start taking your aspirin every day.
When you go home, you should make sure to stay hydrated. You
should also follow up with your primary care doctor and
cardiologist.
It was a pleasure taking care of you!
Your ___ Team | ___ yo male with h/o hypertension, hyperlipidemia, T2DM,
___ and known aortic stenosis who presented with episode
of lightheadedness followed by brief LOC/muscle twitching most
consistent with syncope caused by hypovolemia with incidental
SMA dissection found on imaging. | 286 | 38 |
16765532-DS-13 | 28,637,943 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with worsening lower back pain. An MRI of your spine
showed a herniated disc which is likely causing your pain. You
had surgery to remove this disc.
Please follow-up at the appointments listed below. Please see
the attached list for udpates to your home medications.
Please follow these instructions at discharge:
- Your dressing may come off on the second day after surgery.
- Your incision is closed with staples. You will need staple
removal in ___ days. Please keep your incision dry until
suture/staple removal.
- Do not apply any lotions or creams to the site.
- Please avoid swimming for two weeks after suture/staple
removal.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- No contact sports until cleared by your neurosurgeon.
Medications
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You may 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 | Mr. ___ initially presented with 2 weeks of LBP radiating
down the left leg with difficulty walking, found to have large
disc extrusion at L4/5 on MRI. He presented with mild sensory
and motor deficits in the left foot. He was initially treated
with aggressive pain control and steroids, but was subsequently
taken to the OR on ___ for left lumbar hemi-laminectomy with
left sided disectomy at L4/5. He tolerated the procedure well,
was extubated, and was transferred to the PACU for further
recovery without events.
On ___, the patient remained at his neurologic baseline. He
complained of incisional pain and left leg numbness, along with
distal LLE weakness, both stable from pre-operative exam. He
received Decadron while hospitalized for likely nerve root
irritation; he should continue on a Medrol DosePak at discharge.
He was seen by ___ and was unsteady on his feet, and thus
rehabilitation was recommended at discharge. His pain meds were
adjusted, and he was discharged on a combination of Tylenol,
Valium, Gabapentin, and Oxycodone in addition to the
aforementioned Medrol DosePak.
He remained on his home medication regimen for HIV, Glaucoma,
and recent left corneal transplant. He was monitored on
continuous O2 monitoring for OSA without events.
At time of discharge, the patient was ambulating with
assistance, voiding, and tolerating a full diet. Pain is
well-controlled on oral analgesics. Will return in ___ days for
staple removal, and 12 weeks for routine post-operative exam. He
should follow-up with his PCP for management of underlying
medical issues. | 256 | 256 |
10439110-DS-20 | 22,835,521 | Dear Ms. ___,
Why you were admitted to the hospital:
- You came to the hospital with shortness of breath and rapid
breathing.
What we did why you were here:
- Due to your shortness of breath, you spent a brief time ___ the
medical ICU before returning to the floor.
- You were treated with antibiotics and steroids for possible
tracheitis.
- You were also given a diuretic (Lasix) to remove fluid and
help your breathing.
- We managed your diabetes with insulin because the steroids
made your blood sugars significantly elevated.
What you need to do once you return home:
- Please take Augmentin (an antibiotic) until ___.
- Please follow-up at your scheduled appointments, especially
with your primary care doctor to discuss further management of
your diabetes. You should check your blood sugar each morning
and call your PCP if it is consistently greater than 250.
It was a pleasure taking care of you during this
hospitalization.
Sincerely,
___ Team | Ms. ___ is a ___ y/o woman with PMH notable for HTN, T2DM,
asthma/COPD not on home O2, OSA previously on CPAP, and severe
TBM s/p TBP on ___ c/b persistent severe hypoxemic
respiratory failure requiring trach/peg on ___, now
converted to T-tube, admitted for worsening dyspnea and mucus
plugging for the past 3 days. She was initially admitted to
medicine for what was felt to be tracheitis, for which she was
started on unasyn. Otherwise, she received IV Zofran, lorazepam,
oxycodone, and ibuprofen for pain control. On the night of
admission, the patient developed worsening respiratory distress
with increasing WOB per floor RN, but was maintaining saturation
and stable VBGs. She was then transferred to the ICU for further
care due to concern for tiring out and worsening distress. IP
___ patient and noted a small subglottic lesion, likely
granulation tissue, but no significant mucous plugs that may be
causing her symptoms. Sputum cx grew GPC ___ pairs. She was
started on azithromycin. SHe was also treated with Lasix and
methylprednisolone and her respiratory status improved, so she
was then transferred to the floor on ___. | 150 | 187 |
15080982-DS-11 | 26,958,145 | Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, weight gain of 3 pounds in a day or any other concerning
symptoms.
.
Bring your pill box and list of current medications to every
clinic visit.
.
You will have labwork drawn twice weekly 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 Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
.
Please measure and record your urine output in the "hat" and
urinal provided until you are instructed by the transplant
clinic that you can stop. Bring the record with you to your
transplant clinic follow up visits
.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air. The
staples have been removed
.
No driving if taking narcotic pain medications
.
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
.
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 pressure at home. Report consistently elevated
values above 160 systolic to the transplant clinic.
.
Check blood sugars prior to meals as directed. Continue long and
short acting insulins per your discharge scales.
.
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 female with history of living unrelated kidney transplant
on ___ who now presents with Acute kidney injury, creatinine
increased to 1.9 ___s hyperglycemia at home.
She recently had mycophenolate schedule changed to 500 mg four
times a day which she reports has helped improve appetite
.
Ultrasound on admission showed new hydronephrosis. Foley
catheter was placed and she received IV hydration.
The creatinine was 1.9 on admission and has decreased to 1.6 on
day of discharge.
.
Urology was consulted for ureteral stent removal when the Foley
catheter placement did not improve the hydro on ultrasound.
Stent removal was attempted at bedside, however, the stent broke
off during removal at about 4-5 cm, so will need urology follow
up with planned removal when internal suture dissolves as it
seems the ureteral stent may have inadvertently been sutured in
and will need to wait for the suture to dissolve before
re-attempt by urology to get the stent removed.
.
She was also followed by ___ for help with blood glucose
management. Adjustment has been made to both long and short
acting insulins.
.
Immunosuppression was continued per home regimen of
mycophenolate 500 mg four times daily (for help with nausea and
anorexia at home). Tacro was dosed based on daily levels, and
she is discharged on 2.5 mg twice a day.
.
Patient will be seen in clinic with labs on ___ and
urology will make removal plans most likely in about 6 weeks.
.
She is ambulatory and tolerating a diet. | 386 | 240 |
10331875-DS-12 | 27,596,965 | You were admitted with failure at home after a recent hospital
stay for sepsis, osteomyelitis of the spine, and c difficile
colitis on the background of your melanoma and cirrhosis
history.
You were admitted, given some hydration, your usual home
medications including antibiotics, and you were provided with
nursing care. You improved.
You are being discharged to rehab to get stronger so you can go
home and take good care of yourself. | Brief summary:
This is a ___ with metastatic melanoma and recent spinal
osteomyelitis/ GNR bacteremia c/b C diff infection presenting
with failure to thrive at home and ongoing diarrhea in setting
of missed vanco doses, admitted for rehab placement and workup
of ongoing severe back pain. Workup reassuring, doing well with
nursing care and ___. Discharged to rehab facility. | 70 | 58 |
19654967-DS-23 | 22,051,723 | Dear. Mr. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital with
a cough and signs of an infection. You were treated with
antibiotics and started to get better. You were able to be
discharged home.
Please see below for your follow up appointments and
medications.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team | ___ year old gentleman with history of HFpEF (last LVEF 50% to
55%), atrial fibrillation, and Alzehimer's dementia presenting
for altered mental status and volume overload, found to have
multifocal pneumonia & non healing right thigh ulceration.
======================================
HOSPITAL COURSE BY PROBLEM LIST
======================================
# Community acquired pneumonia, treated
Patient admitted with cough and leukocytosis, with CXR
concerning for multifocal pneumonia. Initially covered on
vanc/zosyn, but narrowed to levaquin given low risk for
resistant agents and clinical stability. Urine legionella
negative. Remained afebrile and on room air during
hospitalization, and finished a 5 day course in hospital on
___.
# Acute diastolic heart failure exacerbation, resolving
Per cardiology clinic note ideal weight of 170 to 175 pounds,
admitted at 195 lbs (although this is bed weight). BNP 8744, at
last admission for HF was in 6000s. JVD clearly elevated,
although difficult to interpret in setting of TR. At home on
bumetanide 2 mg daily, recently increased to BID. He was
diuresed with lasix 80mg IV and then restarted on home
bumetanide prior to discharge. He was 183 lbs on discharge. He
has close cardiology follow up.
# Acute metabolic encephalopathy, resolving
# Chronic Alzheimer's Dementia
Per collateral, patient more confused than at baseline. Likely
secondary infection as above. Improved during hospitalization,
discharged at baseline.
# Chronic non healing ulceration right thigh
# History of latent syphilis
U/S right thigh ___ revealed induration of the skin and mild
subcutaneous fat edema. No focal mass or fluid collection. No
evidence to suggest skin or soft tissue infection. ACS evaluated
patient and this does not need debridement. Recommend keeping
the patient off of the right hip possible. Patient should follow
up with General Surgery Dr. ___ as needed. The possibility
of syphilitic gumma was invoked this admission, however, do not
suspect tertiary syphilis. RPR titer was 1:2 likely indicative
of serofast state given patient has been treated for syphilis x
2 (most recently in ___ ___ years ago according to family).
Unable to obtain records from ___ this admission due to holiday.
Likely right thigh ulceration is secondary to pressure of
subcutaneous benign nodule (per prior biopsy results).
# ___
Cr 1.3 peak from baseline 1.0, pre-renal versus cardiorenal in
the setting of infection and heart failure exacerbation.
Returned near baseline at time of discharge. Should repeat as
outpatient at cardiology follow up.
# Demand ischemia
TNT 0.04 x 3. No EKG changes or angina symptoms. Likely demand
ischemia in setting of infection and heart failure exacerbation.
Not on aspirin, statin, or beta-blocker, presumably due to prior
risk/benefit discussions.
# Atrial fibrillation
CHADS-2-Vasc 4, not on rate control as outpatient and not on
anticoagulation due to prior history of BRBPR and goals of care
discussions. Rates remained in ___.
# Macrocytic anemia
Chronic, close to baseline.
======================================
TRANSITIONAL ISSUES
======================================
[] Please recheck lytes at next appointment to monitor Cr
[] Please ensure patient follows with cardiology outpatient as
scheduled
[] Please follow up on treponemal antibody (sent to state lab)
given quantitative RPR reactive at titer 1:2 (this likely
represents serofast state). Please obtain repeat RPR in 6 months
to ensure stability in this titer. Consider referral to
Infectious Diseases.
[] Unable to retrieve department of public health records this
admission regarding prior courses of syphilis treatment. He was
treated in his ___ in the ___ per family and again in his ___
for reactive RPR in the ___. His last treatment was reportedly
per family by Dr. ___ - ___
___ Care ___.
[] Wound care recs:
1. Commercial wound cleanser or normal saline to cleanse wounds.
2. Pat the tissue dry with dry gauze.
3. Apply No Sting barrier to ___ wound skin.
4. Apply nickel thick layer of Santyl to yellow necrotic tissue.
5. Cover with barely moistened saline gauze. Then cover with ___
ABD pad. Secure with medipore tape. Change daily.
6. Try to offload weight from right hip.
[] If chronic non healing wound persists, patient should follow
up with General Surgery Dr. ___ (has seen
outpatient before)
[] Discharged with Rx for home ___ given unsteadiness on feet
#CODE: DNR/DNI (MOLST, confirmed with sister ___
#CONTACT: ___ - ___ | 74 | 666 |
12351481-DS-48 | 22,351,831 | Dear Mr. ___,
You were admitted to ___ because you became slightly confused,
dizzy, and had low blood pressure. When you came in your blood
pressure got better when we gave you some IV fluids. You also
were found to have a new pneumonia on your chest xray, which is
why we discharged you on oral antibiotics, which you will
continue to take for five more days. You also had low blood
oxygen levels which improved with antibiotics, and will be going
home back on your home oxygen. You should call your doctor if
you have worsening shortness of breath, fever, confusion, or
anything that concerns you. We wish you all the best.
Sincerely,
Your care team at ___ | This is a ___ year old male with past medical history of chronic
respiratory failure, COPD on home O2, chronic diastolic CHF,
AFib, type 2 diabetes, recent admissions ___ for MRSA
pneumonia, Cdiff colitis and acute interstitial nephritis,
___ for acute diastolic CHF exacerbation, admitted ___
with episode of hypotension and hypoxia with pneumonia,
clinically improving on antibiotics and able to be discharged
home on course of Levofloxacin and linezolid for MRSA and
typical organisms.
# MRSA Pneumonia - The patient presented to the ED with
hypotension and multifocal opacities on chest Xray and CT scan.
Of note, he was recently admitted for MRSA pneumonia so per the
radiology team, it was difficult to determine if there was new
pneumonia or whether the air space findings were unresolved
findings consistent with recently treated pneumonia. Since the
patient presented with hypoxia, still had significant disease on
CXR, and is a somewhat frail patient, we decided the benefits of
treating outweighed the risks. He was initially treated with
Vancomycin and Levofloxacin, and then transitioned to PO
Levofloxacin and PO linezolid to cover MRSA as well as atypical
organisms. His hypoxia rapidly improved to home 2L, satting
100% by discharge. Of note, the patient had come in on 10 mg of
Prednisone daily which was supposed to be a finished taper from
his last discharge. He was given pulse dose of 40 mg Prednisone
once in the ED, but then was tapered off of 10 mg Prednisone and
is now not on any steroids whatsoever. Note: the etiology of his
pneumonia was felt to likely be aspiration given known dysphagia
and history of family being non-compliant with dysphagia diet.
# Chronic Anemia: Likely anemia of chronic disease as TIBC low,
iron low, and ferritin high-normal. ___ also be related to ESRD.
Hemoglobin fluctuated between 7 and 8. Continued home iron
supplement and it should be monitored as outpatient.
# Hypotension: In setting of above hypoxia had 80's/40's in ED,
which resolved after 2 L IVF. It was felt that the most likely
cause of his hypotension was infection and overdiuresis (the
patient was started on daily torsemide instead of prn torsemide
on last discharge). He was treated for pneumonia as above and
changed to Torsemide 20 mg every other day instead of every day
to prevent overdiuresis. His Amlodipine was held and we
continued to hold on discharge. We also held his Metoprolol
during his hospitalization but it was restarted for discharge.
#Goals of Care: Pt still currently Full Code. Further
conversations can be continued in the outpatient setting with
the physicians he knows best.
Chronic issues
# CKD stage V - secondary to recent acute interstitial
nephritis. Per the patient during discussions during recent
hospitalizations and in the outpatient setting, the family and
patient have decided not to pursue dialysis but rather
conservative care. We continued Sevelemer. Pt had previously
been receiving a steroid taper for AIN but taper finished while
hospitalized this time. He was given a low-K diet.
# Atrial fibrillation. Apixaban changed to warfarin on prior
admission. INR 1.9 on admission. We resumed warfarin without
bridging given no h/o stroke. Of note, on the day of discharge
his INR rose to 2.3 but the Warfarin dose was decreased from 3
mg qdaily to 2 mg qdaily due to drug interaction with
Levofloxacin. Consider restarting 3 mg once Levofloxacin is
discontinued.
# T2DM. Steroid-induced. Restarted ISS in house due to steroid,
but stopped on discharge. His sitagliptin was stopped during
this admission due to severely impaired renal function.
# COPD. On home ___ O2. No clear exacerbation currently.
Continued home tiotropium & albuterol as above. | 116 | 606 |
16834384-DS-18 | 20,096,259 | Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had chest pain and
were found to have a very low blood count
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were given blood transfusions to help improve your blood
count
- You had imaging of your heart which showed that your heart was
not pumping that well
- You had an upper endoscopy which showed that you had an ulcer
and a polyp which may have been the cause of your very low blood
count
- You had a cardiac catheterization which showed a blockage of
one of the arteries around the heart, so a stent was placed and
you were started on medications to help keep this artery open.
- You had pain and swelling in your joints and were treated with
steroids and pain medications.
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor and Cardiologist
2) It is very important that you take your aspirin and plavix
every day
3) Please do not take indomethacin or any other NSAIDs
4) Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Your ___ Care Team | ___ w/ PMH ___, CAD, stable angina, hemorrhoids p/w chest pain
likely demand NSTEMI and troponin bump in the setting of anemia
of unclear etiology, concern for GI bleed, with astral ulcer
and duodenal polyp found on EGD. Patient also found to have ___
on ___ likely in setting of hypotension and anemia. Also new
reduced EF and RWMA on Echo. Course complicated by recurrent
chest pain, s/p cath with 1DES placed and initiated on DAPT.
Also acute flare of polyarthritis, likely gout, which required
steroid treatment. | 208 | 87 |
15999575-DS-27 | 29,201,713 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a fall and
imaging showed a possible infection in your spine.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We spoke to the radiologists about the imaging of your neck,
and they were very concerned for an infection of the bone.
- The interventional radiologists performed a bone biopsy.
- The infectious disease doctors recommended that ___ leave the
hospital without antibiotics at this time.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications as prescribed
and follow-up with your appointments (listed below).
- It is EXTREMELY important that you follow up with the
infectious disease doctors. ___ will discuss the results of
your bone biopsy and will determine whether you need antibiotics
to treat the possible infection in your neck.
- Please return to the hospital IMMEDIATELY if you develop
fevers, chills, worsening numbness/loss of sensation/or
inability to move your arms or legs, loss of your bowels (bowel
incontinence), inability to empty your bladder (urinary
retention), as these could be signs of spinal cord damage and
would require IMMEDIATE evaluation by the neurosurgeons.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team | ___ with hx of DM1 c/b prior L foot osteo with MRSA, ESRD on HD
TRSa, chronic pain on methadone, HTN, CHF, CAD s/p LAD PCI ___,
and seizure disorder (not on AED) who initially presented to AJ
s/p fall, found to have possible C3-4 discitis/osteomyelitis on
imaging, transferred to ___ for neurosurgical evaluation.
Course complicated by frequent requests to leave against medical
advice -- ultimately, interventional radiology able to perform
bone biopsy on ___. All blood cultures remained negative for
growth with normal inflammatory markers, lack of fevers or
leukocytosis. Discharge plan was made with infectious disease,
patient and his PCA/HCP ___ for the patient to be discharged
off antibiotics after the bone biopsy with plan for close
infectious disease follow-up. | 238 | 124 |
16006840-DS-6 | 26,742,293 | Dear Ms. ___,
You were admitted to the ___
because you had lost consciousness. You were found to have
levels of a certain antidepressant in your blood that required
ICU care for a brief period of time. You also developed kidney
dysfunction and you had to be monitored closely. Your kidney
function improved.
If you are having chest wall pain you may take acetaminophen
(Tylenol), please do not take more than 3 grams (3,000mg) in one
day.
You were given prescriptions for a few days' doses of
sertraline, trazadone, and lorazepam. You should have your
medications adjusted at your follow up appointments.
Please follow up with the appointments that have been set up for
you below. You will be called for an appointment to evaluate
your liver. Please be sure to take all of your medications as
they are prescribed.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team | SUMMARY:
___ with HCV, cirrhosis, cryptococcal meningitis s/p VP shunt
placement who presents with AMS after fall, found to have
+tricyclics in serum, elevated CK and troponinemia.
#Fall complicated by rhabdomyolysis (see below): CT head at
outside institution was negative. C-spine was cleared
clinically. PAtient had tenderness on chest wall, possibly
secondary to fall or chest compressions. A rib series was
performed which showed no fracture. The patient was followed by
physical therapy throughout hospitalization and despite having
some orthostasis and dizziness (which is her baseline) she had
steady gait and was considered to be safe to be discharged with
home ___.
#TCA overdose: +tricyclics at OSH. Originally presented with dry
MM, hypotension, AMS, concerning for TCA overdose. states that
she took nortriptyline, but not more than usual. Possible signs
of TCA overdose on EKG with slurring of deep S wave and widened
QRS. Patient was given 50mg IV sodium bicab x3 and started on
bicarb gtt. pH was monitored while on drip. Toxicology was
consulted. EKG changes resolved and revealed NSR.
#Altered mental status: Resolved by the time patient presented
to ICU. DDx includes ingestion (marijuana vs TCA overdose) vs
hepatic encephalopathy vs infection. UCx and BCx were collected
and showed no abnormal growth for urine and blood cultures ___.
Serum tox/Urine tox were negative here. The patient's mental
status returned to normal by the time she was transferred to the
floor.
___: Baseline Cr around 0.7-0.9, on admission Cr was elevated
to 2.9, likely due to rhabdomyolysis given history of fall and
elevated CK. Patient was bolused with fluids followed by
maintenance IVFs. Urine output was monitored. The patient's
creatinine rose up to 6.0 on ___. Nephrology was consulted.
Analysis of urine electrolytes showed fractional excretion of
sodium of 0.29%, consistent with prerenal kidney injury. The
urine sediment showed no casts. With good PO fluid intake the
patient's creatinine began to drop and by day of discharge was
1.7. She continued to have good urine output.
#Elevated troponin and chest pain: The patient's chest pain was
most likely musculoskeletal in nature, due to reproducibility on
exam. Seen by by cardiology who felt that troponin elevation
likely in the setting of rhabdomyolysis, with neg MB index. Rib
series was done, as above. Cardiac enzymes were cycled. TTE was
performed which showed mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function, high cardiac output. The patient's chest pain
was managed with a lidocaine patch as well as acetaminophen.
#Leukocytosis: On admission the patient presented with a
leukocytosis, which was considered to be secondary to a stress
response from a fall. Upon ICU admission the patient was
empirically started on pip/tazo for possible aspiration
pneumonia, given hte patient's initial O2 requirement, lung
exam, and worsened CXR; however, this was was subsequently
stopped. The patient's leukocytosis resolved but then uptrended
slightly. Repeat urine cultures were drawn and results were
pending on day of discharge. The patient denied any urinary
symptoms throughout hospitalization.
#HTN: The patient was not on any home meds. She developed
hypertension with SBP into the 180s during hospital stay and was
started on labetalol which was uptitrated to 400 mg TID and was
also started on amlodipine. However, the patient had symptomatic
orthostatic hypotension requiring cessation of all BP meds. She
was not orthostatic at time of discharge and was not discharged
on any BP medications.
#VP shunt with exposed shunt hardware: Seen by neurosurgery. CSF
with no evidence of infection. Plan for shunt hardware removal
as an outpatient per neurosurgery.
#DM: The patient was not on any medications, diet controlled at
home. Placed on insulin sliding scale during hospitalization.
# Bipolar Affective disorder: The patient's home lorazepam,
quetiapine, sertraline and trazodone were initially held in
light of possible AMS and EKG findings. After the patient
returned to the floor from the ICU, sertraline and trazodone
were restarted; however, lorazepam and quetiapine continued to
be held. She was discharged home with a few tablets of
lorazepam. Close follow-up was arranged with the patient's
psychiatrist upon discharge in order to reconcile psychiatric
medications.
TRANSITIONAL ISSUES
# ___:
- At PCP follow up please check Chem-7
- Can make outpatient renal follow-up in ___ weeks if creatinine
does not resolve back to baseline
# Leukocytosis:
- At PCP follow up please check CBC
# Hypertension:
- Check BP at PCP office and consider reinitiating
antihypertensive therapy
# VP shunt:
- Patient has an appointment with neurosurgery to evaluate shunt
hardware.
# Bipolar affective disorder:
- Psychiatry f/u to consider med adjustment.
# Cirrhosis:
- The patient will be called to schedule an appointment with Dr.
___ known ___ Will likely need AFP, EGD, RUQUS. | 147 | 763 |
18809552-DS-21 | 28,161,595 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were having shortness of breath
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given medicine to help remove the extra fluid in your
body
- You were given medicine to manage your atrial fibrillation
(irregular heart beat)
- You were seen by the pulmonology team who recommended that you
start a new inhaler
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor, including your PCP on ___ and your pulmonologist.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | PATIENT SUMMARY
===================
___ year old woman with PMH significant for CAD s/p CABG (___),
pAF on warfarin, HFpEF (LVEF 60% ___, COPD, ILD c/b moderate
pulmonary HTN, CVA without residual deficits, HTN, HLD, who
presented to the ED with 3 weeks of worsening dyspnea, found to
have pulmonary congestion and elevated BNP, and admitted for
heart failure exacerbation. She was diuresed with lasix to a dry
weight of 146lbs and discharged to home. While hospitalized she
was also evaluated by pulmonary out of concern for progression
her lung disease. They recommended she continued to be followed
as an outpatient and restart spiriva. She was evaluated by
physical therapy who recommended discharge to home with referral
to outpatient pulmonary rehab.
=====================
TRANSITIONAL ISSUES
=====================
[] Would discuss with outpatient PCP and cardiologist whether
she could be a candidate for DOAC ?cost?. She has normal kidney
function, normal BMI, no history of failed DOAC trial.
[] She continues on her pre-admission Warfarin. Please check INR
at least weekly, and at next visit.
[] Please check electrolytes at next visit with PCP.
[] Was started on Spiriva this admission, please insure she
continues to use daily.
[] Please insure she attends appointment with Dr. ___ on
discharge for repeat PFTs with DLCO.
[] ___ this admission recommended that she participate in
outpatient pulmonary rehab. She was provided with resources to
attend. Please continue to encourage her to attend rehab as
outpatient.
DISCHARGE WEIGHT: 145 lbs
DISCHARGE DIURETIC: Torsemide 20mg every other day ___, TH)
DISCHARGE CREATININE: 1.1
CODE: Full
CONTACT: ___
Relationship: Daughter
Phone number: ___
===============
ACTIVE ISSUES:
===============
# Dyspnea on exertion
# Acute on Chronic HFpEF:
She presented with 3 weeks of dyspnea on exertion with pulmonary
edema and increased BNP. The trigger for her presentation was
not clear, she is adherent to her medications, no dietary
changes. She responded to diuresis with some improvement in her
breathing though with decreased output and still with DOE. Her
LVEF is 60% in ___, repeat TTE this admission showed LVEF of
60% and IVC of 0.4 ___ edema improved with trace edema, CXR
was without effusion or superimposed process, suggestion of fine
reticulation in each lower lung c/w interstitial lung disease,
abdominal US without ascites. Her home torsemide was increased
to 20mg every other day for discharge. She was continued on her
home metoprolol and spironolactone for neurohormonal blockade.
# COPD:
# ILD:
She presented with dyspnea thought to be secondary to volume
overload. However, she continued to be dyspneic despite being
close to euvolemia with diuresis and home sildenafil, so
pulmonology was consulted for other intervention and to consider
if dyspnea could be explained by exacerbation of ILD or pulm
HTN. Given RVSP appeared stable from ___, pulm thought
worsening pulm HTN was unlikely. Pulm also determined that there
was no indication for ILD directed therapy given disease appears
stable on recent imaging. Her PFTs from ___ showed worsening
obstruction, so she was recommended to continue Advair and
albuterol and she was started on Spiriva for LAMA. She was seen
by ___ who recommended that she see outpatient pulmonary rehab
therapist. She will follow up with Dr. ___ in ___.
# pAF: remained in NSR, chads2vasc 8
- continued home metoprolol tartrate 100 mg BID
- continued home warfarin 1.5 mg/2 mg on alternating days
- daily INR checks
================
CHRONIC ISSUES:
================
# Pulmonary HTN: last RHC in ___ with PA ___ (22)
- continued home sildenafil 20 mg TID
# CAD s/p CABGx3 - ___ - LIMA to LAD, SVG to PDA, SVG to the
circumflex ___
- continued ASA, atorvastatin, metoprolol
# DM:
- held metformin while hospitalized, placed on insulin sliding
scale, restarted metformin upon discharge | 154 | 585 |
17554265-DS-4 | 29,775,848 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- There was fluid around your heart
What was done for me in the hospital?
- The fluid around your heart was drained.
- We treated you with antibiotics for an infection in your
lungs.
- You were evaluated by physical therapy and occupational
therapy, and they determined that you are safe to go home with
___ home services.
What should I do when I leave the hospital?
- Please take all of your medicines and attend all of your
follow-up appointments (appointment information below.)
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team | Mr. ___ is a ___ year old gentleman with history of QT
prolongation, CVA, hypertension, diabetes, who presents for
large circumferential pericardial effusion without hemodynamic
compromise s/p pericardiocentesis. | 145 | 28 |
16675693-DS-12 | 20,409,689 | Hello Mr. ___,
It was a pleasure taking care you at the ___
___. You came because of arm pain. In the hospital
you received blood tests that ruled out heart, electrolyte or
acid-base problems. Furthermore, you received a CT scan of the
head which did not show any evidence of a stroke. A chest x-ray
also showed no signs of lung infection. This pain is likely due
to a self-limited nerve or muscle issue. Please continue seeing
your doctors and taking your medications as prescribed. | ASSESSMENT AND PLAN: ___ year old w/ hx of asthma, APBA, hyperCK
of unknown etiology, and hx of shoulder impingement, who
presents with left shoulder and chest pain and left arm
numbness, now with resolved numbness but continued
supraclavicular pain worse with inspiration. | 86 | 44 |
13528187-DS-9 | 20,777,117 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for weakness of the right side of your body
with numbness and tingling of your leg
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We imaged your brain and found brain masses that were biopsied
and showed metastatic
- We started you on medications and treated the brain masses
with radiation
- We scheduled follow up with your new primary oncologist whom
you will see after rehab (details below)
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old female with history of tobacco use
without other known PMH presents with two weeks of RLE>RUE
paresthesias and weakness for two weeks, found to have multiple
brain lesions with vasogenic edema concerning for metastases
with workup revealing a primary lung adenocarcinoma, with ?renal
metastasis vs. primary, admitted to neurosurgery and later
transferred to oncology for initiation of radiation therapy and
underwent cyberknife therapy. | 129 | 71 |
10367793-DS-8 | 24,876,044 | Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with a pneumonia and started on antibiotics. You will need to
complete a course of antibiotics as prescribed. Recommend an
x-ray to make sure it has completely resolved in 6 weeks.
Medication changes:
Please finish course of Levofloxacin | ___ year old healthy man presents with fever, productive cough,
and dyspnea, found to have multifocal consolidative pneumonia.
# Legionella pneumonia: Patient presented with five days of
dyspnea. Chest x ray on ___ showed multifocal consolidative
opacities concerning for multifocal pneumonia. Patient met SIRS
criteria (temp >100.4, HR >90, leukocytosis) but with normal
oxygen saturation. Community acquired pathogens (most likely
S.pneumo) initially suspected. Influenza less likely given
incidence has dropped with the finishing season (also he is ___
days from symptom onset which places him out of the window for
treatment). Patient had no known TB exposure risk factors, but
was checked for immunocompromised state given severity of
pneumonia and ___ age. HIV antibody was negative. Notably he
does not have underlying lung disease (no COPD/asthma). Sputum
culture had extensive contamination with upper respiratory
secretions. A urine legionella antigen was check and positive.
Patient was started on levofloxacin 750mg for a 5 day course.
He was also given albuterol and ipratropium nebulizer for
wheezing on exam and subjective dyspnea. He was given mucinex
as needed for cough and tylenol as needed for fever. Dept
public health notified of positive legionella by the lab.
# Obesity/Metabolic: Elevated blood glucose on testing, needs
repeat HbA1C as an outpatient and well as ongoing dietary and
exercise counseling. | 50 | 220 |
19540066-DS-15 | 25,278,221 | You have three sutures closing your R pectoral wound. Drainage
from there is expected, please come back to clinic to have the
sutures removed.
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.
wound Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the wound
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.
*You have sutures, they will be removed at your follow-up
appointment. | Mr. ___ AKA ___ was admitted to the
trauma service after sustaining stab wounds x2 and a bite wound
in the RUE. He was started on Prophylactic Augmentin and wounds
were washed and examined. They were found to be rather
superficial and did not violate fascia. The Chest wound was
approximated with 3 stitches using sterile technique, leaving
ample space for drainage in between. Serial abdominal exam was
benign and unchanged. His pain was controlled with oral regimen.
He remained afebrile and hemodynamically intact during the
entire hospitalization. He felt well and was discharge in good
condition with plan to continue 5 days of antibiotics. | 298 | 112 |
10906939-DS-19 | 22,350,417 | You were seen for shortness of breath and fluid in your right
lung after your previous surgery. You had a right-sided
thoracentesis that removed 600 ml of fluid from your lung. Your
symptoms are stable and the thoracic surgery physicians are
comfortable with you going home.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your dressing may be removed in 48 hours. If it starts to
drain, cover it with a clean dry dressing and change it as
needed to keep site clean and dry.
* No driving while taking any form of narcotic pain medication.
* Take Tylenol in between your narcotic medicine if you still
are using narcotic pain medicine.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
You should resume taking all home medicines you were taking
before being seen in the hospital.
You may immediately resume your previous diet.
You may immediately resume your former level of activity. | The patient was admitted to the Thoracic Surgerical Service on
___ after presenting to the ___ ED with worsening
shortness of breath x3 days. Of note, was POD ___ s/p
tracheoplasty with mesh, bronchus intermedius and right
main-stem bronchus bronchoplasty with mesh, and left main-stem
bronchus bronchoplasty with mesh. She was admitted to thoracic
surgery, placed on a regular diet and home meds were continued
along with scheduled nebulizers. On HD1 she underwent an
uncomplicated thoracentesis by the interventional pulmonology
team.
At the time of discharge the evening of HD1 the patient was
doing well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The post procedure
chest xray was negative for an acute thoracic process. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 256 | 146 |
10921854-DS-16 | 20,564,488 | Mr. ___,
It was a pleasure taking care of you at ___
___. You presented to us with altered mental status
and difficulty breathing. You were found to have an aspiration
pneumonia. We treated you with 7 days of antibiotics. We
continued all your home medications.
Please take you medications as instructed. Please attend all
your follow up appointments. | Mr. ___ is ___ with history of Hepatitis C, chronic pain on
methadone, COPD on and off prednisone, esophageal stricture s/p
dilatation ___ who initially presented to ___ with altered
mental status and hypotension in the setting of taking multiple
sedating medications, found to have PNA on CT chest. | 58 | 49 |
10152017-DS-14 | 21,303,195 | It was a pleasure caring for you at ___. You were admitted
because you had chest pain that was concerning for a heart
attack. We looked at your heart's rhythm (electrocardiogram) and
determined that there were no changes from your prior study. We
also checked blood levels of chemicals that can sometimes be
elevated in heart attacks. You did not have any increase in
these chemicals.
You underwent a stress test that helps to decide whether or not
you will get a cardiac catheterization. There was no abnormality
on the stress test, and the probability that your chest pain is
due to your heart is very low. You do not need a catheterization
at this point.
There were no medication changes made during this admission
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo M with PMH significant for CAD s/p AMI with multiple DES
and last PCI in ___. Has been chest pain free since this last
procedure. Had episode of ___ chest pain at rest yesterday
evening that lasted for several hours, and eventually resolved
with IV morphine. No EKG changes or cardiac enzyme elevation to
suggest ACS.
. | 136 | 60 |
19846807-DS-4 | 22,801,444 | Please call the access clinic at ___ if you have fevers
or chills, yourleft hand has increased pain, is cold, has blue
fingers, has numbness or tingling this may be a medical
emergency and you should call right away.
Please also monitor for increased incisional redness, drainage
or bleeding, arm swelling or increased pain or the development
of a foul odor on the dressing, at the access site or any other
concerning symptoms.
.
You should check the left arm access daily for a thrill (buzzing
sensation) and if this is not present, you should call the
access clinic right away.
.
Keep the left arm elevated on ___ pillows when sitting or lying
down to help swelling decrease.
.
The arm may be gently washed but do not submerge or soak the
arm. Keep the arm elevated when you are sitting or laying down
to help the swelling decrease. Dressing should be changed daily
and more often as needed. Please report increased drainage or
bleeding or if the wound develops a foul odor.
.
Do NOT allow any blood pressures or lab draws from the access
arm. No tight or constrictive clothing or jewelry to the access
arm and no lifting more than 10 pounds.
.
Continue home medications, dietary and fluid restrictions as you
have been instructed.
. | ___ y/o male with CKD (not yet on hemodialysis) who had dialysis
access created ___, who now returns with evidence of
infection at the antecubital incision area.
.
Patient received IV Vancomycin during his stay. The cellulitis
and erythema as well as purulent discharge evident on admission
have decreased significantly. Access remains with positive bruit
and thrill.
Blood and urine cultures were sent, Urine has no significant
growth and blood cultures are negative to date.
.
He will be discharged with 5 days of PO Keflex and a dry
dressing over the incision area. Patient states wife will assist
with dressing changes.
.
He is tolerating a regular diet. Home medications were continued
as indicated. Appointment with Dr. ___ has been moved to
___ at 12 noon. | 210 | 120 |
18676703-DS-79 | 26,056,730 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were found unresponsive due to low blood sugar.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given sugar to bring your blood sugar back to normal
and briefly had a line into your leg bone because an IV could
not be obtained.
- You had dialysis while you were in the hospital
- You were seen by the ___ team who ultimately recommended
the following DISCHARGE INSULIN PLAN:
TAKE TRESIBA INSULIN 15 UNITS AT LUNCH TIME
TAKE NOVOLOG BEFORE BREAKFAST, LUNCH AND DINNER ACCORDING TO
THIS
SCALE
GLUCOSE BREAKFAST LUNCH DINNER BEDTIME
<100 0 0 0 0
101-150 4 4 6 0
151-200 5 5 6 0
___ 7 7 8 2
301-350 8 8 10 3
351-400 8 8 10 4
>400 10 10 12 5
IMPORTANT TO REMEMBER THE FOLLOWING:
1. CHECK BLOOD GLUCOSE BEFORE EATING BREAKFAST, LUNCH AND DINNER
AND AT BEDTIME.
2. IF YOU DO NOT PLAN ON EATING A MEAL USE THE "BEDTIME" INSULIN
CHART TO TREAT A BLOOD GLUCOSE THAT IS HIGH, ABOVE 200.
3. DO NOT TAKE NOVOLOG INSULIN SOONER THAN 2 HOURS APART- DOING
THIS MAY CAUSE LOW GLUCOSE
4. IF YOUR BLOOD GLUCOSE IS UNDER 100, CHEW ___ GLUCOSE TABLETS
OR DRINK 4 OZ. OF FRUIT JUICE. THEN CHECK 15 MINUTES LATER TO
CONFIRM YOUR BLOOD GLUCOSE HAS GONE UP.
5. FOLLOW UP AT ___ NEXT WEEK.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES:
====================
[] Titrate Gabapentin PRN pain
[] DISCHARGE INSULIN PLAN:
TAKE TRESIBA INSULIN 15 UNITS AT LUNCH TIME
TAKE NOVOLOG BEFORE BREAKFAST, LUNCH AND DINNER ACCORDING TO
THIS
SCALE
GLUCOSE BREAKFAST LUNCH DINNER BEDTIME
<100 0 0 0 0
101-150 4 4 6 0
151-200 5 5 6 0
___ 7 7 ___ 8 8 ___ 8 8 10 4
>400 10 10 12 5 | 511 | 59 |
19285292-DS-12 | 20,809,393 | Dear Mr. ___,
You were hospitalized due to symptoms of slurred speech
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension, prior history of strokes, family history of
strokes, and smoking.
Of note, you were also found to have a urinary tract infection
and we would like you to take an antibiotic called Ciprofloxacin
HCl 250 mg twice for one more day.
Otherwise we are not making any changes to your medication at
this time. However, you were previously told that you should
switch to Plavix and we encourage you to discuss this with Dr.
___ neurologist.
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 | Mr. ___ is a ___ year old right handed man with hypertension
and a history of multiple prior strokes who is admitted to the
Neurology stroke service with slurred speech secondary to an
acute ischemic stroke in the anterior right frontal lobe deep
white matter. His stroke was most likely due to poorly
controlled hypertension, continued smoking and possibly a
non-specific familial predisposition. His workup in the past
has been extensive, including several
TTEs, TEEs, hypercoagulable workup, NOTCH3 mutation. All have
been negative.
He reported taking ASA 81mg daily and has been compliant. At
this time we would recommend switching from ASA to Plavix, but
leave this decision up to his outpatient neurologist Dr. ___.
His deficits improved greatly prior to discharge and the only
notable weakness was in the left arm and leg, residual findings
from his prior strokes.
Of note he was also found to have a UTI for which he will
complete a course of Ciprofloxacin HCl 250 mg.
Of note he was seen by ___ who recommended that he stays one more
day for closer assessment, which he refused. Thus, he will go
home with home ___ at this time.
============================================= | 341 | 194 |
13620446-DS-44 | 29,485,992 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- fever
What was done for you in the hospital:
- we obtained blood cultures and an x-ray which did not show any
signs of worsening infection
- we continued your vancomycin antibiotic course
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ woman with PMHx notable for chronic thoracic
myelopathy, recurrent UTIs, infectious endocarditis, diastolic
heart failure, diabetes, HTN, HLD was re-admitted after one day
at rehab following 10-day admission for MRSA bacteremia with
planned 6 week course of vancomycin. She re-presented from her
rehab facility due to fever to 100.7F with concern for worsening
infection.
# MRSA BACTEREMIA
Re-presented for fever to 100.7F at rehab facility on same day
of prior discharge. Otherwise feeling completely well. Previous
admission was for worsening lower extremity weakness with
discovery of MRSA bacteremia. At that time was discharged with
OPAT plan for prolonged course of vancomycin based on culture
sensitivities from ___. TEE without vegetations. Management
complicated by presence of chronic indwelling port which was
left in place given significant anatomical complexity with
original procedure and need for ongoing IV medications due to
myelopathy. She remained completely stable and afebrile over
course of this admission with borderline leukocytosis that was
overall improved compared to prior admission. Continued
vancomycin course with port vancomycin lock. Discharged with
plan to continue antibiotic course as was prior to re-admission.
# RETROCARDIAC OPACITY
Noted to have retrocardiac opacity on CXR in ED with concern for
pneumonia for which she received a single dose of cefepime.
Remained afebrile and without any respiratory symptoms and so
additional antibiotics were not continued. Asymptomatic and
stable from respiratory standpoint.
STABLE / CHRONIC ISSUES
=================================
# CHRONIC MYELOPATHY / PARAPLEGIA
Reportedly a sequela of Zoster infection. Wheelchair bound at
baseline. Was previously on monthly Solumedrol treatments but
those were held by neurology team during recent admission due to
her bacteremia. Continued home muscle relaxants and pain
regimen.
# CHRONIC DIASTOLIC HEART FAILURE
# AORTIC REGURGITATION
Recent TEE demonstrated preserved LVEF though with
moderate-severe aortic regurgitation, and so possible that it
may be underestimating true cardiac output. Regardless, she was
currently exhibiting symptoms of heart failure exacerbation.
Unclear if she is on ACE and beta-blocker for cardioprotection
(given pEF) or simply as anti-hypertensives. Continued home
cardiac medications. Currently scheduled to follow in heart
failure clinic.
# HYPERTENSION
- amLODIPine 10 mg PO/NG DAILY
- Metoprolol Succinate XL 25 mg PO DAILY
- Valsartan 80 mg PO/NG DAILY
# Hx RECTAL TRAUMA S/P COLOSTOMY
Stool output is currently at her baseline, relatively formed.
Low suspicion for C. diff. Continued home bowel regimen.
# DIABETES
Non-insulin dependent. Blood sugar potentially improved given
that she her Solumedrol is on hold in setting of bacteremia.
TRANSITIONAL ISSUES
=================================
[] Please trend CBC as outpatient, she has a anemia of chronic
disease with discharge Hgb of 7.4
[] Vancomycin IV course ___ through her port WITH
vancomycin antibiotic lock (see medication orders).
[] Throughout the duration of her vancomycin course, she will
need a weekly CBC w/ diff, BUN, Cr and vancomycin trough. All
lab results will be followed up on by ___ clinic and should be
faxed to ___
[] All questions regarding outpatient parenteral antibiotics
after discharge should be directed to the ___
R.N.s at ___ or to the on-call ID fellow when the
clinic is closed.
[] Steroid infusions for her myelopathy will be on hold through
the duration of her MRSA bacteremia treatment.
[ ] Currently on home PPI. Unclear if for GI prophylaxis given
chronic steroids or for GERD. If steroids remain held would
consider weaning PPI unless there is another indication.
[ ] Discontinued Tamsulosin while admitted as unclear utility
given patient is female.
#CONTACT: ___ (nephew: ___ | 171 | 559 |
16738310-DS-20 | 21,277,399 | Dear Ms. ___,
you were admitted for acute cholecystitis, which is an infection
of your gall bladder. You underwent an open cholecystectomy, or
removal of your gall bladder. You tolerated this well and are
ready to recover at home.
You can resume a regular diet.
Please take your pain medications as indicated. You can take
tylenol ___ addition to your pain medications as needed as well.
Do not take ___ over 4 grams per day of tylenol.
You should continue your regular activity, but do not lift over
10 pounds at least for 3 weeks.
You have steri strips (small bandages that help with wound
healing) on your wound. These will fall off on their own with
time. You may shower as needed. Pat the incision dry. You may
leave it open to air. You can start bathing or immersing your
wound underwater on ___ if so desired.
Your former drain stitch wound will slowly close on its own. It
is normal for it to leak a small amount of fluid. You can place
a dry dressing or bandaid on the wound until it becomes more
dry.
Your final pathology is still pending. This will be reviewed at
your follow up appointment, when scheduled by you.
It was a pleasure to take care of you. We wish you a speedy
recovery. | Ms. ___ was admitted on ___ for management of her acute
cholecystitis. She was started on IV cipro and flagyl. This was
subsequently changed to Vancomycin and zosyn once because of
continual fevers. On admission, there was concern that she may
have a gall bladder mass due to right upper quadrant ultrasound
imaging. On ___, there was no mass visualized ___ the
gallbladder during her open cholecystectomy. Her final pathology
showed acute cholecystitis, no mass.
She tolerated her open cholecystectomy well. A JP drain was left
___ place postop. and subsequently discontinued on day of
discharge.
She voided appropriately after her foley was discontinued. She
was transitioned to a regular diet, which she was tolerating on
discharge. Her pain was controlled on IV pain meds and toradol
immediately postop. and then transitioned to oral medication.
She was at her baseline functional status on day of discharge,
ambulating independently. She had no complications during her
hospital stay.
She was discharged home without services. | 222 | 167 |
13821528-DS-14 | 22,799,809 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
Why were you admitted to the hospital?
=============================
- You were admitted to the ___ due to swallowing something
into your lungs, leading to infection of the lungs
What was done while you were at the hospital?
=============================
- You were admitted to the intensive care unit for this
swallowing into your lungs episode
- You were started on antibiotics
- You underwent a scan of your lungs which showed a big
infection of the lungs from swallowing contents into them
- You were continued on antibiotics focused on the infection in
your lungs
- The speech and swallow team also came to see you and
determined that there is risk associated with continuing to
eat/drink
- We had a goals of care discussion with your family, and
determined that you would like to be comfort focused care
- You will go home with hospice, focused on comfort care
What should you do when you leave the hospital?
=============================
- Enjoy your time at home with family
- We hope you are able to enjoy your 91st birthday with them
Yours sincerely,
The ___ Care Team | SUMMARY:
=======================
___ w/h/o COPD, pHTN, mild cognitive impairment, heart failure
and recent gradual decline in functional status, recurrent
aspirations >6mo, fall who was admitted with acute hypoxemic
respiratory failure c/b SVT, acute heart failure, ___ and
hypernatremia. Patient initially managed in MICU and transferred
to floor once stabilized but subsequently remained very weak
with difficulty clearing secretions, ongoing cough, waxing and
waning O2 requirements and likely recurrent aspirations. Speech
language pathology evaluated and noted that there is a large
risk of ongoing aspirations both with eating and drinking, but
also of own saliva and secretions. Transitioned to
comfort-oriented care on ___ following extensive goals-of-care
discussion with patient and family and per their expressed
goals. He was discharged to home with hospice, with hopes of
making it to ___ birthday on ___. | 191 | 133 |
17906374-DS-21 | 21,832,886 | Dear Mr. ___,
You were admitted to ___ for
heart failure and uncontrolled blood pressure.
While you were in the hospital:
- we gave you IV then oral medications to help remove fluid
- we gave you medications to help control your blood pressure
- we gave medications to help with your allergies and eye
inflammation
- you had a repeat ultrasound of your heart that showed
decreasing pumping (lower ejection fraction)
- After extensive discussion of risk and benefit, you decided
you would not want a cardiac catheterization given your
reservations about risks associated. A pharmacological stress
test showed no reversible defect
Now that you are going home:
- weigh yourself every day and call your primary care doctor ___
cardiologist) if you gain more than 3 lbs in two days
- eat a low salt diet
- take your medications every day, if your run out please call
your primary care doctor
It was a pleasure taking care of you!
-Your ___ Inpatient Team | ___ year old man with a past medical history including
hypertension, HFrEF (TTE ___ EF 40% with basal
inferior/inferloateral HK) presumed ischemic etiology although
no prior stress test/catheterization who presents with ___ weeks
of progressive lower extremity edema, dyspnea on exertion,
scrotal edema, abdominal distension and weight gain.
He had run out of lisinopril, lasix, and atorvastatin ___ months
ago and was referred to ED by his new primary care physician.
Likely etiology of uncontrolled hypertension and medication
non-compliance. No active ischemia, new dietary indiscretion,
hypothyroidism nor arrhythmia. Repeat TTE confirmed LVEF 40% and
basal inferior/inferolateral hypokinesis. After extensive
discussion of risk/benefit, patient refusing cardiac
catheterization but ultimately decided to undergo STRESS MIBI
which showed no reversible perfusion defect. He underwent IV
diuresis with Lasix 40mg IV BID with transition to torsemide 40
mg PO daily, at new dry weight of 94 kg. Additionally lisinopril
was uptitrated from 5mg daily to 40mg daily. Additionally given
iron deficiency, iron was repleted IV for 8 days, he will
continue on every other day oral iron. He will follow-up with
cardiology and PCP.
=================================
ACTIVE ISSUES
=================================
# Acute exacerbation of chronic systolic congestive heart
failure:
# HFrEF: TTE of 40% in ___ with WMA c/w CAD, repeat TTE
___ confirmed EF 40%, and basal inferior/inferolateral
hypokinesis. As above likely etiology of uncontrolled
hypertension, high Na diet and medication non-compliance. No
active ischemia, new dietary indiscretion, hypothyroidism nor
arrhythmia. He declined catheterization or stress test to
confirm ischemic etiology. Underwent IV diuresis to weight of 94
kg. Lisinopril was uptitrated to 40mg daily. Carvedilol 6.25 mg
PO BID was initated. IV Iron supplementation was begun (as per
EFFECT-HF) for 8 days given ferritin between 100-300 and
transferrin saturation < 20%, he should continue on every other
day oral iron. He will follow-up with PCP and cardiology.
# History of likely CAD: No known history of chest pain, but TTE
c/w CAD. No hx of cath or stress. Continued aspirin 81mg po
daily, resumed atorvastatin 80mg po qhs. As above would likely
ebenfit from stress or catheterization.
# Hypertension: Elevated to 251/118 on admission. No evidence of
renal dysfunction or ECG changes, and improved with diuresis and
labetolol 100mg po x 1. Chronically with SBP in the 180s per
patient report. Lisinopril was uptitrated to 40 mg PO daily.
#conjunctivitis
#sinusitis
#cough: h/o seasonal allergies and here conjunctivitis likely
viral given watery discharge without preauricular node however
given limited ability for follow-up was covered for bacterial
conjunctivitis with Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE
QID Duration: 5 Days (___). Oxymetazoline 1 SPRY NU BID:PRN
nasal congestion Duration: 3 Days, fexofenadine, fluticasone for
sinus congestion. Cough from post-nasal drip treated
symptomatically with cepacol, tessalon and
Guaifenesin-Dextromethorphan ___ mL PO/NG Q6H:PRN.
# Leukocytosis: Mild likely stress reaction vs viral
conjunctivitis. No clinical evidence of other infection with
unremarkable U/A and clear CXR. Has lower extremity erythema
that looks more like stasis dermatitis rather than cellulitis.
# Prediabetes: A1c of 6.2% in ___. Repeat A1c of 5.4%.
Insulin sliding scale was discontinued on ___.
=================================
CHRONIC ISSUES
=================================
# Housing insecurity
# Health literacy: Noted during last admission that the patient
has a history of poor follow-up and difficulty understanding
severity of illness. Patient was counseled regarding chronic
nature of his condition, social work and nutrition also provided
counseling and resources. He states that he prefers to frame
issues in terms of cost-effectiveness and efficiency however he
is very afraid of diagnoses such as stroke or heart attack given
family experience.
=================================
TRANSITIONAL ISSUES
=================================
- CORONARIES: no prior cath or stress test
- PUMP: LVEF 40% (on ___ TTE)
- RHYTHM: NSR
- to follow-up with ___ MD following HF NP visit
- Continue 80mg oral iron every 48 hrs (after ___ et al.
Blood ___ at least six weeks
- ___ benefit from spironolactone if symptoms worsen and
compliance on current regimen affirmed
- Persistent cough possibly due to viral illness during
admission but concern for potential lisinopril adverse effects.
Please follow up sx w consideration if persistent as outpatient
for ___ switch
# DISCHARGE WEIGHT: 94kg
# DISCHARGE DIURETIC: torsemide 40 mg PO daily
# CODE: full
# CONTACT: ___ (brother/HCP) - ___ | 157 | 695 |
10387377-DS-13 | 21,717,675 | Dear Ms. ___,
You came to our hospital for scheduled catheterization of your
coronary arteries. She tolerated the procedure very well.
During the procedure, we opened up with a right sided coronary
artery with a drug eluting stent. You also underwent an
ultrasound of your legs, which did not reveal any blood clots.
We continued all your home medications, and you should be able
to go home today.
.
No changes were made to your home medication list.
.
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo F with CAD s/p CABG and recent cath with DES and POBA to
LAD, multivessel disease planned for staged intervention who
presents here with chest pain but negative CEs and no
significant EKG changes.
1. Chest Pain: This is likely cardiac chest pain given the
patient's risk factors, known CAD, and similar pain to previous.
This is not likely stent thrombosis due to compliance with
aspirin and plavix and negative enzymes, and quick resolution of
pain. The patient underwent a cardiac cath that showed LAD with
patent stent then 99% mid with distal filling from LIMA (no
change from previous. RCA 40% proximal, 80% mid, 80%
posterolateral. The patient underwent Rotoblator with 1.5 burr
followed by DES of mid-RCA with 2 overlapping DES, Balloon PTCA
of posterolateral with moderate residual stenosis but difficult
to advance larger balloons. The patient also complained of
bilateral leg tenderness, but LENIs were negative for any DVT.
The patient will continue aspirin and plavix indefinitely. She
will continue her metoprolol, lisinopril, nitro, and ranolazine
as needed. | 110 | 176 |
14476268-DS-9 | 29,195,969 | It was a pleasure caring for you during your hospitalization.
You were hospitalized for a urinary tract/kidney infection
called pyelonephritis. You will need to take an antibiotic
called ciprofloxacin until ___.
Physical therapy saw you and thought you would benefit from home
___, but you refused. You understood the risks of refusing
physical therapy at home.
We also found a lung nodule on your CAT scan. You will need to
talk to your primary care doctor about ___ repeat CAT scan. | ___ history of hypertension, obesity, depression, obstructive
sleep apnea non-adherent to CPAP who presents with sepsis from a
urinary source, namely left kidney pyleonephritis from
pan-sensitive E. coli likely from ascending urinary tract
infection. She presented with urinary symptoms, relative
hypotension (SBP 150 --> 90-100) requiring approximately 6 L NS
IVF resuscitation with clearance of lactate. She was started on
ceftriaxone at ___ and transferred to ___ for ICU
level of care due to bed shortage at ___. For unclear
reasons, she was admitted to the medicine floor with above
treatment of her sepsis complicated by mild pulmonary edema
responsive to gentle diuresis. She was swithced to ciprofloxacin
and will complete a 14-day total course.
# Sepsis from a urinary source
Patient presented with urinary tract infection symptoms with
resulting ascending infection resulting in left pyelonephritis
per CT scan. She had a relative drop in SBP from 150 to 100s
requiring 5 L NS fluid resuscitation with resultant pulmonary
edema that was responsive to diuresis. She stabilized and was
switched from ceftriaxone 2 gm IV q 24 hr (___) to
ciprofloxacin 500 mg PO q 12 hr (___-106) for a 14-day
total course.
# Acute renal failure
Baseline Cr is 0.9 per records with admission Cr of 1.7.
Etiology is likely pre-renal from insensible losses in setting
of fever and poor PO intake. There was no evidence of intrinsic
process such as hydronephrosis. Cr has improved with IVF with
resolution of acute renal failure.
# Normocytic anemia:
Patient was noted to have Hgb of ___. The chronicity is unclear
as there is no recent Hgb in our system with last from ___
(normal value). The blood bank did not an anti-C antibody in her
blood with a negative Coombs. Her hemolysis labs and DAT were
negative. The etiology likely represents a chronic process with
some component of superimposed inflammation from the marrow and
fluid shifts in the setting of sepsis as her other parameters
such as RDW, MCH, MCHC are with normal limits. Her differential
does not such as leukoerythoblastic process (like infiltration
of the marrow by neoplasm as sometimes is seen in metastatic
cancer). Reticulocyte index is suggestive of a
hypo-proliferative marrow. Another consideration is that she has
inadequate tissue level B12 although she is not macrocytic. Her
B12 levels in ___ and ___ were 290-326 with no accompanying
homocysteine or MM. Although this "serum level" is normal per
lab reference, tissue level B12 can be inadequate with a serum
B12 level below 400.
Overall, she should have further outpatient work-up of anemia.
#Elevated INR:
Patient had elevated INR of 1.5 that was likely related to poor
PO intake. Her fibrinogen was within normal limits.
#Depression/anxiety:
She displayed impaired coping skills during hospitalization
course and did not want to be discharged home. She denies SI/HI.
She was continued on effexor and ativan.
# Hypertension: She was hypertensive to SBP 140-180s at times.
Her home amlodipine was re-initiated. Her thiazide and ___ are
being held to ensure that she has renal recovery and will be
re-started as an outpatient.
# CODE STATUS: FULL
# Transitional issues
- anemia work-up including routine healthcare maintenance such
as colonoscopy
- referral for ? sleep apnea and ? ENT evaluation given
oropharyngeal anatomy
- repeat CT Chest in ___ months given 7 mm left lower lobe
pulmonary nodule in setting of tobacco abuse history
- re-start thiazide and ___ if renal function has stabilized
- work-up of severe right hip degenerative changes given
suggestion of superimposed inflammatory arthropathy on CT
Abdomen
- repeat INR and work-up as indicated although favored to be
nutritional. Consider nutrition consult
- consider medical work-up for secondary causes of depression
- further patient education regarding anti-C antibody in blood
and carrying card in wallet regarding this finding if needs
blood transfusion in future | 82 | 633 |
14982221-DS-7 | 28,004,916 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue Lovenox 40mg once daily for
4 weeks. If you were taking Aspirin prior to your surgery,
please hold dose until you complete your course of Lovenox
injections, then you can go back to your normal dosing.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by your doctor at follow-up appointment
approximately 3 weeks after surgery.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Non weight bearing on the operative extremity.
Mobilize with assistive devices (___). ROM ___
degrees in ___ brace at all time. No strenuous exercise or
heavy lifting until follow up appointment.
12. ___ CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Physical Therapy:
non weight bearing ___ brace at all times (ROM ___ degrees)
mobilize frequently
Treatments Frequency:
Aquacel dressing to be removed on POD #7 (___),
then DSD prn drainage
Ice and elevate
*Staples will be removed at your first post-operative visit in
three(3)weeks* | The patient was admitted to the orthopedic surgery service on
___ after his left knee aspiration revealed 18,584 WBC,
90 poly's and grew staph aureus. His CRP was greater than 300.
This was indicative of a prosthetic joint infection. He became
febrile overnight with a temperature of 102, so he was started
on vancomycin and zosyn. HD #1, he was seen by infectious
disease which recommended discontinuing vanco and zosyn and
start daptomycin given the sensitivities. On HD#2, he was made
NPO and was taken to the operating room for above described
procedure. Please see separately dictated operative report for
details. The surgery was uncomplicated and the patient tolerated
the procedure well. Patient received perioperative IV
antibiotics. | 567 | 121 |
16916552-DS-20 | 20,404,782 | ================================================
MEDICINE Discharge Worksheet
================================================
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for an infection in your lungs
("pneumonia,") that was complicated by abnormal heart rhythms.
What was done for me while I was in the hospital?
- We gave you antibiotics to treat your infection.
- We gave you medicines to slow your heart rate to a manageable
speed.
- Your medications were adjusted over several days in order to
ensure that you were tolerating them well.
What should I do when I leave the hospital?
- Please note any new medications in your discharge worksheet
below.
- Please note any appointments in your discharge worksheet
below.
Sincerely,
Your ___ Care Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ M with PMHx notable for HTN, CAD who was
admitted to the MICU on ___ with a few days of fatigue,
dizziness, productive cough, and dyspnea found to have
right lobe pneumonia. He developed
atrial fibrillation after receiving IV diuresis, hypotensive
requiring levophed briefly. Hospital course complicated by
pressor requirement and delirium, both now resolved. | 119 | 57 |
17675320-DS-18 | 20,632,158 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
non weight bearing left lower extremity, ambulate with crutches
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis until follow-up with Dr
___.
******FOLLOW-UP**********
Please follow up with Dr. ___ in 1 week for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left foot navicular fracture. The patient was taken
to the OR and underwent an uncomplicated s/p ___ placement,
medial plantar fasciotomy with subsequent closure of wound 3
days later. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status: non-weight bearing left lower extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 213 | 187 |
11292481-DS-17 | 24,008,174 | ___ were admitted to the hospital after a 10 foot fall. ___
sustained right sided rib fractures and a small right
pneumothorax. Your rib cage pain with controlled with
intravenous analgesia, but later changed to oral agents. ___
also reported right knee pain and there was concern for
ligamentous injury. ___ had a brace applied. ___ were
evaluated by physical therapy and recommendations made for
discharge home with follow-up MRI to your right knee. Your
vital signs have been stable. ___ are preparing for discharge
home with the following instructions:
Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause ___ to take shallow breaths
because of the pain.
* ___ should take your pain medication as directed to stay
ahead of the pain otherwise ___ won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk ___ must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* ___ will be more comfortable if ___ use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore ___
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Additional instructions include:
Please call your doctor or return to the emergency room if ___
have any of the following:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ 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.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern ___
Please follow up with your primary care provider for CT of chest
for pulmonary nodule and and recommended ultrasound for ?
hepatic cyst. | The patient was admitted to the hospital after a 10 foot fall
from a deck. Upon admission, the patient reported right sided
rib pain and right knee pain. The patient was made NPO, given
intravenous fluids, and underwent radiographic imaging. Head
cat scan and cervical spine showed no intra-cranial abnormality
or a cervical fracture. On chest x-ray imaging, she was
reported to have displaced fractures of the posterior right
third and fourth ribs and a non-displaced fifth rib fracture.
She was also reported to have a small right apical pneumothorax.
Her respiratory status remained stable. She was encouraged to
use the incentive spirometer and her oxygen saturation was
closely monitored. Because of her knee pain, she was evaluated
by the Orthopedic service who recommended an x-ray of the knee
which did not show any fractures or dislocations. and ___
brace was applied. X-rays undertaken of the right shoulder and
left foot were normal. The patient was evaluated by physical
therapy and recommendations were made for discharge home. Prior
to discharge a repeat chest x-ray was done to determine the
resolution of the right pneumothorax. A small right apical
pneumothorax was still identified. The patient's respiratory
status remained stable. Her vital signs remained stable and she
was afebrile. On HD # 4, the patient was discharged home in
stable condition. Follow-up appointments were ........... | 503 | 237 |
13151599-DS-13 | 28,767,332 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | He was admitted to ___ on ___ for further management of
chest pain and shortness of breath. He was noted to be hypoxic
initially requiring BiPAP. NT-proBNP elevated to 6250 at
___ and 9214 at ___. CXR notable for pulmonary edema.
Status post IV furosemide 40mg x2 ___ and ___ ED) which
facilitated weaning of BiPAP to supplemental oxygen via nasal
cannula. ECG upon arrival demonstrated ST elevations in V2-V3 of
1-2mm and poor positive septal forces. After pericardial drain
placement on ___, he developed worsening chest pressure
somewhat responsive to nitroglycerin and associated with ST
elevations in anterior leads. He went for expedited coronary
angiography which revealed three vessel disease and a balloon
pump was placed. He was taken urgently to the operating room and
underwent coronary artery bypass grafting x 5. Please see
operative note for full details. He tolerated the procedure well
and was transferred to the CVICU in stable condition for
recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from inotropic and vasopressor
support. IABP was discontinued without incident. Beta blocker
was initiated and he was diuresed toward his preoperative
weight. Cultures from the pericardiocentesis were positive for
Strep Viridans. Infectious Disease service was consulted. He
should continue IV Ceftriaxone 2 grams IV Q24H thru ___.
Etiology of pericardial effusion uncertain possible inflammatory
process. Cytology results negative for malignancy. He remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. He developed acute on chronic kidney
disease with peak creatinine of 4.4. Diuresis was held until his
creatnine recovered. His foley catheter remained in for strict
I/Os and following creatnine. By the time of discharge his renal
function was improving and his creatnine was 3.2. Lasix was
resumed. He was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD #8 he was ambulating freely, the wound was healing, and
pain was controlled with oral analgesics. He was discharged to
___ in good condition with appropriate follow up
instructions. | 108 | 348 |
19135791-DS-8 | 20,295,307 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 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.
- You may change DRY STERILE DRESSING daily as needed if any
drainage or if saturated. If no drainage may leave open to air
after post-operative day 7.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Touch Down Weight Bearing Left Lower Extremity
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- You may change DRY STERILE DRESSING daily as needed if any
drainage or if saturated. If no drainage may leave open to air
after post-operative day 7. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to be intoxicated and to have left periprosthetic femur fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for Open reduction
internal fixation left proximal femur fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable with the following exception(s):
Maintained on CIWA scale throughout admission given history of
withdrawal. Valium given for mild AMS on HD 2 and 3. No acute
decompensation and remained hemodynamically stable throughout
admission
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TOUCH DOWN WEIGHT BEARING in the 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. | 337 | 296 |
15281667-DS-21 | 25,982,784 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing right leg
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin for 2 weeks. Please ambulate at least 5
times a day with crutches.
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.
- Clean dry dressing as needed - changed daily or as solied. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right femur fracture and was admitted to the orthopedic
surgery service. The patient elected to be treated non
operatively after lengthy discussion. The patient was initially
given IV fluids and IV pain medications, and progressed to a
regular diet and oral medications. The patient was given
anticoagulation per routine. . 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
touch down weight bearing in the right lower extremity, and will
be discharged on aspirin for DVT prophylaxis. The patient will
follow up with the ___ orthopaedic trauma service per 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. | 188 | 200 |
15564106-DS-14 | 27,446,377 | Dear Ms. ___,
You were admitted to ___ after a fall and mental status
changes which were thought to be due to a seizure. It is
believed that lowering the dose of your anti seizure medicine
combined with your recent immunologic therapy may have increased
your risk of seizure. MRI showed improvement in your brain
lesions, EEG showed no further seizures, but you remained
somewhat confused so a lumbar puncture was performed which looks
clear preliminarily, with evaluation for tumor cells pending.
You had no evidence of any infections. Your mental status
improved during your stay. You were switched to a new
anti-seizure medication and should follow up with your
oncologist as well as your new neuro-oncologist as below.
Please do not drive until you see Dr. ___ in neuro-oncology
on ___. He will help determine if driving is safe for you.
It was a pleasure caring for you,
Your ___ Care Team | ___ year old woman with a history of lung adenocarcinoma with
mets
to her brain s/p XRT, referred to the ED for altered mental
status found to have likely seizure.
# Encephalopathy/Seizure: Patient presented with altered mental
status described as confusion, disorientation and less
responsiveness following a spontaneous fall to the floor and
found to be incontinent of urine and feces are all concerning
for
a seizure event, with mental status changes likely related to
post-ictal state given initial resolution. She has never had a
seizure before but has been maintained on Keppra empirically.
The
patient and outpatient oncology report that her dexamethasone
has
been downtitrated recently to 2mg BID from 4mg BID and the
patient downtitrated her Keppra herself from 500mg to 250mg due
to "feeling jumpy" on Keppra. MRI one month ago showed
improvement in brain mets, but outpatient oncology also reported
recent Keytruda initiation last week. Presentation most likely
related to
underdosing of sz ppx in the setting of increased inflammation
from Keytruda per discussion with outpatient onc, rad onc, and
neuro-onc. Per family, patient has been "off" since starting
Keytruda. 24 hour EEG negative. UA negative for infection.
Valproate level in low therapeutic level so dose increased prior
to discharge. Despite some waxing/waning delirium during
admission, significantly improved mental status approaching
baseline per friends/family at time of discharge. Appreciate
neuro-onc recs: stopped Keppra (mania is a known side effect)
and gave 1000mg divalproex load, started on 500mg BID
divalproex which was increased to 750mg BID on discharge.
Patient may have leptomeningeal involvement leading
to encephalopathy given the concerning appearance of frontal
lobe
lesion so will f/u LP results from ___. Appreciate rad onc
recs: MRI appears improved, NTD from rad onc
standpoint, defer to neuro-onc. During admission, kept on
seizure precautions but no further seizures. Continued
Dexamethasone 2mg PO BID. Discharged with ___ for home safety
eval.
# Adenocarcinoma of the lung with brain metastases: frontal and
cerebellar lesions s/p radiosurgery with cyberknife having
completed 3 treatments. Recently started Keytruda as outpatient
last week (next due ___. MRI with interval improvement in brain
lesions, though neuro-onc concerned for possibility of
leptomeningeal involvement, with CSF cytology pending at the
time of discharge. Continued Dexamethasone 2mg PO QAM and 2mg PO
Q1400.
# HTN/HLD/troponin elevation: Most likely neurogenic
troponinemia
though demand ischemia possible in the setting of recent
seizure. Cardiology consulted in the ED and EKG reviewed, no
evidence of STEMI and no chest pain or cardiopulmonary symptoms
to suggest ongoing coronary lesion. EKG is non-dynamic and
non-specific in T wave inversions isolated to V1 and V2. Repeat
troponins significantly improved. Given low likelihood of ACS
and likely noncardiac etiology,
DC'ed beta blocker and ASA that had been started on arrival.
Neuro-onc also recommended holding ASA and patient refused in
any case given Celebrex rx. Continued home simvastatin,
Losartan.
# Leukocytosis/Dehydration/Lactic acidosis/Transaminitis: LFTs
likely related to muscle break down secondary to
seizure, supported by elevated CK. Now largely resolved.
Elevated Hct to 48
and elevated WBCs, likely dehydration and stress reaction from
seizure, now improved. Lactate 2.8, slightly elevated but
largely
stable from prior and likely related to recent seizure, given no
evidence of poor perfusion.
#Thrush: Continued on nystatin swish and swallow that she has
been taking at home.
#Social: Per RN, patient reports possible verbal abuse in home.
Assessed by SW who felt this issue is no longer active as
patient's left her ex-husband, who lives in ___, for this
reason and is now feeling safe with her family in ___. | 154 | 561 |
19904800-DS-21 | 28,410,318 | Dear Ms. ___,
It was a pleasure meeting you and taking care of you. You were
admitted with subjective fevers and night sweats. We were
concerned that this represented progression of your diffuse
large B cell lymphoma so we obtained a staging CT scan. This
showed decrease in the size of your lymph nodes which was very
reassuring. You were monitored in the hospital and were stable
without fevers or signs of infection. We felt that it was safe
for you to go home and return for further outpatient
chemotherapy.You should continue your R-CHOP as an outpatient.
Your next appointment is on ___. It is VERY important
that you keep this appointment.
We wish you the best,
Your ___ team | ___ is a ___ M->F transgender woman with a history of DLBCL
(dx ___, now on R-CHOP) s/p port placement ___, Cycle 2
R-CHOP ___ w/Neulasta ___, Latent TB (on INH), chronic
hepatitis B (On lamivudine) who was recently admitted for
presumed viral gastroenteritis 1 week ago, now returns with
diarrhea, fever and night sweats and reports of increased
lymphadenopathy. Symptoms were concerning for progression of
lymphoma so staging CT scan was obtained, which showed reduction
in lymphadenopathy. Patient was afebrile during admission
without any hemodynamic instability. She will return for cycle 3
on ___.
#Diarrhea
Patient with recent admission for diarrheal illness believed
to be viral gastroenteritis representing for symptoms of fever,
night sweats, diarreha and exam findings signifcant for RUQ pain
and general aches.
DDx is broad and included AE of R-CHOP versus
viral/bacterial/parasitic etiology, additionally, patient known
to have substance use history and narcotics contract and states
that she lost her most recent prescription therefore possibly
symptoms could represent withdrawl. Low suspicion for
inflammatory bowel disease.
Patient is immunosuppressed and chronic Hep B on viral
suppressive therapy. At risk for uncommon infections. Prior
diarrheal disease not resolved which was prominent prior to
third cycle of R-CHOP decreasing likelihood of medication side
effect. In setting of diarrhea and RUQ pain must also consider
hepatitides and viral infection also associated with diarrhea
however suspicion low given relatively normal LFTs. Patient on
INH w/known potential hepatotoxicity, but LFTs normal at this
time.
Extensive workup sent for viral, bacterial and parasitic
causes of diarrhea including serum and stool analyses. Negative
for C. diff. Prior admission w/o test for norovirus. Negative on
this admission.
During admission patient expressed desire to obtain fourth
cycle of R-CHOP early as she had a family vacation plan.
Given extensive infectious workup for diarrheal disease and
lack of significant symptoms on admission
Tests still pending at time of discharge include:
-Viral Panel: CMV Viral Load; Hepatitis C Viral Load;
Hepatitis B Viral Load; HIV-1 viral load by PCR; Hepatitis C
Viral RNA, Genotype; EBV PCR, Quantitative; Varicella zoster
Antibody, IgM; Varicella Zoster (VZV) IgG Antibody; EBV Antibody
Panel. Norovirus PCR
-Parasitic: Cryptosporidium/Giardia (DFA); Cyclospora; Stool
culture; Microsporidium; Stool culture - Yersinia; Stool culture
- Vibrio; Ova and Parasites (1 of 3);
-C. difficile DNA amplification assay; | 119 | 395 |
18902344-DS-50 | 29,318,290 | Dear Mr. ___,
It was a pleasure caring for you during your admission to ___
___. You were sent to the ___
from rehab for falls and worsening confusion. You were found to
have an elevated level of carbon dioxide in your blood, which
was caused by not using your BiPAP machine.
Your confusion improved when you were treated with the BIPAP
machine. It is very important that you use a BIPAP machine each
night to prevent this problem from returning in the future. You
can also sleep with your upper body elevated to help with this
problem. I have spoken with the company that will deliver your
machine. You should hear from them in a couple of days. If you
have not heard from them please call: ___ at
___.
You have worse swelling in your right leg compared to your left
leg. This is probably related to the deep vein thrombosis (DVT)
or blood clot that was diagnosed during your stay at rehab. You
were started on coumadin to protect you from clots in the
future.
You have congestive heart failure, for which you received
diuresis (water taken off). Please weigh yourself every morning,
and call your PCP if weight goes up more than 3 lbs.
Your insulin was reduced during your hospitalization because
your blood sugars were low. We expect your insulin will need
ongoing adjustment after you leave the hospital.
Per the urology team the dermabond over the surgical site on
your penis will come off naturally over the next few days. You
should keep the area clean. Dr. ___ will call you with the
results of your biopsy. If you have questions for Dr. ___
can reach him at ___.
Best wishes,
Your Medicine Team | Mr. ___ is a ___ male with ___, OSA/obesity
hypoventiliation, asthma/COPD, HTN, IDDM who was admitted from
rehab for progressive AMS, and unobserved fall out of a chair.
He was admitted to ICU and improved with BIPAP and diuresis, and
has returned to his baseline mental status. He has signifncant
edema and erythema in bilateral lower extremities, and is on
coumadin for a DVT in his R calf.
ACTIVE ISSUES
# Altered mental status: Patient was admitted to ICU for Q1H
neuro checks given altered mental status, anticoagulation and
inability to obtain CT scan of the head. On arrival to ICU,
patient remained altered, was disoriented and unable to answer
questions. Patient was supratherapeutic on INR and warfarin was
held. Portable CT head was negative. Records from rehab were
reviewed and decreased weight and low FeNa were noted suggesting
prerenal failure. In the setting of taking gabapentin and
methadone, drugs levels may have contributed to increased
somnolence. The patient also has a history of obesity
hypoventilation syndrome. His gabapentin was initially held and
he was started on IVF for his ___. His mental status improved
back to baseline with initiation of BiPAP. With no eivdence of
head bleed and return of neuropathic pain, he was restarted on
warfarin and uptitrated on gabapentin. Given improvement in
mental status, patient was called out to floor.
# Acute kidney injury - The patient presented with elevated Cr,
which was rising at rehab to 1.8. He was seen by Nephrology at
the facility, who felt that ___ may have been precipitated by
diuresis and recommended holding diuretics. There was also
consideration that he may have had decreased preload from BiPAP.
However, the patient had not been using it reliably. He was
given IVF, after which urine output increased, Cr decrased, and
the patient's mental status improved. He was ultimately diuresed
6L in the ICU.
# Obesity hypoventiliation/OSA: Patient's mental deteriation
thought to be due to hypercapnia. Pt had not been using BIPAP at
rehab, and improved with BIPAP in the ICU. Mental status at
baseline now. HOB elevated at night, and pt given BIPAP nightly,
though did not use consistently. He will be set up with BiPAP as
an outpatient and company called to deliver to his house prior
to discharge. See transitional issues below.
# Acute-on-chronic Diastolic CHF: Diuresed 6L with additional
torsemide in the ICU, and another 1L on the floor until Cr
bumped. He was continue on his home metoprolol. Torsemide was
adjusted to 40mg daily due to rise in Cr and then titrated back
up to original home dose of 60mg daily as outpatient. Discharge
weight was 205.5 lbs.
# Lower extremity edema: ___ to ___ and R DVT. Pt diuresed per
above, and legs were elevated and wrapped. Coumadin continued.
# DVT: Right gastrocnemius DVT diagnosed at rehab, and coumadin
was started there. Coumadin was initially held on admission the
setting of supratherapeutic INR, altered mental status, and
inability to obtain a head CT. However, after CT was negative,
warfarin was restarted. Discharged on 3mg daily with follow up
with ___ clinic.
# Penile lesion: suspicious for squamous cell carcinoma vs
venous stasis ulcer. Underwent surgery with excision on ___
and pathology pending. Per Dr. ___ will notify patient of
pathology results.
# IDDM: Home insulin held in ICU ___ low sugars. on insulin
slidin scale, recieving only ___ units daily. Discharging on
significantly reduced long acting insulin of 8 units lantus
daily with sliding scale. This will require ongoing titration
and close follow up with PCP.
# Right leg pain: Chronic pain likely ___ periperal neuropathy,
exacerbated by increased swelling, DVT. Home gabapentin,
methadone initially held due to mental status and then
restarted. Topical lidoderm applied as needed.
# HTN: Lisinopril was continued
# Depression/anxiety: Home medications restarted after mental
status cleared: citalopram, buspirone, quetiapine. hydroxyzine
PRN insomnia.
# Hyperlipidemia: Home simvastatin continued
# GERD: Home omeprazole continued | 299 | 653 |
18784345-DS-14 | 27,679,787 | Dear Mr. ___,
You were hospitalized due to feelings of dizziness and leaning
to the left while walking. You had some tests done, like a CT
scan of your head and the blood vessels in the head and neck,
which were unremarkable. Based on your neurological examination
and the symptoms you had told us, we believe that your balance
issues are due to an inner ear problem. This is referred to as a
peripheral vestibulopathy. Many things can cause this, we are
not sure of the exact one at this time. We do not think this is
Meniere's disease. This should improve with time. We had
physical therapy see you. You will undergo vestibular physical
therapy once you are out of the hospital, this will help your
vestibular (inner ear) system which is responsible for your
balance recover.
Sincerely,
Your ___ neurology team | Mr. ___ is a ___ year old male with history of CHB s/p PPM and
HTN who presents with 3 days of "dizziness" which is described
as blurry vision, feeling off balance, and difficulty with gait
with notable consistent laterality to the history. His
neurological exam was notable for HIT with corrective saccade to
R, unter___ to L. Overall his exam was suggestive of L sided
vestibular issue. His history and exam were most consistent with
a L sided peripheral vestibulopathy. The exact etiology of his
vestibulopathy was not clear. History not suggestive of BPPV
___ also negative), vestibular neuritis, labyrithitis,
Meniere's. He had CTA h/n done in the emergency room, which was
largely unremarkable. Orthostatic VS were negative. He mentions
some blurry vision in a certain plane which is likely related to
his vestibular function. He was evaluated by physical therapy
and discharged home with outpatient vestibular therapy. MRI
brain was not performed as suspicion for acute ischemic event
was low.
TRANSITIONAL ISSUES
#peripheral vestibulopathy - follow up with neurology in ___
months, start vestibular therapy
No changes were made to his home medications. | 140 | 182 |
14051249-DS-18 | 27,611,097 | ___ were admitted to the hospital because ___ had changes in
sensation and slight weakness in your legs.
WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?
___ were admitted to the General Neurology service after
undergoing an MRI of your upper spine in the ED that revealed an
abnormal lesion. ___ underwent a spinal tap for further
evaluation with some labs pending. ___ underwent an MRI of your
Head which showed other lesions which with your clinical
symptoms is consistent with a diagnosis of MS. ___ were started
on IV steroids which produced some improvement in symptoms. Due
to this improvement, ___ were deemed stable for discharge home
with further treatment as outpatient.
WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- ___ can take Alprazolam as needed for anxiety in the near
future
- Please continue steroid infusions at the BI ___
over the next two days; ___ will be contacted ___ AM to arrange
for an infusion time that day
- Keep your follow up appointments with your doctors
- If ___ experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish ___ the
best!
- Your ___ Care Team | Mr. ___ is a ___ year male with a PMH of anxiety who
presented due to feeling of b/l leg weakness and strange
sensation in his R arm. In ED, he underwent an MRI of cervical
spine which revealed a R C3 hyperintensity concerning for
demyelinating lesion. He was admitted to General Neurology
service and underwent spinal tap which was clean with further
labs (including MS profile) pending. An MRI head was performed
and showed multiple ___ hyperintensities, both enhancing and
non-enhancing. He was determined to have presumed diagnosis of
MS and was started on IVMP 1g for 5 day treatment. He completed
3 days while inpatient with some improvement in his sensory
symptoms (he was seen to have no motor weakness upon initial
bedside evaluation). Due to clinical stability, we agreed with
family to complete last 2 infusions as outpatient. | 241 | 141 |
19707206-DS-20 | 25,778,560 | Dear Mr. ___.
You were admitted for evaluation of acute chest and back pain
likely due to neupogen bony pain. You improved with pain
medication and underwent stem cell collection on ___ which you
tolerated..... Please follow up with Dr. ___ as stated below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | Mr. ___ is a pleasant ___ year-old male with hx of CAD, HTN, DL,
OSA, ID-T2DM, and MM s/p Velcade, Dex, and Revlimid recently
admitted from ___ for stem cell mobilization with Cytoxan.
He presented to ED ___ with severe lower back, chest pain and
associated SOB after beginning high-dose neupogen 960mcg daily
on ___ in preparation for stem cell collection ___.
#BACK AND HIP PAIN:
#SOB (resolved): Presented with severe chest and back pain with
associated SOB. Concern for PE especially as hypercoagulability
is common in patients with MM vs. aortic dissection vs. ACS vs.
bony pain secondary to GCSF. ACS less likely given NSR EKG and
negative troponin. CXR showed no signs of aortic arch widening
concerning for aortic dissection. CTA with no evidence of PE.
Therefore, given above findings, pain in likely consistent with
bony pain secondary to neupogen especially in the setting of
administration of 960mcg neupogen daily since ___. Pain
improves with PRN IV dilaudid now not requiring off neupogen.
Discharged home to resume prior pain management regimen with PRN
oxycodone.
#IGG KAPPA MULTIPLE MYELOMA:
#NEUTROPENIA: Presented in late ___ with 3 month
history of neck pain, prompting imaging which showed concerning
lesions for multiple myeloma. Work up was notable for a
monoclonal IgG Kappa with one marrow biopsy confirming this
diagnosis with plasma cells comprising approximately 70% of the
total core cellularity. He received XRT to the right clavicle
lesions and was initiated on treatment with RVD(Revlimid held
with ___ cycle d/t ongoing XRT). He has received 4 cycles of
treatment with an excellent response to his treatment based on
monoclonal protein and free kappa levels. Treatment has been
complicated by steroid induced diabetes as well as painful
neuropathy of his legs. Velcade was held for Cycle 5 and he
completed the 14 days of Revlimid(last dose on ___. As he
has had an excellent response, the plan is to reassess his
disease and move forward with autologous transplant. Bone marrow
biopsy for disease assessment with marked decrease in
involvement(< 5%). PET scan with decreased burden of disease. He
received high dose Cytoxan for stem cell mobilization on
___, likely the etiology for neutropenia. He was discharged
home ___ with instruction to administer daily 480mcg neupogen
x6
days then to increase to 960mcg x3 days beginning on ___. He
received 960mcg neupogen SC daily through ___. Now s/p
pheresis line placement and stem cell collection ___, with
collection >16. Continues on monthly Zometa outpatient per
outpatient recs, last given ___. Levofloxacin prophylaxis
discontinued ___ as no longer neutropenic. F/U scheduled with
Dr. ___ admission for auto-SCT ___.
#BOWEL IRREGULARITY (Resolved): No further episodes now
constipated likely from narcotics. On admission patient reported
1 episode of loose stool ___ AM. Not associated with fevers,
abdominal pain or cramping. Typical bowel pattern is formed BM
Q3-4 days per patient.
CHRONIC/RESOLVED ISSUES
=============================
#NEUROPATHY: Marked increase in neuropathies of lower legs in
the setting of Velcade and Revlimid. Most likely exacerbated by
lumbar disc disease and diabetes. Requiring increasing amounts
of Oxycodone, 2 tablets, now every 4 hours. Has now tapered off
gabapentin as he felt it did not help and pain persisted. Prior
to admission for acute pain, his pain regimen consisted of
oxycodone, ___ tablets every ___ hours as needed for pain.
Will continue home pain management regimen at discharge.
#Abnormal uptake on Prostate noted on PET scan: Followed by Dr.
___. PSA in 3 range. Was supposed to get MRI for further
evaluation and holding off on invasive procedures as able but
not able to get MRI with the leg pain (could not lie still).
#STEROID INDUCED DIABETES: Home regimen consisted of metformin,
Lantus and Humalog sliding scale insulin. Better control without
steroids. Restarted metformin at discharge.
#SCC: Skin lesion biopsied which shows SCC extending to margins.
Had surgical re-excision with no residual cancer and well healed
area.
CORE MEASURES
===================
# CODE: Presumed Full
# EMERGENCY CONTACT: ___ Relationship: Wife
Phone number: ___
# DISPO: discharge to home ___ to follow up with Dr. ___
in clinic prior to admission for auto-SCT on ___.
TRANSITIONAL ISSUES
[ ] Patient will be seen by Dr. ___ prior to admission for
auto-SCT-patient to be called with this appointment and time. | 55 | 699 |
19293646-DS-11 | 20,578,805 | Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to somnolence and fevers. You were
initially intubated to help you breathe, but extubated very soon
afterward. You received antibiotics for a lung infection and
medications to help control withdrawal. You were having diarrhea
so we tested to see if you had an infection, which you did not.
After discharge, please follow up with your PCP and the
outpatient addictions program at ___. Please consider NA or AA
groups as you felt like these might be helpful. You should
complete the antibiotic (Augmentin) for your pneumonia which
will be finished on ___.
We wish you the best,
Your ___ team. | This is a ___ with a PMHx of polysubstance abuse, HCV, and mood
disorder presenting from inpatient detox with fevers, hypoxia,
and encephalopathy.
# Fever: He had isolated fever at detox program to 102.8, with
associated hypoxia documented by EMS, raising the concern for a
pneumonia. LP was inconsistent with meningitis. UA without
infection. CXR showed bilateral alveolar filling process at the
bases with R>L, which seemed most consistent. He was started on
vanc/levofloxacin for empiric coverage of pulmonary organisms
and transitioned to Augmentin for CAP with anaerobic coverage
for likely aspiration, with last day ___.
# Respiratory Failure: He was intubated given somnolence and
concern for seizures. He was initially sedated on fentanyl and
midazolam given agitation in the ED. He was extubated after
arrival to the MICU and maintained good oxygenation on nasal
cannula. After transfer to the floor he was breathing well on
RA.
# Encephalopathy: By report he was somnolent and had
tonic-clonic activity (patient denies any history of seizures
other than in the setting of EtOH withdrawal). CT head at OSH
unremarkable. His encephalopathy was likely secondary to
polysubstance ingestion and improved with phenobarbital taper as
below. He was also treated empirically for pneumonia as above.
# Polysubstance abuse: He has a history of polysubstance abuse
with benzos, EtOH, cocaine, and marijuana. Urine tox positive
for benzos which he was getting detxoed from, barbituates which
is consistent with phenobarbital use at detox, cocaine which he
endorsed using recently, and methadone which he is on for prior
opioid abuse. He also had cocaine and TCA positivity at
___. Per toxicology recommendations, EKG was monitored
for QRS and QTc prolongation; his QRS never widened and his QTc
was WNL. He developed worsening symptoms of
alcohol/benzodiazepine withdrawal and received rescue load with
5mg/kg phenobarbital on ___, then self-tapered from that dose
and was not given any further phenobarbital. Home methadone dose
and psychiatric medications were resumed with QTc monitoring.
Social work saw the patient but was not able to find a suitable
residential treatment, so he was discharged to his
mother/uncle's house in ___ with plan for Intensive
Ouptatient Program at ___ which also runs his ___
clinic. He would benefit from a therapist and restrictions on
benzodiazepines (his current prescriber per ___ Globe is #1
prescriber in ___). He did have a period of sobriety
for several years during which he was working but currently
feels disheartened about being able to stay clean in ___.
#Diarrhea: on ___ he reported diarrhea for the last couple days
with ~6BMs/day, so C diff was sent and was negative. Likely due
to previous broad spectrum antibiotics, Augmentin, and
resumption of diet.
# Acute Kidney Injury: He presented with creatinine of 1.5,
which was felt to be prerenal from infection, which downtrended
to 1.1 on discharge.
# Thrombocytopenia: Unkonwn baseline. No spontaneous bleeding.
Given history of HCV and 20cm spleen on ultrasound, likely
secondary to sequestration.
# Mood disorder: Per patient report, has bipolar disorder
although denies symptoms of manic episode. He has had problems
with anger management recently but denies any legal problems.
Continued citalopram, oxcarbazepine, seroquel.
# Hypertension: Held anti-hypertensives in ICU given
normotensive on admission. Restarted labetalol on ___ as SBPs
160s and hydrochlorothiazide on ___. He was still hypertensive
to 180s so started on lisinopril 5 mg QD which is home med per
patient report.
# Hepatitis C: viral load not known. Follow-up with PCP. | 119 | 566 |
13138543-DS-6 | 28,049,849 | You were admitted with lethargy and instability while walking.
The cause of this is because you stopped taking your
medications. It is essential that you take your medications as
prescribed otherwise this problem may return.
You will need additional follow up to evaluate your lungs for
any evidence of cancer return. This can be done at your primary
care physician's office.
You were started on a new medication: hydrocortisone. You should
take 15mg every morning and 5mg every evening. | ___ with h/o small cell lung cancer with mets to brain s/p WBXRT
and gamma knife followed by surgical resection of right temporal
necrosis on ___ whose disease is thought to be in
remission who p/w delirium and gait instability in the setting
of not taking his medications. He was found to have adrenal
insufficiency and myxedema coma/hypothyroidism.
# Myxedema coma/hypothyroidism: Endocrinology was consulted. He
was given IV levothyroxine and then transitioned to his oral
levothyroxine. His mental status slowly improved back baseline
at the time of discharge. TFTs should be followed up in ___
weeks. Follow-up was scheduled with ___ endocrine.
# Adrenal insufficiency: He has been on a long course of
prednisone and has had multiple episode of gait instability
while stopping prednisone. It is unclear when he stopped
prednisone. He had hypoglycemia and a low morning cortisol. A
cosyntropin stim test did not show a robust response. Given the
significant hypothyroidism, there was concern that replacing
thyroid hormone could precipitate adrenal insufficiecny crisis.
Thus he was treated with hydrocortisone 15mg qAM and 5mg qPM. Pt
instructed to double his dose if he experiences fever or chills
and call his doctor. Pt to follow-up with endocrine ___ weeks
post discharge.
# Pleural effusion: He presented with orthopnea. This resovled
with treatment of the above conditions. However, he does have
pleural effusion and thickening. This will need to be evaluated
as an outpatient for recurrence of cancer. A CT scan was
repeated and appeared stable.
# Gait instability: He was started on hydrocortisone with XXX
effect. In the past, he has gait instability while stopping
steroids. He was evaluated by ___ and XXX.
# Lung cancer: He will need to follow with his oncologist for
further evaluation and management.
# Incidental Lung Nodule: 4mm found in LUL. This information was
explained to the patient and provided to the patients PCP via
phone and hard copy.
# Social: He needs ___ for medication management. He has had
multiple episodes of suddenly stopping his medications, for
which he often becomes very symptomatic. | 77 | 336 |
11686782-DS-3 | 21,026,904 | Dear Mr. ___,
You were hospitalized due to symptoms of slurred speech
resulting from an Transient Ischemic Attack, a condition where a
blood vessel providing oxygen and nutrients to the brain is
temporarily blocked. 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.
TIA's 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:
-Episodes of low blood pressure causing poor blood circulation
to your brain
-Being off of Coumadin
We are changing your medications as follows:
Coumadin 5mg daily - this dose may be readjusted as needed
depending on your INR levels.
Please take your other medications as prescribed.
Please followup with Neurology, vascular surgery, 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 | Mr. ___ is a ___ male with history of afib on Coumadin, PVD
s/p peroneal bypass 10 days ago for which Coumadin was held and
history of episodes of dysarthria x 2 with stroke who was
admitted to the Neurology stroke service with a transient
episode of slurred speech secondary to a TIA. MRI read as
enlarging infarct of the right corona radiate, although thought
to be expected MRI evolution of stroke. His TIA was most likely
secondary to hypotensive episodes causing watershed poor
perfusion given that his TIA occurred in the setting of SBP
80's, responsive to lying flat and fluids in the past. We did
not consider this a failure of ASA/coumadin. He continued his
antiplatelet therapy of ASA 81 ___s his lovenox bridge to
Coumadin with goal INR ___. His deficits improved greatly prior
to discharge and without notable deficits of speech, language,
or any new focal weakness or sensory changes.
His stroke risk factors include the following:
1) DM: A1c 5.41% - well controlled
2) Patient was off of Coumadin for 1 week prior to LLE bypass
3) Hypotensive episodes with recorded SBP 80's during TIA at
home. However, his SBP has been 120's-150's as an inpatient with
negative orthostatics.
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? () Yes (LDL = ) - (x) 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 >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? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A | 283 | 439 |
12050805-DS-5 | 25,531,024 | 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:
- NWB LLE;
Elevation
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily for 14 days
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic ___
days post-operation for evaluation. Call ___ to
schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
NWB LLE, in splint until follow-up.
Rest, elevation
Treatments Frequency:
cont splint until follow-up | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF L distal tibia fracture,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to homewas 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
NWB in the Left lower extremity, and will be discharged on
aspirin for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. | 327 | 254 |
10346996-DS-14 | 28,926,268 | You underwent removal of your gallbladder and you were
discharged home. You returned to the hospital with abdominal
pain, nausea, and vomiting. You underwent imaging and there was
concern for a small bowel obstruction. You were placed on bowel
rest and a ___ tube was placed for bowel decompression.
During this time, you also had an elevated white blood cell
count. A stool specimen was sent which returned as an
infection, clostridium difficile. You were started on a course
of vancomycin for C. Diff colitis and your white blood cell
count decreased. The ___ tube was removed and you
resumed a regular diet. Your vital signs have been stable and
you are preparing for discharge with the following instructions:
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.
*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. Complete course of vancomycin
as directed | ___ year old female, s/p laparoscopic cholecystectomy on ___,
returned to the hospital on ___ with abdominal pain, nausea,
vomiting, and abdominal distention. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging
which showed dilated and fluid-filled small bowel loops
suggestive of small bowel obstruction. The patient had a
___ tube placed for bowel rest and was placed on serial
abdominal examinations. On HD #2, she was noted to have an
elevated white blood cell count to 35, but she remained
afebrile. The patient had a stool specimen sent for c.diff
which returned as positive and she was started on a 2 week
course of oral vancomycin. Over the next ___ hours, the white
blood cell count drifted down. The patient's ___ tube
was removed and the patient was started on a regular diet. She
continued to have mild abdominal distention and underwent an
x-ray of the abdomen which showed bowel dilatation suggestive of
an ileus. The patient continued on a diet as tolerated. Bowel
function returned and the patient's diet was advanced.
The patient was discharged home on HD #10. Her vital signs were
stable and she was afebrile. She was tolerating a regular diet
and voiding without difficulty. She was ambulatory and did not
require analgesia. A follow-up appointment was made in the
Acute care clinic. Discharge instructions were reviewed and
questions answered. A prescription was provided for the patient
to complete a 14 day course of vancomycin. | 261 | 269 |
12468016-DS-26 | 20,318,456 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with abdominal pain from a Crohn's
flare and were given steroid enemeas, antibiotics, IV fluids,
bowel rest and IV pain medication with improvement. You had a
sigmoidoscopy which showed active Crohn's disease and you should
follow up with Dr. ___ as indicated below. | Mr. ___ is a ___ year-old gentleman with a PMH of
fistulizing Crohn's Disease c/b entero-splenic fistula s/p total
abdominal colectomy (___) and on
certolizumab/hydrocortisone/mesalamine, cholecytectomy and
splenectomy, now admitted RLQ abdominal pain and nausea,
consistent with prior Crohn's flares.
# Crohn's flare: Patient with pain and nausea that usually
characterizes his Crohn's flare, occurring approximately at the
site of his ileo-rectal anastomosis. He believes that his pain
is not severe enough to signify obstruction or perforation. He
continues to have bowel movements at the same frequency and
consistency as his normal. He had a KUB which showed no evidence
of perforation. He was seen by GI and was treated with bowel
rest, IV fluids and hydrocortisone enemas as well as mesalamine
enemas. He was started on IV ciprofloxacin and flagyl which were
converted to oral medications for a 7 day course on discharge.
C. diff was tested and was negative. He had a flexible
sigmoidoscopy which showed inflammation at the ileo-rectal
anastomosis consistent with active disease. Pain was managed
with IV pain medications and on discharge he was transitioned
back to percocet. Stool studies were sent which are pending at
the time of discharge, as is the CMV viral load.
# Hyperkalemia: K was 5.9 on ___, rechecked at 4.8. In the
setting of diarrhea this is unusual. His lisinopril was held
temporarily and hyperkalemia did not recurr.
# Smoking cessation: Counseled for 5 minutes regarding
importance of quitting. Patient is highly motivated to quit and
would like assistance during this admission. Quitting will also
likely lead to fewer exacerbations of Crohn's. He was started on
nicotine patch 21 mg daily and discharged with a prescription
for nicotine patches.
# Hypertension: On lisinopril and lasix at home, normotensive on
arrival. His blood pressure medications were continued during
hospitalization.
- continue home BP meds
# COPD: Takes Symbicort and albuterol at home, wheezing audibly
on exam. He was continued on his home inhalers and given
nebulizers as needed. He maintained good oxygen saturations
throughout hospitalization.
# Depression: Continued on home duloxetine and risperdal. | 61 | 343 |
13212613-DS-19 | 22,974,412 | It was a pleasure taking care of you at ___
___. You were admitted to the hospital after surgery
on your leg. This surgery was done to improve blood flow to
your leg. You tolerated the procedure well and are now ready to
be discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
Vascular bypass Surgery Discharge Instructions
What to except:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes
within a few weeks.
Your incision will be sore, slightly raised, and pink. Any
drainage should decrease or stop with in the first 2 weeks.
If you are home, you will likely receive a visit from a
Visiting Nurse ___. Members of your health care team will
discuss this with you before you go home.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain.
You will also receive a prescription for stronger pain medicine,
if the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
Activity:
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples in your leg have been taken out
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight shoes, socks or knee highs.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your
leg up on a pillows. If your swelling continues, please call
your surgeon. You may be instructed to use special elastic
bandages or stockings.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the stitches or
staples. This is normal.
It is normal to have a small amount of clear or light red
fluid coming from your incision.
This will decrease and stop in a few days. If it does not stop,
or if you have a lot of fluid coming out., please call your
surgeon.
You may shower 48 hours after your surgery. Do not let the
shower spray right on the incision, Let the soapy water run
over the incision, then rinse. Gently pat the area dry. Do not
scrub the incision, Do not apply ointment or lotions to the
incision.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This
will go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician. | Mr. ___ presented to the emergency department at ___ on
___ as a transfer from ___ with a nonhealing
right first toe ulcer, as well as as reported right SFA stent
occlusion and unknown runoff. He underwent a right lower
extremity angiogram on ___, he tolerated the procedure
well without complications (Please see operative note for
further details). After a brief and uneventful stay in the PACU,
the patient was transferred to the floor for further
post-operative management.
During his admission the podiatric surgery service was consulted
given concern for his nonhealing right first toe plantar ulcer
with exposed tendon. After appropriate revascularization, they
underwent Right first ray resection.
Patient was initially started on broad-spectrum antibiotics
including vancomycin/cefepime/Flagyl. Patient was discharge on
10 day course of Augmentin.
Patient arrived supratherapeutic on warfarin, he was given
vitamin K and 1 unit of fresh frozen plasma prior to entering
the OR. Perioperatively he was maintained on a heparin drip for
anticoagulation.
Neuro: Pain was well controlled on oral medications¦
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. Had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge. Patient's intake and output were closely
monitored
GU: The patient had a Foley catheter that was removed prior to
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient was closely monitored for signs and symptoms of
infection and fever.
Heme: The patient had blood levels checked daily during their
hospital course to monitor for signs of bleeding. The patient
received subcutaneous heparin and ___ dyne boots were used
during this stay, he/she was encouraged to get up and ambulate
as early as possible.
On ___, the patient was discharged to rehab. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in 4
weeks. This information was communicated to the patient directly
prior to discharge. | 884 | 364 |
19788382-DS-5 | 23,706,687 | Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were feeling very weak. We found that your
heart was beating very slow and you were having symptoms from
it. We stopped your metoprolol but your heart rate was still
slow. You then had a pacemaker implanted in order to increase
your heart rate and prevent the slow rate. Please follow up with
the appointments scheduled below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is a ___ y/o M with PMH significant for atrial
fibrillation, systolic & diastolic heart failure (EF 30%),
hypertension, and hairy cell leukemia who was admitted to the
oncology service with weakness and lethargy and was noted to
have bradycardia was transferred to ___ for management of
symptomatic bradycardia.
# Symptomatic Bradycardia: Pt was noted to have HRs in the ___
on the onc service, which while not associated with syncope, may
be leading to symptoms of weakness and lethargy. His recent
decline in functional status may be due to bradyarrhythmia. He
was on a beta-blocker at low dose which was stopped. Despite
this, he continued to be bradycardic in the ___ and ___. Since
patients weakness and lethargy could be from the bradycardia it
was discussed with patient and family and decided that a
pacemaker would be implanted to treat the bradycardia with the
hope that this would improve his current symptoms. Pt had a dual
chamber PPM permanent pacemaker placed on ___. He also had
episodes of AVNRT so metoprolol succinate 25 mg PO daily was
restarted. He was discharged on Cephalexin 250 mg PO Q8H
Duration for 2 days for prophylaxis for pacemaker placement.
# Atrial Fibrillation: CHADS2 score of ___ so should be on
anticoagulation but is not currently. We held anticoagulation
given that he needed a pacemaker insertion. Spoke with
outpatient cardiologist who wants to hold off on anticoagulation
given patients history of multiple prior falls at this time. Pt
will consider starting coumadin when he follows up with his
outpatient cardiologist.
# chronic systolic & diastolic heart failure (EF 30%): We
stopped his beta-blocker given his symptomatic bradycardia. We
continued aspirin 325 mg PO DAILY. Would consider starting
lisinopril 2.5 mg daily as outpatient if renal function and BP
remains stable.
# Dementia: Pt with normal TSH of 1.1 and Vitamin B12 level of
840. We stopped Aricept due to anticholinergic effect and
continued Memantine 5 mg PO DAILY.
# Hairy Cell Leukemia: Pt is s/p 1 cycle of Cladribine. Pt was
going to get Rituxan on ___ but this is currently on hold. Pt
will follow up with outpatient oncologist Dr. ___. | 88 | 357 |
18901310-DS-8 | 26,920,053 | Mr. ___,
It was a pleasuring caring for you. You were admitted to help
treat the abscess in your arm/chest and to start insulin to have
your diabetes better controlled. It is important that you check
your sugar and give your insulin as instructed by the diabetes
team.
Please make sure you see your primary care doctor in follow-up
and finish the course of antibiotics.
You are leaving against the advice of your doctors. If you
notice very high (>400) or very low (<70) sugars, if you notice
spreading of the redness or fever or other symptoms that concern
you it is important that you seek medical care immediately.
We wish you the best,
Your ___ Care team | ___ male with history of Hidrenitis Supportivia, OSA on
CPAP, uncontrolled NIDDM2 (last Hba1c 11), HTN, gout, NAFLD,
obesity a/w cellulitis/abscess s/p drainage
#Abscess/Cellulitis of chest wall and left arm
#Hidrenitis Supportivia
Clinically improved with decreased pain, no fevers, no wbc.
Continued on IV antibiotics. The patient was seen by ACS who
recommended ultrasound. This showed a small area of fluid which
was likely to small to be drained. The patient remained afebrile
with normal WBC Count. ___ requested to leave, and was therefore
transitioned to oral clindamycin on discharge. ___ was counseled
to seek care if erythema worsens, ___ develops a fever or has
other concerning signs or symptoms.
#Hidrenitis Supportivia
Unclear diagnosis. If remained in house, plan to consult
dermatology. Has been referred to ___ dermatology through care
connections. Dischared with prescriptions for chlorhexidine 4%
washes per week. Clindamycin 1% solution BID as first line
therapy to prevent subsequent episode until sees dermatology
#Uncontrolled hyperglycemia/diabetes type 2 not on insulin
Patient with significantly elevated blood sugar and HgBA1C of
11.2. ___ was started on insulin which was uptitrated to Lantus
40units at bedtime, Humalog 12 units before meals plus sliding
scale. The patient was seen by the diabetes educator and showed
good understanding of diabetes management and has close PCP
follow ___ was provided with prescriptions for all
medications on discharge. Metformin was held due to poor
tolerance by patient. Could consider re-introducing.
#OSA
-Continued CPAP qhs
#Gout
-Continued home colchicine
-continued home allopurinol
#OSA
-Continue CPAP qhs
#Gout
-Continue home colchicine
-continue home allopurinol | 114 | 245 |
19223616-DS-7 | 22,616,001 | Dear ___,
___ were hospitalized due to symptoms of headache resulting from
an brain bleed (intraparenchymal hemorrhage), a condition in
which a blood vessel providing oxygen and nutrients to the brain
bleeds. 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.
The cause of this brain bleed remained unclear at time of
discharge. High blood pressure can sometimes cause a brain
bleed; however, your blood pressure was normal while ___ were in
the hospital. ___ should have an MRI at the time and date
scheduled below to assess for resolution of the bleed and to
re-assess for any abnormalities that may have led to the bleed.
___ also had a severe headache throughout hospitalization. We
have discharged ___ with an aggressive pain control regimen.
Please follow-up with your primary care doctor regarding further
pain control.
Please followup with Neurology and your primary care physician
as listed below.
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
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing ___ with care during this
hospitalization. We wish ___ all the best! | ___ is a ___ year old woman with a past medical
history of hyperlipidemia who was transferred to ___ ___ from
___ after presenting with a severe posterior headache
with NCHCT demonstrating a right parietal intraparenchymal
hemorrhage. She was evaluated by neurosurgery who did not feel
there was a indication for surgical intervention. She was then
admitted to the neurological ICU for further management.
Repeat non-contrast head CT 24 hours after presentation
demonstrated stability of her bleed. SBP was maintained at <
140. She was subsequently transferred to the floor stroke
service. Anti-platelets and anti-thrombotics were held during
hospitalization.
Etiology of her intraparenchymal hemorrhage was further
investigated and remained unclear at time of discharge. The
hemorrhage location was characteristic of amyloid angiopathy;
however, Ms. ___ young age and lack of other findings
consistent with amyloid angiopathy on MRI made this diagnosis
less likely. Still, this episode could have represented a first
time amyloid bleed. Additionally, MRI/MRV did not demonstrate
any evidence of a venous sinus thrombosis as a cause for her
bleed but it did demonstrate enhancement with contrast
surrounding the hemorrhage. This could be due to disruption of
blood brain barrier at the site of the bleed or be due to the
presence of a mass. Ms. ___ reported being up to date on
her cancer screenings for mammogram, colonoscopy and pap smear.
She will have a repeat MRI in follow-up for further
investigation of this finding as the hemorrhage heals.
Otherwise, hypertension as an etiology was unlikely as she did
not have hypertension during hospitalization or prior history of
hypertension.
Ms. ___ suffered from severe headaches during
hospitalization due to the hemorrhage. She was initially managed
with IV dilaudid. She was starting on Oxycontin to assist with
dilaudid wean. At time of discharge, pain was controlled with
2mg PO dilaudid q8 PRN, Oxycontin 30 BID, gabapentin 300 TID and
Fioricet q4 PRN. Dilaudid will need to be weaned and
discontinued in rehab. Repeat ___ ___ showed a stable
hemorrhage.
On day of discharge, Ms. ___ continued to have a headache
controlled with pain medications.
=======================
TRANSITIONS OF CARE
=======================
-MRI showed: "Thick rind of slightly irregular and heterogeneous
peripheral enhancement seen in/surrounding the hematoma on post
contrast images. This could be a finding seen with a subacute
hematoma, however an underlying mass lesion cannot be completely
excluded, given the thickness and irregularity," indicating that
she will need a repeat MRI for further assessment. This was
scheduled at time of discharge.
-If repeat MRI shows a possible mass, will need a CT torso and
malignancy work-up.
-Wean and discontinue dilaudid.
-Wean Oxycontin as headache improves.
====================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2? ()
Yes - (X) No
3. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
4. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ] | 335 | 536 |
15502354-DS-6 | 21,849,679 | Dear Ms. ___,
It was pleasure taking care of your at ___. You were admitted
with chest pain. You underwent nuclear heart studies which did
not show any evidence of heart attack. You also had left knee
pain, which was due to osteoarthritis and pes anserine bursitis. | ASSESSMENT AND PLAN: ___ with morbid obesity, HTN, HLD, DM
presents with recurrent atypical chest pain. | 46 | 16 |
15229355-DS-7 | 24,824,127 | You were admitted for occasional wheezing and cough. There was
concern for pneumonia but your chest X-ray did not show
pneumonia and your symptoms quickly improved with nebulizers.
Antibiotics were stopped and you tolerated this just fine.
Overall, your presentation is most consistent with a post
infectious bronchitis or asthma like syndrome.
You were evaluated by speech and language pathology who felt you
would benefit from a ground diet with thin liquids to minimize
your risks of accidentally inhaling some of your food when you
eat (which can predispose to pneumonia and coughing fits).
You were deconditioned and had difficulty moving around and
physical therapy recommended going to a rehab facility. You did
not qualify for acute level rehab and so you and your family
elected to go home with maximal services in order to work on
getting stronger at home. | Ms. ___ is an ___ yo woman w/ PMHx of ___ disease
who was admitted for unresolved SOB and cough despite antibiotic
treatment for presumed pneumonia.
# Bronchitis / ?Pneumonia. Recently diagnosed with pneumonia
and completed antibiotic course of doxycycline. Per son had some
intermittent cough and shortness of breath but CXR here showing
no evidence of pneumonia. Currently she denies cough or SOB,
has normal oxygen saturation and clear lungs on examination.
Low suspicion for current bacterial process. She had occasional
cough and wheezing after eating. She was evaluated by speech
and swallow who thought she did overall well and did not think
VSS indicated at this time.
- Atrovent nebs q6h standing for 2 weeks
- Fluticasone inhaler for reactive airways
- Albuterol nebs PRN
# Rash: developed pruritic rash after receiving Levaquin, no
prior history of allergies per patient or son. ___ improved
after Benadryl and currently resolved.
- Added Levaquin as an allergy
# ___ disease
- Continue home meds.
# Difficulty ambulating: Having worsening difficulty ambulating.
___ recommending rehab, patient and family only interested in
___ rehab where she has been before. ___ declined
patient, so family decided to take her home with services.
Code: Full code here
Billing: >30 minutes spent coordinating discharge to home | 139 | 207 |
19395626-DS-29 | 23,455,381 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted after you developed
left-sided back and abdominal pain. Imaging of your belly did
not show signs of infection or other clear explanation. You
were given medications to help with the pain and the nausea.
Ultimately, your pain improved and you were able to tolerate
meals. You may continue to take the pain medications you
received in the hospital as needed at home as your pain
continues to improve.
Please continue your home medications, including furosemide
(Lasix), when you return home. If you find that you are eating
and drinking poorly again, please contact the kidney clinic
(___) to discuss whether your furosemide dose should be
adjusted.
Please have your blood drawn on ___. You can come
to the lab and have your routine transplant labs drawn. It is
important that you have your blood drawn on that day, especially
since your tacrolimus dose may need to be adjusted based on the
level seen. | Ms. ___ is a ___ with history of end stage renal disease
status post deceased after cardiac death renal transplant in
___, coronary artery disease, hypertension, and
insulin-dependent diabetes ___ who presented with
sudden-onset left flank pain radiating to the left upper
quadrant. | 173 | 44 |
19986589-DS-28 | 21,321,609 | Mr. ___,
You were admitted to the hospital for chest discomfort and
anxiety while at rehab. We made adjustments in your blood
pressure regimen to help in case the chest pain was due to heart
disease. We also adjusted your insulin regimen since you had
elevated blood sugars. You should continue your home regimen at
discharge.
Your urine studies revealed elevation in WBC concerning for a
urinary tract infection. You are prescribed 10 days of
Ciprofloxacin antibiotics. | Mr. ___ is a ___ male with history of CAD s/p CABG,
type II diabetes, hypertension, and chronic knee pain, who
presents from rehab with recurrent chest pain with negative
workup for acute cardiac cause, admitted as declined to return
to nursing facility. Patient was ultimately discharged to a
hotel as patient refused to return to prior SAR.
# Coronary artery disease/Microvascular coronary disease:
# Chest Pain:
# Chronic stable angina:
Patient with significant history of CAD and what is felt to be
angina from microvascular disease. Multiple troponins negative
and EKG without ischemic changes. No chest pain since arrival,
and extensive recent workup, including nuclear stress last
month. This was thought to be exacerbated by anxiety. patient
also complained of pleuritic chest pain and lightheadedness and
underwent a CT chest that was negative.
# Osteoarthritis:
# Knee pain:
Patient is unable to ambulate as knees buckle, which has
currently left him wheelchair-bound and previously in rehab.
This is reportedly due to prior failed knee surgery. Plan for
eventual surgery, though first would need to be improved from a
cardiac standpoint. Discharged with wheelchair and bedside
commode.
#UTI
-previously treated with cefpodoxime for a Klebsiella UTI,
patient unaware if he received the antibiotics as he was in
rehab. UA suggestive of infection. Culture pending at discharge.
Given Cipro for 10day course. | 76 | 218 |
14874458-DS-18 | 24,959,850 | Dear Mr. ___, you were admitted for lumbar back ___ and left
lower extremity ___. Your discharge instructions are largely
unchanged since your recent hospitalization from ___ -
___.
Recent Surgery on ___
**you recently underwent complete removal of your spinal cord
stimulator (leads and pulse generator)on ___
**you subsequently underwent laminectomy from T8-T10 with
removal of scar and hematoma from the epidural space on ___
Your incision was closed with staples and sutures which were
removed on ___ while you were admitted.
--- ON ___ you underwent Ultra Sound guided aspiration of
your ___ fluid collection. 40ml of clear fluid was
removed and sent for culture and analysis. Your dressings to the
site of this aspiration have been removed, and your skin is
healing well.
Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided until your follow-up appointment.
You may take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much too soon.
Do not go swimming or submerge yourself in water for four
weeks
The dressing covering your incision(s) has been removed. You
may use a damp washcloth to remove any dried blood or iodine
from your skin but do not scrub directly on your incisions.
You may take a shower and get your incision wet but remember
to pat them dry afterwards.
___ and Medications
Resume your home ___ medications. Since you are already
prescribed ___ medicines and are followed by the ___ Clinic,
you should plan to resume your ___ Clinic home ___ medication
regimen. Prescriptions for gabapentin and tizanadine have been
provided to you following this admission per the recommendations
of the inpatient ___ Service. Please be sure to attend your
outpatient follow-up appointment with Dr. ___ as outlined
below.
You should use Acetaminophen (Tylenol) as well.
Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
What You ___ Experience:
Mild tenderness along the incisions.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
___ medications), try an over-the-counter stool softener,
prescriptions for stool softener have also been provided to you.
Gabapentin, increasing dose:
---- You may up-titrate/increase your dose of gabapentin as
needed for ___. You are currently taking 300mg gabapentin in
the morning and mid day, with 600mg at bedtime. In ___ days if
you are not suffering from side-effects including increased
drowsiness, you may increase your morning dose to 600mg. In an
additional ___ days, if you are not suffering from side-effects
including increased drowsiness, you may increase your midday
dose to 600mg. Therefore in ___ days, you may increase your
dosing regimen to 600mg in the morning, midday, and at bedtime.
Do not increase your dose of gabapentin to greater than 600mg
three times a day.
Call Your Doctor at ___ for:
severe headache, or headaches that are worst when sitting up
or standing, and are better when laying flat.
Severe ___, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Severe Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness
Severe headaches not relieved by ___ relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg | #LLE paresthesias/allodynia/hyperesthesia and lumbar back ___
The pt was evaluated in the ED and MRI of the T and L spine was
revealing for fluid collection at the laminectomy bed with
complex appearance, c/w postoperative blood products with severe
central canal narrowing though without cord compression/definite
cord signal abnormality. He was then admitted to the
neurosurgical floor for frequent monitoring of his neurologic
status and for ___ management. On HD2, ___, Mr. ___
underwent ultrasound guided aspiration of his ___ fluid
collection, yielding 40cc of clear CSF-like fluid. There were no
signs of purulence noted per ___ aspiration. The aspirate was
also sent for gram stain and culture studies. Gram stain was
negative for organism or PMNs. Cultures were pending as of the
time of the patient's discharge.
On HD3, ___, the patients thoracic midline incision and R
lower flank incision were healing well. The sutures and staples
at these incisions were removed at the bedside, revealing well
healed, well approximated incisions with some scabbing noted
centrally.
___
Mr. ___ is an established patient of Dr. ___ the
___ ___. He was evaluated by the
inpatient service who recommended an inpatient ___ regimen of:
1. APAP 1GM TID po ATC
2. Consider Toradol 15mg IV Q6H ATC
3. Dilaudid 4mg po Q6H prn
4. Gabapentin 300mg po in AM and mid day, 600mg qhs, plan to
uptitrate
5. D/C valium
6. Tizanidine 4mg po Q12H prn spasms
7. Morphine ___ IV Q4H prn severe ___ | 574 | 234 |
14835486-DS-25 | 25,539,254 | Dear Ms ___,
It was a pleasure taking care of you during your stay. You were
brought to the hospital because of confusion. We think your
confusion may be due to either an infection or seizure.
There are some medication changes:
- We ADDED VANCOMYCIN IV one gram every 12 hours for treatment
of urinay tract infection. The last dose will be on ___.
Please take the rest of your medications as previously
prescribed.
Please call your doctor or go to the nearest emergency room if
you experience any of the danger signs listed below | Mrs. ___ is a ___ RHF with h/o recurrent UTI and non-convulsive
status epilepticus who is well known to our service with
multiple past admissions for AMS who now presents with ___
weeks of confusion.
# Encephalopathy/delirium
Though available history is sparse, per
report she has been confused, perseverative and intermittently
agitated with excessive motor activity. No clear history of
seizures though earlier today received PRN LZP at her facility.
On exam, is somnolent and extremely perseverative with grasp and
snout reflexes. There was no obvious focality. Differential
diagnosis
includes toxic-metabolic encephalopathy (likely due to
recurrent UTI) vs non-convulsive status epilepticus given the
prominent catatonic signs (perseveration, grasp, alternating
agitation and withdrawal),
recurrent NCSE is high on differential. Patient was admitted to
neurology for monitoring. She has had no event overnight and by
HOD two, her mental status was back to baseline.
# enterococcus UTI
In the past, urine cultures have grown VRE, MDR gram negatives
and ___ species. At times, decision was made not to treat
Ms.
___ (which always appear contaminated) until culture
data are available. Patient was sgiven ceftriaxone and meropenem
in the emergency department but we decided to hold any further
antibiotic as patient seems to be have chronically positive UA
from chronic Foley due to neurogenic bladder. Her urine culture
came back positive >100,000 enterococcus. We made the decision
along with infectious disease consultant to start patient on IV
daptomycin given that her last enterococcus UTI was resistant to
multiple agents and sensitive to only linezolid. Patient is
allergic to linezolid (cause causes thrombocytopenia per record)
and therefore daptomycin was started on ___. A PICC line was
inserted for the administration of daptomycin. Urine culture
final result indicates that the UTI is sensitive to vancomycin
so we switched her daptomycin to vancomycin. Blood cultures
were also obtained on the day of admission but has remained NGTD
thus far. She got a PICC line on ___. She should get a
vancomycin trough before the evening dose on ___. She should
get vancomycin through ___.
#F/E/N
She was given IVF overnight because of concern for infection.
She ate ground diet/nectar thick under supervision once her
mental status improved.
# Transitional Issues
[ ] Please follow up final result of blood cultures
[ ] She should get a vancomycin trough before the evening dose
on ___.
[ ] She should get vancomycin through ___. | 92 | 385 |
14111088-DS-4 | 27,003,807 | Dear Mr. ___,
You were admitted to the hospital because you lost consciousness
and required CPR during a dental procedure. You were found to
have decreased heart squeeze function, also called heart
failure. Please see below for more information on your
hospitalization. It was a pleasure participating in your care!
What happened while you were in the hospital?
- You received medicine through your IV to remove excess fluid
- You were seen by an allergist
What should you do after leaving the hospital?
- Please take your medications as listed below and follow up at
the listed appointments.
- Please weigh yourself every morning at the same time with the
same amount of clothing. If your weight goes up or down by more
than 3 lb in one day or 5 lb in one week, please contact your
doctor ___.
We wish you the best!
- Your ___ Team | Mr. ___ is a ___ y/o male with a history of HTN, HLD, DM,
and obesity who presented to ___ for a bradycardic arrest
(likely d/t vasovagal) after developing respiratory distress
following a tooth extraction, hospital course c/b acute hypoxic
respiratory failure ___ new CHF diagnosis
Discharge weight: 109.8 kg (242.06 lb)
Discharge Cr: 1.1
Discharge diuretic: torsemide 30 mg daily | 155 | 58 |
10800175-DS-17 | 25,805,670 | Dear. Ms. ___,
It was a pleasure taking part in your care at ___. You were
admitted becaue of low oxygen at home. You needed to have a
breathing tube to help you breathe. We found that one of the
lobes of your right lung was collapsed, which was most likely a
result of aspiration into that area. You were also treated with
antibiotics for possible pneumonia and steroids for possible
COPD exacerbation contributing to your symptoms. We were able to
take the breathing tube out quickly and you were stable on your
home oxygen of 4 Liters.
We discussed with you, as have prior physicians, that you
continue to apsirate will all food types. You wish to continue
to eat, and to reduce the risk of aspiration as much as we are
able, you can eat liquids that are nectar-thickened and pureed
foods.
You also had a biopsy of the mass in your left lung as an
outpatient, and the results showed cancer. This is most likely
lung cancer, and given that you have multiple spots in both
lungs, it is advanced. You should talk to your primary care
physician after discharge who will refer you to an oncologist.
The oncologist will discuss any further imaging that is
necessary. They will also discuss how to progress going forward,
but we did discuss with you that given your other illnesses,
chemotherapy options may be limited.
You were seen by physical therapy, who felt you were at your
baseline physical activity level and safe to return home with
your daughter and physical therapy at home.
We wish you the best,
Your ___ Team | ___ year old female with a history of newly diagnosed invasive
squamous cell carcinoma likely lung primary, remote history of
breast and laryngeal cancer, and COPD on 4L home O2 who
presented with acute respiratory distress.
ACTIVE ISSUES
# Mixed Respiratory Failure
She had both hypoxia, hypercapnea and tachypnea leading to
intubatioy. Etiology most likely multifactorial, including 1)
Bilateral GGOs concerning for pulmonary edema vs infection, 2)
Aspiration pneumonitis/pneumonia, and 3) COPD exacerbation. She
was treated for COPD exacerbation with IV methylprednisolone,
duonebs initially, then transitioned to PO prednisone. She was
also started on inhaled fluticasone and tiotropium. She was
treated for HCAP with vanco/cefepime/levoquin initially, but
deescalated to levofloxacin on ___. Sputum culture revealed
was contaminated. Viral respiratory screen was negative.
Investigation for pulmonary edema including BNP, which was
normal. She was extubated on ___ and transferred to the floor.
She remained stable on home oxygen of 4L. Physical therapy saw
the patient and believed she had returned to her baseline
functional status. She was discharged home with home ___ and
family support. She will complete Levofloxacin on ___.
# Aspiration
Prior evaluation has shows aspiration on all food consistencies.
She is at risk for recurrent respiratory distress and failure
because of her aspiration. However, the patient has determined
multiple times and documented in OMR that she accepts the risks
of aspiration and does not want a feeding tube. We have
discussed with the patient and family (daughters) that she will
likely always be aspirating, and we can modify but not eliminate
this risk. The patient has elected to eat with nectar thick
liquids and pureed solids, accepting the risk of aspiration. She
is DNR/DNI, but ok for NIPPV.
# Squamous Cell Carcinoma, Likely Lung Primary
Leftu lng mass biopsy results from outpatient biopsy done ___
showed moderately differentiated SCC. In discussion with the
pulmonary pathologist, it was felt that this was most likely a
lung primary. Patient and family will discuss with her PCP after
discharge seeing an oncologist as an outpatient. She may need
PET CT and Brain MRI for further evaluation/staging. We did
discuss with her and her family that given her chronic diseases,
chemotherapy options may be limited.
# Normocytic Anemia
She received 1u pRBCs for Hgb of 6.9 on ___. She had no
evidence of bleeding and very low reticulocyte count, so anemia
was attributed to chronic illness and frequent phlebotomy in the
setting of poor marrow response.
TRANSITIONAL ISSUES
- Started on tiotropium for severe COPD
- Last day of levofloxacin for HCAP is ___. Her dosing for
renal function is q48h, so she is due for one more dose on ___.
- Lung biopsy done as outpatient resulted as squamous cell
carcinoma, most likely lung primary. Consider PET CT and Brain
MRI with referral to oncology as an outpatient.
- Giver her severe COPD and chronic aspiration, along with
baseline functional status, would recommended outpatient
referral to palliative care to continue symptom management.
- Despite known aspiration on all food consistencies, the
patient reiterated her wish to continue to eat accepting the
risk of aspiration.
- Code: DNR/DNI, OK for non-invasive positive pressure
ventilation
- Contact: ___ (daughter) ___ | 270 | 518 |
12073186-DS-22 | 28,855,696 | You were admitted to the hospital with confusion. This was most
likely due to dehydration and high sugar levels from your
steroids. Please continue to take all of your medications, we
have started you on insulin. | ___ HLD, past CVA, and colon cancer initially resected in ___
(refused adjuvant chemo), now with metastatic disease including
several brain lesions with edemea. He presented to the ED today
with confusion and a febrile illness, likely secondary to
dehydration and heat stroke.
.
# Toxic metabolic encephelopathy: Confused, though largely just
agitated and beligerent. This was initially thought to be
related to his febrile illness and metabolic derangements. The
patient was fluid resuscitated, had his blood sugars controlled
and had his steroids briefly increased and quickly tapered. The
patient's mental status improved to his baseline.
.
#. Fever: Unclear etiology although recorded at 103.8F rectally
in the ED. UA negative. Culture and blood cultures negative.
Head CT showed metastatic disease. CXR showed stable known
metastatic disease. LP was negative. The pt received meningitis
coverage in the ED but antibiotics were later held. The patient
had no further episodes of fever during his hospital course.
Thus, his fever was attributed to heat stroke.
.
#. Metastatic Colon Cancer: Mets to the brain. CT stable.
Multiple brain lesions with vasogenic edema. The patients
dexamethasone was increased from 2mg daily to 4mg QID while in
house, this was tapered back down quickly to his home dose of
2mg daily prior to d/c as there was no apparent increase in his
cerebral edema on CT. He was continued on his home dosing of
Keppra.
.
#. Hyponatremia: Likely hypovolemic given insensible losses with
fever, and very hot apartment without AC. It was also in the
setting of likely hyperglycemia with potential some component of
osmotic diuresis at home. The patient was given IVF and his Na
improved from 125 to 129 while in house.
. | 36 | 282 |
10291112-DS-12 | 28,226,328 | Dear Ms. ___,
You were admitted to ___ for
bilateral lower extremity fractures and underwent Right tibial
and femoral nail, L tibia ORIF, tracheostomy, G-tube placement.
You are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
General Surgery:
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.
Wound care instructions:
*For the left lower extremity you will need daily dressing
changes that consist of warm soap and water applied with 4x4
sterile gauze. This should be allowed to dry and followed by
thin layer of A&D ointment over which xeroform should be applied
over the wound. Next please take ___ sterile gauze 4x4's and
unfold them to create large area with multiple layers of
dressing. Place this over the xeroform bandages. Lastly, wrap
the extremity in Webril gauze.
*For the right lower extremity you will need daily dressing
changes that consist of xeroform applied to wounds followed by
___ sterile gauze 4x4's and unfold and layer them to create
large area with multiple layers of dressing. Lastly, wrap the
extremity in Webril gauze. | Ms. ___ presented to ___ on ___ after being pinned
between two cars with bilateral lower extremity open fractures
and right femur fracture. The patient was seen by Orthopaedics,
Plastic Surgery and Vascular Surgery who coordinated her care.
Regarding her bilateral open tibia/fibula fractures, and right
femur fracture, she went urgently to the operating room for I&D
and ex-fix of the R femur, R ankle ex-fix, and L ankle ex-fix.
She maintained Doppler signals throughout. She was transfused
as needed for bleeding/oozing originating from her leg wounds.
She was transferred to the Trauma ICU for further care and
required pressers. On ___, she underwent R antegrade tibial
nail, R retrograde femoral nail, and washout of the LLE. RUE
duplex demonstrated a superficial clot but was negative for DVT.
Subcutaneous heparin was started. On HD4, the patient remained
afebrile during the day, she was stable on the vent, and she was
started on tube feeds and NG meds. She was given 1 unit PRBCs
for drifting hematocrit.
She had an initial ___ evaluation on ___. On ___, she
underwent ORIF and L tibial nail as well as Right: free gracilis
flap, pedicled soleus flap, split-thickness skin graft,
antibiotic impregnated cement spacer to tibia, and excision of
fibula with open fracture. At this date, she also had irrigation
and debridement of left tibia, removal of external fixator, open
reduction/internal fixator, and left tibial intramedullary
nailing.
On ___, the patient had a BAL which showed ___ e.
coli. She was started on cefepime for the e.coli VAP. The
patient was taken to the operating room and underwent ORIF of
the L tibia & free flap, L gracili to RLE, and aspirin was
recommended per Plastic Surgery. On ___, tube feeds were
held secondary to concern for refeeding syndrome. Levophed
increased from .06->.08 then decreased back to .06. On
___, the patient failed extubation trial and was
reintubated. Tube feeds were resumed. On ___, the patient
received 20mg IV lasix x2 with good response. On ___, the
patient was taken to the operating room and underwent
Tracheostomy. The patient tolerated this procedure well. On
___, the patient's WBC was 18.0, she desatted to the 70's,
and she responded with increased FiO2. On ___, there were
no acute events, she tolerated a trach mask all day, c. diff
was negative. Her IJ was removed and her subcutaneous heparin
was discontinued and she was started on Lovenox.
On ___, Cefepime was discontinued. WBC decreased to 15,000
from 17,00. A passy muir valve was placed, but she could not
tolerate the valve for long periods of time. On ___, a PEG
was placed, foley catheter was removed, but was later replaced
overnight for retention. On ___, the patient's tube feeds
were increased to goal. On ___, the patient's foley
catheter was discontinued at midnight but was then replaced on
___ for urinary retention.
Per Orthopaedics, the patient should remain in b/l knee
imobilizers, a short air cast for the LLE and a long aircast for
the RLE, RUE in volar resting slab. On ___, the patient
underwent and failed FEES with Speech & Swallow. She was made
strict NPO and continued on tube feedings. The trach tube was
down-sized on ___ to a #6 fenestrated, non-cuffed tube. She
tolerated this well and underwent placement of passy-muir valve.
She has had no difficulty in mobilizing her secretions.
On ___, the patient went back to the OR with Plastic Surgery
for a split thickness skin graft to the right lower extremity
and for a PEG placement. Postoperatively, tube feeds were
started and advanced to goal which she tolerated well. On ___,
the VAC was taken down from the skin graft site, which appeared
well-healing. The STSG donor site was left open to air.
The patient continued to work with Physical Therapy and it was
recommended that she be discharged to rehab to continue her
recovery. | 460 | 674 |
14315489-DS-12 | 24,134,899 | Dear Ms. ___,
It was a pleasure being part of your care team at ___. You
were evaluated for chest pain and kidney failure. Your chest
pain resolved shortly after arriving at the hospital and did not
return. We ran several tests to determine the cause of your
kidney failure and it appears to have occurred gradually over
the past few years. You will need to continue the dialysis
sessions which you started at the hospital three times/week and
follow up with your kidney doctor to discuss further management.
It was a pleasure taking care of you. | PRINCIPAL REASON FOR ADMISSION:
___ with h/o DM, HTN, HLD, GERD presents with substernal chest
pressure and acute on chronic renal failure, found to be in
hypertensive urgency | 95 | 27 |
11658675-DS-20 | 22,537,167 | Dear Mr. ___,
Thank you for coming to the ___
___. You were admitted because you were having shortness of
breath. We believe this is related to your churg ___
syndrome. We increased your prednisone dose. You will need to
taper the dose of prednisone and follow up with your
pulmonologist as directed. We are glad that you are feeling
better. We also increased the dose of your fentanyl patch and
adjusted the dose of morphine.
Medication recommendations
-Please take 30 mg prednisone ___ for 2 days then 20 mg ___
for two days then 10 mg ___ until you follow up with your
pulmonologist
-Please increase Fentanyl patch to 62 mg
-Please take ___ mg morphine Q6 hours as needed for pain | ___ male with a history of Churg ___, COPD on 2LNC,
esophageal dysmotility, aspiration PNA s/p PEG tube and history
of PE s/p IVC filter, chronic chest wall pain presents with
shortness of breath and chest, back, and hip pain.
#Dyspnea: He presented with SOB and elevated eosinophil level
suggestive of worsening of his Churg ___ syndrome.
Alternately COPD exacerbation was also possible. His EKG was
unchanged and two sets of cardiac enzymes were normal. His lower
extremity US was did not show any signs of DVT making PE less
likley. He was treated with prednisone 60 mg with a rapid taper
with plan to taper back to 10 mg and follow up with his
pulmonologist. He also received a short course of levofloxacin
for COPD exacerbation or less likely aspiration pneumonia. His
respiration improved and returned to his baseline.
# Chronic Chest/abd/hip pain: Palliative care was consulted to
assist in the management of his chronic pain. They suggested
increasing his fentanyl pacth to ___s giving 10 mg
___ morphine for mild pain and 25 mg for more significant pain.
He would also like to consider a hospice referral for further
mangement of his symptoms.
# Esophageal dysmotility: s/p G tube which appears to be
functioning well. We discussed the risk and benefits of swish
and spit and patient and he strongly desires to continue. He is
also interested in a hospice referral. Reglan and lasoprazole
were continued
# Lower extremity calcifications: as above, lower extremity
ultrasound showed no DVT, but did show vascular calcifications.
On exam the patient had multiple small slightly tender
subcutaneous nodules which were likely these calcifications.
Xrays were recommended by radiology for further
characterization, but we decided to defer more imaging given it
would not change management and was not consistent with overall
goals of care.
# Hyperlipidemia:
- continued pravastatin 40 mg hs
# Depression:
- continued celexa 30 mg qday
# Hypothyroidism:
- Continued levothyroxine 25 mcg qday
# Bipolar d/o:
- continued seroquel
# OSA: Continued home BiPAP
# Osteopenia: Ca + Vit D
TRANSITIONAL ISSUES
-Please refer patient to hospice for further management of his
symptoms | 119 | 372 |
11393208-DS-8 | 21,329,521 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted because of blood in your
stool. Because your blood counts were low, you were treated in
the intensive care unit and given 4 units of blood. You
underwent an upper endoscopy, which showed erosions in the
stomach and small intestine, but no active bleeding. You also
underwent a colonoscopy, which showed diverticulosis. The exact
source of the bleeding was not found. Your bleeding stopped, and
your blood counts started to rise again. We added a new
medication to your list, pantoprazole, which will help prevent
future bleeding. We also temporarily stopped two of your blood
pressure medications, amlodipine and lisinopril, because your
blood pressure was normal in the hospital. We suggest that you
touch base with your primary care doctor about when to restart
these medicines. Finally, we started you on aspirin to help
prevent future strokes.
Best wishes,
Your ___ care team | ___ is a ___ man with history of HTN, CVA,
diverticulosis and prior GIB with unclear source in ___ who
presented with melena, bright red blood per rectum, and
lightheadedness. He was admitted to the MICU with a hematocrit
of 27 (baseline 40); this stabilized after 4 units of pRBCs and
he was transferred to the floor. EGD and colonoscopy did not
identify a source, but did reveal many gastric and duodenal
erosions, as well as diverticulosis. | 157 | 77 |
17727916-DS-19 | 27,479,296 | Dear Mr ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had shortness of
breath when exerting yourself.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We found that you had too much fluid on your lungs. We gave
you medication to remove this fluid.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Please weigh yourself every day, and if your weight goes up by
more than 3 lbs, please call your doctor.
We wish you the best!
Your ___ Care Team | Mr. ___ is a ___ year old male with a PMH of HTN, CKD,
renal artery stenosis s/p stent ___ and PAD who presents with
recent history of exertional chest pain and new bilateral ___
edema, pulmonary edema on CXR and elevated BNP concerning for
new diagnosis of heart failure.
===================
TRANSITIONAL ISSUES
===================
[] DISCHARGE WEIGHT: 54.7 kg (120.59 lb)
[] DISCHARGE CREATININE: 2.3
[] This patient may require maintenance diuretic dose in the
future.
[] Please check CHEM 10 to evaluate renal function on ___
[] Please continue to monitor volume status and weight
[] Call cardiologist if weight goes up by 3 lbs
[] Consider addition of 20 mg PO Lasix for diuretic and for
further hypertension control
[] Please continue to discuss risks and benefits of aspirin with
this patient - allergy to aspirin is listed as "upset stomach"
[] Please follow up SPEP and UPEP
# Suspected diastolic heart failure exacerbation
Exam and labs suggestive of acute heart failure. Pt up ~12 lbs
from dry wt of 120lbs. No prior history of CHF. Acute
exacerbation likely due to increased salt intake, patient
reported eating more canned foods lately. The history was not
thought to be consistent with ischemic heart disease, but this
patient would likely benefir from outpatient stress test. TTE
showed EF 67% with grade II diastolic dysfunction, suspect from
long standing hypertension. He was diuresed effectively with
furosemide 20 mg IV. His hypertension was managed as below.
# Hypertension
Continue on home amlodpine, Imdur, and home metoprolol was
switched to carvedilol. Lisinopril was changed to 20 mg qHS for
___ hypertension.
# Renal Artery Stenosis
# PAD
Continued home Plavix. Please continue to discuss the risks and
benefits of aspirin with this patient, as allergy to aspirin is
listed as "upset stomach."
# Hyperlipidemia
Switched from lovastatin to atorvastatin 40 mg
# GERD: continued home PPI | 114 | 297 |
19438380-DS-9 | 21,190,747 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service due to a R foot infection. You
were given IV antibiotics while here and taken to the OR twice
for debridements. You are being discharged home with the
following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weightbearing
to your R heel until your follow up appointment. Please do not
place weight on the front of your R foot. You should keep this
site elevated when ever possible (above the level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
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.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
Both of your foot dressings will need to be changed daily. Can
apply betadine and a dressing
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ 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.
You were also given creams for your rash as well as a medication
called Fexofenadine to continue taking as your rash continues to
improve.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | The patient was admitted to the podiatric surgery service on
___ with a R foot infection. While ___ the ED, a bedside
incision and drainage was preformed. On admission, he was
started on broad spectrum antibiotics. He was taking to the OR
for Right foot incision and drainage on ___ and for a R foot
debridement with partial closure on ___. Pt was evaluated by
anesthesia and taken to the operating room. There were no
adverse events ___ the operating room; please see the operative
note for details. Afterwards, pt was taken to the PACU ___ stable
condition, then transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis with IV pain medications for breakthrough pain. The
patient remained stable from both a cardiovascular and pulmonary
standpoint. He was placed on vancomycin, ciprofloxacin, and
flagyl upon admission and switched to cefazolin, ciprofloxacin,
and flagyl when culture data was received. Upon starting the
patient on cefazolin, he began to develop a rash on his legs and
arms. He did not have any respiratory compromise. Cefazolin was
discontinued and he was started on benadryl and clindamycin.
Dermatology was consulted who felt that his eruption was benign
___ appearance at this time with no further systemic involvement
to prompt further intervention at this time. They felt this
could be an early presentation of developing mild leukoclastic
vasculitis (LCV) which may be associated with drugs such as
medications, usually these are started a week or so before
presentation so most likely culprit is Augmentin but cefazolin
changed could be, or infection which patient is being treated
for. Per dematology recommendation, he was given fexofenadine
BID and triamcinolone 0.1% cream BID, and we began to notice
improvement at time of discharge. His intake and output were
closely monitored and noted to be adequate. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged while remaining NWB to his R
forefoot. He was evaluated by physical therapy who felt he would
benefit from rehab vs home with ___. Following multiple visits
with physical therapy, physical therapy deemed him safe to
return home with home ___ as well as a walker, commode, and
wheelchair for long distances.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with services ___
place. The patient had been refusing all services while ___ the
hospital. He was advised on multiple occasions that our advice
would be that he have home nursing and home physical therapy. He
was informed that home nursing would be able to monitor his
wound and change his dressing as well as ___ work with him on his
mobility. The patient adamantly refused services. He was
informed that this was against medical advice. He acknowledged
that he was aware of this, but would not accept services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 466 | 524 |
10517359-DS-6 | 25,894,740 | Mr. ___,
You were sent to the hospital because you had very low levels of
red blood cells (severe anemia). You likely have had a chronic
slow bleed from your gastrointestinal tract. You received blood
transfusions, and your blood levels remained stable. You were
also treated with IV iron because your body iron levels were
very low. You had two studies to find the location of this
bleed, which showed that you had ulcers near the part of your
colon that was operated on previously. There was some blood
oozing from these ulcers, which were cauterized to stop the
bleeding. After you had your studies, your condition was
discussed by Dr. ___ Dr. ___ felt that you should
go home on a baby aspirin daily and re-address your need for
blood thinners at you appointment with them next ___.
We have made the following changes to your medications:
Please STOP taking dabigatran (Pradaxa). Do not restart this
medication until instructed by your doctor.
Please START taking aspirin 81 mg tabs (enteric coated), 1 tab
by mouth daily. | ___ w/ PMH of prostate CA in remission, colon CA in remission, L
MCA stroke in ___ with residual mild right-sided deficits,
and afib/aflutter on dabigatran (recently increased), who is
admitted from clinic after being found to have Hct 16.8 and
guaiac positive stool.
.
# severe anemia: due to Pt's anticoagulation with dabigatran and
guaiac positive stool, suspect GI source. Pt has a history of
prostate and colon cancer, both in remission. Given absence of
constitutional symptoms, suspect more benign cause of GI bleed.
Suspect lower GI bleed given absence of upper GI (or lower GI)
symptoms, but cannot rule out upper GI bleed. No evidence of
hemolysis; normal T bili, normal LDH, normal haptoglobin, no
schistocytes on smear. Pt is very microcytic but was previously
normal, suspect that this is a long, slow process, which has
made him extremely iron deficient. Iron studies showed serum
iron 12 (last 18 in ___, Ferritin 4.0 (last 57 in ___, TIBC
534, transferrin 411. Pt last took dabigatran ___ morning and
appears to be very stable clinically. Conferred with GI fellow,
who wanted to wait and scope Pt on ___ after dabigatran has
washed out. Pt received 2 x PRBCs on the evening of admission
with appropriate increase in Hct from 16 to 22. Hct remained
stable and increase throught his admission to 24 on ___. Pt
was started on ferric gluconate 125mg iv daily x 4 days (D1 =
___ for his severe iron deficiency anemia. Pt was also treated
with pantoprazole 40mg iv bid given unclear source of GI bleed,
though suspected lower GI. Pt's Hct remained stable throughout
hospitalization, 24.0 on discharge.
Pt's upper endoscopy on ___ was normal. His colonoscopy
showed large non-bleeding internal hemorrhoids, and ulcerations
and surrounding friability on both sides of the ileo-colonic
anastamosis. There was bright red blood oozing from the borders
of the ulcers. BI-CAP Electrocautery was applied for hemostasis
successfully. Cold forceps biopsies were performed for histology
at the ileocolonoic anastamosis. Per the GI service, these
lesions did not look cancerous, but the biopsies will provide
more definitive information. Their etiology remains unclear and
they may continue to bleed despite coagulation. The situation
was discussed with Dr. ___ Dr. ___ it was decided
that Pt should remain off anticoagulation for now and will be
discharged on aspirin 81mg po daily pending further discussion
w/ his doctors next week.
.
# bradycardia: chronic. Physiologic vs AV nodal disease. Pt was
noted to have several pauses in the 1.6 to 1.8 second range
overnight when sleeping. No acute interventions, Pt was
scheduled for follow-up w/ his outpatient cardiologist.
.
# atrial fibrillation / atrial flutter: chronic, s/p
unsuccessful ablation procedure. Had a large MCA stroke off
medication. Started on dabigatran afterwards w/ dose recently
increased from 75mg po bid to ___ po bid. Repeat ECG showed
sinus bradycardia with irregularly irregular rhythm. His
dagibatran was stopped given his GI bleed, and Pt was started on
aspirin 81mg po daily. CHADS2 score of 3 = 5.9% annual risk of
stroke (for age and stroke). The issue of resuming
anticoagulation will be determined by his PCP and neurologist.
.
# inspiratory crackles, pedal edema: seems to be new per Pt's
daughter, likely over at least 2 weeks. Pt denies any dyspnea or
weakness. BNP elevated at 1155, but no prior for comparison. Pt
had inspiratory crackles and pedal edema. Given his severe
anemia, Pt had an ECG, which showed no evidence of ischemia, and
a repeat echo, which showed no focal motion abnormalities. Pt
had moderately dilated left and right atria, LVEF > 55%,
moderately dilated RV w/ preserved function. Pt also had
moderate-severe TR, moderate MR, and severe pulmonary artery
systolic hypertension. Pt has an appointment with his
cardiologist to address these findings.
. | 173 | 624 |
17224820-DS-18 | 27,550,595 | You were admitted with a severe urinary tract infection with
sepsis. You were treated with fluids, antibiotics, and other
supportive medications and you improved. It was recommended you
go to rehab but you refused. You are being discharged home with
services at your request. | BRIEF SUMMARY.
This is a ___ with dementia, HTN, HL, bladder cancer status post
recent open radical cystectomy, bilateral salpingo-oopherectomy/
partial vaginectomy/ ileal conduit urinary diversion complicated
by mild-moderate acidosis, and admission in ___ for UTI, who
was transferred from ___ with severe sepsis associated with
hypotension likely due to UTI. She was treated with broad
spectrum antibiotics which were eventually narrowed to
ampicillin based on microbiology showing urine + for VRE. A
blood culture was positive for CONS which was thought to be
contaminant as multiple other sets were negative. She had
significant metabolic disarray on admission which improved with
fluid resuscitation and oral bicarbonate administration. She was
recommended to go to rehab but refused and so was discharged
home with services.
DETAILED SUMMARY.
# Sepsis associated with hypotension
# Urinary tract infection: Patient presenting with fever,
tachycardia, worsening leukocytosis, tachypnea, acute kidney
injury concerning for ongoing sepsis. While CXR showed
atelectasis vs PNA, I suspect that her most likely etiology of
her infection is urinary given prior urinary tract infection and
with ED nursing notes reporting that the patient has not allowed
family to change urostomy bag. CT A/P without anatomic
abnormality or evidence of obstruction that would increase risk
of recurrent infections. Urine culture positive for large
enterococcus, VRE, amp susceptible. Transitioned to amoxicillin
at discharge.
# Acute Renal Failure: Admission Cr of 1.9, up from a recent
baseline of 1.0, likely ___ in the setting of hypotension and
sepsis. If her creatinine fails to improve with IV fluid
resuscitation, may also have a component of ATN in the setting
of known hypotension. Slowly resolved, discharge Cr 1.0.
# Anion Gap Metabolic Acidosis with Respiratory Compensation:
Patient with anion gap and non anion gap acidosis, with
respiratory compensation. Potential contributing factors
included lactic acidosis, ketoacidosis, acute kidney injury,
presence of ileal conduit, and significant resucitation with
normal saline. Of note, patient was initiated on sodium
bicarbonate by renal on her most recent hospitalization in
response to an ongoing metabolic acidosis, however was not
taking at home. Bicarbonate was resumed and titrated with
improvement in acidosis.
# Dementia with superimposed
# Acute toxic encephalopathy: She had some waxing and waning
alertness here, thought to be acute toxic encephalpoathy in
setting of UTI. She has underlying dementia. She was alert,
conversant, oriented to self, hospital, and month of the year at
time of discharge. No focal neurologic deficit.
# Possible bacteremia, likely contaminant: CONS in ___ from
admission. Repeat cultures NGTD.
# HTN: Stable. Toprol held here but resumed at discharge.
# Hypothyroidism: Stable. Continued home levothyroxine 100mg
daily.
# Hyperlipidemia: Mild transaminitis noted on prior admission,
for which atorvastatin was held upon discharge. Transaminitis
has resolved. Atorvastatin therefore resumed.
# Chronic anemia: likely ACD (prior ferritin ___
>30 minutes spent coordinating discharge | 44 | 450 |
12275484-DS-11 | 26,338,277 | You were admitted to ___ with complaints of chest pain,
fatigue, muscle aches and fevers. You were found to have a
pneumonia. You were treated with antibiotics and you improved.
You will be sent home to complete a 7 day course of antibiotics,
last dose should be on ___. Please see your PCP ___ ___
weeks of discharge.
.
Medication changes-see below | ASSESSMENT & PLAN:
___ yo ___ and anemia presents with pleuritic chest pain,
found to have a multifocal pneumonia and hyponatremia.
# Community acquired Pneumonia:
The patient presented with a symptom complex that could be
consistent with either viral or bacterial pneumonia. The
patient was started on tamiflu and levofloxacin in the ED after
getting a CT chest which showed multifocal pneumonia. The
patients respiratory viral screen was negative, specifically for
influenza. Her tamiflu was discontinued. The day following
admission, the patient was much improved. She was satting well
on room air and was eager to be discharged. A CBC was check in
the ___ on the day of discharge and her WBC was down trending and
she was a febrile. A safe discharge plan was discussed with her
PCP and close follow up was arranged. She was sent home to
complete a 7 day course of antibiotics, last dose should be on
___.
.
# Hyponatremia:
This was likely due to decreased po intake. This corrected
after given IV fluids. Po intake was encouraged at home.
.
# ___
The patient was continued on her home medications.
.
# Microcytic Anemia
This has been an issue and been worked up by the outpatient GI
team for the last several months. Her distant baseline is a Hgb
in the 13 range. Recently it had been in the 9 range. She had
a negative capsule endoscopy on ___ and GI rec'd a push
enteroscopy which is currently scheduled for ___. She has
previous labs that show evidence of iron defficiency anemia.
When inquired why she was not on iron, the patient replied one
of her teams of outpatient physicians indicated that she should
not be on it. The patient showed no active signs of GI bleeding
while in house or orthostasis. The patient should have a repeat
CBC checked in one week and faxed to her PCP. At that time, po
or IV iron should be considered once her acute infectious issues
resolve.
.
# Transitional Issues:
- complete antibiotic course, follow up pending blood cultures
from ___
- Repeat CBC in 1 week and follow up with PCP to follow anemia
and consider iron supplementation
- continued GI follow up for further work up of anemia
. | 64 | 383 |
18868873-DS-3 | 22,984,481 | Dear Ms. ___,
You were admitted to ___ after you had
toxicity from taking too much aspirin.
WHAT WAS DONE FOR YOU?
- You presented to the hospital in respiratory distress and had
a breathing tube placed. You were initially in the medical
intensive care unit and you were treated for aspirin toxicity.
You fortunately suffered no serious consequences from aspirin
toxicity. You had some confusion during your hospital stay but
this improved significantly.
- You were treated for a pneumonia with antibiotics and these
were finished before you were discharged.
WHAT TO DO NEXT?
- Please take all of your medicines as instructed. Please
follow up with your primary care providers as scheduled.
- You were given prescriptions for cough medicine (pill called
tessalon pearls/benzonatate) to take as needed. You should also
try robitussin which you can buy at the local pharmacy at night
for your cough.
- You were started on a heart burn medicine called omeprazole.
It was a pleasure taking care of you,
Your ___ Care Team | ___ PMHx uterine fibroids s/p embolization ___ leading to
premature menopause, formerly on HRT who was admitted to ___
on ___ as a transfer from ___ given AMS and aspirin
toxicity. She was initially admitted to ___ MICU and
required IV bicarbonate gtt for urine alkalinization. Her
hospital course was complicated by pneumonia and toxic metabolic
encephalopathy. | 173 | 57 |
10769030-DS-6 | 21,539,481 | You were admitted to ___ with gallstone pancreatitis and also
gall stone cholecystitis. Your labs were with very elevated
lipase and LFTs. Due to your not having many symptoms and
imaging without evidence of a blockage at this time, it was
discussed that removal of your gall bladder is the best course
of action at this time. | #Suspected passed CBD stone/choledocholithiasis
#Cholelithiasis
#Gallstone pancreatitis
-Elevated lipase suggests inflammation of pancreas likely
related
to a potentially passed gallstone. No ongoing pain now or
evidence of SIRS at time of admission or discharge. Elevated
LFTs most likely from passed stone and without symptoms at this
time will not keep patient here. Discussed that patient should
follow with primary care provider to get her LFTs rechecked this
week to ensure downtrend. If uptrending she should return to the
hospital at htat time. Patient did received 1 dose of Zosyn in
ED, this was held after admission.
___ surgery was consulted while patient inpatient for
possible cholecystectomy, but was not able to get a booking on
the day of discharge. Patient feels well at this time so will
d/c home with close followup from me (___) and Dr. ___
___ timing of surgery in near future.
At time of discharge patient was told she should return if she
has return of symptoms/fevers/chills etc... | 57 | 158 |
10381484-DS-21 | 25,100,289 | Dear Mr. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because of abdominal pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We performed imaging that showed that intestines were being
compressed from your cancer, causing obstruction.
- We gave you pain medication, and allow your intestines to
rest.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please ensure that you follow-up with the outpatient
oncologist next ___. This is absolutely essential.
We wish you the best!
Sincerely,
Your ___ Team | HOSPITAL COURSE:
=====================
___ with stage IV sigmoid adenocarcinoma s/p LAR (___) with
subsequent POD involving spleen now s/p splenectomy/distal
pancreatectomy/wedge gastrectomy (___) currently on
palliative C1D25 Irinotecan and DVT on rivaroxaban who p/w
diffuse abdominal pain, concerning for malignant small bowel
obstruction.
# Stage IV Sigmoid Adenocarcinoma s/p LAR ___
# S/p splenectomy/distal pancreatectomy/wedge gastrectomy
(___)
# Malignant SBO
A CT scan performed on the day of admission showed a small bowel
obstruction secondary to a 3.2 cm omental implant in the left
mid abdomen and with no signs to suggest bowel ischemia. Pt
noted his symptoms are continuing to improve since arriving to
the ED. Upon discharge and during his hospital course, he did
not have nausea or vomiting, and is passing gas. He did not pass
any stool from the time of admission for discharge. His exam was
not concerning for acute abdomen and was only notable for LLQ
tenderness on palpation which started to resolve during his
hospital course. After speaking to his oncologist (Dr.
___, it was determined that since he could tolerate clear
liquids as well as yogurt, he could be discharged with close
follow up. He will follow up with his appointment with Dr.
___ on ___. If he could not tolerate any PO intake, the
plan was to start inpatient chemotherapy. Colorectal surgery was
also consulted and agreed that surgery was not needed now if
chemotherapy is an option. Please note that there have been some
issues with compliance with chemotherapy in the past, there
might be some process of denial.
# hx DVT
Due to his potential for surgical intervention, his rivaroxaban
was held and he was started on a heparin gtt. After confirming
that there was no need for surgery, he was restarted on his
rivaroxaban.
Greater than 30 min were spent in discharge coordination and
care | 115 | 298 |
19540374-DS-12 | 29,209,487 | Dear Mr. ___,
It was a pleasure taking care of you! You were admitted with
shortness of breath and cough. We determined that you were in
heart failure, a condition in which your heart does not pump
effectively. As a result fluid builds up throughout your body,
including in your lungs. We treated you with intravenous
diuretics to eliminate this fluid, and you improved.
Please take all medications as directed and try your best to
keep all of your scheduled appointments.
Please check your weights daily. If you gain greater than 3lbs
in 24hrs or 5lbs in 48hrs, please contact your doctor. Your
weight at discharge was 90.8 kg or 200 pounds.
We wish you the best!
Your ___ Cardiology Team | Mr. ___ is an ___ gentleman with a PMH significant
for severe AS ___ <0.9 cm2), HFpEF (EF 55%), severe MR, CAD s/p
CABG (___) and NSTEMI (BMS in ___, CKD, AAA s/p repair, COPD,
and recent admission for GI bleed who presents with ___.
# Pulmonary Edema | Acute on Chronic Diastolic Heart Failure
Patient presented with severe volume overload and biventricular
CHF, likely secondary to lack of urine output from ___ as above.
Symptoms worsened by severe AS and severe MR, which reduces his
forward flow and makes him very volume sensitive. S/p furosemide
IV 10mg/hr, pt was net neg 2L on ___ and 3L on ___, but
still appeared volume overloaded, and O2 requirement was still
at 2L. Pt was lightheaded w/ SBPs soft in ___ on ___, and
diuresis was held, w/pt still having sufficient UOP. He received
1 unit pRBC + IV Lasix 80mg as ___ on ___ as below.
Diuresis was then escalated to IV Lasix 80mg BID on ___, but
patient continued to be hypervolemic on ___. He was then
escalated to IV Lasix 120mg bolus x2 and Lasix gtt was started
@10mg/hr, which was escalated to @20mg/hr in addition to
metolazone ___ daily on ___. On ___, patient appeared close
to euvolemic, Lasix gtt was discontinued, and patient was
transitioned to Lasix PO 80mg daily on ___. Patient was
discharged on a diuresis regimen of ***80 mg Lasix BID*** and
his weight at time of discharge on ___ was 90.8 kg. Patient is
not on a beta blocker or ___ due to ___ and history of
hypotension. He should be evaluated for these agents in the
outpatient setting.
# ___ on CKD
Patient with baseline Cr of 2.0, elevated to 5.0 on admission.
Most likely etiology is contrast induced nephropathy given
timing ___ that started ___ days after CTA with reduced urine
output and acute Cr rise. Other contributing factors include his
severe AS, severe MR, and heart failure. Obstruction was thought
to be a contributor, but patient's Cr did not improve
significantly after Foley placement, and renal U/S was w/o
hydronephrosis. On presentation, he was hyperkalemic, but
improved s/p insulin and dextrose and with diuresis as
discussed. Patient's medications were renally dosed. As below,
patient was diuresed for CHF exacerbation, initially with Lasix
gtt @10mg/hr, which was escalated to @20mg/hr, along with
metolazone 5mg + IV Lasix 120mg x2 boluses. Cr improved to
2.2-2.5. On ___, patient appeared euvolemic, and was
transitioned to PO Lasix, receiving PO Lasix 80mg x1. Cr 2.5 on
___. Cr on ___ at time of discharge is 2.3.
# Severe AS | Severe MR: Per TAVR team, pt will pursue TAVR in
the outpatient setting for management of severe AS upon
achievement of euvolemia and normalization of kidney function.
TAVR team will contact patient regarding additional workup and
plan contact: ___, NP on structural team.
# Anemia | History of GI Bleed | Hematuria
Patient was discharged with Hgb 9 last admission. On
presentation, Hgb 7.5. No evidence of acute bleed currently.
Most likely slow oozing from known gastritis that caused prior
GI bleed. Also has history of mild, persistent thrombocytopenia
w/plt high90s-low100s. Fe replete based on studies on ___.
Also had some transient gross hematuria secondary to Foley
trauma. Guaiac negative. Hb ranging from 7.6-7.7. He received 1U
pRBC on ___, w/repeat H&H 8.6/26.5. Hgbs in 9's at time of
discharge.
Patient was continued on home pantoprazole 40 mg Q12H and iron
supplementation.
# COPD:
Patient was audibly wheezing on admission, but this was most
likely due to CHF, as his wheezing improved with diuresis. He
received standing duonebs q6hr in house, but was restarted on
tiotropium for discharge.
# Orthostatic Hypotension:
Patient had SBPs in ___ iso diuresis as above. He was
continued on home midodrine 10 mg PO TID.
# Atrial Fibrillation
CHADS2-VASc of 8. Per daughter, patient has a history of TIA in
the past (father "spaced out" in the kitchen and dropped a
coffee cup) and his mother had stroke. His home dose warfarin is
2.5mg QD with goal INR 2.0-3.0. INR 3.4 on admission and patient
had gross hematuria, and initially held warfarin. Warfarin was
restarted at home dose of 2.5mg on ___ with heparin gtt bridge
upon resolution of hematuria. Heparin gtt was discontinued on
___ when INR moved into range. Patient was continued on home
regimen 2.5mg daily. INR at time of discharge was 2,5.
# CAD
Patient was continued on home aspirin 81 mg daily and
atorvastatin 80 mg QHS. His home ranolazine 500 mg BID was held
given soft SBPs in the ___ 100s and was not restarted for
discharge.
# Hypothyroidism:
Patient was on levothyroxine 125mcg QD at home. TSH 0.21 on
___. Given concern for over-treatment of hyperthyroidism,
repeat TSH ___ was 0.11. Levothyroxine regimen was changed
from 125 mpg daily to 125mcg (___) and 62.5mcg on ___ (7%
dose reduction). Patient should have repeat TFTs in six weeks
(___).
# Gout:
Patient's home allopurinol ___ mg daily was held iso ___, and
will be held until resolution of ___.
# Peripheral Neuropathy:
Patient's home gabapentin 100 mg QHS was held during
hospitalization iso ___, and will be held until resolution of
___.
# BPH:
Patient retained urine requiring a Foley, which he will be
discharged on. He was continued on his home tamsulosin 0.4 mg
QHS and finasteride 5 mg daily. Patient will need urology
outpatient follow-up for a voiding trial.
DISCHARGE WEIGHT: ___90.8______
DISCHARGE CREATININE: ___2.3______
DISCHARGE INR: __2.5_______ | 119 | 909 |
15049237-DS-5 | 28,367,823 | Dear Ms. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
- You were admitted for with cough and found to have a
pneumonia.
- You also had some fluid in your lungs.
What was done for me in the hospital?
- You were started on antibiotics for your pneumonia.
- You were given an IV medication to remove extra fluid from
your lungs and make you urinate more frequently. You will take
the same medication in a pill form when you go home. You will
get a new prescription for this medication (furosemide).
- You will have an ultrasound of your heart done on ___ at
10AM at ___
building. Please make sure you keep this appointment.
What should I do when I leave the hospital?
- You should take all of your medications.
- You should attend your appointments. Please bring someone with
you to your appointments who speaks both ___ and ___.
- Please weigh yourself every morning. If you gain more than
3lbs from the previous day, please call your doctor. If you
weigh more than 3lbs less than the previous day, do not take
your Lasix. Please record the days when you do not take your
Lasix.
Sincerely,
Your ___ Team
Estimada Sra ___,
Ha sido un placer cuidar de que en ___.
¿Por qué estaba aquí?
- ___ fue admitido para ___.
¿Qué se hizo para mí ___ hospital?
- ___ se iniciaron en los antibióticos para una pneumonía.
- Se ___ una medicación IV para eliminar el exceso de líquido
de ___ y te hacen orinar con más frecuencia.
- Tendrá una ecografía del corazón hecho el jueves a las 10 am
¿Qué ___ cuando ___ hospital?
- Debe tomar todos sus medicamentos.
- ___ debe asistir a sus citas. Por favor, que alguien lo
acompañe a sus citas que habla español e Inglés.
- Por favor, ___ mañana. Si ___ más de 3 libras
desde el día anterior, por favor ___ médico. Si ___
pesa más de 3 libras menos que el día anterior, no tome ___
Lasix. Por favor, ___ los días en ___ no ___ Lasix.
Sinceramente,
___ ___ | Ms. ___ is a ___ year old female with past history of
hypothyroidism, dementia, recurrent UTIs who presented with
cough, congestion concerning for pneumonia and partially treated
UTI.
#Pneumonia:
Patient had increased cough, congestion and crackles over
RML/RLL on exam on admission. Patient had a slightly elevated
WBC. Influenza test was negative. Patient had a lactate of 2.5
that increased to 3.5 at peak. Lactate 2.5 persisted during
admission. She was treated with ceftriaxone and azithromycin for
community acquired pneumonia. Lactate subsequently downtrended,
and she continued to demonstrate clinical improvement. On
discharge, she was satting high ___ while ambulating. Discharged
on cefpodoxime and azithromycin for a 7 and 5 day total course,
respectively.
#Acute Pulmonary Edema:
#Unspecified acute congestive heart failure:
Patient had small bilateral pleural effusions with increased
vascular markings on CXR consistent with mild pulmonary edema
and elevated BNP concerning for CHF exacerbation. Patient did
not have a previous diagnosis of CHF or a previous TTE. Trops
were negative and EKG was unchanged. She was given 20 mg IV
Lasix BID for diuresis. Dry weight appears to be 162-163 lbs;
was close to dry weight at 164.7 lbs on discharge. She will have
TTE done as an outpatient; being discharged on 20PO lasix daily,
with close follow up plan.
#Dirty UA:
Patient has UA with moderate leuks and few bacteria and 9 WBC.
She was recently treated for an Ecoli UTI with macrobid
(sensitivities above). Patient is asymptomatic so she was not
treated for UTI. UCx was only contaminant.
CHRONIC ISSUES
# Alzheimer's Dementia: Patient is seen with cognitive
neurology. Per recent neurology clinic note, she was at her
baseline. She utilizes services for cleaning at her home. There
has been some concern per neurology note of home safety for
patient recently. Mini-mental status exam was ___. Continued
Vitamin D, Aricept 10 mg daily
# Hypothyroidism: Continued levothyroxine
# GERD: Continued omeprazole
# Chronic Knee Pain: continued tramadol 50 mg BID PRN
# Insomnia: Continued trazodone 50 mg QHS
#CODE: DNR/DNI
#EMERGENCY CONTACT HCP: Niece ___, does not know phone
number. ___ is in OMR as NOK. Phone number:
___
TRANSITIONAL ISSUES
[] Outpatient echocardiogram to evaluate for heart failure
[] Ongoing titration of diuretic medication, close follow-up of
electrolytes | 340 | 381 |
15760282-DS-16 | 29,037,606 | Dear Mr. ___,
You were admitted to the hospital with shortness of breath
likely from an asthma flare. We treated you with nebulizers and
steroids and you got better day by day. When you leave the
hospital you should see Dr. ___ in clinic on ___ as
planned. You should continue an additional 3 days of oral
steroids upon discharge. You should have Pulmonary function
tests (PFTS) to formally diagnose your likely asthma. You should
continue to use your albuterol inhaler every 6 hours while you
feel short of breath. Dr. ___ will go over your Echo results
with you. It was a pleasure taking care of you.
Best Regards,
___ Care Team | Mr. ___ is a ___ male with
HTN, HLD, pre-DM, obesity, and GERD who presented with atypical
chest pain associated with acute shortness of breath in the
setting of possible influenza 2 weeks ago and persistent dry
cough likely new diagnosis of asthma with acute exacerbation | 111 | 43 |
16549556-DS-15 | 21,638,978 | Dear Ms. ___,
You were admitted to the hospital with dizziness. We got a CT
scan of your head which did not show any stroke. Your dizziness
was most likely from your vertigo.
Physical therapy evaluated you and felt that you'd benefit from
vestibular physical therapy (special therapy to help with your
dizziness).
If this does not help, please contact your doctor, as you might
want to try meclizine.
It was a pleasure caring for you!
We wish you the very best.
-- Your care team at ___ | This is an ___ independently living woman with a history
notable for BPPV, hypothyroidism, hypertension and cervical
stenosis who presents with unsteadiness and weakness/funny
feeling in left leg.
ACTIVE ISSUES
# Dizziness/unsteadiness: history of gait unsteadiness since
___, seen by multiple doctors. ___ presents with positional
complaints similar to previous BPPV episodes, with head spinning
and unsteadiness on standing. ___ maneuver negative,
however. Neurology was consulted in the ED and found no central
etiology (most likely peripheral vertigo), recommended against
MRI. Orthostatics negative. CTA head and neck without
intracranial abnormality or flow-limiting carotid stenosis.
Evaluated by physical therapy and felt safe for discharge home,
and to follow up as outpatient for vestibular ___. Meclizine
previously ineffective, so avoided, given not effective & risk
for adverse effects.
# Left leg weakness: w resolved, per pt. Muscle strength in
flexion & extension ___ bilaterally. Given calf pain, LENIs were
obtained and were negative. CTA head/neck without flow limiting
stenosis, occlusion, dissection, or aneurysm and with no acute
intracranial abnormalities. ___ evaluated and recommended
outpatient ___. Vitamin B12 and Hb A1C levels pending on
discharge.
CHRONIC ISSUES
# Hypertension: normotensive in house. Continued on home
quinapril BID.
# Hypothyroidism: continued levothyroxine, 75mcg 3X/week, 50 mcg
4X/week.
======================================
TRANSITIONAL ISSUES
======================================
# BPPV: will need outpatient vestibular ___. Consider meclizine
trial if ___ ineffective.
# LABS: follow up pending B12 and A1C levels (checked for
subjective LLE weakness) | 83 | 229 |
17429587-DS-24 | 20,350,344 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you lost consciousness. We believe that you experienced
a seizure causing you do pass out. We started you on an
anti-seizure medication. Please go to all of your follow-up
appointments.
All the best,
Your ___ Team
- Atenolol was stopped during this hospitalization. Please
discuss with PCP whether to restart this. (Blood pressure was
low)
- Take warfarin 3mg today ___, then restart 5mg on ___ | ___ year old woman with history of CAD s/p CABG, s/p mechanical
AVR on coumadin, CKD, IDDM, and CVA in ___ w/ residual left
parietal infarct who presents with syncope and question of AMS.
ACTIVE ISSUES
# Syncope
Potential etiologies included worsening valvular disease, cardia
arrythmia, MI, transient CHB, CVA, seizure, and orthostasis. No
ECG changes and nothing initally on tele. CT shows no new
findings from previous. Cardiac enzymes negative. Not
orthostatic on exam. Story from home health aide consistent
with seizure activity. Seen by Neurology who recommended
starting on Keppra. MRI/MRA of head and neck unchanged from
prior. Patient discharged on keppra with Neurology follow-up.
# AMS
Patient very lethargic morning of admission and no oriented to
date or location. Potential etioligies include infection, CVA,
thyroid dysfunction. In addition, patient received a lot of IV
benzodiazepam at ___ prior to arriving to ___.
Concern for infection, but UA normal, CXR clear, blood cultures
negative. Normal TSH but low free T4. Patient became more
awake/alert and ___ (not oriented to date). After discussion
with family, they feel that this is close to her baseline.
CHRONIC MEDICAL ISSUES
# IDDM
Patient no currently on any insult or oral diabetes medications
per PCP. She was started on an insulin sliding scale and her
blood sugars were well-controlled.
# s/p MVR
Patient sarted on heparin drip for coumdadin bridging given
subtherapeutic INR. She was discharged on coumadin, INR goal
2.5-3.5 and plan for coumadin follow-up.
# Afib
Heparin and warfarin as above. Her atenolol was stopped as her
blood pressure was low.
# Hyperlipidemia
Her atorvastatin was continued.
# Depression
Her home citalopram was held during admission and restarted at
discharge. | 89 | 289 |
11555110-DS-20 | 20,585,249 | Please call or come to the Emergency Room if you experience
fever (>101.5F) or chills, recurrent or worsening abdominal
pain, abdominal distension, bilious or bloody emesis, chest
pain, shortness of breath, blood per rectum, or any other
symptoms of acute concern. | Patient was admitted to the transplant surgery service on
___ for bowel rest, fluid resuscitation and serial abdominal
exams for evaluation of abdominal pain. CT scan obtained in
Emergency Department demonstrated interval resolution of small
bowel obstruction s/p numerous bowel surgeries with multiple
anastomoses and ileoanal J-pouch although no evidence of
obstruction or abscess. On HD2, she reported improvement in
nausea and abdominal pain and +flatus/bowel movement. At this
time, her diet was advanced to clear liquids and she was
re-started on augmentin 875-125mg po q12h and ursodiol 300mg
q12h (home medications). She continued to report improvement in
abdominal pain, denied nausea / vomiting, and continued to have
+flatus/bowel movements. Her diet was subsequently advanced to
regular, which she tolerated. On HD3, she reported minimal
abdominal pain, tolerated solid food, and was passing flatus /
stool. Discharge to home was discussed and felt to be
appropriate by the patient and the surgery team. | 41 | 154 |
14276038-DS-6 | 27,936,984 | Dear Ms. ___,
You were admitted to ___ for lower leg swelling and 10
pound weight gain over the past couple of weeks. You were found
to have decompensated heart failure, which caused fluid to back
up and accumulate in your legs. We gave you furosemide and then
torsemide, which were effective in getting rid of that extra
fluid.
In the hospital, your lab tests showed that you have high
glucose levels, and they've been high for some time. You were
diagnosed with diabetes type 2 and given insulin here. When you
go home, you can take metformin for your diabetes. With
metformin, you do not need to monitor your blood glucose levels
daily. If you would like to learn more about your diagnosis,
there are also many helpful resources at ___
(___).
In addition, we found that you had a urinary tract infection,
which we treated with antibiotics. You also had low iron
levels, which caused anemia, and we gave you iron supplements.
When you go home, you will be started on several medications:
torsemide 30mg once a day for your heart (increased from your
original dose), metformin 1000mg once a day for diabetes,
Augmentin 875mg twice a day for the urinary tract infection
(last day ___, and iron supplements.
All of your medications are detailed in your discharge
medication list. You should review this carefully and take it
with you to any follow up appointments.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology and Medicine Teams | ___ with h/o EtOH cirrhosis, HTN, and COPD (on 2.5L home O2) who
p/w 10lb weight gain and increased leg swelling x1 week. Labs
notable also for new undiagnosed DM2, anemia, and UTI.
# HFpEF: The patient presented with ___ edema and 10-lb weight
gain over 2 weeks. TTE ___ showed Grade II diastolic
dysfunction with increased PCWP. BNP was only 352, but may be
misleadingly low given obesity. Given her diagnosis of EtOH
cirrhosis, we obtained a RUQ US, which showed no e/o Portal HTN
or hepatic masses as source of hypervolemia. Pt. was treated
with doses of 40mg IV furosemide with good effect. Her exam
improved, and her weight decreased from 120.4 kg on admission to
117 kg (dry weight ___ was 117.5kg). Her creatinine level also
improved slightly from 1.4 to 1.3. She was switched to torsemide
30mg (home dose 20mg) for maintenance.
# ___: Baseline Cr is 1.0, and up to 1.4 on admission. Cr
levels downtrended slightly to 1.3 with diuresis. Suspect
combination of cardiorenal syndrome, hypertensive nephropathy,
and diabetic nephropathy, though further diagnosis and
management is deferred to outpatient provider.
# UTI: Pt presented with pain on urination and 20 WBC on UA. She
was started empirically on IV CTX. After urine cx was positive
for enterococcus (which CTX does not cover), she was switched to
Augmentin 875mg PO BID x5days (started ___ last day ___.
Sensitivities confirmed bacterial susceptability to ampicillin.
# Anemia: Hgb 8.5 on admission, down from baseline Hgb of 11 in
___. Fe studies showed low Fe and high transferrin,
pointing to likely iron-def anemia. Peripheral smear showed
some dysmorphic cells but no e/o shistocytes. Her Hgb was
stable during her stay, and her guaiac tests were negative. She
received Fe supplements, and received her home pantoprazole
40mg.
# DM2: Patient presented with glucose levels in 300s and A1c
7.8%. Pt. given diagnosis of DM2 with suspected exacerbation
secondary to infection. Inpatient, she was placed on an insulin
sliding scale and her fingersticks were 100-200s. After her Cr
level began to downtrend, she was switched to and discharged on
metformin 1000mg. She worked with a ___ inpatient and
would benefit from follow-up with a diet___ outpatient.
# Transitional Issues:
- Take Augmentin 875 twice a day to treat urinary tract
infection (last day ___
- Torsemide was increased from 20mg to 30mg daily
- Take metformin 1000mg once a day for diabetes type 2
- Continue iron supplements for anemia and consider EGD
outpatient given epigastric pain.
- Blood culture results pending at time of discharge
- Please follow up with nutritionist for meal planning with
diabetes
- Please follow up with your primary care doctor regularly to
monitor the status of your glucose control
- Patient has essential tremors that affect her daily functions.
Consider switching metoprolol to propranolol.
- CODE: FULL confirmed
- Contact: ___ (daughter) ___ | 266 | 481 |
16010785-DS-10 | 25,118,801 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- No pharmacologic DVT prophylaxis necessary. Please ambulate as
much as possible to prevent blood clots
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have proximal radius/ulna fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable. | 208 | 147 |
18056761-DS-27 | 23,061,522 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had an asthma exacerbation causing you to have difficulty
breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received multiple medications to treat the exacerbation
and make sure that your body was receiving adequate oxygen and
that your lungs improved so that it is safe for you to be at
home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Followup with your outpatient doctor in order to make sure you
are able to get all of your prescriptions and take them
faithfully. You are in the process of getting extra health
insurance that will cover more of your costs, and in the
meantime we have given you enough prescriptions to cover you
until then.
We wish you the best!
Sincerely,
Your ___ Team | ___ year old male with severe asthma presents with asthma
exacerbation after having failed outpatient management. | 161 | 16 |
18463648-DS-18 | 23,820,588 | You were seen in the hospital for new abdominal pain. Imaging of
your abdomen was performed and showed a mass in the upper
portion of your left kidney. The shape of this mass is
concerning for kidney cancer. Following discharge, it is
important that you follow up in ___ clinic to discuss
treatment options for this mass. You may need further testing
and possibly surgery.
The urologists are in the process of arranging an appointment
for you in the ___. Someone should be in touch with
you soon about a date and time. IMPORTANT: If you have not heard
from someone in ___ by ___ at noon,
please call the clinic at ___ and ask about the status
of your appointment. It is important that you be seen in clinic
within ___ weeks of discharge.
It is possible the pain you experienced was due to a gallbladder
problem. If you experience recurrence of this pain, or have
nausea/vomiting or fevers/chills, we encourage you to call your
primary care doctor or proceed to the Emergency Room. | REASON FOR ADMISSION:
___ yo man, former smoker, p/w RUQ pain and newly discovered L
upper pole kidney mass concerning for RCC. | 174 | 21 |
12177591-DS-11 | 22,751,578 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you ___ to the hospital?
- You were found unconscious by staff at your assisted living
facility ___). Upon waking up, you were confused and
brought to the hospital for further evaluation.
What did you receive in the hospital?
- On presentation you were found to have a possible urinary
tract infection, and you were started on an IV antibiotic.
- Because you did not have any symptoms, we decided to stop the
antibiotic after 1 day.
- To make sure your heart didn't cause you to go unconscious, we
monitored your heart rhythm.
- Our physical therapists recommended that you go to rehab to
get stronger.
What should you do once you leave the hospital?
- You should follow up with your primary care provider which
will be arranged by the rehabilitation facility.
- If you notice any pain on urination, lightheadedness or
dizziness please return to the emergency department.
We wish you the ___!
Your ___ treatment team | Ms. ___ is a ___ year old female with history of breast
cancer, GERD, HTN who presents from her assisted living facility
on ___ after being found unconscious with confusion, found to
have hypotension, hypothermia, and a urinary tract infection. | 177 | 41 |
13281344-DS-18 | 27,966,916 | You were admitted to the hospital with chest and abdominal pain
attributable to acute cholecytitis. You subsequently underwent
a laparascopic cholecystectomy and recovered in the hospital.
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.
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. | The patient was admitted to the Acute Care Surgical Service on
___ for evaluation and treatment of abdominal and chest
pain radiating to the back. A Chest CTA and CXR were negative
for pulmonary embolism or evidence of acute aortic pathology or
intrathoracic process, respectively. Additionally, nonspecific
EKG abnormalities with normal troponins were noted. An
abdominal ultrasound,however, was consistent with acute
cholecystitis. The patient susbequently underwent laparoscopic
cholecystectomy; please see operative note for details. After a
brief, uneventful stay in the PACU, the patient was transferred
to the general surgical ward for further observation.
Post-operatively, the patient experienced nausea with emesis
related to intravenous Morphine. The pain regimen was
transitioned to intravenous acetaminophen with intravneous
morphine prn until tolerating a diet. At this time, the pain
regimen was transitioned to oral oxycodone and tylenol with
adequate pain control. The diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirrometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge on POD3, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 333 | 256 |
16363064-DS-8 | 28,594,230 | Ms. ___,
You were admitted because you had left side pain in the back of
your head and thighs. We were concerned about shingles due to
the type of pain you were having and the appearance of some
rashes on those regions. We did further biospy of the rash and
found out that this pain may be related to your chemotherapy
brentuximab. We were also concerned about the diarrhea you had
during your admission but this has seemed to resolve. We also
thought that the diarrhea may be related to your chemotherapy in
concert with other medications you are taking. We consulted with
neurology about your symptoms and it would be best if you follow
up with an outpatient neurology provider for further assessment
and management of this pain. We discussed with you taking
neurontin, lyrica or receiving injections to help alleviate your
pain and you did not want to do this at this time. We completed
further imaging of your head and neck today and your outpatient
provider, Dr. ___ follow up with you regarding the
results.
It was a pleasure taking care of you. Do not hesistate to
contact us if you have any questions or concerns about your
care. Please refer to below for follow up appointments with your
outpatient provider. | IMPRESSION AND PLAN: ___ is a ___ yr old female on
___ s/p a BEAM auto-HSCT for Hodgkin lymphoma presenting with a
few day history of occipital HAs now with two days of fevers and
a progressively developing papular rash of the face and anterior
chest with a patchy rash on the RLE.
## Papular rash of the face and anterior chest with a patchy
rash on the RLE: The ddx is infection vs. drug reaction vs.
combination of both these etiologies. Specifically, given the
prodromal L occipital HA as well as current L ear
pain/?vesicles, the most concerning etiology is herpes zoster;
however given the lesions are not localized to a single
dermatome, the concern would be dissemination. She was
prescribed valtrex 1g TID and took 5 doses as an outpatient (she
discontinued ___ AM as she thought it was causing diarrhea).
In terms of medications,
brentuximab can cause a rash and aside from restarting valtrex,
this is the only new medication she has initiated.
-Derm consulted, final path suggestive of drug hypersensitivity
-Send VZV Abs (IgM)PND
-HSV PCR PND
-Discontinued IV acyclovir as final path on derm bx was not
indicative of shingles, restarted prophy dose of acyclovir.
-MRI head/neck ___, result pending
-Will follow up outpt with neurology
## Fever: Fevers have resolved since admission. Localizing
symptom is the new rash, myalgias (see note above r/t zoster),
and now-resolved loose stools; there are no areas concerning for
bacterial superinfection. She does have pyuria, but is
asymptomatic with a urine culture pending. Blood cultures NGTD.
Her CXR had no infiltrate concerning for infection. She did
receive cipro/flagyl in the ED.
-urine cx neg, cipro d/c'd ___
-F/U blood cultures
-If she has recurrent loose stools, we will send a C. diff
## Bilateral thigh myalgias: She has notable TTP on exam. This
occured with her first cycle of brentuximab and this seems to be
the most likely etiology. CK wnl.
## Worsened thrombocytopenia and slight anemia: ? drug
effect(brentuximab, bactrim) vs. ? viral suppression (? zoster)
-No need for transfusion today
-Tranfuse if hgb < 7 and plts < 10
-Held pharmacologic PPX given plts of <50
## Relapsed Hodgkin Lymphoma: D ___ s/p BEAM auto-HSCT
currently on brentuximab maintenance (last ___ dose on ___
##Electrolyte imbalances - possibly due to hydration r/t IV
acyclovir
-on sliding scale
-repeat lytes prn
## HTN:
-Continue home dose of atenolol
## Esophagitis:
-Continue home PPI
## DM:
-Hold home metformin on admission as this was thought to
contribute to her diarrhea, restarted at d/c
-___ consult, insulin sliding scale started, BS between
100-170s
-Check BS as ordered
-Per ___, consider follow up with endrocrinologist locally | 213 | 417 |
14916430-DS-22 | 20,488,338 | Dear Ms. ___,
You were admitted to the hospital because you were confused and
having fevers. You were first admitted to the ICU because your
blood pressure was very low. The cause of your symptoms was a
skin infection of your right leg. You were started on
antibiotics and your symptoms revolved. We will send you home
with a antibiotics to take through ___. It is very
important that you follow up on the appointments listed below.
It was a pleasure to be a part of your care!
Your ___ treatment team | Ms. ___ is a ___ year old woman with a history of EtOH
cirrhosis complicated by HE, SBP, ascites, no varices on most
recent EGD, who initially came in w/ AMS and fevers found to
have RLE cellulitis and initially admitted to the ICU given
hypotension, stabilized and transferred to the floor
ACTIVE ISSUES
==============
# AMS/sepsis/cellulitis:
AMS most likely due to acute insult of sepsis on top of
cirrhosis. She initially met SIRS criteria based on tachycardia
and fever to 103 (rectal). Lactate 4.8 initially, subsequently
downtrending. Only identifiable source was RLE cellulitis. Less
likely hepatic encephalopathy, given absence of asterixis and
that MS cleared without additional lactulose. Toxicology screen
negative, no head trauma, no recent changes in diuretics or
other medications. IV vanc/cefipime were started in the ED and
mental status cleared after 4L IVF. Given concern for cellulitis
involving labia, broadened abx to vanc/cef/flagyl for anerobic
coverage. Home dose furosemide and spironolactone were initially
held due to hypotension, but were then restarted and well
tolerated. Her cellulitis improved dramatically and she was
transferred to the floor. She was transitioned to PO clindamycin
and tolerated this well with continued improvement in her RLE
cellulitis. She is discharged home to complete a 10 day course
of antibiotics through ___. She was alert and oriented x3
when transferred to the floor and remained so for 48 hours until
discharge.
# Alcoholic cirrhosis:
Baseline T bili 3.1 stable around recent baseline of ___. Has
chronic ___ edema, on diuretics. Initially held home dose
spironolactone and furosemide; however, these were then
restarted and well tolerated. On ___, there was some
concern for hepatic encephalopathy and the patient had not had a
BM in 2 days, so lactulose was increased to q2hrs. Home dose
cipro was held in the setting of receiving IV vanc/cef/flagyl.
Her mental status quickly cleared and she was transitioned back
to lactulose TID. Her cipro was restarted on discharge.
CHRONIC ISSUES
================
# T2DM:
Recently diagnosed with blood glucoses 400-500, multiple ED
visits, followed by ___, insulin regimen appears to be in
flux given recent dx. She was maintained on home ___ with good
blood sugar control in house. She is discharged on her home
regimen.
# Back pain:
Secondary to vertebral compression fractures, has chronically
been on oxycodone since ___. Continued home oxycodone
# Pancytopenia/coagulopathy:
Chronic since at least ___, thought ___ cirrhosis. Stable
INR up to ___ in ___, stable in-house ~ 1.7-2.1. Subqutaneous
heparin was given for DVT prophylaxis and platelets were
carefully monitored.
# H/O adrenal insufficiency:
Developed several years ago in the setting of withdrawing
steroids for alcoholic hepatitis, does not appear to be active.
Continued home dose midodrine.
TRANSITIONAL ISSUES
====================
- Should received Hep B vaccine as outpatient (surface ab
negative on ___
- Patient to take clindamycin through ___ | 90 | 457 |
15136878-DS-11 | 28,521,733 | Dear Ms. ___,
It was a pleasure taking part in your care at ___
___.
You were admitted for a an infection in your blood. There were
multiple different types of bacteria growing in your blood. It
is likely that the cause of this serious infection was
contamination of your PICC line. There was no evidence of any
abdominal infection, urinary tract infection, pneumonia, or any
other source of infection. Also, there is no evidence of
infection spreading to the heart based on the ultrasound of your
heart that you had performed while you were in the hospital. You
are being treated with three oral antibiotics, ciprofloxacin,
linezolid, and voriconazole. Your infection has improved
significantly during your admission and the oral antibiotics
have been working well. You should take these antibiotics until
___.
It is important that you go to a lab to have your blood drawn
twice a week. For your information, the results should be faxed
to the infectious disease department at ___
___.
I wish you all the best in the future, and a speedy recovery! | ___ year old female with hx asthma, bipolar disorder, PCOS, IBS,
Hep C, recent admission earlier last month for Strep viridens
bacteremia in setting of dental abscess discharged on vanco with
PICC line, chronic abdominal pain, who was recently admitted to
OSH ICU for severe gram negative sepsis, left AMA, and came to
___ for further management.
#Polymicrobial bacteremia: Her presentation was most concerning
for intentional contamination of her PICC line with stool given
blood cultures were consistent with fecal flora. At OSH she had
blood cultures positive for 4 different gram neg species. Blood
cultures drawn from ___ grew two types of enterobacter cloacae,
klebsiella oxytoca, klebsiella pneumoniae. The microbiology lab
at ___ was contacted klebsiella senstivity resistant to
ampicillin, but sensitive to all antibiotics tested.
Enterobacter was resistant to ampicillin/cefazolin, but
sensitive to everything else. She had peripheral cultures
growing yeast (non-albicans) and lactobacillus. Her initial PICC
line was removed at OSH. With the polymicrobrial nature of her
initial cultures she was started on IV vancomycin, aztreonam,
and micafungin. TEE on ___ negative for valvular
vegetations/abscesses. A new PICC line was placed for her IV
antibiotics. During her hospitalization here, she had occasional
fevers and a rapid increase in her WBC with return to normal a
couple days later. These were thought to be secondary to
continued contamination of her new PICC line. Her PICC was
pulled on ___ and switched to po linezolid, ciprofloxacin,
and voriconazole for a treatment duration of 2 weeks to end on
___. With combination of linezolid, voriconazole, and
sertraline, patient is at increased risk for serotonin syndrome.
Given that she is unable to have IV abx secondary to recurrent
contaminations, her antibiotic options are limited and must
remain on this regimen. The risks were thoroughly explained to
her and she was instructed to notify her doctor if she
experience any of the symptoms. Additionally, she was instructed
to have CBC, BMP, and LFTs drawn twice a week with results faxed
to ID department for the duration of her treatment.
#?Factitious Disorder: Her presentation is most concerning for
intentional contamination of her PICC line with stool or some
other bodily fluid. The speciation of her cultures with
lactobacillis, enterobacter, klebsiella, ___ is
most consistent with fecal contamination. Her WBC count during
admission (jumped up to 28) and returned to normal (5) from day
to day. When her PICC was removed and she was transitioned to po
antibiotics, she remained afebrile and WBC was normal. During
the admission, patient denied any intentional tampering with
PICC. Also consistent with her behavior is her intentional
wheezing when given most drugs or antibiotics Pt is often found
to have a forced upper airway wheeze with most medications
(never has any uritcaria) and thus insists on benadryl. As per
psych, this diagnosis is one of exclusion and cannot be made
without actually witnessing alleged behavior.
# Strep viridins bacteremia: Patient recently admitted ___
for S. viridens bacteremia ___ maxillary abscess from a tooth
that she self-extracted. She was started on vanco on ___ and
discharged with a PICC with plans for ___ecause she
had an allergic reaction to pencillin. However, she was not
compliant at home with vanco as per ID records in OMR. TEE
during that admission was negative for valvular vegetations. As
described above, she needed to be transitioned to po antibiotics
secondary to self contamination of picc. She finished her
antibiotic course as on ___ for strep viridins and
polymicrobrial infection.
#Medication allergies - Patient reports to have many allergic
reactions to many different antibiotics in the past. She has
been having "reactions" to both vancomycin and aztreonam, often
witnessed to have an exaggerated forced wheeze. Never had any
urticaria or true airway compromise. Her symptoms rapidly
resolve with Benadryl. During this admission, she was
administered benadryl prior to all antibiotic administration. | 176 | 638 |
11389801-DS-22 | 26,325,032 | Dear ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had palpitations
and a 4 pound weight increase.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were monitored and found to have frequent extra beats.
Electrophysiology recommended increasing your beta-blocker
medication to better control your palpitations and continue to
use your heart monitor.
- You were initially started on a medication called
spironolactone for your heart failure, but this was stopped
after we increased your atenolol
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
Please take 2 of your atenolol tablets (25mg total) until you
run out, and then use new prescription
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor, or the
Heartline at ___ if your weight goes up more than 3
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.
- Your discharge weight: 79.2kg. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | ___ female w/ history of VF arrest in the setting of
inferolateral STEMI, status post DES to LCx (___) who
presents with palpitations, dizziness, dyspnea, and reported 4
lb weight gain.
==================== | 210 | 31 |
14325592-DS-11 | 21,304,791 | Dear Ms. ___,
You presented to ___ on ___ after suffering a motor
vehicle collision. You were found to have a rib fracture, left
lung puncture, a right hip fracture and a left radius fracture.
You were admitted to the Trauma/Acute Care Surgery team for
further medical treatment.
On admission, you were noted to have seizure activity and
Neurology was consulted. You were started on Keppra and it is
recommended you continue to take this medication for at least
the next 6 (six) months. Please do NOT drive for six months.
You have a follow-up appointment scheduled with the outpatient
Neurology clinic.
You were evaluated by the Orthopaedics and Plastics teams. On
___, you were taken to the Operating Room and underwent
surgery for your right hip fracture. On ___, you had
surgery to repair your left radius fracture. You tolerated
these procedures well.
You have worked with Physical and Occupational Therapy who
recommend your discharge to rehab. You are tolerating a regular
diet and your pain is controlled. You are now medically cleared
to be discharged to rehab to continue your recovery.
Please note the following discharge instructions:
* Your injury caused a left rib fracture which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
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. | The patient is a ___ F s/p MVC, unrestrained driver in head-on
collision. Taken to ___, where she was found to
have left 6th rib fracture, small pneumothorax s/p CT placement,
left wrist fracture, right acetabular fracture, and 6 cm facial
lac. At OSH, she was noted to have seizure-like activity and was
intubated. Left chest tube and foley were placed. She appeared
to have received a bolus of fosphenytoin between ___ and
MedFlighted to ___ for further evaluation and management.
Upon arrival to ED, patient intubated, primary and secondary
revealed above documented lesions. She was transferred to
Trauma SICU for close monitoring of seizure activity,
ventilartoyr support. EEG obtained and neurology consulted. Per
neurology team there were no seizure activity demonstrated on
EEG. A CTA head/neck obtained demonstrated no abnormal
findings. Results from a lumbar puncture performed by neurology
were within normal limits. Her ICU course was remarkable for
fevers on HD2. She was worked up with a bronchoscopy and BAL
which returned positive for GPCs. Since HD2, she was started on
Vanc/cefepime. On HD3 the chest tube was discontinued with no
residual PTX. On HD4, she passed RSBI, extubated successfully,
passed bedside swallow evaluation and patient self-limited to
sips due to pain w/swallowing. She was transferred out of the
SICU on HD5 with no active issues and uneventful hospital stay
summarized below.
On HD8, the patient had her foley removed. She then experience
some urinary retention, and the catheter was replaced. It was
removed on the following evening, and she voided without
difficulty. On HD10, the patient went to the OR with the hand
surgery team for closed reduction and percutaneous pinning of
left distal radius fracture. For more details, see operative
report. She was taken from the OR to the PACU in stable
condition, and then moved to the surgical floor. She recovered
from this procedure well. ___ and OT continued to work with the
patient, and by day of discharge, ___, the patient was deemed
safe to return home. On the day of her discharge, she was was
tolerating a regular oral diet, pain was well controlled with
oral medications, she reported normal bowel function and
voiding, and she was able to ambulate with assistance. All of
her questions were answered to her satisfaction. | 732 | 385 |
17347746-DS-19 | 28,391,273 | Dear Mr. ___,
It was a pleasure taking care of you!
Why you were admitted:
-you had worsening shortness of breath and an exacerbation of
your chronic lung disease
What we did for you:
-We changed some of your medications to better treat your lung
disease.
Your next steps:
- Please complete your course of azithromycin antibiotics. It is
scheduled to end on ___.
- Please take all of your medications as prescribed.
- Please attend your scheduled follow-up appointments
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Your ___ Medicine Care Team | ___ ___ speaking male with history of CAD with 3v CABG
(___), HFpEF (TTE ___- LVEF of 50%, with grade 1 diastolic
dysfunction, HTN, HLD, colon cancer, s/p resection, asthma/COPD
(obstructive dz dx on last admission ___, arthritis, and
GERD, who was referred to ___ ___ by his nursing home for
evaluation of shortness of breath.
# Dyspnea
# Asthma/COPD exacerbation: Per patient's son, patient used to
smoke in early adulthood, 1 cigarette/daily for ___ years. He
carries a history of asthma, and is on albuterol inh as an
outpatient. On prior admission last week ___, he had profound
wheezing on exam c/w obstructive pulmonary disease. He was given
duonebs Q6h:prn, was started Fluticasone-Salmeterol 250/50
inhaler BID with improvement, and both of these in addition to
his albuterol INH were continued in house and for discharge. He
also received PPSV on ___. On this admission, he
presented with some dyspnea when sitting up or walking, diffuse
expiratory wheezing on exam, but with O2 sats in the ___ on RA,
and only mild pulmonary vascular congestion on chest x-ray.
Overall, picture was more consistent with obstructive lung
disease exacerbation vs heart failure exacerbation. patient was
started on azithromycin, azithromycin 500mg x1, followed by
250mg daily x4 days (Day 5: ___. His fluticasone-salmeterol
dose was increased to 500/50 BID, with a plan to continue this
following discharge. He was continued duonebs q6:prn, which is
being transitioned tiotropium for discharge. As above, he was
continued on his albuterol INH q4:prn. Patient improved, was not
longer dyspneic when sitting or walking, and had reduced
wheezing on exam. At the time of discharge, he was able to
ambulate without symptoms, and had sats 91-95%. Following
discharge, patient should be evaluated with outpatient PFTs
following resolution of acute exacerbation to delineate whether
his primary process is asthma or COPD.
# Hear failure with preserved ejection fraction (LVEF 50%): TTE
obtained on prior admission last week ___ showed only mildly
depressed EF of 50%, with grade 1 diastolic dysfunction.
Discharge weight on ___ was 87.2 kg/192 lbs on 40mg PO
Lasix once daily. Patient's exam was notable for absence of
crackles, JVD, and peripheral edema, and overall did not appear
volume overloaded. He was continued on his home furosemide 40mg
daily, home metoprolol succinate 100mg daily, and home losartan
100mg daily, and home amlodipine 2.5mg daily.
=============== | 95 | 388 |
12406461-DS-19 | 24,547,521 | Dear Ms. ___,
It was a pleasure treating you. You were admitted for a fever
and chills, and were found to have bacteria and fungus in your
blood stream. You were treated with antibiotics and antifungal
medications and your condition improved. Additionally, we
removed your Hickman line and replaced it with a new silicone
catheter on the right. We have also replaced your J tube. You
have been discharged with continued IV antibiotics, which you
must take until ___. It is imperative that you
continue to take these antibiotics, and that you followup with
your GI team and you PCP.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with a history of left Hickman
for home TPN, eosinophilic gastrointestinal disease,
gastroperesis, and postural orthostatic tachycardic syndrome who
presents with Enterobacter asburiae bacteremia and ___
parapsilosis fungemia.
# Enterobacter asburiae bacteremia: the patient presented with
enterobacter asburiae bacteremia, tachycardia, and fever,
meeting SIRS criteria for sepsis. Her only positive blood
cultures were in ___ bottles on the day of admission, ___.
Given this, the most likely source was GI seeding, with low
suspicion for port infection. She was initially treated with
daptomycin/Zosyn, which was narrowed to Zosyn 4.5g q8hr on ___,
and further to ceftriaxone 2g Q24H on ___. As some enterobacter
species can become resistant to ___ generation cephalosporins,
she was switched to cefepime 2g Q12H on ___. On ___ she had
her Hickman line exchanged for a silicone line with ethanol
lock. This line became displaced, and was replaced with a right
tunneled silicone line on ___. She was discharged on ertapenem
1g IV Q24H, and will complete a 2 week course (last day ___.
# ___ parapsilosis fungemia: Patient grew ___
parapsilosis in blood cultures drawn through her central line on
___. She had no other positive fungal or Gram stains. Patient
has had no constitutional symptoms since the night of admission.
She was started on fluconazole 400mg IV Q24H for 2 weeks (last
day ___.
# Nutrition: patient normally receives TPN daily, and has had no
significant PO intake in ___ years. Patient's home TPN was
initially held due to concerns of port infection. TPN was
restarted following catheter replacement on ___.
# J tube replacement: Patient has a G tube and J tube at
baseline. On ___, her J tube was removed by ___ and replaced by
a GJ tube. The event has been disclosed to the patient. ___ team
as well as the primary team is aware. Patient has been provided
information to contact patient relations. Quality improvement
has also been contacted to prevent future similar events. This
tube was replaced with a J tube on ___.
# Eosinophilic GI disease: patient vented G tube frequently, had
minimal PO intake.
Her home GI medications were continued. Her pain was managed
with her home fentanyl patch and additional dilaudid 1mg
Q4H:PRN. Her nausea was well controlled with IV promethazine.
# Pancytopenia: patient was down in all cell lines, consistent
with lab values from previous infections. CBC was trended daily.
CHRONIC ISSUES:
==========================
# POTS: Patient was occasionally tachycardic to the 140s.
- Home metoprolol was fractionated to 25 mg Q6H
# Peptic ulcer disease:
- Continued home pantoprazole
TRANSITIONAL ISSUES
==========================
- Patient is on 2 week ertapenem course on discharge, last day
___
- Patient is on a 2 week fluconazole course on discharge, last
day ___
- Patient should establish providers in the ___ area,
including GI, primary care, and chronic pain
- monitor LFTs/triglycerides as patient is on TPN chronically | 112 | 474 |
13591121-DS-8 | 25,946,841 | Dear Ms. ___,
You were admitted to ___
worsening shortness of breath.
WHAT HAPPENED DURING YOUR HOSPITAL STAY?
==========================================
- You were given medications to help you breath (nebulizers),
antibiotics due to initial concern for infection, and diuretics
to help you urinate.
- You were placed on a mask to help you breath. Lab tests showed
signs of heart dysfunction and an echo/ultrasound showed that
your heart was not pumping well. You were observed in the
cardiac intensive care unit overnight.
- Once your breathing improved with nebulizers and diuretics,
you were taken for a cardiac catheterization to evaluate the
vessels of the heart. Ultimately, there was mild to moderate
narrowing, but not enough to explain the changes. We believe
you have "stress induced cardiomyopathy" which can be treated
with medications.
- You were started medications to help your heart as well as a
blood thinner called Coumadin to help prevent strokes from this
heart dysfunction in the future.
- Once you were deemed stable on your new regimen you were
discharged.
WHAT SHOULD YOU DO FOLLOWING DISCHARGE?
=========================================
- You should take all of your medications as prescribed.
-- You should give yourself the Enoxaparin injections once a
day, until you are told to stop (once Coumadin levels are
appropriate).
- You should get blood draws to confirm Coumadin levels are
appropriate. These can be done at the ___
___. Please get your blood drawn next on ___.
- You should attend appointments with your PCP and cardiologist,
scheduled below.
It was a pleasure taking care of you during your hospital stay.
If you have any questions about the care you received, please do
not hesitate to ask.
Sincerely,
Your Inpatient ___ Cardiology Team | Ms. ___ is a ___ with a history of COPD/asthma, GERD, HLD, and
Stage IIIA Colon Cancer s/p resection, and a recent TTE with
inferior/posterior hypokinesis who presented with weeks of
increasing dyspnea on exertion and orthopnea consistent with
decompensated diastolic heart failure, found to have newly
depressed EF.
# CORONARIES: unknown
# PUMP: LVEF 30% (___)
# RHYTHM: sinus tachycardia
#Shortness of breath: In the ED the patient was wheezy and
appeared volume overloaded. She was given IV Lasix, nebulizers
and empiric antibiotics. She was placed on BIPAP and sent to the
Cardiac Care Unit for close monitoring. Her breathing quickly
improved with diuresis and better control of COPD exacerbation.
Determined to have no signs of PNA or infection and antibiotics
were discontinued. Ultimately thought to be from COPD and
decompensated cardiomyopathy (discussed separately below).
___ Induced Cardiomyopathy: Patient was found to have
elevated Troponins and placed on IV heparin gtt. A TTE revealed
a depressed EF from 60% in ___ to 30% on ___ this
admission, with regional systolic dysfunction and apical
aneurysm concerning for Takotsubo cardiomyopathy. EKGs were
noted to have nearly global T-wave inversions. Unclear if was
stress induced cardiomyopathy or ischemic pattern. Patient was
taken for cardiac Catheterization on ___ which showed mild to
moderate branch vessel CAD, not consistent with echo changes,
confirming stress induced cardiomyopathy. Troponins likely
stress induced. Patient was started on metoprolol and Lisinopril
with plan to continue as outpatient. Given apical akinesis and
aneurysm (no LV thrombus on TTE), she was discharged on lovenox
bridge and Coumadin (plan for daily dosing of lovenox for ease
of delivery by family member). Was discharged also on Lasix 20mg
___.
#Asthma/COPD with Acute Respiratory Distress:
Patient was admitted for severe shortness of breath and
progressive worsening dyspnea on exertion. While CHF was thought
to be contributory, still was noted to have diffuse wheezing on
exam. Initially required standing duonebs, Spiriva,
beclomethasone, as methylprednisone in addition to the diuresis.
While D-dimer was >1700, patient was unable to tolerate lying
flat for CTA chest. Given her rapid improvement with diuresis
and nebulizers, PE thought to be less likely. The patient
follows with ___, last ___, concern for
worsening dyspnea due to cardiac and pulm processes. Discharged
on home regimen with plan to follow up with pulmonary
outpatient.
CHRONIC ISSUES:
=================
# Hyperlipidemia: Continued home atorvastatin 40mg
# GERD: Asymptomatic, continued home omeprazole 20mg daily
# L>R Shoulder pain: Continued on APAP 650mg TID standing per
___ protocol.
# Stage IIIA Colon Cancer
stage IIIA node-positive colon cancer status post lower anterior
resection in ___ who did not receive adjuvant chemotherapy
and has been monitored on surveillance. There were no sign of
recurrence on ___ CT chest/abd/pelv. Patient is followed by
Dr. ___. | 273 | 452 |
14542087-DS-16 | 22,476,393 | ================================================
Discharge Worksheet
================================================
Dear Mr. ___,
You came to ___ because you were having bloody bowel
movements. You received multiple units of blood and had two
colonoscopies with placement of clips. Your bleeding stopped and
you were started on a heparin drip for your mechanical valves
and started on your home dose of Coumadin. Once your INR was in
the therapeutic range your heparin was discontinued. Your blood
counts remained stable. You were also treated for congestive
heart failure which was likely caused by the blood transfusions.
Your insulin doses were decreased because you are eating less.
You should continue to monitor your sugars. You will be
discharged to rehab to improve your functional status.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | ___ with h/o GAVE c/b ___, hydrocephalus s/p VP shunt, prior
ICH, mechanical AVR on warfarin, HFpEF on Lasix, CAD, DM2, and
OSA on CPAP/ home O2 who presented with post-polypectomy bleed
in the ascending colon causing hemorrhagic shock.
# Acute GI Bleed
# Acute on Chronic Anemia
Prior to arrival to the ICU, the patient had received a total of
3 units of packed red blood cells (1 at OSH, 2 in the ED). His
initial presenting hemoglobin in the ICU was 7.0, and he was
hemodynamically stable. His bleeding was thought to be
secondary to polypectomy on ___ during which a 4 cm
sessile polyp was removed from the ascending colon. GI was
consulted and the patient was prepped overnight for colonoscopy.
Given that the only availability for colonoscopy was on the
___, the patient was transferred to the ___ ICU for
further management prior to colonoscopy. Colonoscopy showed 4cm
ulcerated area where the polypectomy was performed but no active
bleeding. Clips were placed and APC was performed. He did not
require any further blood. He ended up receiving a total of 4
units. He was restarted on a heparin drip following the
procedure. He was improving with no further bleeding and was
transferred to the floor.
On ___, he returned to the ICU with after triggering on the
floor for marked change in mental status as well as hypotension
and increased melenotic stool. He received two additional units
pRBCs during this time, with essentially no net change in his
Hgb. He was taken back for urgent colonoscopy, where his oozing
polypectomy site was injected with epinephrine,
electrocauterized, and endoclipped with seven more endoclips.
His anticoagulation was held for 48 hours, with permission of
cardiology consultants. After this procedure, his GI bleeding
remained fairly stable, although he was transfused one
additional unit on the night of ___ (his eighth overall). A
heparin gtt was started which he had tolerated for 24 hours
without clinical evidence of re-bleed at time of transfer out of
the ICU. On the floor he was restarted on coumadin with heparin
gtt and discharged when his INR was >2.5. His H/H was stable on
therapeutic anticoagulation. H/H on discharge was 8.1/___.4.
# Mechanical Aortic Valve (INR goal 2.5-3.5) for bicuspid valve
# Supra-therapeutic INR
Patient has long history of mechanical aortic valve on chronic
warfarin, where they target the lower end of his INR goal of
2.5-3.5. s/p reversal of warfarin with vitamin K 5 mg. On the
floor he was restarted on warfarin with a heparin bridge until
his INR was therapeutic. His goal INR is close to 2.5 given
history of GAVE and bleeding. INR on discharge is 2.6. The
patient generally takes between 7.5 and 10mg of Warfarin at
home. He will be discharged on warfarin 10mg. Next INR should be
checked on ___ and dose adjusted accordingly.
# Mild delirium
# Hydrocephalus s/p VP shunt
Patient's cognitive status has declined over last few years
because of this. He often takes a long time to wake up and his
wife says he often doesn't realize he was dreaming for several
minutes. In the hospital he had mild delirium manifesting as
slight agitation, paranoia and emotional lability. It was
attributed to elevated bicarb from OSA and CPAP was encouraged.
He was given one dose of Seroquel 50mg for agitation which
resulted in significant somnolence. This was subsequently
avoided. His bicarbonate was stable at 36 on the day of
discharge. The patient remains intermittently confused.
# Leukocytosis (resolved)
Unclear etiology, but likely stress response vs infection.
Reassuringly afebrile and no localizing source. UA wnl. Blood
cultures were NGTD throughout hospitalization.
# DM II
Patient normally on metformin, glargine BID, and ISS at home.
Per the patient's family often snacks and eats in the middle of
the night. The patient's home insulin dose was reduced to
Lantus 25 units twice daily in addition to Humalog sliding
scale. This is much lower than the patient's home regimen.
Fingersticks should be checked 4 times daily and insulin
titrated based on these fingerstick measurements.
# Acute on chronic diastolic heart failure
# CAD
The patient has a known history of CAD based on ___ stress
test at ___: Small, mild reversible inferoapical wall defect
suggestive of zone of myocardial ischemia. LVEF of 51% with
normal LV wall motion. Home Lasix dose 80 mg qAM/40 mg qPM.
After blood transfusions/ volume resuscitation, the patient was
volume overloaded requiring diuresis. He was ultimately
transitioned to his home dose of Lasix prior to discharge. The
patient is also on metolazone on this medication was not
restarted you can consider restarting it if weight increases or
respiratory status declines. The patient also takes
supplemental potassium this was held on discharge as the
patient's potassium levels were within normal limits without
repletion. The patient's metoprolol and aspirin were both
resumed prior to discharge. The patient is on his home ___ NC.
# MGUS
Patient has been worked up for myeloma in the past, which
revealed MGUS which has been stable.
# OSA (on 2L O2 at home and CPAP when sleeping
Likely a mixed picture of central and obstructive sleep apnea.
he was continued on CPAP here and should continue at home at
night and for naps. The patient's bicarbonate is elevated on
discharge at 36.
#GAVE
- continued PPI | 139 | 879 |
14573810-DS-16 | 23,744,384 | Dear Ms. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were having pain in your abdomen.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We put in a breathing tube to put a camera down into your
stomach
- We found that you have a large hernia of your stomach
- You received antibiotics and supportive treatment because you
were having trouble breathing after food went down the wrong
pipe (aspiration)
- Our speech therapists did tests to evaluate your safety for
eating and recommended a modified way of eating that will be
safer for your
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Eat ___ small meals daily
- Always stay upright for an hour after your meals
- Only eat food that has been pureed
Sincerely,
Your ___ Care Team | =================
SUMMARY STATEMENT
=================
Ms. ___ is a ___ ___ female with recently
diagnosed late onset Alzheimer's disease and recent falls who
presented with epigastric/Left upper quadrant pain and
coffee-ground emesis. She underwent CT scan that was consistent
with a gastric volvus with large hiatal hernia. She was treated
for aspiration pneumonia and was intubated for an EGD showing
the hernia and no significant other abnormalities. She was not
considered a surgical candidate for her hernia. She was
converted to DNR/DNI. Speech and swallow recommended the patient
remain NPO based on multiple bedside swallow examinations. On
___ she had a video swallow study that showed no aspiration
with pureed food and thin liquids. She was recommended to have a
modified diet, frequent small meals, and to remain upright for
at least 1 hour after eating due to risk of late aspiration with
her hiatal hernia.
===================
TRANSITIONAL ISSUES
===================
[ ] Patient is at risk of aspiration and should have close
supervision of all meals and should remain upright at 90 degrees
for 60min after every meal due to risk of late aspiration
[] will need ongoing discussion with family about goals of care
however, PEG tube/J tube is not an options for her given her
complicated anatomy
[] Holding home donepezil 5mg daily, buspirone 10mg TId,
quetiapine 50mg BID, and mirtazapine 15mg daily due to strict
NPO status.
New Medications
-----> Lansoprazole 30mg daily
-----> Acetaminophen 650mg q6hrs PRN pain
Code Status: Full
=============
ACTIVE ISSUES
=============
#Aspiration Concern
Patient presented with epigastric pain and was found to have a
large hiatal hernia. She was also hypoxic and in respiratory
distress and was treated for an aspiration pneumonia, after
which time her respiratory status improved. She failed multiple
bedside swallow examinations and was therefore recommended to be
strict NPO given concern that her anatomy was leading to
aspirations which ultimately cause her respiratory failure. She
was maintained on maintenance fluids while the palliative team
was consulted and goals of care were reviewed with the family.
The family expressed a desire to pursue long-prolonging
measures. PEG and NG could not be placed due to her anatomy. On
___ she had a video swallow study that showed no aspiration
with pureed food and thin liquids. She was recommended to have a
modified diet, frequent small meals, and to remain upright for
at least 1 hour after eating due to risk of late aspiration with
her hiatal hernia. Her diet was therefore re-introduced on ___.
Of note, late aspiration can not be fully ruled out by this
study and she is therefore thought to be at risk for this.
#Goals of Care
Both the ethics team and the palliative care team were consulted
for Ms. ___ case. Family identified longer life as a high
priority, but also value comfort and
dignity. At this time, the family is not interested in a
comfort-focused approach to hydration and nutrition. The patient
was made DNR/DNI during the hospitalization. We were initially
faced with a very challenging decision when she was recommended
to be NPO due to failing her swallow studies, but fortunately on
___ a video swallow showed she did not aspirate with thin
liquids and pureed solids and therefore we were able to
introduce a diet.
#Hiatal Hernia
Found to have a very large hiatal hernia with almost her whole
stomach in her chest. She had an EGD that did not show
significant erosions. Given her high risk of morbidity and
mortality from a corrective surgery, there were no operative
intervention available. She was stared on a PPI.
#Anion Gap Metabolic Acidosis
Mild metabolic acidosis noted on ___ with anion gap. Likely
driven by ketones from lack of eating for prolonged period.
Thankfully started eating today so will not
treat further.
#Dementia | 140 | 608 |
12073331-DS-3 | 21,889,981 | Discharge Instructions
Ventriculoperitoneal Shunt Infection and Removal of shunt
Surgery
You had surgery to have your VP shunt removed. Your incisions
should be kept dry until sutures or staples are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing, or
other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT allowed
to drive by law.
No contact sports until cleared by your neurosurgeon. You should
avoid contact sports for 6 months.
Medications
You have been discharged on Keppra (Levetiracetam) and Valproic
Acid. These medications help to prevent seizures. Please
continue these medication as indicated on your discharge
instruction. It is important that you take these medications
consistently and on time.
You have been discharged on Meropenem. This medication is for
treating infection. Please continue this medication as indicated
on your discharge instruction. It is important that this
medication is given consistently and on time, as you needed to
undergo desensitization to this medication.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
Headache or pain along your incision.
Some neck tenderness along the shunt tubing.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ Nursing Home resident s/p aneurysm rupture in ___ s/p
clipping and VP shunt placement presents with exposed VP shunt
hardware. Patient was admitted to the Neurosurgery service.
#Exposed Shunt Hardware
NCHCT and shunt series were obtained to evaluate shunt. Patient
was taken to the OR on ___ for shunt externalization of
proximal tubing, distal tubing removed, wound closure. Proximal
shunt attached to EVD system leveled at 15. CSF sent from OR for
culture grew gram negative rods. ID was consulted and patient
was placed on Meropenem. CSF cultures growing E.coli, meropenum
was changed to ceftriaxone per ID. Repeat CSF was sent per ID.
Blood cultures obtained. EVD was dropped to 5cm and draining
clear CSF. EVD was subsequently dropped to 0cm however there was
no change in output. Output remained between 110cc and 130cc in
a 24 hours period. Her exam fluctuated slightly, likely in
setting of her infection and respiratory illness however she
remained easily arousable and following commands. ICPs remained
single digits. Given positive CSF cultures On ___, the patient
was taken to the operating room and the right frontal EVD was
removed and an EVD was placed on the left side.
She recovered in the PACU and was later transferred to the ___
for close neurologic monitoring. EVD was weaned and clamp trial
was done on ___. Repeat CT on ___ showed stable vents and the
patients exam remained stable in the setting of the clamp trial.
On ___ the EVD was removed. A post-pull head CT was obtained
and was stable. She was transferred to the floor, and continued
to do well without evidence of delayed hydrocephalus.
#Infectious Disease
CSF culture from initial shunt externalization was positive for
gram negative rods, ecoli. Infectious disease was consulted. She
was started on a course of Meropenem. PICC line was placed. She
will continue IV Meropenem through ___.
#Allergic Reaction
On ___ patient developed red urticarial rash over chest, back,
arms, thighs. Given solumedrol, Benadryl, cetirizine. Patient
was transferred to ICU. Allergy team was consulted. Reaction
likely to IV CT contrast, possibly meropenem. Patient underwent
meropenem desensitization on ___ in the SICU. Following
desensitization the patient tolerated the meropenem without
issue.
#Dysphagia
Given aspiration event patient was evaluated by speech and
swallow. She was made NPO. NGT was placed for TF. She underwent
video swallow and diet was progressed to puree/nectar. Tube
feeds were discontinued and PO intake encouraged. She tolerated
the diet and NGT was discontinued.
#Aspiration and Respiratory Distress
Patient vomited after eating and likely had aspiration event
evening of ___. Overnight she became increasingly tachypneic
and tachycardic with a new oxygen requirement. Initial CXR
unrevealing but strong suspicion for aspiration pneumonitis vs.
pneumonia. Patient was transferred to the ICU for closer
monitoring given respiratory status. CTA chest was done to rule
out PE which revealed no evidence of PE however ground glass
nodules concerning for aspiration/aspiration pneumonia. Serial
CXRs did not show focal consolidation and her oxygen requirement
decreased. She was transferred to the ___ on ___ when she
tolerated supplemental oxygen wean to ___ via nasal cannula. A
CXR performed on ___ showed low lung volumes bilaterally a small
left pleural effusion. The patient ultimately maintained an
oxygen requirement, however multiple chest x-rays did not reveal
evidence of cardiomegaly, vascular congestion, or acute focal
pneumonia.
#Carotid Stenosis
Home Plavix for known carotid stenosis was held. CTA neck was
done to evaluate stenosis which revealed occlusion of the left
ICA. The patient was restarted on her home Plavix due to risk
for stroke.
#Multiple Chronic Pressure Ulcers RLE
Wound consult was placed for management and care of the
patient's known and pre-existing pressure ulcers and to prevent
further skin breakdown. | 390 | 621 |
12364425-DS-11 | 26,119,098 | Dear ___,
___ was pleasure taking care of you at ___
___. You were initially admitted to the ICU for
treatment of your small bowel obstruciton (SBO) and very
elevated blood pressure. You underwent a surgical operation to
relieve your SBO, and you tolerated this procedure well. You
were able to eat and drink and have normal bowel movements prior
to discharge. While you were having your SBO, you also developed
some acute decrease in your kidney function. This gradually
improved as your condition improved.
You were found to have an infection in your belly called
peritonitis. For this you are on treatment with two antibiotics,
one called ciprofloxacin and one called flagyl. You will take
ciprofloxacin twice a day for 4 more days, then daily ongoing.
You will take flagyl three times per day for 4 more days, then
stop.
For treatment of your very elevated blood pressure you required
high doses of IV blood pressure medications. Your blood pressure
gradually decreased. You were transitioned to oral blood
pressure medicaitons prior to discharge. It appears that you
have very elevated blood pressure at baseline, and your blood
pressure was at your baseline prior to discharge. Please
continue to take these blood pressure medications after you are
discharged from the hospital. Also, please discuss with your PCP
if you require any additional work-up of your high blood
pressure as an outpatient. Despite your elevated blood pressure,
you did not have any symptoms. If you develop symptoms of
headache, vision changes, or any other symptoms that concern you
while your blood pressure is very elevated, please return to the
Emergency Department immediately.
For your cryoglobulinemia you were evaluated by the phresis
team. They felt that you would benefit from phresis treatments.
A large dialysis line was placed in your neck vein, and you were
started on phresis. You will need to follow up with your renal
doctors to determine if you need any additional treatments after
discharge.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ with h/o severe HTN, Hep C, stage IV CKD ___
cryoglobulinemia/MPGN, SBO from internal hernia s/p reduction
___ by ___, presents with abdominal pain and KUB findings
suggestive of SBO.
# SBO: History and KUB from OSH consistent with SBO. Has h/o
prior SBO from strangulated internal hernia. NGT placed at
___, bolused 1L IVFs there. Seen by surgery in ED,
recommended admission to ___ given uncontrolled BPs. She
underwent ex lap, LOA and SBR with Dr. ___. Postoperatively
she had an ileus and required NGT replacement. This remained in
place for two days and then the ileus resolved and NGT was
removed. She regained normal bowel function and tolerated a
regular diet without difficulty.
# Severe hypertension: Patient has long-standing history of
poorly controlled hypertension, on multiple agents at home.
Reportedly has had secondary hypertension w/u (renovascular w/u
negative). No evidence of end-organ ischemia and EKG largely
unchanged from priors with strain pattern. Was initially treated
with labetalol drip. Postoperatively she was managed with a
nicardipine drip. She underwent plasmapheresis for five
treatments in attempt to assist in BP control. She was weaned
off of IV BP meds and was restarted on oral BP meds. Her SBP
ranged from 130-150s prior to discharge, which is reportedly her
baseline.
# AOCKD/cryoglobulinemia from Hep C: Baseline creatinine appears
to be around 2.5. CKD thought to be secondary to MPGN from
cryoglobulinemia. Previously had been on rituximab for
cryoglobulinemic syndrome, unclear if she is still on this.
Current ___ likely pre-renal from hypovolemia. Creatinine
returned to baseline postoperatively. She underwent 5 phresis
treatments total, which were well tolerated. She will follow-up
with her outpatient nephrologist to continue to monitor.
# Bacterial peritonitis: During the hospital course, she
complained of severe abdominal pain and fever, and was noted to
have some ascites. Paracentesis was performed, and ascitic fluid
was consistent with peritonitis, which could be spontaneous or
secondary to a surgical cause as she was post-op. She was
initially started on iv antibiotics and successfully
transitioned to cipro and flagyl with no further episodes of
fever. She will complete a total 10 day course. She was also
instructed to continue taking cipro ongoing for prophylaxis
against additional SBP. She will follow-up with her hepatologist
as an outpatient for additional monitoring.
# HCV: Chronic hepatitis C genotype 1B with a previously low
viral load and normal liver transaminases as well as liver
biopsy in ___ showing mild disease, grade 1 inflammation and
stage I liver fibrosis. Not a candidate for interferon given
cardiac and renal disease reportedly. HCV viral load was
elevated on this admission. She was scheduled to follow-up with
her outpatient hepatologist after discharge.
# Chronic systolic CHF: Most recent echo with EF ~40-45%. She
did not have any active issues on this admission. She was
maintained on ACEi, BB, low-sodium diet and 2L fluid
restriction. She was not on aspirin or statin on admission, and
consideration can be given to starting these meds as an
outpatient.
TRANSITIONAL ISSUES:
- consider starting aspirin, statin | 340 | 506 |
19830951-DS-27 | 28,715,053 | Dear ___,
___ were admitted after falling at home. ___ were found to have
a fracture(a break in the bone) of one of your back bones. ___
were seen by the bone surgeons and were given a brace(support
structure) to wear when out of bed. ___ were seen by our
physical therapy team who recommended continuing your care at a
rehabilitation facility. Your blood pressure was very elevated
and we increased the dose of your home valsartan/clonidine and
started ___ on amlodipine. Given some signs of kidney injury,
home lasix(water pill) held on discharge to rehab. The providers
at the rehabilitation facility will restart the water pill when
appropriate.
Sincerely,
___ Care Team | ___ yo F with multiple medical problems here with BLE weakness
found to be due to an L4 vertebral fracture.
ACTIVE ISSUES
# Hypertensive emergency/urgency : Blood pressure 208/70 on
admission without end-organ damage. Per review of OMR, patient
is typically fairly hypertensive (many SBP's in 180's). SBP in
200-210s earlier on admission. ___ AM, had one episode of
nausea/voming concerning for end-organ damage from hypertensive
emergency. Had CT head w/o contrast done for eval of bleed given
nausea/vomiting. CT unremarkable. Last admission, had similar
episodes of hypertensive emergency. SBP was better controlled
with labetalol. Labetalol switched to carvedilol in the past
given concern for bradycardia at cards f/u. Pt was started on
amlodpine 5mg daily and home clonidine increased from 0.2 to
0.3/day and valsartan from 80mg BID to ___ BID. Switched
carvedilol 25mg BID to labetalol, but switched back given
bradycardia to upper ___, low ___. No sign of RAS on U/S. Renin
___ sent, pending on discharge. SBPs improved with
discharge SBPs 130-160.
# Spinal fracture: L4 vertebral burst fracture. Most likely
traumatic from fall out of bed. Patient seen by Ortho Spine in
ED. They recommended LSO while OOB and follow-up in clinic. Got
LSO brace on ___. Evaluated by ___ and discharged to rehab.
Advised to follow up with orthospine in 1 week.
# acute on chronic kidney injury: increase from baseline of 2.2
to 2.7, most likely pre-renal in the setting of poor po intake.
Home lasix held on discharge. Will need daily BMP check and
lasix should be restarted when Cr downtrending or patient
develops signs of volume overload.
CHRONIC ISSUES
# Hyperlipidemia: Continued statin.
# Type 2 diabetes: Diet-controlled. sliding scale as needed.
# Chronic Diastolic CHF: BNP elevated but, but most likely in
the setting of renal failure. No evidence of volume overload.
given ___, lasixx held on discharge.
# Gout: Continued allopurinol.
# OSA: on CPAP at home, continued on CPAP
===========================
TRANSITIONAL ISSUES
===========================
-LSO brace while OOB until f/u in ___ clinic.
-Medication change: Increased dose of valsartan, clonidine and
started amlodipine with good BP control.
-Cr increased on day of discharge to 2.7 from 2.5(baseline
around 2.2). Home lasix discontinued. Please check electrolytes
daily, and encourage PO intake. Restart lasix when creatinine
downtending or any signs of volume overload.
-7 mm peripheral nodular density in the right lower lobe,
possibly scarring from prior infection. Followup chest CT is
recommended in three months to ensure stability
-Aldosterone pending result at discharge.
CODE: FULL | 110 | 412 |
16474066-DS-24 | 26,779,141 | Dear Ms. ___,
You were admitted to the hospital for chest pain. Your chest
pain resolved with medication and you had a cardiac
catheterization which showed no new blockages in the coronary
arteries of the heart, which is reassuring that your chest and
back pain is unlikely related to a new heart attack.
It is very important that you continue to take all your
medications as prescribed. All of your medications are detailed
in your discharge medication list. You should review this
carefully and take it with you to any follow up appointments.
The details of your follow up appointments are given below, for
primary care ___ and cardiology ___.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ yoF with extensive CAD history with numerous stents most
recently last year on Plavix, h/o instent restenosis, HTN, IDDM,
and HLD who presented with an acute onset of left back,
shoulder, and chest discomfort concerning for ACS.
#Chest pain: In the ED she was started on nitro gtt as SLN did
not relieve chest pain. She was able to be taken off nitro gtt
without recurrence of chest pain. Trops were neg x3 and EKG did
not show ischemic changes. CTA ruled out PE and aortic
dissection. However, given extensive CAD history as well as
history of MI without changes in EKG or cardiac enzymes, she was
taken to cath which showed 3 vessel native CAD angiographically
unchanged from prior cath in ___. 2 of 3 bypass grafts were
widely patent. Negative pressure wire study across moderate
in-stent restenosis in SVG to D1. She was discharged home with
PCP and cardiology ___. | 120 | 155 |
19420214-DS-20 | 22,995,802 | Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-Bloody diarrhea and bloody vomit
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were given blood through a transfusion while you were in
the ICU because your red blood cell counts were low.
- Our gastroenterology team did an imaging study where they
looked inside your stomach with a camera to look for a source of
bleeding. During that procedure an ulcer was found in your
duodenum, which was likely the source of the bleeding and
stomach pain. You were started on a medication called
Pantoprazole to reduce the acid production in your stomach,
which should help the ulcer heal. You were also started on
another medication to help the ulcer heal, called sucralfate.
- Your blood sugar was very elevated on admission (over 900). We
started you on an insulin drip to bring down the sugar and
ketones in your blood while you were on the intensive care unit.
When you left the ICU, you were seen by the diabetes specialist
team who started you on a new insulin regimen for better blood
sugar control.
- Due to the pain you were having in your stomach, we started
you on a pain control regimen with acetaminophen and Oxycodone.
- You were found to have a large clot in your iliac and femoral
veins. You were started on an increased dose of the blood
thinner you were on before your GI bleed, called Apixaban.
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 take the new insulin regimen prescribed to you by our
diabetes team
- Please take your increased dose of apixaban (10mg twice a day)
until the end of the day on ___. At this point you
will be transitioned to a lower dose (5mg twice a day)
We wish you all the best!
Sincerely,
Your ___ Care Team | ___ with hx of idiopathic chronic pancreatitis s/p
pancreatectomy with islet cell auto-transplantation c/b bowel
obstruction and bowel resection, T3c DM, iron Deficiency Anemia
with recurrent Feraheme transfusions, alcoholism (reported last
drink ___ who presented with DKA and Upper GI Bleed
requiring MICU admission, found to have non-bleeding ulcer on
EGD and new proximal iliofemoral DVT | 342 | 56 |
19303134-DS-14 | 24,511,012 | Dear ___,
You were hospitalized because you had greatly increased seizure
frequency at home. This was likely caused by a combination of
your recent lack of sleep, your pregnancy, and a urinary tract
infection. Keppra was increased to 2250 mg twice a day.
Tripleptal was increased to 900 mg in the morning and 1200 mg at
night. You were seen to have multiple seizures overnight that
was recorded on the EEG monitor.
We strongly encouraged you to stay in the hospital for another
night for seizure monitoring while we are adjusting your
medication. Risks of undertreated seizures include prolonged
seizures, which can lead to breathing or heart problems, and
sometimes death (Sudden unexpected death in epilepsy patients).
You understood the risks of going home, despite our advice that
you stay for optimization of your seizure control. Please come
back to the hospital or go to the nearest ED if you experience
more than your typical seizures per day.
As you know, please avoid any activities that could be dangerous
if you were to have a seizure during them including but not
limited to swimming alone, cooking near a hot stove, operating
heavy machinery, driving for 6 months from most recent seizure
as per ___ law.
Sincerely,
Your ___ neurology team | Patient was admitted to the epilepsy service from ED for vEEG
monitoring and titration of medications. The increased seizure
frequency was thought to be due to decreased sleep for the past
several days, a new UTI, and questionable adherence to
medications. The urinary tract infection was treated with
macrobid, plan for 7 days. Keppra was increased from 1500 mg QAM
and 2250 mg QPM to 2250 mg BID. During her stay, patient had 4
of her typical seizures captured on EEG associated with
tachycardia, but without electrographic correlate. Oxcarbazepine
was increased from 600mg QAM and 900mg QPM to 900mg QAM and
1200mg QPM. Patient was strongly advised to stay in the hospital
for an additional night for continued EEG monitoring and AED
titration. However, patient insisted on leaving AMA, despite
multiple providers counseling her otherwise. Information about
SUDEP was provided. Patient instructed to follow up with Dr.
___ ___ weeks and to return to hospital immediately if
she has increased seizure frequency compared to baseline.
Transitional Issues
[ ] follow seizure frequency on increased dose of Trileptal and
keppra
[ ] please check a sodium level and oxcarbazepine level 1 week
after AMA discharge on (___)
[ ] 7 days of treatment for UTI with macrobid
[ ] MFM follow up
[ ] follow up with Dr. ___ on discharge | 208 | 215 |
Subsets and Splits